The Competent Physician
Chat Highlights
September 21, 2005

On Wednesday, September 21, 2005, Dr. George Spaeth, a glaucoma specialist at Wills, and the glaucoma chat group discussed "The Competent Physician."

Moderator:  Welcome back to the chat room, Dr. Spaeth. The topic tonight is "The Competent Physician."  How would you describe a competent physician?

Dr. George Spaeth:  For nine years I served on the ethics committee of the American Academy of Ophthalmology.  We had to decide what made a doctor competent. What do you think we concluded?

Moderator:  His record of success?

P: Paying attention, listening, and taking notes?

P: Using good judgment, plus common sense.

P: The ability to make the patient feel confident, and to admit when they don't know something

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P: Relevant training, open-mindedness, and being thorough about examining, recording, and reviewing.

P: Taking time to answer questions and keeping the patient well informed about his or her treatment.

P: A doctor who does not hesitate to refer the patient to a specialist when one is needed.

P: A doctor who is compassionate and understanding of our fears.

Dr. George Spaeth:  We concluded there had to be three components to a competent physician.  He or she had to know things, be skilled at doing things, and use good judgment.  The brightest and most skilled surgeon needs to know when to operate and when not to operate.

The ophthalmologist may say, "What you have is complex. I need to see you again, and probably again after that."   Then you, the patient, may have to travel and upset your lifestyle.  But the doc should not say that simply because he wants your business.

P: Many outstanding glaucoma specialists were fellows at Wills.  Can you point to any single characteristic they had in common?

Dr. George Spaeth:  There was no commonality; some became great physicians and some did not.  They were all bright and possessed surgical skill, but that's not what made them great.  Some had better judgment, and one of the most important aspects of judgment is knowing that you don't know everything.

P:  Although choosing a physician is one of our most important decisions, many people select their physicians according to only a name and location in an insurance provider's directory.  They usually don't realize they made an unsatisfactory choice until something goes wrong.  What suggestions do you have for choosing an eye doctor?

Dr. George Spaeth:  I think the best way to select a doctor is to get advice from somebody you trust and who knows.  Your family doctor may know, your friends probably don't know.  If they had a good result, they think the doc was good; if they had a bad result, they think the doc was bad.  But that doesn't follow.  Trust is built on behaving in a trustworthy way and by admitting that you don't know everything.

Moderator:  Isn't it hard for specialists in a particular field to admit they don't know something?

Dr. George Spaeth:  That is the real danger. It is hard to admit we don't know, and if we can't admit that to ourselves and others, we become dangerous.  I think that being self-critical is easier for some than for others, and it is hardest for those who think they are great, and for those who lack self-confidence.  One of the most reassuring things a doctor can say to a patient is, "I don't know," because it means he or she is honest.

Let's get specific.  A patient says, "Ever since I started using that new drug, my stools have been green."  The doc says, "That can't be a result of the new drug."  The patient should see another doctor, because that one does not know whether the drug does or does not make the patient's stools green.

What the doc should say is, "That's interesting. Let's stop the drug and see what happens."  I had a case exactly like that.  When the patient stopped using pilocarpine, his stools returned to a normal color.

How do I explain that?  I can't.  But we really only understand about .0000001% of what there is to know about the human body, so we have to rely on science.  Science says we don't know, so we will test it in a way that eliminates, as much as possible, our biases.

For example, drug companies don't think drugs cause side effects, surgeons don't think surgery causes complications, etc., so we have to use the methodology of science, the first part of which is to say, "I don't know."

Now how about some questions from you patients about things you wonder about and how we can start to answer them?

P:  Competence in treating glaucoma by general opticians and ophthalmologists can vary considerably.  How strongly do you feel that a glaucoma patient should consult a glaucoma specialist, at least once, if the patient can't be treated by a specialist near where he or she lives.

Dr. George Spaeth:  There are competent opticians, optometrists and ophthalmologists and incompetent ones.  The challenge is to find one who has skill, knowledge, and good judgment, and then become a partner with that doctor.

P:  Isn't a lot of glaucoma treatment guesswork?

Dr. George Spaeth:  Very little about the treatment of glaucoma is guesswork.  A good, competent doc should be able to know what tests to order, how to interpret them, and what to do on the basis of that.  Very little is guesswork.

Consider the visual field test.  The test results vary, depending upon whether the patient is tired or angry, or whether the test is administered properly.  But that does not mean the results don't tell the doc important things.  The doc should know how all those things affect the test results, and factor them into his or her interpretation.  Thus, the visual field that may look worse on paper may actually be better.  A good doc can tell the difference.

P:  What kind of pressure is there on physicians to keep abreast of new developments in medical understanding and treatment?  In particular, what are the most important resources for increasing professional knowledge in ophthalmology?

Dr. George Spaeth:  First, the most pressure comes from inside the doctor.  If you love your patients, you want to help them.  To help them, you have to keep up to date.

Second, pressure comes from licensing and regulatory boards.  But they can be fooled. When I was on the ethics committee, it was disturbing to see how easily some docs fooled themselves.  They didn't really care about their patients, and they could get around the regulations. Therefore, we are required to get continuing medical education credits (CMEs) every year to renew our licenses.  The caring docs, however, don't need that requirement, because they want to help their patients.

P:  My brother's doctor told him that he was to have a combined cataract removal and shunt implantation to improve his vision.  That gave my brother a lot of hope.  Then the doctor who was to perform the surgery told my brother that his vision did not warrant surgery at this time.  Now my brother doesn't know what to do.  Should he get a second opinion?

Dr. George Spaeth:  Have your brother get some specific information.  How much improvement in his vision can he expect?  How likely is he to get better?  How likely is it he will stay the same or get worse?  Have him ask the doc to put that information in a letter.  If the doc is reluctant to do that, your brother should get a second opinion and ask that doctor the same questions.  It is always possible to help a patient.

