Keep the patient in the loop when docs talk amongst themselves

I had a patient recently left out of the loop as a colleague and I debated her fate and care! A large proportion of my patients live hundreds of kilometres away who are referred for surgery. I am often left with the challenge of co-managing them with the referring eye care professional without getting to examine them myself. Unfortunately for this patient, the referring ophthalmologist and I spent so much time talking amongst ourselves that we hadn't realized that the patient was not being kept informed of our thought processes.

This patient had previously been referred to me for uncontrolled glaucoma that I treated with an Ahmed Glaucoma Valve. Although this is successful in 90% of patients at 2 years and decreases the need for glaucoma drops from on average 3.4 meds prior surgery to 1.1 meds afterwards, there are still some patients in whom the glaucoma remains inadequately controlled. This was the case for this patient as despite adding glaucoma medications and several 'needlings' to help break scar tissue over the implant was still not enough.

Broken telephone

The referring ophthalmologist and I exchanged several emails, faxes, and phone calls regarding the best next step in this patient's care. I had made the erroneous assumption that as this patient lived far away that the referring doctor was conveying the information to the patient after we talked amongst ourselves each time. We each actually spent quite a bit of time discussing how best to care for this patient and settled on the idea of augmenting her prior surgery with a small amount of diode laser cycloablation therapy. Little did I know that the patient was never made aware of any of our conversations and was just sitting at home, worrying about why nobody was helping her get her glaucoma under better control.

My office arranged for the patient to come back to Vancouver in order to undergo the cycloablation by calling her. It was a complete surprise to her as nobody had explained anything to her as I later found out. The patient had many questions but was told by my office staff something along the lines of "Dr Schertzer is really very busy and won't be able to talk to you when you come for your procedure," or at least that is how it was remembered by the patient.

Fortunately, a few days before the patient was to come to see me for the cycloablation, she called me on my cellphone. I clarified what my office staff meant in that I was squeezing in her procedure after my morning surgery in the operating room and before my afternoon patients, which was not meant to sound like I have no time for her. Over the phone I was able to explain to her that her referring eye doc and I had thoroughly discussed various options including a repeat round of 'needling,' an additional drainage tube, and supplemental cycloablation and the rationale for why the latter would be best for her.

Communication lines need to always remain open between doctor and patient so they are actively involved in the treatment decisions. I usually strive for this in the patients I see on a regular basis but in this case I should have picked up the phone to call the patient and am grateful that she tracked me down so we could speak. She and I have since joked about the whole thing.