March 2019


12 steps to handle unhappy refractive patients

by Vanessa Caceres EyeWorld Contributing Writer

Managing expectations and listening with empathy are two first steps

You performed refractive surgery on a patient, and you thought everything went well. Next thing you know, the patient returns to the office and is unhappy with his or her postop vision. Maybe there’s residual refractive error, or maybe dry eye is marring optimal visual results. In any case, the patient’s experience is less than perfect.
This is where you as the surgeon need to step back and thoughtfully assess how to handle the situation, said Vance Thompson, MD, Vance Thompson Vision, Sioux Falls, South Dakota, and John Jarstad, MD, associate professor of clinical ophthalmology, director of cataract and refractive surgery, Mason Eye Institute, University of Missouri School of Medicine, Columbia, Missouri. Both surgeons bring different perspectives on the topic. Dr. Thompson gave a talk on the dissatisfied refractive surgery patient during the 2018 American Academy of Ophthalmology Annual Meeting. Dr. Jarstad was one of the first ophthalmologists to have laser refractive surgery in both eyes in the early 1990s and lived through an array of complications, so he has empathy for patients’ woes.
Here’s how Drs. Thompson and Jarstad recommend handling the unhappy refractive patient.

Before surgery

1. Manage patient expectations in advance. Advance warning about surgery’s limitations can help reduce postop complaints for most patients. “A lot of times, people expect a quick fix,” Dr. Jarstad said. “When we do surface ablation, we have to warn patients they won’t get perfect vision overnight. Sometimes it takes a week before it’s clear,” he said. Dr. Thompson finds that by day 4 the epithelium is often intact but it is still rough over the pupil. By a week it is better, and he tells patients the best vision is at 3 months.
The importance of managing expectations is clear-cut for Dr. Jarstad, who had a patient who was unhappy with a 20/25 result and sought a “touch up” from another LASIK surgeon. A LASIK “enhancement” surgery led to the patient eventually needing a corneal transplant, which probably could have been avoided if the patient had taken to heart the expectation of vision improving over a short wait, Dr. Jarstad said.

2. Standardize your patient education. Better patient education can help clear up future complaints. Considering that many patients either don’t follow instructions or interpret them incorrectly, Dr. Thompson’s staff will repeat instructions multiple times, and they make sure that any instructions given are consistent in person, over the phone, and on the practice website.

3. Cultivate a connection. Dr. Thompson will not operate on a patient with whom he doesn’t feel a bond. He’ll let the patient know he or she could return another day, and the two of them may feel more of a connection. However, he doesn’t want to risk a lack of connection and how that may influence postop satisfaction.

4. Anticipate what may go wrong. As refractive surgeons know, dry eye can be a common complaint postoperatively. Dr. Jarstad aims to optimize the ocular surface of patients before surgery with cyclosporine and punctal plugs. In some patients experiencing troublesome dry eye after surgery, he will insert in the lower tear duct collagen punctal plugs that last about a month. He will then insert permanent ones if dry eye is still bothering them.

After surgery

5. Designate a point person for all unhappy patients. At Dr. Thompson’s practice, that person is him. “You can get in and out with routine surgery and follow up, but if you are my patient you can’t get out of the practice unhappy without seeing me,” he said.

6. Do your due diligence with staff in advance. Prior to operating on a patient who the staff is concerned is not a good candidate, Dr. Thompson will talk with staff to find out what happened to create this concern and to find out how staff members were treated by the patient. “I’ll ask my team to let me know about anything out of the ordinary, and I’ll ask if there’s anything that would make them not operate on the patient,” he said. Although occasionally he won’t make the same decision as his staff, their insights are extremely valuable, he said.

7. Put unhappy folks in the express lane. When unhappy patients return to your office for a follow up and to state what happened, have front office staff bring them back immediately, Dr. Thompson recommended.

8. Listen carefully and calmly. This may seem like common sense, but it bears repeating, Dr. Thompson said. “The last thing a patient needs is you reacting with your temperament,” he said. “If there was ever a time to be empathetic, it’s now.” You might feel defensive as a patient outlines his/her perception of what went wrong, but remember that the patient probably feels lonely as he or she shares the story of what happened. Dr. Thompson said he’s never improved a patient conversation by acting upset or defensive, although he’s had success acting parental with a patient who is being childish. “Staying calm, going back over the details, and telling them you understand their concerns and are going to help them get to a better place is helpful,” Dr. Thompson said. “It is our job to diffuse the psychology of the situation and help them understand if they have a real complication or not, then help them from there.”

9. Identify how you can relate with the patient. This isn’t so hard for Dr. Jarstad, who experienced haze, initial overcorrection, and several other complications after his laser refractive surgeries (he said this was partly his fault because he took out his bandage contact lens every day to film his progress). His own complications influence the empathy he shows for patients. “In my patients, I haven’t seen all of the complications I had, but they probably follow directions a lot better than I did,” he quipped.

10. Get personal with your contact information. Dr. Thompson hands out his business card to unhappy patients, but it doesn’t have his cell phone number printed on the card. Instead, he will hand write his cell number on it. Patients seem to appreciate having that personal invitation to reach him.

11. Stay positive about follow-up treatment options. Ophthalmologists have a lot more options to offer to patients nowadays to turn negative experiences into positive ones, Dr. Jarstad said. From implantable collamer lenses to more presbyopic treatments, let patients know you will work with them to find a better visual solution, he advised.

12. Track your patient satisfaction data. Find out why patients as a whole may be unhappy. “You may discover from your practice’s patient questionnaires that patients think you are not spending enough time with them or answering all of their questions,” Dr. Thompson said. This is something you can make efforts to improve on, but only if you track, read, and share data with your staff, he said.

Editors’ note: The physicians have no financial interests related to their comments.

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