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    Lessons From 40 Years of Practice

    I write in response to Dr. Parke’s column on measuring phy­sician performance (Current Perspective, May). Dr. Parke is absolutely correct with his comments about the tertiary care provider dealing with the most complex and time-consum­ing cases. No system can measure the extra hours that the truly conscientious physician spends returning phone calls to anxious patients. The great joy in the practice of medicine is in connecting with patients and gaining their trust and confidence. This takes time—a lot of time. After 40 years of practicing comprehensive ophthalmology, I think I have found the secrets to a long-lasting and trusting physician-patient relationship.

    Above all, listen to the patient. Also, it pays to personally check the visual acuity (VA) in the OD, OS, and OU. The pa­tient will be impressed that you actually checked their vision! Most of the time the VA that I record is quite different from what the technician records.

    Make an effort to practice hands-on medicine, which builds trust and confidence. Have the patient look down while you raise both upper lids to check the superior bulbar conjunctiva. The patient will be particularly impressed if you evert the upper lids and check the tarsal plate and skin/lash margin, especially patients with ocular surface disease signs and symptoms.

    Take the time to discuss the findings. Explain what best-corrected VA (BCVA) is and whether new spectacles would offer significant improvement. Discuss the eyelids and skin/lash margin, the ocular surface, ocular motility, and the degree of cataract they have and how it is affecting BCVA. Describe what the optic nerve, macula/retina, and retinal vessels look like (an OCT scan image is very helpful).

    Be straightforward with the patient about the findings. Every patient who comes to see an ophthalmologist secretly feels deep down inside that they are going blind! Most of the time you can end the discussion with the simple phrase, “Mrs. Jones, you are not going blind, and your current glass­es are perfectly fine.” In patients with an evolving cataract, encourage them not to spend money on additional spectacles that will not substantially improve their vision. By the end of the visit, make sure you’ve addressed all the patient’s key questions.

    On a final note, if you have a complication in ophthalmic surgery, please spend time talking to the patient and the pa­tient’s family about the implications. You will find that most people are extremely forgiving about surgical outcomes once they realize you did your absolute best. Treat every surgical patient as you would your own mother.

    Judson P. Smith, MD
    Fort Worth, Texas

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