This episode of Interventional Mindset is the third part of the series on finding success with premium lenses and self-pay products as ophthalmologists.
In this episode, Drs. Preeya K. Gupta, MD, and Neda Shamie, MD, discuss how to deliver on patient expectations with premium lenses.
Interventional Mindset is an educational series that gives eye physicians the needed knowledge, edge, and confidence in mastering new technology to grow their practices and provide the highest level of patient care. Our focus is to reduce frustrations associated with adopting new technology by building confidence in your skills to drive transformation.
Browse through our videos on a variety of topics within cataract and refractive surgery, glaucoma, and ocular surface disease to learn practical insights into adopting a variety of new surgical techniques and technology.
What does it mean to deliver on expectations?
To start, Dr. Shamie mentioned how, over time, premium intraocular lenses
(IOLs) have taken a larger share of her practice’s offerings because she believes in the value that they provide patients. The question of how to deliver on expectations is multifaceted. Patients are now more informed than ever and enter the practice often already equipped with information (or misinformation) found online and expect that advanced options will be offered to them during the consultation.
As such, practices that don’t have premium offerings are missing out on the opportunity to meet the expectations of a demanding market (i.e., informed patients). Dr. Shamie explained that when premium options are considered for every patient who is deemed a good candidate, realistic expectations need to be emphasized and a central part of the conversation.
Some practices use marketing campaigns promising or guaranteeing 20/20 vision, which can fuel unrealistic expectations and backfire on both the patient experience as well the doctor’s ability to establish trust with the patient
. Even if the patients have an excellent treatment outcome, if they are expecting to have “perfect” vision and don’t achieve that, the result might be considered a failure from their perspective.
Establishing expectations prior to the procedure
Dr. Gupta emphasized that she often encounters patients who come to her clinic with a particular IOL in mind, which could be an advanced technology lens based on their research or recommendations from friends and family. Her strategy to identify the best matching lens is to ask the patient to outline the desired end result(s) in their vision.
This question helps to immediately establish an expectation between the surgeon and patient about the potential outcome of the procedure. From here, it is the responsibility of the surgeon to determine and communicate whether the patient’s expectations are realistic. She added that this seemingly simple step will need to occur prior to any surgery or procedure.
Further, it is vital to initiate the conversation around advanced technology IOLs
(ATIOLs) to avoid miscommunication. This requires self-confidence and experience from the surgeon to have a clear understanding of their medical and surgical abilities as well as their capacity to communicate this to the patient in a digestible manner, explained Dr. Gupta.
Similarly, Dr. Shamie noted that she tends to ask patients, “How do you use your eyes throughout the day? How do you use contacts and glasses?” This helps highlight the limitations the patient is experiencing in their current state and helps also delineate the tasks that are their highest priority. It aids the surgeon in understanding if the patient is accustomed to reading with or without glasses, if they are fully dependent on glasses at all times, if they are tolerant of imperfect vision, etc.
Taking the time to understand the patient’s daily routine helps identify treatment approaches that target their visual limitations and deliver an outcome that fits their lifestyle needs. She also likes to ask patients what they think the ATIOL might be able to deliver for them. Asking the patient to vocalize their expectations from the ATIOL helps her address their misperception and unrealistic expectations head-on.
Matching patient expectations to realistic treatment outcomes
Often, when patients are asked open-ended questions about their vision in the context of IOLs, the common response tends to be that they wish to no longer need glasses or want the vision they had when they were younger. Having this conversation upfront gives the surgeon the opportunity to highlight that there are no perfect IOLs that will solve all of their visual problems, so the goal is to match the patient’s needs as closely as possible to available technologies.
This discussion is an appropriate time to “set the stage” for the patient to understand what options are available and remind them that there are limitations to both the technology and the physiology of the patient’s eye. The goal of the surgeon is to pair the patient with an appropriately matched IOL
to potentially deliver enhanced outcomes and match as closely as possible to their visual demands.
Dr. Shamie added that it can be helpful to have family or a spouse in the room with the patient while discussing treatment options because they can help provide information about the patient that they might struggle to relate to the surgeon during the consultation.
In order to determine the patient’s personality type, Dr. Shamie likes to ask, “Are you the type of person to notice small imperfections or mistakes around the house?” to discern whether the patient has a “Type A” personality and, in turn, may need a more in-depth discussion about the limitations of some advanced technology lenses. Often, the patient denies having a highly discerning personality, while the spouse sitting in the room is quick to give examples to the contrary.
Techniques for reiterating expectations with patients
To ensure that patients hear the recommended treatment expectations as often as possible, at Dr. Shamie’s practice, the technicians and optometrists who see the patient first for the workup have been trained to use the patient’s medical history, narrated expectations from surgery, and findings from the preliminary imaging
done to anticipate which IOL or IOLs the surgeon will likely recommend.
For example, if the patient has a history of corneal refractive surgery
with topographic findings consistent with that history and desires the best distance vision possible, the staff knows to focus on discussing light adjustable lenses (LALs) more in their narrative, as it is likely what will be recommended. Similarly, if a patient is myopic and reads without glasses, the staff recognizes this cue to highlight either multifocal lenses, LALs with the goal of possible monovision, or monofocal and leaving the target at near.
