As more ODs embrace the medical model, we are tasked with the tough role of bearer of bad news. Advances in instrumentation increase our diagnostic reach. But we need to handle this new responsibility well, judiciously, compassionately and wisely. In addition to an ethical, and caring service issue, this is also a business issue, which can greatly affect your practice.
Any optometric physician with a medical eyecare practice knows how hard it can be–sometimes on both patient and doctor–to communicate the sad news that the patient has a sight-threatening condition. Patients are unnerved, and an OD can sometimes struggle to strike a balance between remaining compassionate and communicating the seriousness of the condition and the need for ongoing care.
I find glaucoma and macular degeneration to be the hardest diseases to tell patients they have. They are difficult diagnoses to give because they are potentially blinding, and, in the case of glaucoma, asymptomatic. Both, in the initial phases, may not be creating a noticeable threat to vision, so it is difficult for patients to accept the diagnosis and begin a treatment plan, and accept the need for more frequent eyecare.
BALANCE HONESTY & COMPASSION
I focus on the patient, turning toward them, looking into their eyes, holding their hand (if it seems necessary) and not looking at my EHR. I want to really be certain they understand the diagnosis, and I want to provide them with resources to further understand and cope with their “new normal.”
PATIENTLY EXPLAIN DIAGNOSIS AND TREATMENT PLAN
I verbally explain the treatment plan and reinforce the verbal patient education with written patient education. I ask if there are questions after I give the diagnosis, and after I discuss the treatment plan. I also invite them to contact me with any questions that arise after they go home.
For example: “Mrs. Smith, let’s take a look at your retinal photographs from this year versus last year. As you can see, there are some small dot and blot hemorrhages in the mid-periphery of the retina. This is an indication that your blood sugar control needs improvement, and, if left unchecked, diabetes and your consistently elevated blood sugar places you at risk for permanent vision loss.”
MAKE SURE THE PATIENT UNDERSTANDS
I ask the patient to repeat to me what I just told them regarding their ocular condition. I ask them if they understand the circumstances that brought about the change in their ocular health. We discuss a treatment plan (medical intervention and nutrition). I explain that we want to “use our food as medicine.”
We discuss nutrition at length, both in the form of ideal daily diets and nutraceuticals. I prescribe Macuhealth nutraceuticals to all patients with drusen and/or a positive family history with a first-degree relative with wet or dry AMD. And I prescribe Macuhealth for patients with a history of smoking.
ANTICIPATE TOUGH QUESTIONS
The most difficult question to answer is: “why did I develop this condition?” In the case of glaucoma and AMD, there is a genetic risk, and not every patient is knowledgeable about their ocular and systemic family history. I find that many patients confuse cataracts and glaucoma. When the diagnosis is dry AMD, I like to empower patients with the fact that AMD has modifiable risk factors, and if they stop smoking, exercise, and be sure to eat more foods rich in carotenoids, they can minimize their risk of significant vision loss.
Another hard question is whether the patient will be able to continue driving. Driving is a task so critical for a person’s independence, and any loss of their central acuity can rob patients of their independence for driving and for many activities of daily living. In response to that question I might say: “We are going to closely monitor your eyes and vision, and follow the treatment plan I have prescribed, and hopefully, together, we can keep you driving safely for years to come. I can’t make any promises, but we’ll try our best.”
COMMUNICATE DIAGNOSES CAREFULLY TO ELDERLY & CAREGIVERS
Generally, the caregiver prefers not to be in the exam room, and if they are, they do not offer any information regarding the patient’s medications or medical history. I prefer to communicate with adult children of the patient and the primary care physician. Recently, a 91-year-old couple called my office because their adult children live in Arizona and California. They have no family here, and they could not start their car. We need to have a person to contact in the event of an emergency. This is so important today, when many families are not living near one another.
How do you communicate serious diagnoses in your practice? What lessons have you learned over the years about doing this in a way that ensures compassionate care, while protecting your practice?
Mary E. Boname, OD, MS, FAAO
Mary E. Boname, OD, MS, FAAO, is the owner of Montgomery Eye Care, P.A., in Skillman, NJ. To contact her: firstname.lastname@example.org.