First, let me tell you a true story of a 10-year- old boy, who was referred to our hospital, a major tertiary care institute in north-west India. Though this happened nearly 40 years ago, it is fresh in my memory as if it happened only yesterday. 

I was all of 27, a senior resident, and as is usual at that age and position in a major teaching hospital, I was highly confident and even  arrogant, my head brimming with newly minted knowledge. 

The ten-year old boy was accompanied by his father and had been complaining of blurred vision. One look at his retina and I announced loud and clear, "your son has blood cancer!" What happened next was beyond my wildest imagination. The father was shocked and collapsed on the floor, bleeding profusely from serious head injuries. 

That day, I realised how ignorant I was, despite all my medical knowledge and skills. Nobody in the medical school or the post graduate institute had taught me how to break bad news to a patient that could alter his life forever. 

This episode certainly changed the way I practiced medicine the rest my life. However, ironically, even today, almost half a century later, young medical graduates do not get any training in communication skills.

William Osler, father of the modern medicine, advised his students not to twitch a muscle while breaking the bad news to the patient and his family. He indeed was the father of ‘cool detachment', but he is a misfit today.

Breaking bad news to a patient is an art that a doctor needs to practice, ophthalmologists more so as they deal with the vision of the person. To give you an example, glaucoma, a disease which can blur a person's vision and eventually, if left untreated, may blind the patient. Most doctors have equal access to information, knowledge and, I am sure, the necessary technology. 

Most can diagnose and treat with equal competence. But are all the experts equally good in a patient's eyes? Not really. 

What then is the game changer for a successful practice? It is how you communicate with the patient, how much information you share with the patient and how much you involve the patient in his own care.

For nearly 100 years, we have followed dutifully ‘the Oslerian equanimity', a philosophy that is an antithesis of ‘empathetic care'. William Osler, father of the modern medicine, advised his students not to twitch a muscle while breaking the bad news to the patient and his family. He indeed was the father of ‘cool detachment', but he is a misfit today.

Put yourself into the shoes of a patient who just received the bad news. I would suggest ophthalmologists read ‘Seeing glaucoma from the patient's perspective' by Ralph Sanchez in the June 5 issue of  Reviews of Ophthalmology. Dr Sanchez was diagnosed with glaucoma as a young man while he was pursuing a degree in arts. 

He changed track, pursued medicine, became an ophthalmologist and specialized in glaucoma. ‘It is shocking experience. Once you break the news, he is no longer listening to you. He is already visualizing loss of his job, lack of finances, and lack of support," says Dr. Sanchez in the article. 

That's why many doctors now keep handouts, booklets, and DVDs that explain the disease in a simple, layman's language. Most people, once they overcome the initial shock, are able to comprehend the fine nuances of the disease and its treatment.

One of the most critical questions that an ophthalmologist faces is: should unpleasant information be withheld from the patients? Is he going to go blind? How long would he be able to see? How long would the treatment last? Should they be informed if the doctor is not sure of the diagnosis? 

Should he be told of the thought process that went into making a diagnosis, howsoever, tentative it might be. In the context of glaucoma, is it early or is it late? Is it based on the evaluation of visual fields and optic disc cupping or OCT alone? Is it Red-OCT glaucoma or Green-OCT glaucoma? 

If the patient is myopic, how has myopia confounded or compounded the diagnosis? Is it para-central glaucoma causing damage even at normal eye pressure? Does the patient have a positive family history? Is he of African-descent? Is the patient an estrogen deficient woman?

Does he have a support system at home? Would he be able to put drops himself? Are there any side effects of the drops? These are some of the  questions that need to be addressed during the course of interactions with the patient.

During the course of the follow-up visits, you need to address the question of the progression of the disease. Is it progressing on the visual fields or on OCT or both? Is he able to achieve the target pressure? Is he able to handle multiple drops several times a day? Is he able to afford the treatment? 

All over the world, the glaucoma experts bemoan the lack of compliance by their patients. Have they ever tried to make the patient, a major stakeholder, in any case, a partner in his own treatment? This will happen only when the patient is fully informed and comprehends the nuances of the disease and its treatment.
"The single biggest problem with communication is the illusion that it has taken place," said George Bernard Shaw eons ago. Pull up the chair and face the patient, and stay focused. Do not look distracted weighed in by the number of patients waiting to see you. Make eye contact, you look more convincing and authoritative.

Electronic health records have come under severe criticism all over the world as these eat into almost 90% of the time the doctor spends with a patient. However, as Ophthalmologist, you can use the computer screen to effectively communicate with the patients and actually navigate them through images of their own optic disc, OCT, and visual fields, and whether these have shown progression, or have remained stable over a period of time. This, at once is reassuring and convincing, and gives a sense of participation to the patient.

Address your patients by their first name. It may or may not mean much to you, but to the patients, it means a lot. "My doctor remembers me", is highly exciting--- and comforting. The stress of being anonymous in the doctor's clinic is already gone in the first few seconds of the encounter. If they are apprehensive while entering your clinic, it immediately reassures them that they are in safe hands. If the patients miss their review visit, show your concern for their welfare by sending emails or letters.

If despite the best efforts you are not able to save the patient from an unhappy outcome, I recommend keeping in your clinic, a print of the most iconic paintings of an empathetic doctor by Luke Fildes. In 1890, Sir Henry Tate commissioned a painting from Luke Fildes. The artist chose to recall a personal tragedy of his own when in 1877, his first son died at the age of 1 year. His biographer later wrote, "The character and bearing of their doctor throughout the time of their anxiety, made a deep impression on my parents." Dr. Murray became a symbol of professional devotion which inspired the painting "The Doctor".

Dr Amod Gupta is a globally renowned ophthalmologist and a former dean, PGI, Chandigarh