Over the past decade or longer, there has been a shift toward patient-centered care owing to advances in technology and an evolution in practitioners’ mindsets. For glaucoma specialists, our mindset must be to partner with patients who will likely require care for the rest of their lives. The best approach in my experience is to treat every patient with intention, not only from a clinical perspective but also from an interpersonal perspective.
Glaucoma is a complex disease process that requires patients to undergo regular checkups, examinations, and potentially multiple pharmacologic and surgical interventions during their lifetime. In every interaction we clinicians have with patients, we must remember that they are facing a tough opponent and that having us as an ally could mean the difference between compliance and complacency. By partnering in their care, we can guide them toward the most efficient treatment pathway while creating a meaningful bond. Maintaining transparency is key.
I treat a lot of patients with advanced glaucoma, and I feel a great sense of obligation to offer them something different from what they might receive from their comprehensive ophthalmologist. Most comprehensive ophthalmologists provide effective medical management for glaucoma, but the decision-making process becomes more complex as the disease progresses.
My goal for the first interaction with a new patient is to spend time painting the long-term landscape. I educate them on the basics and explain that glaucoma is a lifelong disease that requires constant observation. I also talk about how we’ll start treatment with the goals of preserving visual function and preventing further damage in mind. This discussion can be completed efficiently with a focus on building rapport.
In an era of electronic medical records, I am often typing on a computer or tablet and looking away from the patient. Rather than talk to them about glaucoma while I’m looking at a screen, I wait until I start the exam to explain the disease to them. I look into their eyes, and I use language such as, “I’m not sure whether or not you have glaucoma yet or to what degree, but as I examine your eyes, I want to explain a couple of things to you.”
In addition to building the framework for the doctor-patient relationship, this strategy helps me to get a better feel for patients. How much have they heard about glaucoma before? Do they seem amenable to drop therapy? Is another intervention likely needed? Should another office visit be scheduled to give the patient time to think about their options, or should I immediately go on to the next step? Asking and answering these questions, in addition to the findings of the clinical examination, help me determine the best potential treatment pathways for the individual.
STRIKING A BALANCE
I make sure to share with patients only the options that I feel are most appropriate for their condition. Explaining all of the available treatments can overwhelm them, and it could scare them away from making any decision at all. If it is not an urgent situation (ie, the IOP is not critically high), I think there is value to performing a repeat examination and pressure measurement at a follow-up visit. This provides more insight into diurnal fluctuations and regression of IOP to their mean, and it gives patients a chance to digest the information they just learned. It also strikes a delicate balance between informing patients of their options and providing the tools they need to make an educated decision for themselves.
The same balance can be found for patients with concomitant glaucoma and cataract. My first consideration is whether the primary area of concern is the cataract or the IOP. To make a determination, I ask patients about their vision and what symptoms they have. If cortical changes or a posterior subcapsular cataract is present and the patient has already lost accommodation, I may proceed with cataract extraction and a less aggressive glaucoma procedure. If, however, the lens is clear, my thinking shifts toward glaucoma surgery.
Once I know the surgical focus—cataract removal or IOP control—I discuss options. I explain the advantages and disadvantages of each approach, and I tell patients that there is no right or wrong decision. I say something like, “Each surgery has subtle differences, and the right choice for you depends on your tolerance of risk, your personality, what you do for work, and your hobbies.”
Something I learned from a past colleague, J. William Harbour, MD, currently the David Bruton, Jr. Chair in Ophthalmology at UT Southwestern Medical Center in Texas, is to give patients the time they need to understand what is going on inside their eyes. Our interactions should be devoted not only to the diagnostic and surgical services these patients require, but they should also extend to learning about them, quelling their fears, and helping them navigate the complexity of a glaucoma diagnosis. Giving patients more time and maintaining transparency about their condition and overall outlook are not only courteous. They also go a long way to solidifying the doctor-patient relationship.
I practice in an academic setting. When residents and fellows are observing me in clinic, I ask patients, “Is it okay if we do a little bit of doc talk about what’s going on with you and we fill you in if there are parts of it that you’re not understanding?” In this setting, patients get two explanations. They hear the medical side—where we’re talking about the case and what to do—and they hear a more digestible explanation. Most patients appreciate hearing both sides. They feel more involved in their care because they witness firsthand how much thought goes into the decisions we make.
I want patients to know that I am a steadfast partner in their long-term care. Being intentional about delivering customized care to patients and maintaining transparency about their condition are key to winning patients for life.
For a European perspective on this topic, click here to read an article by H. Burkhard Dick, MD, PhD, FEBOS-CR, and Ronald D. Gerste, MD, PhD