The Best Laid Plans…

Larry E. Patterson, MD

Almost every week, I run into a problem that I suspect most of you also encounter on a regular basis: patients who don't follow their preop instructions. My primary surgery is cataract, but the problem surely exists with other procedures.

Over the years, my surgical instructions have become very concise and specific. They are quite clear, and based on decades of experience, both mine and that of many leading surgeons across the country. (I would say around the world, having worked with ophthalmologists in six other countries, but that's just unnecessary bragging, so I won't go there.) The goal is a perfect outcome, and preop preparation on both the part of the surgeon and the patient help realize that goal.

During surgery, I used to have problems with mucous and oil in the patient's tear film obscuring my vision. Hot compresses to the lids twice a day for two days preop greatly reduced that problem. Telling patients not to wear eye makeup is helpful also. Based on studies of CME prevention, pain reduction and pupillary dilation, I use NSAID drops two days preop. Based on similar studies regarding antibiotic efficacy, I start antibiotic drops simultaneously. All patients are NPO for eight hours prior to the surgery time.

All these instructions are carefully explained verbally both to the patient and a family member or friend. They are also put in writing, a document that has been revised over many years to be as clear and as easily understood as possible. And the patient is phoned a few days preop to review it all one more time, answering any questions that may have arisen.

Regardless, every week patients arrive in noncompliance with one or more of these tasks, ranging from 10% to 20% of my cases. Before we blame this on aging alone, get this: two days ago I had a bright, young (early fifties) woman, a business leader, who somehow was using an expired bottle of TheraTears in place of her non-steroidal drops!

Here's the real dilemma: the patient and possibly her driver have taken off work that day, driven sometimes an hour or more to get here, and have complied with much of what we told them. Even though they didn't do all they were instructed, it's still relatively safe to operate, but with perhaps a tiny increased risk. If our preop instructions weren't important, we wouldn't have given them to begin with, but there is real increased inconvenience and expense for all concerned if we don't operate on the scheduled day.

I consulted with a healthcare attorney as to my options, suggesting to him that we develop a supplemental consent form explaining that the patient did not follow all the directions and therefore might have a slightly increased risk of complications or a suboptimal outcome. He wasn't too impressed with that idea.

I have no conclusion to this story. It's a plea for help. Thousands of you out there perform about two million cataract surgeries a year in this country. Am I the only one with this problem? What's the answer? Please send your stories and solutions to me at larryp@ecotn.com.