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When microinvasive glaucoma surgery is a potential treatment option, surgeons should present it as neutrally as possible.
Take-home message: When microinvasive glaucoma surgery is a potential treatment option, surgeons should present it as neutrally as possible.
By Vanessa Caceres; Reviewed by George L. Spaeth, MD
Philadelphia-Ophthalmic surgeons introducing microinvasive glaucoma surgery (MIGS) for the first time to patients will want to think carefully about how they describe the procedure and present treatment options to patients, said George L. Spaeth, MD.
“We have a responsibility to enhance our patients’ ability to care for themselves, we need to help them more than harm, and we need to be fair,” said Dr. Spaeth, Esposito Research Professor, Wills Eye Hospital/Thomas Jefferson Medical College, Philadelphia.
Patients need to make decisions about their care that is appropriately accurate. However, most often, patients make a decision based on the way that the physician presents treatment options, he said.
“Our recommendations are rarely challenged,” he said. “Patients are reluctant to say that they don’t understand something. We’re really making that decision.”
Specific to glaucoma, Dr. Spaeth’s presentation focused on how the zeal for a new type of surgery may steer patients specifically to MIGS and reveal a surgeon’s bias.
The first goal of any physician is to help the patient, he said.
“We hear frequently, ‘First, do no harm.’ That’s not a good principle,” he said. “We don’t want to harm, but that’s not our first goal. Our first goal is to help. Every treatment involves some harm.”
Dr. Spaeth gave the example of telling a patient he or she has a narrow angle. The physician may worry about upsetting a patient with this news.
“But by not telling them, it is harmful, as that deprives them of making a decision about appropriate care,” he said.
Dr. Spaeth explained that the wording used by surgeons to describe a procedure can be misleading. Some surgeons may intentionally or unintentionally bias patients to want to choose MIGS because it is newer and works better. However, that is deceiving.
“A lie is not an untruth,” he said. “It’s wrong to lie to patients, and it removes the ability to make an informed decision. . . . You can say that new surgeries work better than old ones, but if that’s used to entice a patient to do a new procedure, it’s a lie.”
He also pointed out common wording used by physicians that can be deceiving. For example, saying “We expect” is more deceptive than “We hope.” Using the word “safe” is not as cautious as saying “adequately safe.”
“Every time we use the word ‘safe,’ we have to be aware that nothing we do is safe,” he said. “It may be adequately safe, but it’s not safe.”
There are also problems with saying something has been studied or is recommended, Dr. Spaeth said.
“Just because something has been studied doesn’t mean it’s proven,” he said. “Just because something is recommended doesn’t mean it’s widely accepted. And something may be less invasive, but perhaps it’s also less effective.”
Dr. Spaeth said that physicians are capable of bias in their desire for more effective glaucoma surgeries.
“Those who are passionate about finding a better glaucoma procedure are the ones who must be distrusted because they have the greatest propensity to be biased,” he said.
To keep a surgeon’s language more neutral, Dr. Spaeth shared an example of what to say when presenting glaucoma treatment options:
“I’m going to recommend a ____________ because for you, my opinion is that the balance of risk and benefits favors this. The procedure is still under development. If it works as well as we hope, it will benefit not only you, but others as well. However, you must understand that long-term effects are not known, whereas we do know that __________ worked well in most people like you.”
If the patient is taking part in a MIGS-related study, the surgeon can go on to explain he or she would have to do some things beyond the usual preoperative or postoperative surgical care, such as taking part in extra tests or returning for extra visits.
“If we are disappointed because the patient chooses not to have the MIGS, we know we are improperly biased,” Dr. Spaeth said. “We have an ethical responsibility to develop better treatments, but not for our benefit. The procedure is for the benefit of the patient.”
George L. Spaeth, MD
This article was adapted from Dr. Spaeth’s presentation during Glaucoma Subspecialty Day at the 2014 meeting of the American Academy of Ophthalmology. He did not indicate any proprietary interest in the subject matter.