New M.D.

His Cure Would Come From Above

By Lauren Eckstein, M.D.

A few days before completing my residency, I had the opportunity to take care of a kindly, elderly gentleman with glaucoma.

Mr. Jones (his name has been changed) sat in my exam chair and told me that he had not been taking his IOP-lowering medications as prescribed. In fact, he told me that he had not been taking them at all.

"When was the last time that you used your drops?" I asked. He then calmly went on to explain that he had never taken any of the pressure medications that had been regularly prescribed for him.

Mr. Jones had been followed for years, and concurrent with the deterioration of his clinical exam, prior physicians had slowly escalated the intensity of his regimen. He was now receiving four different medications. As his intraocular pressure remained elevated and his optic nerve demonstrated evidence of progressive loss of the neural rim, Mr. Jones had been referred to me to be considered for a trabeculectomy.

A True Believer

After a prolonged conversation, Mr. Jones revealed that he believed Jesus would save his sight. Because he was convinced that divine intervention would be forthcoming, he was not interested in any medical interventions. Despite a clearly articulated understanding of his condition, his current level of vision loss, and the very real possibility of permanent blindness in the future if left untreated, he nonetheless refused any form of therapy — eye drops, pills, laser procedures or surgery. Not surprisingly, my efforts to alter his decision were unsuccessful.

Unfortunately, so too were discussions between Mr. Jones and his minister during a conference call that I arranged later that afternoon. Indeed, during our extended interaction, Mr. Jones could not be swayed from his deeply held beliefs.

Amiable but Adamant

Although we ultimately parted ways, he agreed to return to clinic at regular intervals to monitor the progression of his disease and to revisit theissue of instituting treatment at these later encounters, Mr. Jones amicably consented to participate in these future discussions about the need for treatment.

This case highlights a critical, but all too often overlooked, skill in the development of new physicians. Although we may have myriad interventions available in our medicalor surgical armamentarium, the choice of intervention rests as much on our medical expertise as it does on the patient's wishes. If a patient does not desire a particular therapy — no matter how perfectly suited it may be for the treatment of their ailment — it is inappropriate, and we must work with the patient to find a more acceptable solution. In the case of Mr. Jones, no intervention was tolerable beyond mere observation and counseling.

Know the Patients's Wishes

Two important points emerge. First, we must regularly hold open and honest discussions with our patients, not only to inform them of their condition, but also to inform ourselves of their desires concerning therapeutic modalities. And second, although we may emphatically disagree, we must (of course) respect those same desires. The physicians who previously cared for Mr. Jones, and who finally referred him to me for surgical management, failed at these charges. Although they accurately diagnosed him with advanced, progressive glaucoma, they did not take the time to discern what sort of treatment he preferred. Unfortunately, these oversights contributed both to patient discontent as well as to inefficiency within the medical system.

Listen and Learn

Although we may often feel pressured for time, taking a few moments to have these important discussions strengthens our connection with our patients and enhances our ability to deliver effective and appropriate treatments tailored to their individual goals and desires. Ultimately, these benefits pay dividends by maximizing both physician and patient satisfaction. Their value cannot be overstated, and their role in resident education must not be neglected. Encouraging residents to slow down and listen to their patients isa critical task, as the art of listening is an essential component in the success of any physician. OM