Red Flags

Parag Majmudar, MD, joins Gary Wörtz, MD, to talk about the occasions when it might be best to say no to a patient seeking care. They discuss the red flags to watch out for when meeting a new patient and the importance of looking beyond the eye and considering the patient's overall well-being.

Gary Wörtz, MD: Open, outspoken. It’s Ophthalmology off the Grid—an honest look at controversial topics in the field. I’m Gary Wörtz, MD.

An overreaction to minor inconveniences. Mistreatment of the practice staff. An unwaveringly cold disposition. The red flags.

As health care providers, what we want most is to help people, to improve their vision and hopefully their quality of lives. However, although mostly few and far between, there are occasions when we must say no to patients who need care.

Despite our hyper-focus on the eyes, we are, in essence, treating the entire patient. That makes us responsible for their full wellbeing. And sometimes, that means we must screen out patients not for ophthalmic reasons but for psychosocial ones.

Here today to help us dive into this topic is Dr. Parag Majmudar. With substantial experience performing refractive surgery, Dr. Majmudar is tuned into the process of identifying patients who may be predisposed to dissatisfaction. He’ll weigh in on the subtle cues he looks for and the approach he takes when having to dismiss a patient.

Coming up, on Off the Grid.

Speaker 1: Ophthalmology off the Grid is an independent podcast supported with advertising by Alcon.

Gary: This is Dr. Gary Wörtz, and welcome back to another episode of Ophthalmology off the Grid. Today I have the distinct pleasure of having a great conversation with my friend Parag Majmudar. He is the President and Chief Medical Officer of Chicago Cornea Consultants and an Associate Professor of Ophthalmology at Rush University in Chicago. Parag and I have known each other for a number of years. We've always had great conversations, and every time I put mitomycin C on the cornea after PRK, I thank Parag in my mind.

Parag, thanks for coming on the show. I'm excited to hear about your practice, and also we've got a really interesting topic that we're going to unveil here in just a second.

Parag Majmudar, MD: My pleasure, Gary. Thank you for having me.

Gary: Yeah, absolutely. So, Parag, we had an email exchange. There's a group of us that were sort of emailing back and forth about some of the more challenging patients, shall we say, and you had a patient that you described that really struck a nerve with me because I feel like I've met this patient in a number of various settings. So, the topic that we're going to discuss today essentially is when to say no. When do you say no to a patient who for all the ophthalmic reasons you should be saying yes, but for other reasons you feel like you're not going to be able to make them happy. So as a preamble to that, or as an intro, why don't you just give us a little bit of the background on your practice and then give us a little bit of the story about this patient in particular, and we'll go from there.

Parag: Sure. I actually did my cornea fellowship so I feel a strong attachment to that institution, which has turned out some great ophthalmologists over the last 20 years that I've been there. And I'm happy to have had a part in that. As I said, I've been practicing now for 20 years, so I can easily say that I'm on the back nine of my career, and with that definitely comes wisdom. Knowledge is one thing, and I think wisdom is another thing. And certainly we have to earn both, but with time wisdom definitely comes, and you get a sense of when things don't seem to add up.

I started practicing in 1998, and, at that time, the LASIK boom was in full swing. For example, we felt that we were invincible, we could treat anybody. I think it's a broad generalization we probably did, and we found out things like corneal ectasia reared its ugly head, and we kind of figured out what to look for. We've come up with really great screening tools and come up with a systematic approach, for example, to LASIK screening. And I think we've done a good job of that, especially over the last few years.

So now, we don't feel like we have to operate on everyone who comes through the door. I think that's a valuable lesson, especially for younger ophthalmologists when they're coming out is that they don't have to operate on every single patient. There's this internal pressure that anybody comes through the door, we have to make them extremely happy. And it sometimes takes a little bit of that wisdom to realize that even if I don't operate on this patient, that may be the best way to make this patient truly happy in that surgery potentially might not be in the best interest of the patient.

As an example, we were talking about sharing some different difficult cases that came in. This is a patient that I saw probably about 2 months ago, I want to say. She'd come in for a LASIK evaluation, and off the top of my head I remember her as a 51- or 52-year-old lady. What struck me is, most of the time, I think I'm a fairly personable kind of guy; I walked in, and I introduced myself. I'd never met her before. And she made very little eye contact with me, and that was an initial red flag for me that something doesn't seem right because either she's upset about something. So, I looked a little further, and I found that she'd actually been to the office to see me before, yet I had never seen her because she had left without being seen.

