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Cover Focus | September 2020

Setting the Stage: Talking to Patients About Refractive Surgery

Empathy is Key to the Doctor-Patient Relationship

By Andrés Benatti, MD

Recently, communications specialist Mar Castro, PhD, of Lugo, Spain, presented an extraordinary webinar at Oftalmo University about human communication. One of her statements, I thought, was brilliant: “Our communication skills are going to influence our patients.”

Today, the refractive surgeon who does not understand that communication is a vital element of practice is at a disadvantage. Among the different types of communication we carry out daily in our office, communication with our patients is, without a doubt, the most important.

The medical consultation, in its four stages (reception, obtaining information, exploration, and explanation) must achieve a key component: empathy between the doctor and the patient. Achieving this is the basis of the doctor-patient relationship.

It is essential to adopt specific behaviors in order to accomplish this connection.

LOOK, LISTEN, SMILE

We must look into the patient’s eyes. Yes, this sounds ironic for an ophthalmologist, whose job is to look into the eyes—but it is true. We must achieve connection with our patients by looking at them. Visual contact must be fluid and at the same time respectful.

And we must actively listen to what patients are saying. They must feel that they are being heard and that their story is important to their surgeon. We must listen to their doubts, their fears, and, above all, to the expectations they have regarding the future following surgery.

We must also display a moderate smile and an open facial expression to make patients feel comfortable and thus connect better with the prospective surgeon. Our tone of voice and gestures should be relaxed and indicate that we are showing interest in what patients are telling us.

When we explain a procedure to patients, it is vital to do it sympathetically and without haste or anxiety regarding what is being communicated. We must describe the experience in such a way that patients manage to understand point by point what is being detailed.

Remember, the refractive surgeon must always communicate the possibility of complications and undesired results of surgery. Doing this in the right way will generate confidence on the part of patients. It will show them honesty and responsibility.

Finally, don’t forget that refractive surgery is elective surgery (most of the time), and it is patients who choose their surgeon. Beyond the academic training and experience that we professionals may have, the empathy that patients end up achieving with us will be the key to our having the honor of becoming their surgeon.


Using Clear Language Helps Patients Know What to Expect

By Amir H. Marvasti, MD

Messaging is a crucial part of the refractive surgery experience, and it starts before the surgeon sees the patient. The language used on your practice’s website and words chosen by the personnel in your call center, your technicians, and your support staff all supplement one another in creating your practice’s message. Clear and consistent language helps patients understand what you are offering and what to expect throughout the refractive surgery journey.

For example, in a typical consult, I use phrases such as “stable nearsightedness” and “normal corneal map with healthy thickness.” This terminology communicates to patients that we are evaluating their candidacy for a variety of refractive procedures, not just LASIK.

STRAIGHTFORWARD LANGUAGE

During the consultation, my approach is to talk patients through the testing and exam findings using language that they can understand. Hearing some of the details of their examination helps them understand why they are, or are not, good candidates for refractive surgery. Corneal topography, corneal thickness, and the traffic light appearance of the Belin-Ambrósio display on the Pentacam (Oculus Optikgeräte) are easy to understand when explained properly.

This communication serves as patient education, ensures patients that there is a process and rationale to determine candidacy, and makes a great transition into discussing refractive surgery options.

After examination, I initiate a discussion for understanding the patient’s refractive goals, discussing the procedures of choice, and counseling the patient on each procedure. This might be a quick discussion, like, for instance, recommending LASIK for a young patient with stable mild myopia, or it might be a more involved one like choosing between a cornea- versus lens-based procedure for a presbyopic patient.

A BASIC UNDERSTANDING

It is important for patients to have a basic understanding of how the chosen procedure works. For laser vision correction (LVC), for example, I use phrases such as “reshaping of your cornea,” whereas for refractive cataract surgery I will say I’m “replacing the cloudy lens with one that both clears your vision and corrects astigmatism.”

