While ophthalmology had become more precise each year with improved instrumentation and techniques, mistakes still occur. Though recent studies suggest the rate of endophthalmitis at approximately 1/3000, for that one person there is often a severely poor outcome. While we do our best to control the rates of endophthalmitis with well-constructed wounds and/or antibiotics post-operatively, other consequences we may feel more responsible for. These may include rupturing the posterior capsule, dropping the cataractous or intraocular lens, traumatic iridodialysis, etc. When these events occur, it is important to know what to tell the patient.
Before discussing with the patient, one must recall that most patients are not ophthalmologists, let alone surgeons. They have put their faith in you to perform their surgery and are often nervous. Sometimes we are so quick to explain every detail (eg. "Intraoperative floppy iris syndrome caused severe miosis and difficulty viewing the lens") that we forget this and leave the patient even more bewildered and scared. Other times physicians will take the "wait and see" approach, hoping that residual lens material will dissolve or that prolapsed vitreous will not cause problems down the road. This too, is not recommended. There are also those who would blame the patient (eg. "Everything was going fine until you spoke and moved your head. I told you not to move your head and you ruined everything!") This is probably the worst approach one could take, as not only is it confrontational and possibly untrue, but it also puts the patient in an angry state. It is often these patients who go on to seek legal counsel for possible malpractice.
Rather, the ophthalmologist should be open and honest, yet not technical. While the truth should be told, it can be done so positively or negatively. For example, let us say that during cataract surgery the posterior capsule is ruptured and a fragment of nuclear material is seen heading posteriorly. After an anterior vitrectomy is performed, a three piece IOL is placed in the sulcus. The following are two possible discussions with the patient:
- Doctor A: "Mrs. Jones, I'm happy to tell you that I was able to remove the majority of the cataract and put a brand new lens in your eye. Once fully healed I expect that you will see wonderfully. During surgery, however, a small piece of the lens broke off and landed near your retina. There is nothing to worry about but I am going to have you see one of my retina colleagues so that he can remove it. You do not need any surgery on your retina, I just don't feel comfortable operating that close to the retina and that’s why I didn’t remove it right now. Once he's removed the piece, and this doesn't need to be done today but we'll get it scheduled for you soon, again you should see great.
- Doctor B: "I’m very sorry Mrs. Jones, but during surgery I broke your capsular bag and the cataract fell backwards. You're going to have to have a second surgery and hopefully you’ll be ok."
These are both exaggerations, and while neither is perfect, Mrs. Jones would leave the ASC much more comfortable after speaking with Dr. A than Dr. B.
Sometimes there are complications that we do not recognize until later after the day of surgery, such as infection or retained lens fragments. Again it is important to tell the patient what is going on. Provided the correction is not too burdensome financially or physically, most patients are completely accepting of your advice. Remember, you are the doctor. That being said, some patients do become distrustful when something does not go the way they expected. It is important to recognize this and offer them to seek a second opinion. I have seen many patients for second opinion and without question can say that those patients purposely referred by their ophthalmologists have much better continued relationships with their physician than the others. I am no exception to the rule, I too will often recommend a patient to another ophthalmologist (both within and outside of my practice) so they can feel comfortable with the course of action. Almost immediately after saying this, the patient will usually smile and give a sigh of relief, thanking me for offering them that option. This always makes it easy for them to return after seeking a second opinion and, once fixed, to go on telling others how their doctor takes great care of them.
Ultimately, every doctor will practice medicine the way they are most comfortable. That said, success with handling complications properly will ensure high patient satisfaction and keep word of mouth for the practice strong.