Complicated Cases: Part 2

Marguerite McDonald, MD, invites Russell Fumuso, MD; David Goldman, MD; and Sumit (Sam) Garg, MD, to join the podcast and discuss some of their most complicated cases. Gain insight into how this panel of experienced surgeons manages these complex scenarios and how they educate patients along the way.

Speaker 1: Informed Consent: Getting to Yes, is editorially independent content supported with advertising by Alcon.

MARGUERITE: Welcome to Informed Consent: Getting to Yes. This is the podcast where we explore the fair and balanced words that leading eye surgeons use to get their patients to say yes to the recommended treatments. I’m Marguerite McDonald of Ophthalmic Consultants of Long Island, in Lynbrook, New York.

Today’s podcast is Complicated Cases: Part 2. We had so much to cover about complicated cases that we couldn’t fit it all into a single episode. So today I’ll be talking with three well-known surgeons, beginning with my colleague Russel Fumuso, the founding partner of Ophthalmic Consultants of Long Island, who handles complicated cases. It’s great to talk with you Russ.

RUSS: Thank you very much.

MARGUERITE: My second guest is Dr. David Goldman, an internationally recognized expert on cornea, cataract, and refractive surgery from Palm Beach Gardens, Florida.

DAVID: Thank you for having me.

MARGUERITE: And finally, I’m extremely pleased to be speaking with Dr. Sam Garg, Vice-chair of Clinical Ophthalmology and Medical Director at the Gavin Herbert Eye institute at the University of California Irvine.

SAM: Thanks Marguerite, pleasure to be here.

MARGUERITE: So Russ we all have complications that we create on our own with challenging patients. I know that you have quite a few referred into you. I personally think that's a tougher situation to deal with than the angry referred patient. But since you see so many of them, do you have any tips, any advice for us on how to handle them?

RUSS: At first, I listen what they're saying. I listen to what they thought happened, what they think the result was, what their expectations were, what they're experiencing at the present time, what makes them think that something went wrong. And then I examine them. Basically before I say anything about the other doctor I just tell them, "I was not in the operating room, was not in the examining room with you when the doctor spoke to you prior to surgery or afterwards." I say "Just let me examine you. Let me see what I see or what I can determine from the physical exam. Maybe I can see and have an idea of what went wrong during surgery or what didn't go wrong during surgery."

SAM: When patients come in who had complex surgeries or complications either from within our own practice or outside the practice I think the first thing is to try to figure out what happened. Often times, the story that the patient gives you and what you're seeing on the exam don't necessarily line up. And I think it's important for the patient to understand what happened and what the expected outcomes can be.

I think it's important to give them hope, if there is hope. And also to be fairly frank with what the expected steps are to get to that point and that generally it's an extended recovery. It's not the same as going into the eye the first time.

MARGUERITE: All of us have had complications. It's also tough when they're referred in, or when they have surfed the web and decided to come in on their own for a second opinion. They often have anger that they want to displace, or they want to ask us to blame the referring doctor. So, this is all so complicated. How do you deal with that, when you open the door and you face the angry, upset patient?

DAVID: I think the first thing is to acknowledge the patient's anger, and a lot of times it's something, as physicians, we don't do. The patients will come in, and we're just working so hard to get them fixed that we don't take a moment to say, "I understand why this is frustrating and upsetting to you." Just that little bit of recognition, I think, just kind of defuses the situation quite a bit.

RUSS: I think it's for us sitting there, listening to them, and not challenging them and not defending the other doctor but not also being defensive. Just listening, let them vent, let them speak. Let them try to explain as best as they can. And then I examine them and then we go from there.

SAM: You know, it's always difficult when the patient's looking to blame someone for the outcome. And I always mention to patients that part of operating is to have complications. I have complications myself. I've been involved with cases referred to me that have had complications and often times these things are unpredictable and that's why we talk to patients about the possible risk before surgery.

I try very hard not to assign blame when it comes to cases that have had complications because that really doesn't help the situation and it doesn't help the patient move on and try to work towards a resolution.

DAVID: I'll go really into detail with what the problem is, and I don't get into the blame game. If the patient's really pushed, I say, "Anyone can have a mistake." And a lot of times the patient's come in, for example, a negative dysphotopsia, which is not something that the physician could have anticipated and is not their fault at all.