It is equally important to set appropriate postoperative expectations. In the case of LASIK in a presbyopic patient, for instance, not educating that patient on the potential need for reading glasses postoperatively, or not discussing blended vision options, is an easy way to create dissatisfaction, despite a perfect surgery. Therefore, I always discuss both short- and long-term expectations.

Finally, I remind our patients that the refractive state of their eyes and their vision goals might change as ocular maturity continues throughout life, and I reassure them that we will be there to meet their visual goals at each stage in their lives.


Both Surgeons and Staff Should Emphasize the Value of Refractive Surgery

By Bogdan Spiru, MD

Refractive surgery practices generally treat patients like customers. Patients are extremely demanding in Switzerland, where I practice, so it behooves me to put on very fine white gloves and cater to their needs, so to speak. Steve Jobs once said, “You’ve got to start with the customer experience and work back towards the technology.” It seems this approach pays off more than the newest laser on the market.

Like many practitioners, I see generational differences among patients. I find millennials generally to be easygoing. Most of them present to the practice based on social media leads and have already decided to undergo refractive surgery. As a result, they typically do not require a long discussion before scheduling surgery. In contrast, baby boomers and members of generation X are prepared to spend more out of pocket, but they need extra education. An essential component of communicating with patients at a refractive surgery practice is, therefore, learning to convey that a vision correction procedure is the best option for them.

The value of refractive surgery is not a message that should be delivered only by you. It should also be conveyed to patients by every point of contact they have with your practice. The customer experience is like a masterpiece by a fine orchestra. Every tone counts, and every detail matters to the whole experience. Remember, a happy client is worth more than a dozen (expensive) marketing campaigns. Now, to achieve such a performance, you need a happy orchestra. As Richard Branson, the founder of the Virgin Group, famously said, “Take care of your employees, and they’ll take care of your business. It is as simple as that.” Happy, knowledgeable employees are more capable of communicating effectively with potential customers, translating to a more positive interaction and optimizing their experiences at your practice. It is all about how you communicate and relate to others—to your colleagues, to your employees, to your patients, to your customers. It is not about how practices can promote themselves on social media, but how they can activate their patients to do the promotion for them.

I have nine tips for talking to patients that I learned from my mentors, and they have served me well. These are outlined in the accompanying sidebar.

TIPS FOR TALKING TO PATIENT

Drop the jargon. Use plain language so that patients understand what you’re saying.

Don’t make assumptions. Keep an open mind when communicating with patients.

Be decisive. Offer alternatives and be prepared with arguments for your recommendations. Sometimes being decisive about an issue of medium importance carries more weight than hesitating over one of high importance.

Build trust. Set realistic expectations and take responsibility for any complications.

Be prepared. Have a backup plan (or two) and be ready to manage complications.

Listen to the patient. Effective communication involves listening as well as talking. You may learn of a contraindication simply by listening to the patient.

Learn how to identify difficult patients. Even very good results can make some patients unhappy, depending on their personality. Learn to identify and read picky patients.

Show appreciation. Ask patients why they chose your practice. Consider sending a small gift at an appropriate time and acknowledge the sources of word-of-mouth referrals.

Make connections. Open up to your patients. Human interaction is what makes life worth living.

CONCLUSION

Communication with patients is one of the most important parts of the customer experience, especially in the field of premium medical procedures. When effectively executed, it will create loyalty and drive more leads than expected. As Jack Welch said, “Change before you have to.”


Words Matter

By L. Felipe Vejarano, MD

Talking to patients about refractive surgery should always be a friendly conversation. The surgeon should talk about the safety of the procedures we perform and explain how good the results are immediately postoperatively. We can assure patients, at least with LASIK, that there will be no pain, no sutures, no needles, and only topical drops to use postoperatively. These assurances boost patients’ enthusiasm and give them great encouragement.

Depending on the patient’s age, I use different ways of correcting their refractive defects; one of those is LVC. Recently, I have begun using different words in describing these procedures. During the ongoing pandemic, the Refractive Surgery Alliance offered an excellent webinar that gave me some new ideas regarding how to talk about refractive surgery and also reinforced other ideas that I had already incorporated into my practice.

