Educating Patients on the Value of Femto

Mitch Jackson, MD; Russell Fumuso, MD; and Quentin Allen, MD; join Marguerite McDonald, MD, in a discussion of how to explain the value of laser cataract surgery to patients. Dr. Jackson shares how he breaks down the procedure for patients-from describing what a cataract is to how the femtosecond laser works. Dr. Fumuso gives insight into how he educates patients on the overall safety and precision of this surgery. Finally, Dr. Allen explains how he discusses premium lenses in the context of laser cataract surgery.

Speaker 1:

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Marguerite :

Welcome to the fourth episode of our podcast Informed Consent: Getting to Yes. I'm Marguerite Mcdonald of the Ophthalmic Consultants of Long Island in Lindberg, New York.

Rona:

And I'm Rona [inaudible 00:00:25] of Eyewire TV.

Marguerite :

Femtosecond lasers and cataract surgery, that's what we'll explore today. What are the right words to efficiently, ethically, and truthfully get patients to say yes to having femtosecond laser assisted cataract surgery.

Rona:

And we'll also focus light of some of the ways this technology is bundled with premium intraocular lenses.

Marguerite :

With us today are three successful high volume surgeons who are all very confident in their approach to talking with patients about the value of femtosecond lasers in cataract surgery.

First, it's my huge honor and pleasure to welcome the inimitable Dr. Mitch Jackson, who is the founder of Jacksoneye in Lake Villa, Illinois. Next month, Mitch will have been in private practice for 25 years. He's an expert on cataract surgery and, in particular, femtosecond cataract surgery. So welcome, Mitch.

Mitch:

Thanks, Marguerite. I don't know if I'm an expert but I'll try my best, and it's great to be on the show with you. Femtosecond is what I do every week with cataract surgeries, so this will be fun sharing my experiences with you and whoever is listening.

Marguerite :

Also commenting on femtosecond lasers is my colleague at OCLI, Director of Office Design and Development, the esteemed Dr. Russ Fumuso. Russ is a very successful, very high volume cataract surgeon, and I'm always glad when he agrees to contribute his thoughts.

Russ:

Well, thank you very much, Marguerite.

Rona:

Finally, the incomparable Dr. Quintin Allen, who practices in a group with five offices in the Port St. Lucy and West Palm Beach area of Florida, will also add his two cents.

Marguerite :

We always appreciate your thoughts Dr. Allen, but if you don't mind, we're going to start with Mitch.

Well Mitch, what we all want to hear is, when you've selected someone for femtosecond cataract surgery, pretend I'm Mrs. Smith, how do you get me to yes? Can you tell me exactly what you say to her?

Mitch:

I explain to them what a cataract is and go through that process. I briefly tell them, "It's a ten to 15 minute procedure. Eye drops only. We don't use any needles or shots in the eye. You'll get an IV for a little feel-good medicine." I jokingly always tell them, "It's the modern day Woodstock experience because you get a light show, music, and good drugs for your procedure." They get a kick out of that.

Then I go into talking about, if they're a candidate, if they want an advanced vision correction option. Assuming they do, I go through what that is. Then I always tell them, "The package always includes two other technologies." I go briefly into intraoperative aberrometry. I tell them it's a laser guided real time device, it gives me a precise reading on the table of the lens implant power that I'm going to need. I also tell them they're going to get laser assisted cataract surgery. I don't always say the word femto laser to them, I'll just say laser assisted cataract surgery because femto might be a little to confusing to them.

What I do is I go through and I say, "Well, what are the advantages of that?" I say, "Part of the reason you were referred to me or had a friend referred to me is we use advanced technology here at Jacksoneye to try and get the best outcomes." I tell them, "What the laser does, pretty much, it automates the process for me as a surgeon, and it takes your cataract ... " Which I've already explained to them is like a rock, and it's hard, and we normally use ultrasound to break it up and vacuum it out of the eye. I just tell them the laser actually fragments the lens, softens it to like Jello, I tell them. I say, "Normally cutting through a cataract is like cutting through a hard cube of butter, so now it's going to be like Jello versus a hard cube of butter," which they kind of relate to. So that means less trauma in the eye, less inflammation, and faster vision recovery. In my opinion, based on some of the science we have, I can honestly tell them I feel it's going to be safer.

Marguerite :

Russ, I know your conversion rate is excellent. What do you say to those patients you feel would benefit from femtosecond cataract surgery to get them to agree.

Russ:

Well, I try to make patients understand exactly what cataract surgery is. I describe what the cataract is. I use the analogy of a lens of camera which is clear when they're born, and as they get older gets yellower and yellower. I tell them that cataract surgery requires actually removing that lens and implanting a synthetic lens that stays in their eye for the rest of their lives.

