How to proceed if patients push back

Before any patient can go to the operating room, they need medical clearance from their primary physician. I look at this as a good thing.

Occasionally, a routine chest x-ray reveals lung cancer. Or, blood work shows abnormal values that point toward leukemia.

The bottom line for me is that I never argue when a primary care physician or specialist, such as a cardiologist, says the patient is too sick to have surgery. I always tell the patient that their primary care doc or their heart doctor knows them much better than I do.

Many times the patient gets frustrated. They don’t always realize that an eyelid procedure — as much as they may want it — carries risks.

It’s my job as a doctor to care for a patient’s “whole self”– not just their eyelids.

Several months ago I encountered just such a patient. She was a feisty elderly lady with extremely droopy eyelids. Her eyelids drooped so far into her vision that she had difficulty reading or watching TV.

Unfortunately, she also had terrible protoplasm, as we say in the medical world. She had bad lung disease and an irregular heart rate. Her primary care doctor and her specialists all said “no way” to her eyelid surgery.

I, naturally, agreed.

As her lids continued to droop and go south, as all our parts do after a certain age, she became more annoyed. She would call our office, asking us to go against her doctors.

I said, “No way.”

I ordered some special double-sided tape made to improve the appearance of eyelids in movie stars. I called her in to the office and my technician and I made several attempts to get her eyelids in a better position with that dang tape.

Still, no go.

The months went by and her lids drooped lower. I assume she pestered her primary care doctor and specialists, too. Out of the blue, I got notes from her primary care doctor and specialty doctors, saying she could proceed with the surgery.

This whole sequence of events gave me pause.

It’s not every day that a doctor will say that a patient is too sick for elective but medically necessary surgery, then reverse themselves and say the patient can now have the surgery.

After much hemming and hawing, I agreed to see the patient in the office. My staff scheduled her surgery and, indeed, her doctors all signed off on it.

On the day of surgery, I had a heart-to-heart talk with her beforehand.

I told her that we would proceed. However, if she moved or had any medical changes, I would stop her surgery immediately. I was probably more serious with this patient than I had ever been. Her feisty mask dropped away and she nodded.

Sometimes, when I am in a challenging part of a surgery, I will hum to myself. My staff has told me this many times. Often, I am not aware of it.

During this case, I hummed out loud. In fact, the patient asked me if I was humming her a lullaby!

When the case was over and all had gone well (except for all those new gray hairs on my head), she just looked at me in the recovery room.

“I told you I could do it!” she said with her feisty game face back on.

The truth is, in this case, we all got lucky. Her surgery went well without any additional medical drama.

Could it have gone the other way? I’m afraid so.

Was it worth it? Well, that’s a very good question. I admit her quality of life, when it comes to reading and watching TV, will be improved because she will truly not have to strain to see.

However, you can rest assured that I will think long and hard before taking on another case like that.

If you have patients who “push back” on how you want to proceed, don’t be afraid to give it right back to them.

Not in a mean, angry or condescending way, of course. But give it to them straight.

Then set yourself straight on how you want to proceed and stay the course.

Starla Fitch is an ophthalmologist who blogs at Love Medicine Again.

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  • NormRx

    I am scheduled for cataract surgery in a couple of months. I realize this surgery is very safe and I doubt if it ever resulted in death. With that being said if the risk of death was 1-3% I would still proceed with the surgery. This is the first time in my life where I am really looking forward to surgery. I find it very difficult to read, watch TV or drive, so I am restricted in all of these activities. I quit statin therapy because of leg pain. Nothing in life is risk free and as we get older we constantly have to do a risk benefit analysis.

  • Adarin

    A lot of patients, perhaps even most, don’t realize that medicine is built entirely upon weighing the risks versus the benefits of a treatment, then deciding whether the potential benefits outweigh the potential risks. Nothing is 100% safe–everything you can consume, even good ol’ H20, has the potential to kill you depending on the quantity and circumstances. Sometimes nothing is honestly the best thing the physician can do for you–as the Hippocratic Oath goes, first of all do no harm.

  • medicontheedge

    In this world of Press=Ganey scores governing many providers pay, good luck with that “push=back”.

  • Kaya5255

    Benefit vs. risk…..only the consumer is in the position to decide!

  • http://www.CommunicatingWithPatients.com/ Edward Leigh, MA

    Your article brings up so many important points. There are many variables at play with your example — demanding patients, managing input from other physicians, patient safety, etc. My area of expertise is patient engagement, which people often mistakenly thinks means “doing what ever the patient wants.” It is all about forming a trusting relationship with the patient and discussing risks vs. benefits. Thank you for sharing your story. Edward Leigh, MA, Founder & Director, Center for Healthcare Communication