When I questioned her about that, I said, "What happened that day? Was there some issue that we can improve upon?" Maybe there was something that had gotten her upset. And I think that she had felt that we had done too much testing, and she got really anxious and felt like this wasn't worth her time to be there and left. I just got the sense from her talking after I had a chance to open up with her a little bit that she seemed like a person who had a lot of other issues going on.

Much has been made recently over the last 4 or 5 years about the psychosocial factors that are involved in LASIK satisfaction. We've had various different studies now that have made association between poor outcomes and depression and suicide in patients who have these psychosocial factors. I think that's kind of playing a role a little bit in of course when I evaluated her past medical history and medication history and so on and so forth. There was certainly a number of medications, psychotropic medications, the patient was on. I think these are kinds of the soft criteria, despite the fact that for the most part from a physical standpoint, physical characteristics of her eye and ocular surface and cornea, I thought she might be potentially a good candidate. I think she was a relatively medium to moderately high myope of -5.00 or -6.00. I thought she potentially could have a good outcome with refractive surgery, corneal-based refractive surgery, in terms of corneal thickness and curvature and everything else.

But just something didn't quite add up, and some of that was her inability to handle what I would consider minor, or most of us probably would consider minor, inconveniences being at a doctor's office. Then, given her other history about how various other systemic issues may impact on her mental status, and how she would respond to a potentially less than ideal outcome. So, these are the kinds of things that were going through my mind when I examined her. And I felt that she, despite being, as I said, a fairly good candidate, I thought there was something that just didn't quite make sense to her whole story.

That was kind of the thing that struck me, and I said, "What would I have done 20 years ago?" Well, I would have plowed through. I would have said, "Let's do LASIK. I think we're going to do great." And she might have done well, but we certainly have those cases that we've seen scattered throughout our collective experiences where patients have done relatively well, we think, from a vision standpoint, but they complain of intractable dry eye or glare or halo or some kind of process that may be not related necessarily to their physical outcome but more of an emotional or psychosocial outcome, which ruins their lives.

So, we not only think about ourselves and hey, I don't want to deal with this patient for the next how many years if she's not happy, but I also don't want the patient to have to unnecessarily go through a procedure that might make them less happy than they might otherwise be with their current situation wearing glasses of contacts.

Gary: Parag, you've said so many interesting things, and I feel like this is a tip of a very large iceberg as we unpack this. The idea of I think just the brief psychological history that we can gather not only from walking in and the normal social cues, shaking a hand. I think I remember you telling me that she wouldn't shake your hand or she doesn't do that, something like that.

Parag: I remember saying that. I think it was something, I don't know if she was a germaphobe or what. There was some issue. She didn't make eye contact when I offered my hand, she didn't shake it, and it was sort of a ...

Gary: A cold interaction?

Parag: Yeah, I don't remember exactly the situation in terms of whether she was a germaphobe. I always make it a point to do the sanitizer as soon as I walk in, and so I'm wiping my hands before I even offer a handshake. So, I think there was some potential, but then again these are little clues that should trigger a response, and my point in that email was that most of us are so, especially in our early part of our career, we're so focused on, "Hey, let me look at her lens again, let me look at her cornea, let me look at her refractive ... I can do this. I know I can give her an outstanding physical outcome." But what's the relationship to that with her psychosocial function and how they perceive that. It's a big hurdle.

Gary: Yeah. Patients are more than a cornea, they're more than an eyeball, and once you operate on them, you really own them for a while if not, in some ways, indefinitely. I've had a number of patients where I just get the sense that they are asking for something, what they are seeking in the outcome from a surgery is not necessarily just improved vision, but they are seeking a deeper answer. They're potentially seeking happiness, and they're in some ways thinking that this is the thing that's going to make them happy. When it doesn't, even if they have a perfect outcome or a great outcome, or God forbid they have a less-than-perfect outcome, in those situations, I think we can be a little more sympathetic, or we can at least understand why they would be upset. But when their regular life problems are still there after surgery and it has not made them happy, there really is this sense of almost a greater sense of failure because they're trying so hard to achieve some level of happiness and despite their expense in trying yet another thing, it hasn't delivered on the goods.