We'll tell the patient, "Here's what's going on, here's what we need to do to make things better. Your surgeon referred you to me because this is what I do, and we want to get you seeing as best as possible. I want you have confidence in me."

Because sometimes the patients will feel that I might be in cahoots with their referring physician. Why did they refer to me versus somebody else? And I always tell them they can get a second opinion, I'm fine with that, but the reality is this is a lot of what I do and this is why they're referring their patient to me. I think if we go sort of a just step-by-step explanation of how to correct the problem, the patients are a lot more comfortable with it.

MARGUERITE: Do you ever mention, going into it, you know, you were a higher-risk patient, you had this thing called Pseudoexfoliation Syndrome, or whatever. Do you ever use that, or do you try to just push forward and not go backward?

DAVID: If there was some preexisting condition, I think it's very important to bring it up to the patient, whether it's Pseudoexfoliation, Fuchs' Dystrophy, or someone who had a refractive surprise with prior LASIK. I think it's very important in those situations, where you know that it was out of the doctor's hands in a lot of cases, that you explain that to the patient. And also, you know, this could have easily happened in my hands, too. You know, I might have picked that exact same powered lens if I was the surgeon. Nothing they did was particularly wrong. This is just, you know, on some level bad luck and we were starting at a disadvantage.

RUSS: If I think something can be done, first I'll try to understand what happened and give the patients my idea of what possibly could've happened and what the risk factors were as found on the examination. And did the doctor talk about risk factors or not? Lots of times the patients say the doctor didn't, but in reality most probably they were gone over. But patients sometimes forget or there are too many things being thrown at the patient prior to surgery for them to understand everything. I give them options. I tell them what I think the options are. I tell them what I think statistically the chances of it getting better are. I look to see if they've had everything done that was supposed to be done afterwards.

The key is basically it's just being very understanding, speaking slowly, speaking clearly, making sure they understand what you're saying. And then ultimately letting them make the choice of what they want to do. And then we move on from there.

MARGUERITE: I also find that the more upset they are, the closer I sit to them. And sometimes I put my hand on their hand or whatever. Do you feel that physical signals make a difference while this is going on?

RUSS: Well I think it's important that you face the patient and give them your undivided attention. I mean it's just sitting back, making eye contact, and letting them know that you're actually listening to what they're saying and you're interested in what they're saying. I think you have to get that across to let them know that you really want to know what went on, what's going on.

DAVID: I'm sure everyone uses TMR now, and it always forces us to look away from the patient when we're inputting data. I try to make a point to either make a quick note to come back to later, or save it for the end, but I'll really spend the time looking at the patient the entire time that we're speaking, acknowledging all their questions, and trying not to look away to input any data. Because I do feel that that breaks a little bit of that bond. And I agree. The closer you can be with the patient for that sort of intimacy, showing them you care, also is very helpful.

MARGUERITE: How do you deal with the friend or family member who's actually more upset or angrier than the patient? Who keeps sort of whipping it up again and again?

DAVID: In my practice I would say it's mostly the spouse that tends to stoke the fires. Usually, I'll just look to them and say, you know, again acknowledging their frustrations, and say, "Let's focus on what we need to do to make you better." I'll repeat that over and over again, to try to not cast the blame game.

A lot of times the patients want to know why. Why did this happen? What did the doctor do? We try not to go there as much, and just focus on, "This is where we are now and this is what we need to do to get you better." Focusing on that, you know, the anger is not going to help anything. Let's be positive, and let's work towards a common goal here.

MARGUERITE: I certainly find, that the informed consent process is critical and I personally spend a great deal of time on informed consent. Do you find that with the complicated cases referred to that, it appears at least, that maybe, sometimes, there wasn't enough of that?

SAM: Right. It's a tough situation to be in because by and large complications are infrequent and just take cataract surgery for an example. You know, people can do hundreds and hundreds of cases prior to having any kind of complication. And because it's so routine we often go through the complications very quickly or we leave it to them to read.

I try to individualize risks for the patient. So, particularly if a patient has pseudoexfoliation or if they have Fuchs’, I will notate on the chart and also verbally tell them that, "Hey Mrs. Jones, you have something called pseudoexfoliation. That puts you at higher risk for X, Y, and Z." But I think it's really hard with the constraints of time.

