“Patients want more than simply learning about a problem and how to treat it. Patients want reassurance. While I summarized the proposed surgical treatment, I watched for signs of anxiety or lack of understanding. Ultimately, my patient wanted to have confidence that I was the right person for the job and that I would do whatever was necessary to make things turn out well.

I believed that delivering the message personally was important. I was both providing knowledge and gaining trust as I described the surgery and its potential risks and benefits. It has been well documented that patients facing surgery may remember only half of what they have been told ahead of time. Given that statistic, even if patients cannot recall many details, I hoped that my patients felt comfortable that their questions had been answered, that surgery was indicated, and that they were in good hands. I was reminded of the aphorism: ‘They may not remember what you said, but they remember how you made them feel.'”

Paul Pender is an ophthalmologist and can be reached at his self-titled site, Dr. Paul Pender.

He shares his story and discusses his KevinMD article, “The dichotomy of patient needs and patient wants.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Rate and review the show at KevinMD.com/rate. Subscribe at KevinMD.com/follow.

Today, we welcome back to the show Paul Pender. He is an ophthalmologist, and now he’s working in industry. He’s been on the show multiple times, so feel free to search back and listen to his fantastic past episodes. His latest KevinMD article is “The dichotomy of patient needs and patient wants.” Paul, welcome back.

Paul Pender: Hey, thanks for having me back again, Kevin.

Kevin Pho: So let’s get straight into this article. Tell my audience what it’s about and the story behind writing it.

Paul Pender: OK. Well, I found while I was practicing ophthalmology that patients who had blurred vision often came to me and sought answers. When you have to educate the patient, if they haven’t gone to medical school or had advanced degrees, they may not understand what a cataract really is. So I had to go through a description of what was causing their problem, and then I wanted to demonstrate exactly where the lens was. I held up a plastic eye model, and I went through various teaching aids so that the patient would appreciate what the nature of their problem was and then what I planned to do to fix it.

The reason why there’s a dichotomy is because, as you all know, patients may feel like they want to get this information, or you want them to have the information, but what they really need, oftentimes, is reassurance. I think I wrote the article because I felt like in today’s health care climate, you are now facing asynchronous learning. Students are sent to a website. They’re trying to essentially automate an educational process, and it’s not easy, because when the patient watches this particular information plug for your practice, if you will, it’s hard to know if they’ve retained it. If you’re sitting there in an exam room going through this, and you’re looking at their face and you can see that there’s either anxiety or they don’t understand what you’re trying to say, then you can go back and pick up the pieces and start over, or do what you have to do.

It was funny, because my scribe had heard this monologue from me so many times, she could probably repeat it word for word. And I realized, well, OK, I suppose I could have just given the patient my usual spiel about risks and benefits and sent them off to watch a standardized information video. But I just didn’t feel that was going to be adequate. I found that if I added a personal touch, if I did have this exchange with the patient, if I did spend the time to answer the questions, then I felt like I was doing my job: The patient would be reassured, they’d feel like I was the right person for the job, and I was going to do whatever it took to make this turn out well.

So the dichotomy is that the patient may have certain needs to understand their situation, but they really want more than that. They want to feel like the doctor is in their corner, that the doctor is ready to exercise whatever professional judgment has to be done in order to come up with a good result.

Kevin Pho: So take us into the exam room. You’re an ophthalmologist, so I’m sure you’ve dealt with hundreds, if not thousands, of people coming in for potential cataract surgery. Tell us a little bit about an interaction. What kind of questions do they ask, and how long, in general, would that interaction take?

Paul Pender: OK, so the exam part might be relatively short, 10-15 minutes. The explanation might take at least as long. But I think that it was funny, there are certain types of patients, and you know the personality: “Doc, just do it. Don’t tell me what’s going to be involved. Just do it. You have my permission. I just trust your judgment. Just do it.” And I felt like that patient still needed to understand what they were getting into.

I remember this one gentleman. I was trying to describe how giving a local block injection, not in the eye itself but below the lid, was going to numb his eye, because I really had to have ultimate control over the situation, which was different from my usual approach with just topical anesthetic. But having to give this injection below the eyelid, I started to go into detail, and he said, “Doc, I have a high tolerance for pain. I attended parochial schools.” So I thought, “OK, then you just trust me to do this right.” “Yeah, OK, fine.” All right.

But in general, I’ve felt that the way patient education is going about now, for certain conditions, whether it’s surgery or something else, is that often they’ll use cartoons to get a point across. But really, the patient wants to hear the physician’s voice. The patient wants to interact with the physician and ask questions, and I think ultimately, they have to come away feeling like, “OK, I trust this person, and I’m ready to go through this indicated surgery.”

One of the points that I make in my article is that it’s been well researched that patients, afterwards or before they actually undergo their surgery, probably remember less than half of what the surgeon told them ahead of time. The aphorism that I quoted in the article is, “They may not remember what you said, but they remember the way you made them feel.” That is important. Giving that patient a feeling of confidence that you’ve made this connection with the patient is going to serve you well in the future. That’s a really important part. The dichotomy may be even more exaggerated these days, with health care going to a lot of virtual training and learning, but I really think that personal touch is very important.

Kevin Pho: I completely agree with you. The scenario you describe, I face it a lot in primary care, whether it’s a difficult diagnosis or a procedure they’re about to undergo. I think that there’s a lot of tension, certainly, between what you’re proposing and the current reality of our health care system, which is based on volume, based on quantity, based on less time for each patient. So how can we give that personal touch to patients, which inevitably takes time, in our current health care setting, which really focuses on volume?