So, I really feel like looking at someone's med history, if they're on antidepressants that's one thing. If they're on benzodiazepines, I personally feel like that is even a higher level red flag than a serotonin reuptake inhibitor. So, the people who are having a hard time, and that's not to say the people who are on these meds are crazy and unreasonable, no, I'm all for medical therapy of these things, but it's a clue. It's one part of the picture, and it's something that we, I don't think we're trained potentially as well as we could be. Or maybe it's not as intentional in residency to talk about what patients you should screen out, not for ophthalmic reasons, but for psychosocial reasons.

And that's why I feel like having this conversation can really clue people in on just some little softer, subtle hints. Patients like though that are very demanding, they only respect their own time, these are the patients who get mad at you for doing too much testing, and at the same time after surgery would be mad that not enough was done. Don't you agree with that?

Parag: I agree 100%. I think you hit the nail on the head in terms of the happiness factor. I think that's really important point. And I think you see that a lot in the plastic surgery world where patients are getting things done to their bodies in the hopes that that's going to be a surrogate for making them happy. And I think with eye surgery, that's probably partly the situation as well.

I think that when you exactly hit the nail on the head is that when there's something that's not quite up to their expectations, that, to them, equals I'm not happy and it didn't fix the rest of my life. So, that's kind of the very thing. I think that we surgeons have to do certain things to screen for these intangible kinds of things. And that's really the kind of point of your suggesting this discussion because I think it's a great learning tip for anyone out there, especially those coming out and just starting their practices.

I think that most of the successful outcomes that we've had, and we've seen this hundreds of times, thousands of times, where we may not hit the nail on the head with a refractive lens exchange or cataract surgery or even LASIK, but the patients are happy, and we have that concept of 20/happy. I think a lot of that hinges on a great physician-patient relationship. That begins with a great physician-patient interaction, and there has to be that level of trust. And sometimes you can't get that in the first visit. Obviously, I didn't feel that there was enough of a bond with that first visit. Now, if I felt like there was some potential for future, I might have told the patient, "I think I see some dryness. Let's have you go on some different drops or some medications, and then maybe let's have you come back and repeat some of these pictures." I just didn't feel like there was any way for me to make this person happy based on her emotional situation at the time. And with the previous episode that she had coming into my office and being upset with too much testing and whatever else the situation was, I didn't feel there was that level of trust. And I think that's important. When outcomes are great, you may not have the best level of trust and nobody really cares that much, but once that outcome is slightly less than we expect or if patients are, as you mentioned, relying on that as a surrogate for their happiness, that can set into motion a very difficult series of events. And we've seen that time and time again. So, hard to sometimes read patients.

It's certainly an art form to get that initial read of what they're expecting: if they've been to 100 different consultations, if they have a very type-A personality, or if they're an engineer type person, they're extremely nervous, no eye contact like this patient, agitated with minor little inconveniences or unreasonable expectations. I think we're pretty good about screening for unreasonable expectations. If somebody says, "I want to see 20/20 all the time. Distance, near, this, that.” That might not be something that's realistically an option. I think we're all comfortable saying, "Look, we can't really do that." But I think the problem and the crux of this discussion is that when we can deliver we think everything the patient wants, but yet there's still something that's not quite right, I think that's the difficult part. I think that's what deserves this discussion.

Gary: One other thing I'd like to get your input on, I'll tell you what we do at our office. We have realized that sometimes patients treat the doctor very differently than they treat the front office staff, the technicians, the checkout people. So we've had conversations with our entire office to say, "We collectively have to own this potential problem." As doctors, we only see a snippet of their visit. Sometimes patients, because of our position, may defer and be a little bit nicer to us, but also as a leader in an office, we have to protect our staff.