I go over the fact that, for the past years, the most efficient way cataract surgery has been done, it has been with a ultrasonic method, requiring an incision into the eye to remove the lens. A lot of people think that this was the old laser. In fact, I'm sure all cataract surgeons have heard, for the past many, many years, "Have you used a laser? My friend had a laser." When in fact, it was ultrasound they were speaking of.

But now we actually do have the laser, and I describe that to patients. I tell them that no matter what, cataract surgery is a procedure. It is intraocular. We are entering the eye. We are breaking up the cataract, removing it from the eye, and inserting a lens. Now, we have at our disposal the most advanced way to do this, and that would be femtosecond laser assisted cataract surgery.

I inform them that cataract surgery is still requiring that incision and that ultrasound, but what laser does, it takes it to a new level of precision and safety. I let them know that cataract surgery has always been a very precise and safe procedure but wave tech makes it more precise and more safe. This is how I begin and usually I go from there and answer their questions regarding the different realities of cataract surgery and how it applies to them.

Marguerite :

I like that way of explaining it. I'm going to adapt or adopt some of the things you just said into my explanation. I also find when I hold my hands up and I say, "There's no pair of human hands that can match the submicron accuracy of the laser," they seem to get that.

Do you find that they're put off by the cost, of course? Do you mention that most practices, including ours, have various ways to pay for it over time? Actually, I think a very high percentage of the people in our practice do that, don't they?

Russ:

Yes, they do. The cost is always an issue, and again, some people are reticent about making that payment and moving up to that level because of financial reasons, and I totally understand that. I certainly don't try and push upon them that this is the only way to do, and that if you don't do it with femtosecond laser you're at increased or severe risk.

I try to be very honest with these people. I try to understand their financial situation. I don't hard sell it. I give them the facts. I'll tell them that if insurance covered it, I'd be doing it on a 100% of my patients. I truly believe that it makes a difference. It makes the surgeon's job easier. It is precise. It is exquisite.

But sometimes people just say, "No, I don't have a problem not having femto," and I just say, "I'm totally okay with that." I just basically say, "You know what? Any decision you make is going to be okay with me. You have to be comfortable with the decision you make."

Of course, it's informed consent and also explaining to people what to expect after surgery. If they do not have multi focal lenses or extended focus, I let them know, "You, most probably, will need reading glasses." I make them understand that. We put it in the chart. Well, we have scribes. We document that. So there's no misunderstanding afterwards. People might think, "My friend had surgery, didn't pay anything, and can see distance [inaudible 00:08:02]." I say, "Well, that doesn't necessarily mean they have good vision," as we've all examined patients who come in and say, "No, I see fine," after cataract surgery, "I don't need glasses," and they're 20/60 uncorrected. But they might be near-sighted, not be myopic as a result.

I try and just make people feel comfortable. I certainly make eye contact with them. I make them feel that they are the most important person there and that what I'm recommending is what I truly believe. I try to make them understand that I will do my best to have the most perfect outcome for them.

Marguerite :

Okay, Dr. Allen, it's your turn.

Quintin:

Initially, I felt that there were some cases where maybe it was beneficial in a multifocal lens but for the most part, I could do a good enough capsulotomy, and I didn't really need the femtosecond laser to make their surgery a success. But now I like to reduce the number of variables at the time of cataract surgery. So having the ability to have a consistent, reproducible, exactly round, well centered, capsulotomy on every single case, I think that adds an extra layer of variable reduction.

Now my thought process on this is that I want every multifocal lens, and even they accommodating lenses, every premium lens in my practice, I really prefer them to have the femtosecond laser, especially the multifocals just because I consider that capsulotomy. I can make it small enough, so we've got 360 degree overlap with the inter capsule.

Marguerite :

What about toric lenses.

Quintin:

Now, with toric lenses, I still occasionally will allow a patient to have a toric lens without use of the laser because I think the need for the toric lens in some patients is so high, and they don't want to pay the extra for the laser in each case. But for my presbyopia correcting lenses, I pretty much insist at this point that they all have the femtosecond laser.

Now, you know there's a different category also, the distance correction where maybe they have monofocal lens and we're doing astigmatism correction with the laser. So that's kind of another discussion.

Marguerite :

But usually you mention it after the first decision is made: "Okay we're going to do a multifocal." Then do you talk about the femto at that point?

Quintin:

Not really, because if they ask me about the different options ... If they were kind of interested in getting out of reading glasses, I can funnel quickly into the multifocal discussion, and I assume that as long as they're a candidate for the laser, then we're going to use a laser in that premium lens case.

Marguerite :

Okay. So basically you say, "This is the premium way to do it. We'll use the laser, and we'll use the multifocal." Okay.

Quintin:

Correct.

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Marguerite :

Mitch, don't you offer a basic package with femto, where patients don't have to chose the premium package to get the laser?