Paul Pender: Yeah, I understand that, and time is so precious, because often patients feel like they’re not getting enough time from the doctor. OK, and I’m going to flip it back to you for just a minute, because in your primary care practice, you have patients who come in with printouts from their Google feed about what they think their condition is: “Can’t you just write me a prescription, doc, for this?” So their time is important as well, and there are pressures to abbreviate that entire encounter instead of trying to expand it to actually answer the questions.

Sometimes I think it requires being able to set aside, maybe, our professional egos to say, “But did you consider this?” or “That’s an interesting point, and I’m sure that a lot of people experience that. However, you have an unusual case.” Or you bring it back to them and say, “Because this isn’t a general approach to things, I’m recommending something for you specifically.” In that case, I think the patient and everything should just kind of grind to a halt: “OK, so what is it that you’re recommending to me, doctor?” Because maybe all this has just been a lead-up to what they want to hear you say anyway.

And I think that under a time crunch, there may come a point where the exam is shortened to the essentials, and then the discussion has to take place afterwards, and that’s going to be more meaningful. But I also think that perhaps reinforcement can come if, after the doctor encounter, there’s some follow-up, something to close the loop. It might be someone in the practice. It could be a medical student who’s been mentored by the doctor, who picks up the phone and says, “Do you have any questions after your visit, and how might we be able to address those questions now, things that you may not have thought about before?” So I think there are ways to create touch points, and I think that part of what we hope can develop is a kind of program by which the professionals we are using as intermediaries and as patient advocates can actually provide more of those touch points in personal care.

Kevin Pho: Now, what’s the role of technology here? We have so many different ways to connect asynchronously with patients. Like you mentioned, there are videos and cartoons. We normally send them away, and they can watch things on YouTube and whatnot. So tell me the role of technology. Can technology supplement some of these touch points that you’re talking about and give a little bit more of that personal touch?

Paul Pender: I think it can. I think the bulk of my practice was in the era of handing out brochures after the patient was sent back home, and then they would review printed material. I think nowadays, people have access to patient portals. They can ask questions asynchronously, and the doctor can, maybe between patients, come back and answer some things. It gets to be added pressure on the doctor, for sure. This has all occurred really since I retired three years ago, and I find, when I’m reading some of the essays on your platform, that doctors are now inundated by a lot of these peripheral questions and things that take up their time, that are often given free, OK? So there’s got to be some happy medium between a doctor being able to address questions in a timely fashion and the patients feeling like they’re not constantly on hold, you know what I’m saying?

Yeah, I think there has to be respect for time, both the doctor’s time and the patient’s time. And I think the more that patients can learn about a condition beforehand, in a way that’s really under the control of the doctor, I kind of favor that. So what our academy has done is provide patient portals, if you will, or access to a website that addresses generalized questions, whether it be cataract, glaucoma, what have you, macular degeneration. These are ways for patients to learn about something beforehand and maybe even to follow up after their visit.

Kevin Pho: We’re talking to Paul Pender. He’s an ophthalmologist, and he wrote the KevinMD article “The dichotomy of patient needs and patient wants.” Paul, I’m going to ask you again to take us back into your exam room. What are some specific things that you’ve said, specific questions that you’ve asked, that really reassured patients and really gave them that personal touch? Because a lot of times when we’re in the exam room, we don’t quite know what to say. So from your years of experience, what would you say are some of the best things that you’ve said?

Paul Pender: I would maybe prioritize them in a way that you first have to address what may be an underlying fear when people hear about it: “You’re going to do what to my eye?” Yes, you’re going to remove the lens and replace it with a new one, one that works better and that is clearer. So, of course, the fear of operating on someone’s eyeball is paramount. They may have had a friend or an aunt or uncle or someone who’s already been through this, and they feel like, “Oh, well, you survived it. Oh, it’s a piece of cake.” A lot of my patients would hear that but say, “OK, prove it to me. Show me that this is not as difficult as what maybe their grandmother had gone through.” So they’re carrying some of these fears that are unfounded.

So you address some of those things. You say, “No, it’s not going to hurt.” “What do you mean it’s not going to hurt?” “Well, it’s because we happen to give you a type of anesthetic that coats the eye, so you don’t feel me working. You may have some bright light, and you may feel maybe a burning sensation.” And I said, “Oh, and by the way, because of the instruments that break up the cataract and rinse out the cloudy material, some of that might run off onto your cheeks, so you might feel a little bit of water on your cheek.” So I tried to prepare them ahead of time for what they might expect when they were actually under the sheet, in the middle of their procedure.

And ultimately, I’d say, “I’m going to do whatever it takes to make this work out well for you.” I’d put my hand on their shoulder, and I’d say, “This is going to work out well for you.” I would tell them what the risks were, and I’d say, “This is something that can occur in a very low percentage of patients, but I think you’re going to do just fine.” And that was really the message that I gave the patient who was about to undergo this type of work.

Kevin Pho: And my final question: What are some of your take-home messages that you want to leave with the KevinMD audience?

Paul Pender: Well, I think your viewers and your readers appreciate the perspective that physicians and nurses and medical students have on their interaction with their patients. My interaction with my patients, I felt, was part of the joy that I received as a professional. But I also realized that each person was different, and I tried to individualize my presentation to them. Oftentimes it was based upon just their vocabulary and their level of education. So I would redefine how I was going to present something so that they would better understand it, or if they were very sophisticated, we could get into more of the details about the actual surgery itself. But really, it was to try to meet the patient on their level, with what they needed, in order for me to feel like I’d done my job educating them, and then to give them the confidence that they had to go forward.

Kevin Pho: Paul, thank you so much for sharing your time and insight, and thanks again for coming back on the show.

Paul Pender: Kevin, thank you so much for having me back.