I'm very protective of my staff. If someone is rude to my staff, whether it's the front office person, someone sweeping the floors, to the anesthesia staff, anybody, we really have this single black ball, red flag that goes up. Our techs will tell us, "Be careful, this patient has been very demanding,” or “They've been rude,” or “They've been saying things that are off-color." I have had conversations with patients who, again, would potentially be great candidates for a multifocal lens, cataract surgery, LASIK, refractive lens exchange, but based on how they treat my staff, it gives me another insight into, alright, this patient is highly demanding, and if something doesn't go quite right, I'm going to be on the other end of that ire postoperatively.

I'd like to know what you think of that as the first question. And, second, how do you handle that conversation when you do decide to forego surgery? Do you have a typical response? Go either direction you want with that.

Parag: I think that your point is very valid and something that we don't think about because we're so, again, focused on walking with the patient, trying to develop that physician-patient relationship. We're trying to not treat the patient as a cornea or a lens or anything else, but we're focused on objective findings, and we're trying within that several minutes that we have to really make a connection, figure out what's going on, and tell them, "Hey, we can help you."

And we sometimes lose the forest for the trees, if you will, when patients have been complaining to the front desk, "Hey, I don't like the music in your waiting room," or "How much longer is it going to be?" or if they're downright rude. We definitely do not try to coddle these patients. When they're rude to the staff, we make it a point that, we tell them, "Look, we won't tolerate this behavior. We won’t tolerate disrespect. It has to be a mutual respect if we're going to develop a relationship and try to help you in the future."

I think it's very important to be on the side of your staff. I commend you for that. We obviously try to do that as much as we can as well. And having that infrastructure where you can be warned before you see the patient or maybe soon after, whatever the case may be, where the front desk flags the patient's visit and says, "This patient was very rude or off-color," or they were very demeaning to the staff or the technicians who have potentially a little bit more of a connection with them during the examination.

I think those are great things to discuss with your staff and say, "We are there for you. We are on your side. We are all in this together, actually. And we want to make the patient experience great, obviously, but if there are certain things that are preventing that on the patient side, please let us know because that lets us understand how they deal with seemingly minor issues. And if they are not able to deal with those minor issues, we're going to have a problem potentially, even if there's not a major issue which hopefully there isn't, but even if there are minor issues following the surgery, I think that we all are going to be dealing with that."

I've always said, even in my early career, "Look, I don't need to make a billion dollars and operate on every single patient that walks through the door. I want to have happy patients, and I want to have patients that we can do good for." And if I don't think we can do good for them, whether it's from a physical standpoint or whether it's from this more intangible psychosocial concept, then I think we need to nip that in the bud and tell the patients somehow.

Now, how do you discuss that with the patient? I certainly think that my style is typically, as a lot of us I think are, is to probably under-promise and over-deliver. So, we kind of downplay the potential benefits in terms of acuity or this or that and independence from glasses, of course. And I think if patients still have issues, that's a good way to sort of let them down easily and say, "Look, I think I know you want to see, Mrs. Jones, distance and reading and also be able to see sheet music 24 inches away, but we don't have a lens that can do that at this time. Maybe we ought to revisit this." Or if they have a LASIK appointment, you might want to say, "Well, you know, your cornea is a little bit on the thin side." Or there may be some way to kind of couch it and say that maybe this is not the ideal situation for you in terms of what we can deliver.

I would almost never tell the patient that I don't think he can handle the results from a psychosocial standpoint. I don't think that would be an appropriate way to discuss it with patients. But I think there's enough information out there. What I told this particular patient, if I recall, is that I think that there was some discussion that she had being in her early to mid 50s, low to moderate myopia, I think it was, I can't remember the number, but there was some issue where she had indicated that she still wanted to maintain near vision for some other task. So the way I couched it for her, and I gave her the benefit of the doubt, is that I said, "Look, I think that LASIK may not be the best solution for you in terms of being able to deliver vision for distance as well as some more near vision-related tasks. Maybe we ought to wait a year of two, let things kind of stabilize, and then maybe there may be options in the refractive lens exchange arena that we can kind of explore. There's always new lens implants that are coming out, and we have potential for vision that might be able to be accomplished with one procedure where we can accomplish multiple goals and tasks." And so on and so forth.

That's kind of how I approached it with this patient, and I don't think that there was anything in that that she took from me that it was in any way condescending or demeaning or that I didn't want to treat her. That's certainly something that we want to not come across, as we are trying to let the patients down easily.