One of the most important things to communicate to patients, in my opinion, is that we are making a visual plan for their life. The procedure we offer will depend on the age of the patient. Based on a specific range (see Age-Appropriate Ranges for Various Refractive Surgery Procedures), I will offer as many options as possible, but I will also direct the patient toward the one I believe is the best based on their case.

WHAT’S IN A NAME?

Most of the time, I recommend LVC in standard cases. Previously I called the procedure refractive surgery or LASIK when I talked to patients, but now I say the actual term, laser vision correction. I notice that this inspires more interest in patients. They have been hearing about LASIK for a long time, but they have never heard about LVC. Further, they understand what the phrase means, whereas LASIK is just a word that they don’t understand. LVC sounds innovative, sounds like a new procedure.

I have also changed the terms I use to describe the two levels of laser treatment we offer; this strategy helps to emphasize the contrast between them. Our standard treatment is now called a basic treatment. Standard sounds like a very normal treatment, and patients may associate the term with the standard of care. Basic treatment sounds like it is a little less than the standard, and the patient may associate this with minimal care. This increases the contrast with the other option, a customized treatment. With a choice in treatments between basic and customized, the patient clearly understands the differences.

Age-Appropriate Ranges for Various Refractive Surgery Procedures

10 to 17 years

  • Glasses
  • Contact lenses
  • Phakic IOLs
  • LVC (LASIK/KALA)

18 to 43 years

  • Glasses
  • Contact lenses
  • Phakic IOLs
  • LVC (LASIK/KALA or ASA)
  • Customized Phaco (in high refractive defects)

44 to 60 years

  • Glasses
  • Contact lenses
  • Phakic IOLs
  • LVC (LASIK/KALA or ASA)
  • Customized phaco or RLE with a premium IOL
  • Pharmacologic management of presbyopia with drops (FOV Tears)

60 years and older

  • Glasses
  • LVC (LASIK/KALA or ASA)
  • Customized phaco or RLE with a premium IOL
  • Pharmacologic management of presbyopia with drops (FOV Tears)

Abbreviations: LVC, laser vision correction; KALA, advanced laser-assisted keratomileusis; ASA, advanced surface ablation; RLE, refractive lens exchange

I have also changed the name of the techniques themselves. As I mentioned, everybody knows the term LASIK, even if they don’t understand what it means. I call the procedure advanced laser-assisted keratomileusis (ALAK or, in Spanish, KALA). The patient can understand that the word advanced means new, modern, and innovative. I changed PRK to advanced surface ablation (ASA in English and Spanish). This name also gives the patient the sensation of something new and different from the standard of care.

Finally, I have also changed how I talk about the price of LVC. Previously, I referred to the cost of a procedure—but now I talk about an investment in that procedure. This gives patients the sensation that they are not spending money, they are investing money in their quality of life.


The Pandemic Has Changed the Conversation

By Jared R. Younger, MD, MPH

Refractive surgeons have their own styles of patient education that they have honed over the course of their careers. They have a tool set, based on their experience and data-based discussions, for making recommendations to patients looking for a vision correction solution. In the challenging year of 2020, however, changed circumstances require us to rethink certain aspects of our patient consultations.

As always, a clear, concise recommendation is key. Presenting simple options, such as distance vision correction with laser astigmatism management, or the range of vision options offered by presbyopia-correcting lenses, helps patients choose. I believe it is best practice to give a patient two recommended options, or in some cases three. For example, in addition to the main recommendation, we may also note that the patient is a candidate for monovision based on previous contact lenses or laser vision correction. It helps to avoid getting wordy with technical details such as the specifics of the laser system or the lens implants; keep the discussion big picture and focus on your vision plan and target outcome.

CHANGING CONVERSATION

In this pandemic year, however, the other key to good messaging is to adapt our patient conversations to our new environment and to modify the discussion formats that we used previously. Consultations must, of course, retain the core information regarding examination and testing results and our refractive plan recommendations for each patient. But now we must be extra sensitive regarding safety.

