New M.D.

A Seemingly Irrational Patient

By Allen Chiang, M.D.

The green digital display on my pager read 6:15 p.m. Another harried, unpredictable day in the urgent care walk-in clinic was finally coming to a close. Fridays are perpetually the most hectic, as patients and referring doctors rush to ensure that problems receive attention before the weekend. In this instance, the ensuing holiday weekend made the load of patients even greater.

I grabbed the last chart. In red ink at the top of the routing slip, the patient's chief concern read, "High eye pressure." I quickly called the patient in and, after a formal introduction, started taking a history. Over the past week, the patient had been seen several times by an outside ophthalmologist for advanced angle-recession glaucoma in his left eye, which was already reduced to barely hand-motion vision. Despite multiple topical medications and increases in the dosage of oral Diamox, the IOP remained sky-high.

A No-Show, but Why?

On further questioning, the patient said he had been scheduled for a glaucoma tube-shunt surgery the day after the holiday weekend, but skipped his preop appointment at the last minute because he "didn't feel well and didn't have a good feeling about that particular surgeon." In spite of his actions, he did believe that he needed eye surgery and headed for UCLA after a friend told him about the walk-in service.

I could not help but think to myself, "What is this guy thinking? He had the appropriate surgery all arranged and ready to go."

I examined him and found the physical findings to be completely consistent with his history. The IOP in the left eye measured 52 mm Hg.

"I totally agree with your previous ophthalmologist's recommendation for glaucoma surgery because the pressure is very elevated in spite of maximum medical therapy," I stated. "Is there something that concerns you about the surgery?"

"Well, I just don't feel like the other doctor was genuinely interested in answering my questions," he said. "On top of that, I've been experiencing strange needle-like sensations in my arms and legs and nausea over the past few days."

I explained that these were common mild-to-moderate side effects from the oral Diamox.

"You see, this is why I didn't feel comfortable with the other surgeon," he replied. "These kinds of details weren't explained to me."

A Patient's Confidence Is Golden

I acknowledge that I did not have all the facts about this particular patient's care prior to presentation and make no judgments with regard to the community ophthalmologist's care of the patient prior to arrival. If anything, the diagnosis was correct and the intended management appropriate. Yet it serves as an illustration of what was important to this particular patient.

While there are a number of different lessons that can be gleaned from this patient encounter, what struck me the most is that a patient's confidence in a physician or surgeon and a prescribed treatment cannot be assumed. It needs to be earned. This entails more than arriving at the correct diagnosis and treatment alone.

As young physicians and surgeons, we cannot forget that even if the diagnosis is obvious to us and the indications for treatment are straight-forward, for our patients this may not be the case. It may be cliché, but if we could try to put ourselves in their shoes we would be in a better position to win their confidence and motivation, realizing that their concerns may be entirely different than what we had anticipated.

How will it affect my ability to drive? When will I be able to go back to work? What should I look out for in terms of side effects? What if I accidentally put in more drops than prescribed? In the midst of a busy clinic, these may sound like peripheral questions to us, or even silly ones, but for the patient they can be significant.

As a young ophthalmologist, I believe this case serves as a reminder that even as we strive to attain greater efficiency and proficiency, we should remain poised to take that extra minute with our patients. If we demonstrate a concern and willingness to address their concerns, we can gain their confidence and become much better physicians and surgeons in the process. OM