Now, again, if they have been rude to the staff or obviously threatening violence, we've had that happen as well too sometimes, I think those are patients that we have to have a firm hand and say, "Look, I don't believe that we are the right practice for you. I don't believe that we can deliver on what your expectations are, and I think it would be in your best interests to find another doctor. I hope you find a doctor who might be able to take care of you." I think that's something, as you pointed out, being on the side of your staff goes a long way. You've got to deal with your staff for a lot longer than you have to deal with one patient.

Gary: Yeah, I think these are all excellent points. We totally agree on this. I think that the LASIK practices that have been dealing with these patients for longer maybe have an advantage in the refractive cataract arena to have their antennas up or radar out, however you want to say it, for these higher demanding patients. For people who are just sort of dabbling in refractive cataract surgery, these patients can show up and really throw a wrench in the system, especially to a practice that's used to doing bread-and-butter general ophthalmology. I think it's these patients potentially that have spoiled the punch for a lot of good technologies that, in the right patient, the doctors may have had a different experience and have been more of an advocate for; but instead, they've sort of been once bitten, twice shy. What are your thoughts on that?

Parag: I agree 100%. I give talks as you do, too. Various different levels of ophthalmologists, whether they are a refractive cataract practice or the cataract surgeon who's dabbling in sort of a one-off toric IOL or premium IOL for the first time, and it really is a huge advantage to come from a refractive background. As I said, I was kind of thrown into the fire in 1998 when it was 100% LASIK, and we were doing a million procedures, so to speak, because it was such a new thing and everyone was interested in it. So, we really had a trial by fire in terms of weeding things out.

I think the practices that were just used to doing bread-and-butter cataracts and still leaving a lot of astigmatism on the table and not really having patients upset about it are in that same boat as a new surgeon coming out. They're trying this new technology. They want to do everything they can to make it perfect for the patient, and sometimes that means maybe biting off a little more than you can chew. I think that's kind of the same situation that we deal with when we're starting out in practice. I always tell them, "Look, you really want to take a situation where, until you get your feet wet, not only in terms of how to deliver outstanding results from a surgical standpoint, you know preop testing and surgical meticulous technique and postop management, but also some of these more subtle arts of how to read a patient and how to figure out what's going to make them happy, what's going to make them tick. I think that you definitely have to go slow."

I think something that I would recommend, when you are starting out either in your practice for the first time or trying something new as in premium lenses or refractive type cataract or other technology, is to go slow and find those patients who are going to be your homeruns. Really low-hanging fruit is where you want to start off with, not only to help hone your skills on the surgical side but also to hone them in analyzing these patients and seeing where they're coming from and getting a sense of what's going to make them happy.

We're in the business of making patients happy. We're not in the business necessarily of making patients 20/20 or 20/15. We're making them happy in terms of how they perceive their vision helping them throughout their lives. And that's been a great blessing of being involved in refractive and corneal and cataract surgery over the last 20 years. But with it comes certainly a high percentage of cases where we have to take a step back, evaluate the big picture, and ask ourselves, "Are we doing this to make us happy, or are we doing this to make them happy, and can we successfully do that?"

Gary: Parag, those are some great pearls. I know this is going to be incredibly valuable to a lot of folks listening. I'm sure almost everyone will have a patient or two that comes to mind when they think of this. And I just think it's great reminder that there's more to the picture than just the topography. There's more to the picture than which lens you're going to put in the eye, for example. It really requires this holistic approach to the refractive patient. I appreciate you sharing some pearls today.

Parag: Gary, it's been my pleasure. Thank you so much for asking me to come on. I've heard some of your podcasts, and I'm very impressed. Keep doing a great job.

Gary: It’s never easy, but it is important to remember that you do not have to perform surgery on every patient. We are, as Parag said, in the business of making patients happy. At the end of the day, patients don’t care whether they are 20/15 or 20/20. They know how they feel, and if we have made them feel better, then we have succeeded.

But a perfect visual outcome does not guarantee happiness. The best we can do is take a holistic approach to patient care, pay close attention to the cues outlined by Parag, and trust our gut when we sense something is off.

With that, thanks for listening to the 50th episode of Off the Grid. For more episodes like this, visit eyetube-dot-net-slash-podcasts. Until next time.