Ophthalmologists are not formally trained in the art of talking with patients about potentially stressful medical diagnoses; yet, this skill is important and can be the most challenging part of practice for glaucoma specialists.
Reay H. Brown, MD, discussed why instilling hope is so important for patients with glaucoma during Glaucoma Subspecialty Day at the annual meeting of the American Academy of Ophthalmology.
"What we say to these patients can make all the difference," said Dr. Brown, in private practice in Atlanta. The main concern for patients in this population is not pain or high IOP-it is whether or not they could go blind.
"We focus on documenting the steps we are taking to prevent it," Dr.Brown said. "If the IOP and the visual fields are stable, we are doing our job, but the patient's concern might become secondary."
Ophthalmologists should not ignore patients' fears, he emphasized. Yet, the challenge becomes introducing hope into the visit. When a patient is hopeful, adherence to medication therapy improves, as do follow-up and outcomes. Dr. Brown cited an editorial1 in which the authors state, ". . . no patient should ever leave a visit with a physician without a sense of hope."
The challenge is to convey hope to patients who have learned that glaucoma is blinding, incurable, and that some patients do not achieve success with medication or surgery. The reality is that most patients do well, most do not become blind, treatment failures are rare, and the visual field progression develops slowly. Comparisons of glaucoma with other chronic diseases, such as diabetes and hypertension, have shown that patients with glaucoma usually do well. The ophthalmology specialty benefits from excellent monitoring technology, which leaves no doubt about the patient's status. If patients are compliant, the treatment is usually successful, he said.
Despite hearing the facts of the clinical situation, patients are often fearful. Dr. Brown gave an example of a patient who thought she had reached the end of her medication options and that surgery was the next step; she feared blindness.
What the patient thought she knew, however, might not have been based in reality. In her case, the IOP was not ideal, but it was acceptable, with moderate visual field loss. The patient's vision had been stable for the past 3 years; no change in therapy was indicated and no surgery was needed. Nevertheless, the patient had been devastated by what a referring physician had said.
Dr. Brown emphasized that the following phrases should not be communicated to patients: "Nothing is working." "I've tried everything." "I don't know what else to do." And especially, "I give up."
"Ophthalmologists should keep in mind that there are many therapeutic options and almost always something else that can be attempted," he said. "If a physician is outside of his or her comfort zone, referral might be a good option. But words should be chosen wisely."