A consumer mentality has developed among a seemingly unlikely patient segment – older people who traditionally have felt that "doctor knows best." As a result, the way you present and manage your practice and procedures is more important than ever.

Today’s cataract patients have been educated by unprecedented consumer advertising – not to mention friends and relatives who’ve had diverse surgical experiences. They know and expect to find out more before selecting a surgeon and signing the consent form.

To succeed, you must make quality the driving force in your practice. In today’s medical environment, patients still seek quality – as well as low fees. Even if you’re in a managed care organization, you want to be selected from the panel. After all, patients can still choose their doctors in this setting.

You can meet the challenges of this changing market by improving quality through patient education, good presentation of surgery, wise intraocular lens (IOL) selection, patient-oriented risk management and interpersonal interactions.

How you present yourself and the services and materials that you offer affects consumers’ opinions. You can improve quality in your office by providing clear, pertinent and complete pre-operative information.

Material specific to your practice is best. While glossy, pre-printed brochures from vendors are useful for describing surgical procedures, they don’t describe what you do in your office, how you manage various situations and what the pre-operative and post-operative steps are. Your brochure should:

• discuss what a cataract is
• give pre-, inter-, and post-operative instructions
• briefly describe the anatomy of the eye, with a picture
• list the risks and alternatives of surgery.

Select a type style and size that cataract patients can read. We use 14-point Arial. You can use a laser printer to produce the brochure. If you wish to upgrade it a bit, put it in a colored folder with a clear cover.

Personalize it to your office and give it to patients on the initial visit, emphasizing that you want and expect them to read it. When patients return for surgery after reading the brochure, they’ll have almost no questions because you will have already answered them. And the brochure takes care of an important part of the informed consent process.

Remember to keep the brochure up to date. At little cost, it can be revised as your practice patterns change. Every 6 months, ask staff and certain patients to read and critique it. You don’t want patients to ask, "Are you still treating astigmatism only 6 months after surgery?"

How you present surgical issues has a tremendous effect on patients’ perceptions of success. Here are some pointers:

• Briefly discuss IOL power issues with patients
. It’s not particularly relevant if they’re hyperopic because you’re probably going to aim for around plano. But if they’ve been lifelong myopes, you should ask them whether they want to get rid of their myopia.
• Avoid unreasonable expectations.
Every patient knows somebody who "can see perfectly without glasses after cataract surgery." Downplay these expectations or everyone will expect 20/20 vision at distance and for reading without glasses. Never promise spectacle-free function, and tell them there’s always a trade-off. Move attention away from spectacle use issues and focus on the safety of the surgery and on functioning well.
• Consider clear cornea surgery
. This has had an extraordinary impact on my practice. When patients look in the mirror the next morning and their eyes are white and clear, their sense of well-being improves and they feel you’ve given them the best care possible. I think clear cornea surgery has the same "wow" factor as laser-assisted in situ keratomileusis (LASIK).
• Discuss astigmatism control.
When you perform an astigmatic procedure, like limbal relaxing incisions, tell patients that there are benefits and limitations. If a patient comes in with 3 diopters, don’t promise them that they’ll leave without any astigmatism. Say something like, "My goal is to reduce your astigmatism so that you’ll see a little bit better without glasses." Soft pedal it a bit. Then, if they end up having great uncorrected vision, they’ll think it’s wonderful. But if they improve to 20/40 or 20/50, they’ll still appreciate it. Set the expectation bar at an appropriately low level.
• Provide instructions.
Give each patient two copies of pre-printed instructions on how to use post-operative prescription drops – one when they first come in and the other during the pre-operative visit.

Selecting the IOL type and power is obviously a critical issue. One of the things that you must address is patient selection and education regarding the AMO Array multifocal IOL.

The screening process is very important. My technician and I both look at each chart to select potential candidates. Then, we give those patients the Array brochure. Here’s what we look for:

• Tolerance of suboptimal vision.
A patient who comes into your office with 20/70 or 20/80 vision is a much better candidate than a patient who complains of 20/25 vision. Patients who complain of poor visual function with milder cataracts may not tolerate halos or other visual problems possible from a multifocal IOL.
• Night driving.
Patients who drive a lot at night may be hampered by halos and, often times, aren’t good candidates for the Array.
• Existing ocular conditions.
Patients with other ocular pathologies, corneal disease, glaucoma of any significance or macular degeneration aren’t good candidates.
• Need for bilateral surgery.
I prefer the Array for patients undergoing cataract surgery in both eyes. Bilateral implantation maximizes patients’ visual performance with this lens.

Also, you must have very accurate IOL calculations and astigmatism control if you’re going to use the Array lens. Currently, it’s only available in the 16 to 24 diopter range. Thus, one of the easiest things you can do is screen your patients by IOL power.