So, I think if you talk to a patient about their specific risk and then sort of make generalizations about the other ones. To me, that seems like a good way to sort of cover all your bases. And then if there are certain patients that require a little more in-depth discussion, make sure you take that time. Either on the day of the consultation or you bring them back again for another eval, where you can go over the complications and the process for surgery in a little more depth. But what you don't want your patient to feel is that you glossed over anything.

DAVID: Obviously when you have the patient with pseudoexfoliation or Fuchs' Dystrophy, and you don't discuss it with the patient preoperatively and then there's a complication, it's a lot harder to say it was a preexisting condition than a complication.

RUSS: When I give my patients their pre-op talk about cataract surgery, that although cataract surgery is one of the most common and safest operations done, there's always a small risk. I always try to make them understand that there is always a possibility that things could happen. And I do tell them and I've been operating now 35 years and over tens and tens of thousands of cases, every now and then something goes south. And even though you have the best intention, you're doing everything correctly, things happen.

MARGUERITE: I found that the more upset they are or the further they have come to see me, the more time they expect to get. And sometimes this can absolutely stop your clinic or office hours and get you backed up. So, the tech comes in with a note telling you how many people are waiting to see you. And the patient is upset, you can't get out of the room.

Sometimes I have said "You know the exam is over and I'm delighted to talk to you more about this. May I call you later? There is an emergency waiting for me." And that has worked for me on a number of occasions. Have you ever done anything like that?

RUSS: Absolutely. I've told people that. I've offered to call them after hours when they're at home. When I'll say I'll give you as much time as you need after office hours are done, after all my responsibilities are done in the office, then you can just chat as long as you like till you're happy with what you're hearing or satisfied with what you're hearing.

DAVID: Yeah, if I feel the conversation is going a little too long and the clinic is starting to back up, usually my staff will come in and say to me, "Dr. Goldman, we have an emergency. We need you to come see." Then I'll take their cue, and say, "All right. Well, listen. I need to go, but I'm at your service. We can speak on the phone later." If I think the patient may have unrealistic expectations, or may still be a little agitated, I'll say, "I think it's better if you come back again, and we'll discuss this a little bit further before doing any surgery."

MARGUERITE: That just about wraps up this episode. I like to thank my guests Dr. David Goldman…

DAVID: Thank you very much. I appreciate it.

MARGUERITE: Dr. Russell Fumuso…

RUSS: Anytime Marguerite. You take care, be well.

MARGUERITE: And before we say goodbye to Dr. Sam Garg, I have one last question. I know you work closely with a retina specialist. Does it help for the two of you to work together in speaking to the patient?

SAM: Yeah, I think it does. The retina specialist that works with me actually is in clinic with me on the days that I see patients so it actually works out quite well, hand in hand. We can go and talk to the patient together, if it's needed. Sometimes it's also the patient, I'll refer to him to get his evaluation and we'll each have our own conversations with the patient.

MARGUERITE: I think speed helps, instead of dragging it all out and having them come back multiple times. Anything that you can do to avoid that. I think is, is very helpful.

SAM: Yeah, absolutely. I think if, when something does happen, I think first number one is to own up to it. Complications happen and I think it's important to address them rather than to try and sweep it under the rug and pretend it's something else. And then also to involve the appropriate sub-specialty early. And at least, there may be no intervention needed from a glaucoma specialist or a retina specialist, but most times patients feel reassured that you've asked for help. That puts them at ease that you've listened, you've asked for help and you're okay doing that and you're looking out for their best interest.

MARGUERITE: I couldn't agree more. And often, when you do see lawsuits, one of the things that the plaintiff’s attorney is most likely to charge the doctor with is, "You didn't look for help. You didn't ask for a second opinion. You didn't bring in other experts and, or you didn't do it early enough." So I couldn't agree more.

SAM: These are the patients that you want to embrace and not run away from. These are the patients that when they're in your waiting room you try to expedite them. You know, that you're available during office hours and after office hours. I think that's really important for them to feel like you care and that you really do care, not that they just feel that way, but you make the extra effort.

MARGUERITE: Great insight Sam.

SAM: Thanks very much. Take care.

MARGUERITE: You’re welcome. And thanks to all our listeners. Please watch for our next Informed Consent: Getting to Yes podcast.

Speaker 1: Informed Consent: Getting to Yes, is editorially independent content supported with advertising by Alcon.