Of Treatment

you devoted a large chunk of your life to understanding the statistics that make your treatment logical, but these concepts are very new and counterintuitive to your patients.

The best way to understand this is to go back to the graph in Chapter 5 that shows the ETDRS results for treating macular edema. From the standpoint of a treating physician, the graph is great, but Figure 1 shows what it looks like if it is flipped around so you see it from the standpoint of a patient. Although everyone can agree that the control group did horribly, it is clear that, even with treatment, there is a downward trend—especially if the patient lives for any length of time. You might even consider giving patients a crash course in Cartesian coordinates by using your hand to display a rapid downhill course without treatment and then a gentle downhill course with treatment in order to help them understand what they may expect.

Figure 1. A "patient's eye" view of the graph from Chapter 5 showing the ETDRS results for treating macular edema. This graph makes doctors happy, but this view shows the need to constantly remind the patient about having realistic expectations; diabetic eye damage can still drag the patient downhill, even with perfect treatment. Note the elegant symbolism suggested by the flipped labels: The doctor has to totally wrap his or her head around the patient's point of view to really be able to relate. This was not done because it is easier to flip the original image without changing the labels—it was done on purpose for art's sake.

Figure 1. A "patient's eye" view of the graph from Chapter 5 showing the ETDRS results for treating macular edema. This graph makes doctors happy, but this view shows the need to constantly remind the patient about having realistic expectations; diabetic eye damage can still drag the patient downhill, even with perfect treatment. Note the elegant symbolism suggested by the flipped labels: The doctor has to totally wrap his or her head around the patient's point of view to really be able to relate. This was not done because it is easier to flip the original image without changing the labels—it was done on purpose for art's sake.

Of course, patients can improve,or at least stabilize, especially with good control and careful laser (and judicious use of intraocular medications if needed—see Chapter 11). They are no longer condemned to follow the dotted line in the graph above. The problem is that if you dwell too much on the possibility of stability or improvement, it may be all the patient remembers of your discussion. They can then become very frustrated with the reality of treatment and end up not returning for follow up. This is by far the worst possible outcome, because they usually return only when they have severe symptoms and awful disease that may be impossible to control. You must anticipate and address anything that may interfere with compliance from the beginning. (See the section at the end of the chapter about treating retinopathy in developing countries for an expanded explanation of this.)

Don't forget that there is another big reason why a patient may want to blame your laser for vision problems, even if the treatment is working perfectly: It is reassuring for some patients to be able to blame the treatment because it is a lot easier to do that than to accept the responsibility for years of poor control. The only way you can work around this is with continual education—and sometimes you have to accept the fact that you will always be the bad guy, even if you have snatched such a patient from the jaws of blindness.

There is one big problem, though, with trying to convey the reality of treating diabetic retinopathy. It turns out that if you communicate this information effectively, and if patients seem to understand the possible "slower rate of decay" concept, they may then draw an additional conclusion that is very erroneous (and you may not hear about it). They may well assume that you mean that they will go downhill forever and that, at best, you will only slow down their inevitable descent into total blindness.

Anticipate this type of conclusion as well, and try to head it off. Remind them that although you can never guarantee anything, it is very unlikely that they will go totally blind from diabetic macular edema, especially if they are good about their control and follow up. Explain that, over time, they may be irritated by their vision, but they are unlikely to ever become helpless, which is what they really fear. Again, throw in plenty of "no guarantees" so their conclusion pendulum doesn't swing to the other side and have them thinking they are off scot-free— but by giving them this reasonable assurance you may save them lots of unnecessary anxiety.

Have you ever had a patient tell you that some doctor told them that they were going blind when they weren't even close to going blind? You may get a sense of superiority from such a comment—you can reassure the patient (and yourself) that there is no way you would ever be so stupid as to say such a thing. Well, it is hard to imagine that any doctor would be so stupid as to say such a thing, but now you can see how a patient could come to such a conclusion after a thorough informed consent.

If you think you are a great communicator and that no patient would ever think that you would say that they are going to go blind, just try this simple experiment: After you explain the potential downhill trend inherent in even successfully treated diabetic retinopathy, ask the patient if this means that they will inevitably go blind. You will be surprised at the answers you get. And get ready to take a deep breath and start over—patience is your most valuable surgical tool.

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Diabetes 2

Diabetes 2

Diabetes is a disease that affects the way your body uses food. Normally, your body converts sugars, starches and other foods into a form of sugar called glucose. Your body uses glucose for fuel. The cells receive the glucose through the bloodstream. They then use insulin a hormone made by the pancreas to absorb the glucose, convert it into energy, and either use it or store it for later use. Learn more...

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