All Together Now

Patients typically value clinicians who establish a good relationship, listen to their concerns, and counsel them about their disease. It’s not simply crowd-pleasing behavior; quality doctor-patient interaction can enhance the therapeutic value of administered treatments (1). And yet its perceived importance may have diminished in our era of modern technology medicine.

Thankfully, the pendulum is beginning to swing back – a shift in focus reflected by FDA guidelines that stipulate quality of life (QoL) metrics must be a key endpoint for all new randomized clinical trials (RCTs) in ophthalmology (2). Our fundamental job is to evaluate and improve our patients’ QoL, not simply treat their disease; a holistic framework that considers psychosocial dimensions is required.

Counseling empowers patients to make their best possible health choices. It informs them of the resources available, the different treatment options, as well as the likely side effects and strategies to minimize them. And it may also alleviate unspoken fears for the future (3). Although I take the time to counsel patients during clinical practice, I also encourage patients to seek further information from a third party, such as a patient advocacy group. There is only so much a patient can absorb in a medical consultation, especially when stress from a recent diagnosis might impair their comprehension. I believe it is beneficial for patients and family to hear the information again from an alternative, independent source and have an opportunity to ask further questions. Selected Internet resources can be useful as well. These approaches improve clinical care: patients who acquire information from sources external to their doctor often have the best medication adherence (4). 

Glaucoma Australia is a not-for-profit organization that provides a free patient advocacy service, including access to counseling, leaflets, support groups, regular glaucoma newsletters, and it is currently building an informative and interactive website.

One of the first of its kind, a short-term RCT was published recently measuring the impact of glaucoma-specific counseling on glaucoma knowledge and disease-related anxiety (5). The standardized verbal and written information provided by Glaucoma Australia to new patients was evaluated. A total of 101 newly diagnosed open angle glaucoma patients from 13 centers across Australia were randomized 1:1 into the intervention arm (usual clinical care from ophthalmologist with counseling from Glaucoma Australia) and the control arm (usual care from ophthalmologist). After four weeks, the intervention arm but not controls had improved knowledge levels (p=0.02 vs. control); intergroup analysis revealed a significant reduction in anxiety from the intervention (p=0.02 vs. control). So, third party counseling might not only improve medication adherence, it might also improve glaucoma-knowledge and reduce anxiety, at least in the short term.

How might this change clinical practice? In an ideal world we always counsel patients well; in reality, there are multiple conflicting pressures that often hamper our performance. Time constraints, overbooked clinics, administrative needs, teaching requirements and technological demands can all detract or distract from our core role as quality care providers. Everything is a juggle, a compromise – and we do best with what we value the most. We must remember our roles as teachers, care providers, listeners and advocates. We must also remember we don’t have to do it alone; there are important services at our fingertips to help.

As we move forward, we need to evaluate further what kind of counseling is appropriate – what are the right things to say and the right times to say it. We must train our junior doctors in the art of clinical interaction, not just the science and skills of medicine and surgery. We should embrace new technology to improve patient education and communication, harnessing the wonderful opportunities provided by sophisticated networking, personalized devices and digital media. Building bridges with advocacy groups and other healthcare professionals, and strengthening the bonds of the glaucoma health team can only be beneficial to our patients.