Presbyopia-correcting lens implants are becoming the standard of care for practitioners who have learned to conquer the technical and psychological aspects of setting up patients’ expectations and then delivering on them. Providing spectacle freedom to patients has a snowball effect, in which happy patients refer their friends and family specifically for these premium lenses. Conversion rates to premium implants of 75% or more are not unusual.
In my own practice in Southern California, I have seen similarly enthusiastic acceptance of these lenses by patients, which I do not believe is the result of patients simply wanting a “Southern California lifestyle.” Like my colleagues from more rural states who have had similar success, I believe that observing simple principles, which I offer here as 10 commandments, will contribute to your success in educating patients about the best premium IOLs for them.
COMMANDMENT NO. 1. BELIEVE IN THE TECHNOLOGY
If you are new to premium IOLs, it takes a certain leap of faith to recommend them enthusiastically to your patients. Even 10% reservation in your voice when discussing a lens will be apparent to your patient, and the level of his or her interest will reflect it. With experience and many happy patients, both your and your staff’s excitement will develop naturally. Until then, remind your staff members that it is easy to remember a patient who is unhappy while forgetting the majority who love their results and refer their friends.
COMMANDMENT NO. 2. UNDERSTAND THE IMPORTANCE OF THE DISCUSSION
What takes only a few minutes to discuss has a lifelong impact on patients, and for most of them, the costs involved in a premium IOL are daunting. Rushing the process will prompt patients to opt out by default and forego a choice that would truly improve their life. If asked, many patients will say, “I don’t mind wearing glasses. I have worn them my whole life.” This is why I do not begin the discussion by asking whether the patient is interested in a premium implant. Instead, I take the time to explain the benefits of a high-technology IOL in understandable terms to every patient. My staff schedules extra time for this discussion with patients who are expected to be ready for cataract surgery.
COMMANDMENT NO. 3. MATCH THE TECHNOLOGY TO THE PATIENT
Before patients visiting my practice meet with a surgeon, they fill out a questionnaire that rates their visual disability and determines their need for distance, intermediate, and near vision. A patient’s answers to the survey (which is a modification of the survey created by Steven Dell, MD) help me to understand his or her needs, but it does not substitute for asking directly what activities the patient enjoys. I describe the benefits of what I have determined to be the most suitable implant for him or her in the context of these activities. Retailers say that most large purchases are driven more by an individual’s emotional motivation than by exhaustive analysis. Showing the benefits of each lens choice for the patient’s individual lifestyle helps him or her understand its advantages on a personal and emotional level.
COMMANDMENT NO. 4. LET THE DOCTOR DO THE EDUCATING
I use a number of educational tools, including brochures, videos, consent forms, and my practice’s Web site, which are available to patients before their consultation. The first verbal discussion about implant choices, however, is with me. This ensures that the patient has reasonable expectations, and it allows the educational process to be customized to his or her needs. Information should come from the most trusted source—the surgeon.
COMMANDMENT NO. 5. KEEP IT SIMPLE
Rather than present brand names of lenses to patients, make a recommendation of one implant. Most patients do not want to analyze the unique features of each lens. Instead, they want to know which IOL is the best choice for them. Most patients feel it is the doctor’s duty to make this choice. In your discussion and in your paperwork, refer to premium implants as the “new standard” or “a better IOL” rather than “premium.” Avoid referring to monofocal implants as “standard.” Many patients, especially those born around the Great Depression, have never opted for anything premium in their lives.
COMMANDMENT NO. 6. OFFER MORE THAN ONE TYPE OF IMPLANT
With the online availability of information about various implants, patients often ask for a specific lens. If it is an appropriate choice, I am happy to comply. If not, I will explain from my experience why their preference might fall short of their expectations.
Either way, I can credibly speak to the patient’s best interests rather than forward a one-size-fits-all preference.
COMMANDMENT NO. 7. BE CLEAR AND UNAPOLOGETIC ABOUT LIMITATIONS
I counsel patients not to expect perfection. I tell them, “If you compare what you have to perfection, you may be disappointed—whether you are talking about your lens implant, your car, your computer, or your spouse. If you compare vision to an old-fashioned implant, though, the difference is huge. Ninety percent of people can pass a driver’s test without glasses, but you may need glasses to feel comfortable reading road signs at night. Ninety percent can read a newspaper, but if you are going to read it cover to cover, you might prefer to wear reading glasses. Expect to need glasses for some things, such as prolonged reading or for fine print.”
COMMANDMENT NO. 8. BE CLEAR AND UNAPOLOGETIC ABOUT EXTRA COSTS
Most patients have no frame of reference for the cost of a premium IOL, and they are likely to be shocked by any four-digit price. Three strategies may soften this effect. First, although you may find it uncomfortable, I believe it is best for you the surgeon—the most trusted individual—to explain pricing to the patient. Second, present the implant’s costs in the context of the overall cost of cataract surgery, including anesthesia, the surgery center’s fees, and the surgical fee itself. Compared with this larger anchor price typically paid by insurance, the patient understands that upgrading to a refractive implant is an incremental cost. Third, let the patient know that financing is available, because you want to make the best technology available to everybody.
COMMANDMENT NO. 9. TELL THE PATIENT WHAT YOU WOULD DO FOR YOUR SISTER
If you would honestly recommend a premium IOL to a loved one, end the discussion on this point. There is no way to more genuinely express your belief that better technology will lead the patient to a better life.
COMMANDMENT NO. 10. FOLLOW UP AND FOLLOW THROUGH
With premium implants, there are two critical followup efforts after the consultation. At the end of your consultation, make a note in the chart as to how likely you believe the patient is to choose a premium lens. If you felt confident of a premium choice but learn later that a patient has changed his or her mind and chosen a standard monofocal implant, pick up the phone and make sure he or she has not based the decision on misinformation misinformation. I find that scenarios like the following occur all too often in practices. A patient with significant corneal astigmatism is told by a friend that he or she should expect perfect uncorrected distance vision with a “nocost” implant. A patient with preoperative hyperopia in both eyes is told he or she will be able to read without glasses after surgery with a monofocal IOL. Sometimes, you will have to explain reality again. If you do not, patients will expect the same vision as their friends, however unrealistic this may be. If patients are disappointed, they will naturally blame you rather than their choice of implant.
The second and more important time to contact patients is about 6 months after surgery. Some will be beginning to develop posterior capsular opacity, and some may have a mild residual refractive error that is interfering with their spectacle independence. These marginally happy people may not be bothered enough to initiate a visit to your office, but they will tell their friends how disappointed they are with their expensive implants, which can be very damaging to your reputation. In my practice, I do not wait for patients to complain. I routinely perform a complete examination on all premium IOL patients 6 months after surgery. If I detect that the patient is even mildly disappointed with his or her results, I recommend a no-charge enhancement or whatever treatment is appropriate. In my practice, the mantra is “you deserve to be happy.” Patients greatly appreciate this extra effort, and they tell their friends about it.
SUMMARY
Organize your discussion with patients about premium implants, take extra time, say what you believe, and believe what you say. Your practice will be rewarded by more patients’ adopting premium IOLs and by their satisfaction with this exciting technology.
John A. Hovanesian, MD, is in private practice at Harvard Eye Associates in Laguna Beach, California. He is also a clinical instructor at the UCLA Jules Stein Institute. Dr. Hovanesian may be reached at (949) 951-2020; drhovanesian@harvardeye.com.