Mitch:

We call it our basic LENSAR package, and as a disclosure have an consult where patients can have this femtosecond laser. They get astigmatism correction to be compliant, but I don't promise no glasses. They're getting a reduction in their astigmatism, and they're still going to wear glasses, and if they decide to go driving there's an option, or presbyopia [inaudible 00:11:35] option, which we call Legal to Drive or Forever Young laser is included with that.

So they will get a package to take home, the Forever Young Presbyopia package, which includes laser, and they'll get the basic LENSAR package, which if they decide to stay in glasses, at least what the cost will be for the laser only. I make them sleep on it. We always bring patients back for a scheduling visit, and at that time, whether it's a day later or a week later, they have to sleep on it. Never make a decision the same day on their eyes.

Then, our surgery coordinator tries to close at least one of those packages. We're lucky. It was at least 86% of patients are getting femtosecond. It might be part of an advanced vision correction package or it might be stand alone or basic LENSAR package.

Marguerite :

Do you think overall your conversion rate is higher because they go home and sleep on it and come back for a second visit?

Mitch:

Mostly they come with somebody, but I think it's good for them to go home and review everything. They want to know what the costs are, and then they may have other questions. Give them information. Because I've told them a lot of stuff really fast, and I try to use lay terms. I don't mention the words astigmatism, toric, presbyopia. I'm just saying that to you now. I use terms like driving vision, and we jokingly say, "Forever young," you know, "Your long arms," and, "You can't put make up on," if it's a woman. Whatever it might be, reading your iPad. Or your cell phone's always the best because everybody lives off their cell phone.

But people get it is when I say, "The laser to me is like a GPS compared to a compass for a pilot." It's probably the pearl I could give tonight, because most patients go, "Yeah, I want that. I at least want the laser." Then I go, "If you want to wear glasses or not, I can do whatever you want, that's your lifestyle."

Marguerite :

I love that, because you have very clearly presented the case without using any confusing terms at all. So driving vision means distance correction, of course. If you had to guess, what percentage of patients say, "Oh, I don't think I want the fancy intraocular lens. I'm just fine with driving without glasses, but I want the laser." Do you get a lot of those? They want the laser but they're willing to wear readers.

Mitch:

Yeah, so that's very common. A lot of people will say, "Hey, my friend doesn't have to wear glasses." So I'm very careful because we have ... I always say it this way. So to be really clear I tell patients, "The insurance companies cover the basic option," meaning take out cataract, put new lens in, see better. But I tell them, "You will have to wear glasses full time for everything for the sharpest vision. It may be legal to drive, but the basic option means glasses full time." That's no laser.

Then I only narrow it to two options. I get a sense from the questionnaire they filled out. If they really want driving or if I see they checked every activity, I know they're really active and they need full range of vision, then I'll only tell them, "You're going to get the basic. It's what the insurance pays for no matter what. Or driving vision option or Forever Young option." I don't give three options. They only get two.

Rona:

What do you tell them about the Forever Young option?

Mitch:

If you want our Forever Young option, that's where we can correct all levels of vision. About 95% of the time, I'll turn the lights down in the room and say, "If you're in a restaurant, you may need help." I pull out the little reading cards say, "You're not going to be able to read the fine print on the bottom of this thing. Most things aren't that small in life. This is the area you're going to be most of the times, cell phones, iPads, laptops, books, magazines, eye makeup, whatever it is."

So I say, "You're going to be pretty much free 95% of the time." I tell them, "With that option, you're going to get the laser." I honestly say, "You're going to sleep on it, come back. We're going to give you the cost. My other staff will give you a package to review at home. If you don't want to go with the no glasses option, at least consider the laser because you can have the laser alone without the no glasses option."

Rona:

And what about the driving option?

Mitch:

The driving option I'm kind of promising them they'll be legal to drive without glasses. I use our aura, and we use laser. We use everything to help get that driving vision legal for them.

Marguerite :

Let's change gears a little bit. I'd like to find out if anyone is a little more strident or more forceful in promoting the femtosecond laser to patients where it really would stack the deck in favor of success, like super hard nuclei, early Fuchs' dystrophy, or pseudoexfoliation. Russ?

Russ:

Yes, absolutely. If I think that this will really make a really material difference in the outcome, I will stress that to the patient. I'll say to them that this is really a game changer in your particular case. I elucidate the reasons why in terms of final outcome, recovery period, expected success rate. Yes, those people I am maybe a little bit more stringent [inaudible 00:16:44] words you use in describing it and making sure that they fully understand the benefits of femtosecond laser.

Marguerite :

Do you find that the surgical coordinator plays a role?

