GRIN FAIRY TALE: DEALING WITH THE UNHAPPY LASIK PATIENT

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by Maxine Lipner Contributing Editor

The much-storied laser in-situ keratomileusis procedure usually has a fairy-tale ending, with individuals not only happy about the procedure but returning to their kingdoms to tell others about the wondrous technique. Even in the best of hands, however, things can and do go wrong. Occasionally, a patient who is downright unhappy to have fallen under the procedure's spell emerges from the forest.
There are two levels of dissatisfaction that practitioners commonly deal with, said Richard L. Lindstrom, MD, clinical professor of ophthalmology at the University of Minnesota, Minneapolis, and managing partner at Minnesota Eye Consultants. "One level is the patient who is not satisfied with their outcome, meaning they have a visual symptom - they don't see as well as they'd like to, they have halos or some other objective phenomenon," Lindstrom said. "Then there is another group - patients who really have a satisfactory outcome but are unhappy with something about their care." Some of this has to do with unrealistic expectations of what their visual outcomes should be and of the kind of care or attention patients think they should be getting.
Patients are generally looking at the whole process of LASIK, said Daniel S. Durrie, MD, director of refractive surgery for Hunkeler Eye Centers in Kansas City, Mo. This can include everything from how they were treated in the preoperative exam to their follow-up care months or years afterward. "It isn't just whether they're seeing 20/20 or whether they're able to go without glasses, but it's their impression of their whole quality of care," Durrie said. "This is an expensive elective procedure, where people want to feel that they got their value for their money." There are patients who are ecstatic with 20/40 results and others who are unhappy with their care because they had to wait 15 minutes for their follow-up exam, he said.
From a clinical standpoint, there's no telling what will set a patient off, said Robert K. Maloney, MD, director of the Maloney Vision Institute in Los Angeles, "One of the things that has been very striking to me is how my most angry patients often have pretty good results and often my patients with the worst results are relatively benign and trusting." Maloney cites the three times in his career when he has been sued. One patient was overcorrected by 1/8 of a diopter, another patient had preoperative floaters and developed more postoperatively, and the third involved a person who had a buttonhole in her flap. Maloney aborted the procedure and her vision came back to 20/20 corrected. On the flip side are patients who had big overcorrections and other problems. "I'm not sure whether there is really any relationship between how bad a complication is and whether or not you get sued," he said. "The main thing is how well you handle your relationship with the patient and, truthfully, what kind of a person the patient is."

Following the numerical bread crumbs

Keeping patients happy, however, is the refractive practice's bread and butter. "Theoretically, every happy patient sends you five others and every unhappy patient costs you 20," Lindstrom said. "That means that if you don't have an 80% satisfaction rate, you're not building a practice and if you don't have a 90% satisfaction rate, you're not going to be building a practice very well." Lindstrom's patient-satisfaction indices have fared exceedingly well, at 99%-plus. However, even this small, dissatisfied percentage can prove costly. "It turns out that even one in 100 dissatisfied patients, while they're not going to destroy your practice, take an awful lot of time," he said.
Meanwhile, Maloney has found a strong relationship between patient satisfaction and postoperative symptoms like dry eyes, eyelid soreness, eyelid sticking, or sharp pains. Patients with these symptoms are less happy with LASIK overall. In the survey, 111 of 425 patients with symptoms reported a satisfaction rating of less than eight out of 10 compared with similar unhappy ratings from 53 of 403 patients with no symptoms, Maloney said.

The bedside story

When it comes to dealing with the unhappy patient, the temptation may be for the practitioner to deny that a result is less than optimal or to avoid the patient altogether. This is a big mistake, Maloney said. "The most important thing is that the patient not feel abandoned by the doctor when it's a bad result," he said. "If a patient feels abandoned, they usually get very angry and that's what leads to lawsuits." Maloney thinks that this is the time to keep in close touch with the patient. He said that if the patient is unhappy, so is he. This, he finds, puts him on the same team as the patient.
Roger F. Steinert, MD, assistant clinical professor at Harvard Medical School and in private practice with Ophthalmic Consultants of Boston, said, "I make sure that the patient realizes that we take his/her unhappiness seriously and don't dismiss it, letting the patient know that we will do everything possible to identify the reason for the unhappiness." If an enhancement would alleviate the complaint, he does it at no charge. He also thinks that patient communication and constant re-education are paramount. "Although preoperative information is very important, we find that postoperative is even more important," he said. "Once the procedure is performed, the patient needs to know what symptoms and healing patterns are normal and to have reasonable expectations reinforced repeatedly."
Durrie makes patients aware that he's working on solving the problem and that they can contact him at any time. He looks at LASIK as being 5% surgery and 95% patient management. "I give all patients my e-mail address and they really appreciate that," he said. "My experience has been that patients who are unhappy and stay unhappy are usually the ones who have gotten the impression that either the doctor or the staff doesn't care about their problems."
Lindstrom tries to instill realistic expectations about LASIK. "The typical patient who comes in today for LASIK expects to have a perfect result the next day," he said. "We spend all kinds of time telling them that while the visual recovery is quite quick, you only get maybe 75% of your vision back on the first day and then there's a slow recovery." He also tempers expectations by telling patients that they're going to likely have halos, dry eyes, and might need an enhancement.
At times, he dissuades the patient from having the procedure. "There are some times that we tell patients that the surgery is not that good and ... maybe they should wait," he said. With approximately 1 million LASIK procedures performed per year in the United States, a 1% dissatisfaction rate amounts to 10,000 potentially angry voices, Lindstrom said.

