Communication with Patients Who Have Low Vision

Vision rehabilitation is a clinical discipline in which there is a great deal of discussion with patients--reviewing patients' goals; educating patients about their ocular condition; outlining rehabilitation options; and often conveying "bad news," such as the assessment that a patient can no longer drive or that it is anticipated that a patient's vision will never improve. This article reviews two published models of physician-patient communication and addresses how each may apply to health care professionals in vision rehabilitation who communicate with patients, such as discussing the need to stop driving with patients who have age-related macular degeneration (AMD). Communication with patients is a core clinical skill for all health care professionals that can be evaluated, taught, and improved. Medical schools historically taught this skill informally and referred to physicians as having or not having a "good bedside manner." Today, more emphasis is placed on communication as a teachable skill in the health care setting, with a shift toward communication skills being more explicitly taught and evaluated. In the United States, the Accreditation Council for Graduate Medical Education requires that "residents must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their patients' families, and professional associates" (Hutul, Carpenter, Tarpley, & Lomis, 2006, p. 401). One can consider how clinicians communicate with patients who have AMD by considering how one would approach a discussion in the following hypothetical scenario: Mr. B is a spry 80 year old who lives alone. He was diagnosed with AMD three years ago and has had photodynamic treatment in one eye and antivascular endothelial growth factor intravitreal treatment to his left eye. Mr. B's acuity is now 20/100 OD and 20/200 OS. His contrast sensitivity is markedly reduced, and he has large scotomas in the left eye and scotomas encircling the central retina in the right eye. His wife recently died, and he moved to a neighboring city to be closer to his two daughters. Mr. B drives only during the day. He reported that he is depressed, having fallen recently and experiencing the symptom of seeing "people and faces" that he knows are not there. He set his car keys on the desk beside him when the interview started and cried twice during the interview. How does a clinician approach a patient who needs to be told that he cannot continue to drive? How does a clinician approach a patient who begins to cry during the interview? This scenario presents many issues for a vision rehabilitation clinician to discuss with Mr. B. THE SPIKES STRATEGY Robert Buchman is an oncologist who wrote both a text, How to Break Bad News: A Guide for Health Care Professionals (Buchman, 1992), and an article entitled, "Breaking Bad News: The SPIKES Strategy" (Buchman, 2005). He defined bad news as any news that is contrary to a patient's expectations. It is the patient's perception of the situation that determines how bad the news is, not the clinician's perception of the significance of the discussion. The SPIKES protocol is a strategy, not a scripted language, for approaching discussions with a patient. It recommends that health care professionals consider the sequential steps outlined by Buchman: setting, perception, invitation, knowledge, empathy, and strategy and summary. The SPIKES protocol first recommends that clinicians attend to the setting, so that significant news is discussed at a time when privacy is assured, the appropriate individuals are present, the clinician can be comfortably seated at the same level as the patient, and the clinician can be attentive and not rushed. In the second step, perception, the clinician asks before he or she tells. As Buchman (1992, p. 140) noted, "Before you break bad news to your patients, you should glean a fairly accurate picture of their perception of the medical situation--in particular, how they view the seriousness of the condition. …