February 2010




Screening tool protects patients, physicians

by Rich Daly EyeWorld Contributing Editor


Psychology-based screening tool could help physicians tailor treatments and keep risk-averse patients from elective procedures for which they are ill suited

Elective surgery and rigid patient expectations can be a poor combination. But when an increasingly litigious environment and mental illness are added, the results can be disastrous.

One possible way to diffuse conflicts among the growing number of elective vision-correction procedures is to quickly and reliably test patients beforehand to identify personalities that are hard to please or even psychologically unfit for the surgery. A new tool may make that possible.

Steven Berger, M.D., Springfield, Mass., has worked with psychologists over the last several years to develop screening tests for prospective patients seeking elective vision correction. Their efforts have so far produced one patient test, called the Berger-Owens Surgical Screen I (BOSS-I), which aims to predict patient litigiousness. That 36-item measure correctly predicted 90% of cases in tests.

“That was meant to provide a screening tool for the increasingly litigious environment that we’re in,” said Dr. Berger, who uses the patient test with his LASIK patients.

The need for patient screening was highlighted by research in recent years by Jennifer Morse, M.D., psychiatrist, San Diego. Data she presented in 2007 from pre- and post-op questionnaires given to patients at the U.S. Navy’s refractive surgery clinic in San Diego revealed that a patient personality index was the factor—after uncorrected visual acuity—most closely associated with patient dissatisfaction.

Knowledge is the goal

The BOSS-I screen is not designed to prevent surgery on perfectionist patients who are prone to expect unrealistic outcomes from elective procedures. Rather, Dr. Berger said, patient screening alerts the physician to patients who may need additional steps, such as enhanced informed consent and increased patient follow-up, to build a strong bond and increase patient satisfaction.

“I was extremely happy that I knew that [a patient had exacting standards] on the front end so that I could go the extra mile to better ensure patient satisfaction,” Dr. Berger said.

The benefits seen from the use of BOSS-I led Berger and his co-authors to recently expand their effort and produce a more comprehensive tool with greater accuracy. To that end, they developed a 100-question screening exam that expands beyond just predicting litigiousness to predicting overall patient satisfaction.

Effort underway

The new screen, known as BOSS-II, is being tested and validated at four practices, with the goal of completing it at the end of 2010. The testing will be completed more quickly if additional ophthalmologists participate, Dr. Berger said, and several are considering joining the effort.

The goal is to produce a 30-question, 10-minute test that provides physicians with a 90% reliable patient satisfaction prediction rating within 24 hours. The exam will also include detection of clinical depression in patients, which generally bars their participation in any elective procedures, said Shane Owens, Ph.D., associate director, psychological services, Farmingdale State College, Farmingdale, N.Y., and a co-developer of the screen. Andrew Berger, Ph.D., adjunct professor of psychology, Hofstra University, Hempstead, N.Y., also contributed creation of BOSS-II.

Dr. Owens noted that the exam aims to identify patients who are more likely to be dissatisfied regardless of their surgical outcomes so that clinicians can alter their management to allow the best possible perception by the patient.

The BOSS-II test also moves beyond existing self-rating questionnaires in which patients may falsely describe themselves as non-perfectionists. One such questionnaire developed by Steven J. Dell, M.D., director of refractive and corneal surgery, Texan Eye, Austin, Texas, and medical director, Dell Laser Consultants, Austin, asks patients to rate their personalities from easygoing to perfectionist. The Dell approach also requires the technician working with the patient and the treating ophthalmologists to rate the patient on the scale.

Dr. Owens said the BOSS-II aims to remove patient misinformation from the calculus by including questions aimed at identifying people who are lying about their personality.

“If they are gaming the test, then you have learned something very potent about that patient,” Dr. Berger said.

The test aims to balance reliably valid responses with a test patients are able to complete quickly and that provides timely results to physicians, said Dr. Owens. However, it will not be “bullet proof,” and the testing may not reveal some patients who are perfectionists, Dr. Owens said.

Other potential problems may include patient reluctance to take such exams. Dr. Owens estimated up to 30% would refuse to submit to such a screen. Additionally, the screen does not account for other factors that could strongly affect patients’ satisfaction, including events in their lives before they come in for surgery, wait times, and the personalities of the staff and clinicians.

But the alternative is the continued use of instinctual guesswork in practices where pre-op time with patients is increasingly limited, while elective vision surgeries prone to litigiousness are more common.

“In general we think it will be a lot better than what we have now, which is basically instinct,” Dr. Berger said.

Physician need identified

Dr. Berger said his presentations on the screening tools at clinical meetings, including the 2008 and 2009 ASCRS Symposium & Congress, have drawn a positive reaction from ophthalmologists, who are “intrigued” by a tool that could take some of the guesswork out of predicting patient satisfaction.

One such clinician is Michael Goldstein, M.D., co-director, Cornea and External Disease Service, Tufts Medical Center, Boston. He said many tools are available to assess a prospective patient’s physical ability to benefit from surgery, but better tools are needed to assess patients’ mental ability to benefit. The few personality questions included on standard patient preparation forms provided by some laser manufacturers are among the first data he examines when assessing whether a patient is a good fit for elective refractive surgery.

“With elective surgeries your personality and your expectations going into it have a large impact on how successful you will perceive it to be,” Dr. Goldstein said. “There are definitely cases where the outcome is good from the surgeon’s perspective but not from the patient’s.”

Dr. Goldstein, who is considering participating in the BOSS-II testing, said other ophthalmologists he has talked to about the screening tool are also excited about its potential.

Editors’ note: Drs. Berger and Owens plan to commercially release BOSS-II when it is completed. Dr. Goldstein has no related financial interests related to his comments.

Contact information

Berger: stbmd@cox.net
Goldstein: 617-636-0626, MGoldstein@tuftsmedicalcenter.org
Owens: drowens@optonline.net

Screening tool protects patients, physicians Screening tool protects patients, physicians
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