It is unfortunate when a patient has an unexpected postoperative result from refractive surgery. Sometimes, these patients experience a great sense of visual loss, and they may go through several different stages of grief.
Dealing with disappointed patients is challenging for you and your staff. In this article, I attempt to explain the various phases of unhappiness a patient may endure after a failed refractive procedure and suggest how to help them and your staff cope with the situations, based upon my experiences.
STATE OF SHOCK
Patients' first response is usually shock, which can last for a few days. This reaction protects patients from having to deal with a difficult concept: they have not gotten what they expected from their refractive surgery procedure.
Patients are sometimes accepting of their current situation, because they are numb to its impact. Stay in close contact with patients that achieved a less-than-favorable visual result from refractive surgery. I suggest seeing them weekly for a month or so. Patient/surgeon contact remains important as patients advance to the second stage of grief.
EXPRESSION OF EMOTION AND ANGER
After their sense of shock passes, patients usually become highly expressive of their emotions—typically, anger and frustration. A natural response is to back away, and it may be prudent to put some space between you and your patient initially. It is important, however, for you to strive to become closer emotionally with the patient.
The next critical step is to say what the patient needs to hear, not necessarily what you want to articulate. At this stage of the grieving process, the patient will remember nearly every word you say. Because inconsistency and a lack of sincerity on your part can damage your relationship with the patient, I suggest creating and following a rubric for these interactions.
When expressing remorse to patients with an error, I suggest you use the five Rs: (1) recognition; (2) regret; (3) responsibility; (4) remedy; and (5) realignment. In my opinion, it is best to recognize that a problem exists first. Next, sincerely express your regret without asking for the patient's forgiveness or attempting to distance yourself emotionally from the patient. Asl for forgiveness can cause a patient to exclaim that you have no idea what he is experiencing and the level of suffering he has to endure. Next, take responsibility, and ask the patient what you can do to help improve the situation. You should then determine a remedy. If you are aware of the next steps for treating the patient, tell him so. The final step is realignment. Errors occur infrequently. It is appropriate to tell your patient so and to ask for him to share with you his progress so that, if an error in treatment occurs again, you will be better prepared to help the patient.
DEPRESSION AND LONELINESS
Patients may feel confused, which can lead to a depressed mood and a sense of loneliness. It is not uncommon for patients to tell their surgeons that they have thoughts of ending their lives. Although I have not encountered any patient who has followed through on these ideas, it is important to recognize these thoughts and address them. Based on my experience, you should see these patients at least monthly. A telephone call is adequate from time to time, and you need not say a lot. Be sure, however, to communicate your concern for the patient's well-being effectively.
For surgeons, perhaps the most alarming phase of patients' grief occurs next. They may start complaining that their vision is so poor they cannot see to work or perform basic daily duties. Other symptoms may arise that are unrelated to their eyes. Address these emotions and find out if the patient is still working and performing daily activities. Do not challenge patients on their assessments. Show compassion and understanding or risk damaging the doctor/patient relationship.
Patients may fixate on their poor postoperative vision and become extremely anxious. In my experience, at this stage, surgeons make the most mistakes in judgment. Patients are desperate and will do almost anything to correct their visual defects. Additional surgery is not an option for an anxious patient who is grieving about his current results from refractive surgery. Often, the outcomes of another procedure are not what the patient or surgeon wanted, which further strains their relationship.
Although I have found that patients' feelings of guilt seem to last approximately 2 weeks,it is important to recognize these emotions and be prepared for them. Patients may ask if they should have had refractive surgery in the first place. Acknowledge that this is a natural and reasonable concern. If you have had similar encounters with patients before, you might share that with the patient. Finally, support the patient by communicating that these feelings of grief will diminish with time.
ANGER AND RESENTMENT
Anger and resentment over what the surgeon did, or did not do, is the next phase of the grieving process. During this period, the patient may have an overwhelming sense that you have forgotten how much he has suffered.
Patients may express their suffering to you for months, even years. Some will communicate their dissatisfaction on the Internet via anti-refractive surgery Web sites. It is important for your patients to seek advice from you or another physician; the Internet is simply not a very good doctor.
A patient may resist further intervention. You may schedule another surgery only to have patients say they do not want the treatment or not show up for appointments. The harder you push the patient for additional treatment and/or appointments, the more resistant he will likely become. I suggest backing off after communicating that an additional procedure is an important decision and telling the patient to take the time to consider if another treatment is right for him.
Gradually, hope returns, and your patients will begin to experience their lives differently and for the better. Also, you may find that your patients are now ready to pursue additional surgery to improve their vision.
I have had patients apologize for their past behavior, and countless others have offered to help patients who have had similar experiences. In my opinion, medical malpractice is a rarity when surgeons and patients work together toward a possible resolution of postoperative visual problems. You can preserve your relationships with patients by recognizing and respecting the different phases of their grief.
This article was adapted from Potter J. Communicating with the unhappy refractive IOL patient. In: Chang DF, ed. Mastering Refractive IOLs: the Art and Science. Thorofare, NJ: Slack, Inc.; 2008:807-810.
John Potter, OD, is Vice President for Patient Services for TLC Vision Corporation. He currently devotes his full time and attention to patient advocacy, dispute resolution, and conflict management in refractive surgery. Dr. Potter may be reached at (636) 534-2300; firstname.lastname@example.org.