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Refractive Surgery | Jun 2009

The Perception of Excellence

Every interaction and every observation contributes to an impression of success.

The successful development of a refractive practice is dependent on many things. Obviously, the achievement of surgical success is an element that, as trained physicians, we are all striving for. But even if we are successful, it is difficult to transfer evidence to new patients. One less obvious element of a successful refractive practice is what I call the perception of excellence. In many ways, patients do not have a way of accessing the quality of a refractive practice other than the perception of their surroundings and the interactions they have with the surgeon and the staff. New patients are anxious, and their evaluation of what they see and how they see people act can be powerful.

Surgeons are trained over many painstaking years, gradually building their technical skills. We are judged during this long process by grades on exams and our surgical successes, which may mean a successful anatomic outcome with appropriate physiologic functioning of the target organ. It can also mean avoidance of intra- and postoperative complications. In ophthalmology, we can record visual acuities and determine what percentage of our patients achieves 20/20 vision. These are metrics that we can record to determine if we are achieving excellence in surgery.

Unfortunately, a prospective patient interviewing a practice does not have access to any objective measurements of the surgical success of the physician. As a result, it is the patient's perception of the surgeon that ultimately determines whether the practice is the one they will trust with their care. The perception of excellence is when every interaction and every observation contributes to an impression of success.

Much has already been written on the importance of every interaction that we have with patients. From the initial phone call to the checkout desk, we know that our dialogue, inflections, and mannerisms have a profound impact on how comfortable our patients are and, ultimately, how much they trust us. We have gone to great lengths to teach greeting methods and body language. We have even scripted most of our important interactions so that nothing is left to chance.

What to say and how to say it has been a common focus as practices move into refractive surgery and now premium IOLs. The perception of our patients regarding our practice is at least as important.

We have all heard realtors describe the emotional response evoked by driving up to a property as curb appeal. In real estate, it is the initial impact that a property has on a prospective buyer. Curb appeal is a type of first impression that can be positive or negative. Like it or not, our practice elicits a type of curb appeal as well, and it can be very powerful. The practice's general appearance should match the practice's mission statement. If a high touch, high-end practice is your goal, then it should be reflected in your building, location, elevations, furnishings, and landscaping.

The look of our practice tells patients a lot about who we are and the way we practice medicine. It can send a message to the patient about how we might keep things in the operating room. If the reception area, which is out on display, is not clean, then why would the operating room be any different? Cleanliness is just one component of an overall perception of the practice.

If a practice has built some of its reputation on technology, this should be evident in the reception areas and examining lanes. What can we do to demonstrate that we are proud of what we do and how we do it? This is what our practice should show.

One of the biggest opportunities to create a perception of excellence is to always be in control of how we look and behave. Patients can tell a lot by the way we act, the things we say, the way we say them, and the expression on our faces (Figure 1). They can tell if we know what we are talking about by the confidence in our voice. It is not just what we say that influences the patient's perception but it's also how we say it.

Patients can also tell a lot about our skill by the confidence of our staff. Our staff's expression of confidence indicates whether they truly are committed to a recommended procedure and also how sure they are that the results will be excellent. Both the surgeon and the staff constantly give subtle clues about the conviction to a recommended procedure.

One great example of this is the selection of what premium IOL is best for an individual patient. Some patients read about the variety of lenses prior to visiting our center and are unsure about what one is best. Part of the reason they have chosen us is for our experience and skill at not just the procedure but also our skill in matching the right lens to the patient. Our recommendation will be carefully scrutinized by the alert, anxious patient. Everyone in our practice must be updated on how successful our patients are and how well the lens in question performs. This way they can confidently recommend it to our patients in a way that is reassuring.

One place that patients and their families—if they are allowed to observe—will build their perception is during surgery (Figure 2). The way that we speak to the patient, speak to our assistants, and act in general articulates volumes to the patient and their loved ones regarding how well the surgery has proceeded. Stress in our voice comes through loud and clear to a nervous patient whose inability to see us only heightens his listening acuity. Even asking for an instrument that the scrubs do not have or by a name they do not recognize tells patients that something is not proceeding as planned. This is an argument for well-trained staff that are educated on what should be said, and what should not be said, in front of patients.

Sometimes, patients hear things that we say and interpret them in interesting ways. They remember things out of context and not always accurately, thanks to administered medications. They will retain certain things, however, and may try to assign comments to any problems they are having postoperatively, real or imagined. We have all seen patients who feel that because they thought they heard something that their surgery was complicated, despite all evidence to the contrary.

Use all postoperative opportunities with the patient to build his perception. How many times have we seen patients who were happy with their surgical results only to be discouraged by a comment or mannerism of a technician during a postop exam? Even though the patient was 20/happy, the gestures and attitude of the tech relayed a sense to the patient that he was not seeing well. The long and difficult refraction and the disappointment of not reading several letters on the 20/15 line tells the otherwise happy patient that maybe he is not doing as well as he thought. For these reasons, it is prudent not to overtest and to build confidence by performing the visual acuity exam from the top down.

Excellence cannot be simulated. Make no mistake that unless we are truly providing the best care, no amount of training or acting will lead to a sustained, positive perception by the patient. People can tell when you are misleading them, and we are obligated to be absolutely truthful to our patients. We do not advocate misdirection, rather the careful selection of words and mannerisms so as not to lead a patient to believe something is wrong when it is not. It is desirable to create a perception of true excellence when it exists, but impossible to do when it does not.

Patients' perception of your practice is affected by many things. From the confidence of the person answering the phone regarding our credentials, to the curb appeal of the building, to our mannerisms and gestures, patients glean a lot from subtle clues. One of our greatest challenges is to let our surgical success shine through in the patient's evaluation of us, our staff, and our practice as a whole.

The perception of excellence is reached when the sum of all of the patient's suspicions and observations is the conclusion that the doctor is skilled and that an excellent result is very likely. It is sustained when they have an incredible experience and their results match their expectations. It is then transferred when patients tell those who surround them. This is difficult to achieve and requires an effort from all members of our team. We know we have succeeded when our patients enjoy their experience, love their outcome, and refer their friends and relatives.

William J. Lahners, MD, FACS, is the Medical Director of Center For Sight, Sarasota, Florida, and Assistant Clinical Professor of Ophthalmology, University of South Florida, Tampa, Florida. Dr. Lahners states that he is a consultant to Abbott Medical Optics Inc., Alcon Laboratories, Inc., and Bausch & Lomb and is a speaker for Vistakon. He may be reached at tel: +1 941 925 2020; fax: +1 941 330 2200; e-mail: wjlahners@centerforsight.net.