As you know, the FDA currently requires us to give patients a brochure prepared by AMO describing the Array lens. It’s somewhat negative in tone, and it leaves patients with the impression that "yeah, maybe I’ll be able to read without glasses, but those halos at night are going to be a problem." To avoid this, we present the brochure, as required, with a preface. We say, "This was mandated by the FDA. All of the information in here is factual and important, but it does tend to over-emphasize the problem with rings at night. Now, these can occur, and if you’re worried about having them, we don’t want you to get the lens." This usually puts the issue in perspective.

Provide the brochure with the introductory conversation and document the discussion in the chart. Just make a note: "Discussed risks and alternatives to using an Array lens." This could be particularly helpful if the Array patient later is unhappy and insists on an IOL exchange.

Obviously, being sued is one of the most devastating things that can happen. Therefore, patient-oriented risk management is central. I call it "patient-oriented" because it’s designed to properly inform patients and provide them with the best care, while providing risk management. Here are some strategies that have been useful in my practice:

• IOL consent form
. In our office, we still use a version of the detailed IOL consent form that the FDA once required – it’s very complete and lists all the potential complications. Our consent form includes the FDA’s original list of complications, even the worst possibilities, such as loss of vision, loss of the eye and death. We’ve simply modified it to keep it current.
Before surgery, give the patient a copy of the consent form to take home, and document it in the chart. This way, you’ll never be criticized for rushing them to sign a form that they never had a chance to read.
• Visual complaint form
. Medicare documentation and justifying surgery are much easier when you require patients to complete and sign a form documenting their pre-op visual complaints and limitations. As you know, a complaint must be documented. If a patient isn’t having a problem with daily activities, cataract surgery isn’t indicated – or allowed – according to Medicare guidelines.
To find out specifically how cataracts affect each patient’s life, I use either the patient questionnaire followed in the American Society of Cataract and Refractive Surgery (ASCRS) outcomes programs or a checklist required in Texas, where I practice. By checking this form, the patient documents the visual complaint and his or her desire to have surgery.
• OR considerations.
Have a system in the operating room (OR) that keeps the surgeon focused. Distractions can lead to complications that are devastating to patients. I think we tend to forget what it’s like to be told that something went wrong during surgery. Do what you can to make the OR a place where you can concentrate, relax and be highly effective.

Emphasize friendliness, courtesy, respect and concern for each patient’s welfare. It’s easy to lose sight of how frightening the prospect of losing vision is, particularly with a difficult patient. Many patients who are "difficult" during the pre-op visit are simply expressing their anxieties about surgery.

To improve relations with your patients, try implementing these techniques:

• Stop performing nonessential technical tasks.
This helps you maximize face-to-face interaction. Ideally, you should be talking to patients, while doing those portions of the examination that can’t be done by anyone else. This helps you develop strong relationships and see more patients.
• Don’t avoid patients who’ve had complications.
You should talk to these patients as soon as seems reasonable after surgery. Don’t avoid them because you feel guilty or embarrassed; they need your extra time and compassion more than ever. Often, if you bring them through a difficult time, they’ll end up being the most grateful because you’ve hung tough with them when they needed it most and when it might have been hardest for you. Simply sitting there with them and sharing their concern or sadness can be therapeutic to them and to you.
• Call patients at home on the night of surgery.
This probably takes less than a minute, and it absolutely amazes patients. They may not be staying at home, so get a number where you can reach them. Ask, "How you doing? Are there any problems or questions?" Importantly, one out of five will have a question that they wished they’d asked during the day.
• Use patient surveys and schedule regular team meetings.
This helps you get feedback, air issues and implement changes. Also, consider an incentive system to reward your team for outcome quality and positive responses on the survey.

Quality is the driving force in what we do, despite all of the other factors impinging on our practices. We take care of people who need our help, and we must do it in the best way possible. Besides offering the highest quality clinical and surgical care, we must consider issues such as patient education, presentation of surgery, IOL selection, patient-oriented risk management and interpersonal interaction with patients.

Managing cataract surgery patients is more difficult as we strive for efficiency in this era of declining reimbursement. But don’t compromise quality. Even if there’s a busier practice in your community, there shouldn’t be a better one.

The first time a patient comes to see you, he’s nervous and may forget much of what you say. It’s extremely helpful to send a letter to new patients summarizing your findings. This letter, which you can dictate in less than a minute, provides an extraordinary benefit to patients and is also a practice builder because it reinforces your relationship with the patient. It’s remarkable how many patients will remember it a year or two later.

As you know, IOL calculations are very important. I’ve found that immersion is most accurate. Patients are consumers, so they can be unhappy if they’re more than 0.75 diopters off. We obtain two measurements using two different devices. The technician does it with one, and then takes the other probe and does it with the other one. It only takes about 10 seconds longer. We take two to three keratometry readings as well.