When to wave the magic surgical wand

Knowing when to surgically step in with unhappy patients can prove important. Lindstrom recommends that practitioners stall when pressed to perform follow-up procedures. Current studies show that vision tends to improve with time and interface haze, irregular astigmatism, and night halos often go away. "Just keep reassuring people that natural healing will take care of a lot of things," he said. He also has an eye out for the unrealistic patient, like the pre-presbyopic individual with 0.25 D of residual myopia. "They're not happy. They're not happy and you go in and do an enhancement and then they come back +0.5 D, seeing worse at distance and at near. By being too aggressive, you've created yourself a problem," he said. "So, you have to sit on your hands every now and then."
Durrie also advises against doing surgery just to make a patient happy. "It's better to ... say, 'Gee, I wish I could do something for this, but there just isn't an available procedure that's safe,'" he said. He points to a recent patient who had 20/25 uncorrected results following surgery. While the patient wanted to see if an enhancement could get him to 20/20, Durrie pointed out that the problem was irregular astigmatism. "I told him that there was not a solution that would help today, but that there may be one in the future," Durrie said. This, he thinks, helped convert the patient from one who was potentially unhappy to one who is content with his results.
Steinert advocates surgery in cases where he thinks that the benefit-to-risk ratio is favorable. As a result, he does a fair number of enhancements. "Some of my best referring patients are those who did not have a perfect initial result and realized that we worked with them to enhance this result and improve the outcome," he said.
To grandmother's house we go: Second opinions
Second opinions come into play in two situations - in the case where the practitioner is overwhelmed or when the patient has lost confidence, Maloney said. "If the practitioner feels that they are getting in over their head, it is much better to ask for help early rather than late," he said. Maloney finds that a consultation with another surgeon can also help reassure the patient who has lost confidence that the surgeon has done a good job.
If the patient has lost trust, not facing it can be a mistake. Maloney cites the case of a patient who came to him after having an aborted LASIK procedure following a bad flap. The patient didn't trust her initial surgeon anymore. She wanted a refund so she could pay Maloney to re-operate. The surgeon refused, saying that he had, in fact, operated on her. "That's one of the most foolish things I've ever heard," Maloney said. "Much better to part with a couple of thousand dollars then to charge the patient for not doing what you promised and risk angering them." In the end, the patient sued the practitioner, something Maloney thinks wouldn't have occurred had he just returned her money.
Lindstrom agrees that this is not a time to pinch pennies. To help rebuild confidence, he even offers to pay for a second opinion. "We've learned that that pays off," he said. "You just got a $3,000 to $4,000 fee from the patient, and if you spend $200 of it trying to get them a second opinion one in 100 times, it's not that big an investment."

Aiming for happily ever after

Maloney spends a half-day a week just dealing with patients with LASIK complications who have been sent to him on referral. "It's difficult, because generally they don't get to me until there has been some fracture in the relationship with the surgeon," he said. If he can, Maloney reassures the patient that the surgeon didn't make any mistakes. "I empathize with the patient and always give the patient the sense that there is something that can be done - it may not be immediately, but certainly in the future," he said. "With the speed of evolution of technology, I really believe that all of the people who have complications will be corrected."
If the initial surgeon has done something wrong, such as put in the wrong axis for an astigmatism, Durrie said, it's important to acknowledge it. "I think that if you truly have the facts, it's important to just say, 'I found the problem. Here it is - it looks as if this happened,' and then address it," he said. "I've seen a couple of these and none of them have gone to lawsuits."
In the end, Lindstrom thinks, it all comes down to how practitioners deal with patients. While most people think cataract surgeons do a pretty good job, satisfaction surveys suggest that most have only an 85% to 90% success rate. "We have a lot of disappointed cataract patients - about 10 times as many as disappointed LASIK patients," Lindstrom said. "But for some reason, it seems that we don't manage the disappointed LASIK patient quite as well." In the future, he thinks it may come down to learning how to talk to the younger, more demanding patient.