As technicians and optometrists manage the initial round of patient education, they have been trained at her practice to avoid phrases such as “perfect vision,” “success 100% of the time guaranteed,” etc. By the time Dr. Shamie enters the continuum of care, the patient has already been educated on the likely lens choice(s) that would match their ocular history and their visual expectations.
Dr. Shamie then completes the discussion by filling any gaps with more directed questions, evaluates the examination and imaging to further validate or invalidate the choices available, and finalizes the recommendation. The patient leaves having heard the strengths and shortcomings of the recommended lens from three sources in sequence and leaves feeling well-informed.
She often tells patients who choose advanced lenses, “You will likely need to wear glasses for some activities, and while your dependence on glasses will be lessened, it will not be eliminated fully.” Then, she dictates to the referring doctor what IOL she recommends to reiterate all of this in front of the patient to ensure that they hear the information yet again. Additionally, patients are given paperwork with Dr. Shamie’s notes and additional details on the different lenses so they can review the information at home.
The value of precise, individualized medical records
Even with all of these interventions in place to guide patient education and set clear expectations, there are still patients who will be upset if they don’t have “perfect vision” after the procedure or need to wear reading glasses occasionally. She advised surgeons to dictate the discussion in their notes; that way, they can go back and have concrete evidence of what they discussed.
Dr. Shamie added that the challenge with electronic health records (EHRs) is that if surgeons customize their notes too much and don’t individualize their discussion for each patient, they may begin to doubt what actually was discussed prior to the procedure. For this reason, she advocated for individualizing patient notes and, if a scribe is available, writing down the discussion with the patient as thoroughly as possible.
Tips for supporting unhappy patients after self-pay procedures
It is critical to help the patient not feel abandoned after the procedure if the results fail to meet the patient’s expectations, emphasized Dr. Shamie, because this will likely only add to their frustration and lack of trust in the process. Her personal approach to supporting unhappy patients is to call them as soon as she can, see them in the office shortly after, and clearly explain to them that she will continue to guide them through this process of getting them an outcome that they will be happy with.
While she can’t promise perfection, she can walk them through the journey and zero in on the next best step. These are the patients with whom it is paramount to spend extra time to provide comfort, support, and direction, Dr. Shamie highlighted. Often, the problems are relatively easy to manage, such as ocular surface disease
—which can lead to suboptimal outcomes or missing the refractive target
, in which an enhancement may be necessary.
Occasionally, the visual aberrations are related to the patient’s inability to tolerate the optical quality of a multifocal or extended-range lens
, and consequently, being able to exchange the lens is an important skill. She added that for some of her Type A personality patients who opt for a multifocal lens, she makes sure to let them know upfront that they may need to exchange the lens in order to meet their visual expectations.
Dr. Gupta agreed, observing that a patient who is marginally unhappy can become infinitely more unhappy if they feel that they are being shut out of the practice. It’s important to keep in mind that part of the patient’s expectations is that they will be taken care of following the surgery, she noted.
Conversational pearls to align with patient concerns
It can also be helpful to reframe the treatment outcome conversation. Dr. Shamie explained that mentioning the beneficial aspects of the ATIOL and/or procedure are positive steps towards their overall visual goals to aid in identifying where there is room for improvement. This helps to show patients that you, as the surgeon, are working to problem-solve with them.
She added that one approach to avoid in conversation with an unhappy patient is, “You’re doing fine,” since this effectively downplays and diminishes their concerns. Reiterating and acknowledging the patient’s feedback is crucial.
As such, Dr. Shamie often explains to patients who are 20/20 and still unhappy, “Based on the clinical examination, we have hit the target, but I hear you that the 20/20 measured in our exam lane is not what you are experiencing in your day to day. So let’s see what we can do to line up your experience with what I’m seeing in the exam.”
This simultaneously informs the patient that they have achieved the visual goal(s) agreed upon prior to the procedure, but that they will also get more support to meet some level of their post-operative expectations.
Utilizing imaging to visualize treatment outcomes
Imaging, such as topography
, and macular optical coherence tomography (OCT), can also be helpful tools for demonstrating the clinical results of the procedure and potential limitations caused by ocular health. As such, these resources can become educational tools to explain why the surgeon might need to regroup and put together a treatment plan to address roadblocks such as ocular surface disease, which might have stood in the way of the result they seek.
At times, Dr. Shamie also finds it beneficial to show patients what their vision was like prior to the procedure or what it would feel like if they had gotten a monofocal IOL to contextualize the current visual outcome.
Maintaining a clear, communicative, and collaborative tone while discussing upgrades and self-pay treatments with patients is key to setting and meeting expectations as well as getting as close as possible to their visual goal(s).
To streamline communication, it is recommended to set realistic expectations about the treatment outcome prior to the procedure, reiterate the expected outcome and potential complications, stand by the patient if they are unhappy afterward, and lean on imaging tools to aid in communication and demonstrate post-operative improvements.