Russ:

Yes, we have videos that are shown the patient when they go into speak to the surgical coordinator. We have actually a video series that goes over not only femtosecond laser, but multifocal lenses and toric lenses. When I speak to the patients prior, I tell them after I've described femtosecond laser, I usually say, "I know this is a lot of information and the word 'laser' gets thrown around a lot in our society, but when you speak to our surgical coordinator, she'll be showing you exactly what I'm speaking about. If you have any questions you could ask her or if she's not answering the questions to you adequately," I say, "you can speak to me."

But yes, I think the fact that visually showing these people exactly what the procedure is, is an enormous way of making them decide towards having femtosecond laser.

Marguerite :

I travel actually to three different offices, and some of the coordinators are comfortable showing the films, and some don't or aren't. But after listening to you, I think I'm going to insist that all three coordinators do it, because you think it really is a game changer, after you've spoken to the patient, to reinforce it to see it?

Russ:

Oh, without a doubt. Without a doubt. At some level, most people just think lasers have been around forever and don't really understand the different types of lasers. So using the videos has really been a changer for us. Once we started using the videos, and just letting the patients sit there and see them, we've had a much higher conversion rate, because of just basic understanding of what exactly is going to happen.

Rona:

Dr. Allen, you use the videos too, don't you? Why?

Quintin:

Just to kind of clarify the process. The patient is shown a video that I believe is the Eyemaginations video. It's about three minutes long, and it covers laser, cataract surgery, and presbyopia correction options, and toric options, and doesn't take long to go through that. Then my scribe actually goes in the room at that point and they see the lifestyle questionnaire. So the scribe will say, "So Mrs. Jones, you watched a video. We're you interested in hearing options? Dr. Allen's going to talk to you about different options, and we do have some options to help get you out of glasses if that's something you're interested in."

So they do a cursory survey to ask what the patient's level of interest is, and also to tell them that some of these options are out of pocket.

Marguerite :

So the videos are useful in helping patients to see the value of the femtosecond laser. But this podcast is about the specific language we use with patients. I've learned that changing only one word can make a difference. For example, I used to call it standard versus laser surgery. Now I call it basic, because nobody wants a basic hotel room. Standard sounds like what everybody gets, it's the standard.

Mitch:

Standard, everybody wants standard. Basic, nobody wants basic, and don't ever use the word traditional, because everybody likes tradition. So that's even worse than standard. So for those out there saying traditional surgery, that's bad because everybody wants that. Basic is probably the best. I use the word advanced. So you have a basic or advanced option, and I tell them which advanced option I think that would be best for them, and then they decide.

In terms of money and cost, I never discuss money with them. I always joke with them like, "Yeah, if you want me talking about money, I feel I'm undervalued already by the insurance companies, so I'm probably going to charge more. So you're probably better off having my surgery coordinators who know the real price talk to you about money or price. It will be a little bit more cost affordable." So I kind of say it that way, and then they laugh.

Then usually they give them a package of information to take with them, which gives more details, and has more of the medical ... it has to have more of the stuff for ABNs in there. But it explains stuff what I've talked about. It gives them the cost breakdown. So we always give them our quote-un-quote basic LENSAR package so at least that's laser only. But they still have to wear glasses. Or we give them one of the advance options I presented, whether it's the driving option of the Forever Young option.

My referring optometrists know all my lingo. So if they have a patient who wants the driving option, they'll say, "Talk to Dr. Jackson about that driving vision option." They don't say, "Talk to him about the toric lens option." The patients don't know what that is. So even my referring ODs try and use the same language as we do. So that helps in the transition when they're referred. So we've educated them as well in some of our meetings and quarterly meetings with my top referring docs.

Marguerite :

Thank you, Mitch.

It was great learning everyone's approach to getting to yes on femtosecond laser cataract surgery. Does anyone have a final thought? Go ahead, Russ.

Russ:

Well, I've always tried to speak to people in a language they understand. I try to make them feel comfortable. I always give them a chance to ask questions. I tell them: I believe in the technology, I believe in what I do, I love what I do. I think this is a real gift that we have such a great technology to do this. I let them understand that I feel privileged that they will allow me to do this surgery. I let them know that if a member of my family was having this surgery done, or myself, I certainly would want to have femtosecond laser assisted cataract surgery. I think that's what people expect of me. I would not ask or recommend anything to any patient that I would not recommend to a member of my family. That's always been my mantra over the years.

Rona:

That's a very strong endorsement.

Marguerite :

It certainly is. I thank all of you so much for being here.

Russ:

My pleasure, absolutely.

Quintin:

Well, thanks for having me.

Mitch:

Thanks, guys.

Marguerite :

You're welcome, Mitch. And on behalf of Rona and myself, thanks to all our listeners. We hope that you'll be with us again for the next episode of Informed Consent: Getting to Yes.

Speaker 1:

Informed Consent: Getting to Yes, is editorially independent content supported with advertising by Abbot.