New M.D.

A Lesson Learned in Sensitivity

By Allen Hu, M.D.

It was a typical day in the retina clinic. I was in charge of the intravitreal injections for the tide of age-related macular degeneration patients.

It started out as a typical patient encounter. I called Mr. L, from the waiting room area and brought him into the examination room. He seemed a little nervous, but most patients in this clinic knew they were coming to have a needle placed into their eyes. Some degree of anxiety was the norm, rather than the exception. Mr. L, who was "count fingers" in his right eye from wet macular degeneration, sat down. After the usual introductions, he immediately fired a series of direct questions at me about his condition, "Doctor, I know I have the wet type in my right eye, what are the chances that I can get this in my other eye?" he asked anxiously.

A Wrong Answer

I thought this was a rather straightforward question and I thought that the best way to answer was to quote him the results of the Age-Related Eye Disease Study: "Three out of ten patients with your exam findings can develop the wet type in your other eye over the course of 5 years," I replied. "Fortunately, we currently have efficacious treatments for this condition which didn't exist 5 years ago."

I thought that I had given an appropriate answer that would reassure the patient that the odds were in his favor and that, if he did develop wet AMD in the other eye, we would be able to treat it. He seemed to accept my answer and had no further questions. The intravitreal injection was uneventful and Mr. L went home.

Mr. L returned to the clinic the next day. He said he returned to the clinic because his eye was in mild pain and wanted to make sure everything was okay. His eye exam was unremarkable. When I asked him if he had any more questions, I learned why he was really there. He said that I had really upset him and he couldn't fall asleep the previous night because I told him that he would "go blind" in his other eye.

Sensitivity is Key

This brief patient encounter is an excellent example of the impact our words can have on our patients. As physicians, we have been trained to intellectually conceptualize disease processes. Moreover, because we encounter these disease processes on a daily basis, it is easy to become desensitized to the psychological impact sight-threatening diseases have on our patients. Sometimes we have to relay information regarding prognosis that patient's don't want to hear. We have a duty, as physicians, to provide accurate, up-to-date information. Nevertheless, it is always important to deliver the information in a considerate and sensitive manner, being cognizant of our patient's emotional state.

The Better Answer

Each patient in residency offers an opportunity to learn. However, I never would have never guessed the lesson I would learn from Mr. L when I first met him. I wanted to know how more experienced physicians would respond to Mr. L's questions. One of my professors offered her advice on how she counsels wet AMD patients. She told me in her experience, "One of the greatest fears that people have is that they will go completely blind."

She first tries to reassure them by telling them their peripheral vision will not be affected and they are very unlikely to lose vision completely. "Focus on the positive information first," she said, "because oftentimes that is the information that patients will grab onto and remember."

Reflecting on this experience, I could have easily told Mr. L, "Seven out of 10 patients with your exam findings don't go on to develop the wet type in the other eye."

Basically, I would have been giving him the same information but phrasing it in a different, more sensitive way. Some people would say that by telling him that 7 out of 10 patients do not go on to develop wet AMD in the other eye I would have been guilty of putting a positive "spin" on my answer.

I prefer to think that I would have been a bit more sensitive to a patient's feelings. I also think that Mr. L would have liked that answer better. OM