We must explain the new safety measures we have put in place in our office and the surgery or laser center where the patient’s procedure will take place. A quick review of screening procedures (questionnaire and temperature check), mask requirements, and the increased cleaning being performed by the staff can help to reassure patients.

In this regard, I have now made a few messaging changes in my consultations. Instead of explaining the surgery center flow (eg, safety, time spent there, steps, anesthesia) last in my conversation with patients, I now explain the precautions and additional measures being taken at the surgery center or laser suite first.

When I walk into the exam room, my steps are now as follows: an introduction, brief summary of the main patient complaint or diagnosis, and then a jump into a discussion of how our office has been stepping it up in recent months with better scheduling, cleaning, and safety protocols.

If the visit is a refractive consult, I add that, “Yes, our center has been busy, flowing well the past few months. The addition of temperature checks, everyone wearing masks, and the use of our health questionnaire at check-in allows us to do surgery safely and efficiently.” Then I pause and get back into the discussion of the vision plan.

PATIENTS HEAR REASSURANCE

There are more stringent safety policies if a center is located within a hospital, but for outpatient ophthalmic surgery centers and laser suites this type of messaging can work well. Once patients hear your reassurance, they are more open to listening to the fun parts: talking about anatomy, lasers, lenses, and vision correction plans.

The overall message today must be safety first. After that, we can discuss getting patients to their vision goal using the latest technology with laser and/or lens implants.

Telemedicine Consults for Refractive Surgery

By Blake K. Williamson, MD, MPH, MS

If necessity is the mother of invention, then crisis is the father. Amid the pandemic, Williamson Eye was forced to jump head-first into the world of telemedicine. Six months later, we no longer feel forced. Rather, we have chosen to stick with it and incorporate various aspects of telemedicine into our practice.

In our experience, one of the most successful uses has been in virtual consultations with patients for laser vision correction. July was my busiest month for laser vision correction since I’ve been in practice. Although some may think that was due to a backlog from cases postponed during the pandemic, actually the vast majority of these came from virtual consults with new patients.

We used social media to promote our virtual LASIK consult campaign and made it easy to sign up for time slots on our website. We have a highly knowledgeable and engaging refractive counselor who connects well with patients. Patients feel safe because they can get most of the information they need at home, and I think the opportunity to connect with a human being face-to-face, albeit virtually, has greatly increased the likelihood that patients will subsequently schedule an in-person workup and proceed to surgery.

If there have been any silver linings with COVID-19, baptism by fire with telemedicine has certainly been one for our practice.

Blake K. Williamson, MD, MPH, MS
  • Refractive and anterior segment surgeon, Williamson Eye Center, Louisiana
  • Member, CRST Editorial Advisory Board
  • blakewilliamson@weceye.com
  • Financial disclosure: None
Andrés Benatti, MD
  • Cornea and refractive surgeon, Cofounder, and Chief Operating Officer, Oftalmo University, Clinica de Ojos Córdoba, Argentina
  • andresbenatti@gmail.com
  • Financial disclosure: None
Amir H. Marvasti, MD
  • Cataract, cornea and refractive surgeon, Coastal Vision Medical Group, Orange County, California
  • Volunteer Clinical Instructor, UCLA Department of Ophthalmology, Los Angeles, California
  • amarvastimd@gmail.com
  • Financial disclosure: None
Bogdan Spiru, MD
  • Cornea, refractive surgery, and complications management fellow, IROC, Zürich, Switzerland
  • spiru.bogdan@gmail.com
  • Financial disclosure: None
L. Felipe Vejarano, MD
  • Chief of Surgery, Fundación Oftalmológica Vejarano, Popayan, Colombia
  • Universidad del Cauca, Popayan, Colombia
  • felipev@fov.com.co
  • Financial disclosure: None
Jared R. Younger, MD, MPH
  • Cornea, cataract and refractive surgeon, Orange Coast Eye Center, Fountain Valley, California
  • youngerjared@gmail.com
  • Financial disclosure: None

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