Moderator:  This question is from a woman with nail patella syndrome (NPS) and glaucoma.  She says some doctors say they don't have time to read the pamphlet that some patients with NPS hand them.  She wants to know: "What is the best approach to use to get a doctor to take you seriously when you have a rare condition like NPS?"

Dr. George Spaeth:  I don't know the answer to that good question. I think you need to sit in the examining room until you get an answer.  The best answer may be, "I don't know, but I can send you to someone who does, or tell you where to find out."

P:  Is there a list of competent and recommended doctors?

Dr. George Spaeth:  Members of the American Glaucoma Society (AGS) and similar groups are approved by their peers.  The lists of best doctors and the information doctors put on the Web would also help you.

P:  I was misdiagnosed and inappropriately medicated for several years.  As a result of my own research and persistence, I eventually consulted an enlightened ophthalmologist, and my treatment was changed.  For a while, I felt as if I were fighting my own battle.  To what extent do you think it's incumbent on us patients to study our own physical condition?

Dr. George Spaeth:  There are four secrets to good health.  First, learning.  The more you learn, the better.  One of the things you need to learn is that you only know a little, even after you have studied a lot.  Second, listen with your inner ear.  We have wonderful ways of telling whether or not we are healthy, if we listen honestly to our bodies.  If we are 50 pounds overweight, and it is an effort to walk up the stairs, we are being given a lesson by our bodies to which we need to listen.  Third, live like a Neanderthal. We need to eat all kinds of different foods, but not too much.  Exercise.  Get outdoors.  Be vigorous, and so on.  Finally, we need to think positively and lovingly.  So, yes, the more you learn, the better partner you can become with your doctor.

P:  What do you think of a doctor who will not communicate with his patients?

Dr. George Spaeth:  Doctors are pushed for time, but if they don't want to talk to their patients, why are they doctors?  Remember, "doctor" is only a word for "teacher."  I don't think much of doctors who won't communicate with their patients.

P:  Do you think it's necessary for a glaucoma patient to seek a glaucoma specialist's opinion if damage is not progressing?  Wouldn't it be preferable to at least see a glaucoma specialist for an opinion?  How can a newly diagnosed patient know if an optician treating them for glaucoma is competent, unless the patient's glaucoma worsens, which could take years and have been unnecessary?

Dr. George Spaeth:  Holding fast to what is true is important. I'm a believer in getting the best opinion you can get.  That may be from an experienced general practitioner or a good specialist.  If you see a specialist, you have to realize that he or she he may only look at one aspect of you.  I think it is always advisable to get the BEST opinion you can.  My advice is to see the specialist, and then be as skeptical of what the specialist says as you are skeptical of what the non-specialist says.

P:  Eye doctors always ask if I have pain.  Why is that?

Dr. George Spaeth:  Pain is a sign that something is wrong.  It is something that needs to be explained.  Pain could be a sign of an infection, a tumor, a broken blood vessel, a clot or many other things.  But it goes back to being healthy and listening to your body. If you have pain, something is wrong, and your body is telling you: "Find out what's wrong!"

When you have pain, you need to know (1) where it is, (2) when it occurs, (3) what makes it worse, (4) what makes it better, (5) how long it lasts, (6) if it's getting worse, (7) what the characteristic are, i.e., sharp, dull, throbbing, intermittent, etc.  That information gives you clues to the cause.  If the doc just writes on the chart "pt has pain," you need to see another doc.

P:  We want to trust our doctors, not be skeptical about them.  How could we skeptical about them and still trust them?

Dr. George Spaeth:  Great question.  You need to have trust in your doctor.  Your job as a patient is to tell your doctor what you are feeling.  The doc's job is to make sense of that. But your doctor is a human being, and may not hear you right or may come to a wrong conclusion.  If you think your doctor is wrong, you need to say that. The trustworthy doctor will thank you and think over the matter again.  It is not that you are not trusting, but rather that you are helping the doc come to the best conclusion.

I teach my trainees not to believe anything they read in a medical journal unless they have examined the material carefully and concluded that the article is a good one.

P:  Xalatan is losing its effectiveness for me and my IOP is increasing. I've been taken off brimonidine due to irritation and redness.  Now my doctor and I are discussing argon laser trabeculoplasty (ALT).  I've been told it is effective for a few years and can only be done once.  These treatments seem like band aids, not solutions. Is the treatment of glaucoma really nothing more than a series of band aids?

Dr. George Spaeth:  All treatments are band aids.  Cures are extremely rare.  Laser is great treatment, for the right person. That is where the knowledge and the judgment come in. If I had primary open-angle glaucoma and needed treatment, the first treatment I would want would be laser.  Laser lasts longer than eye drops and is safer.  If the effect wears off, you have had a period of control without drops without any down side.

P:  How do glaucoma doctors keep track of changes in patients' optic nerves, other than using the new machines?

Dr. George Spaeth:  By serial examinations that are competent.  Good disc photographs, good examinations with the ophthalmoscope, and now -- though not as accurate -- good examinations with an OCT (ocular coherence tomography) or HRT (Heidelberg retinal tomography).  The machines are not as good as a skilled eye doctor looking carefully and carefully documenting what is seen.  But that takes a great examiner and time.  That's why the machines, especially the photographs, help.  What the doctor looks for are changes in the width of the rim of the optic nerve and a few other things.

Moderator:  Thank you for answering our questions, Dr. Spaeth.

Dr. George Spaeth:    I hope I was not too touchy-feely.  My patients frequently ask: "Do I have glaucoma?"  I frequently answer: "I don't know whether you have glaucoma, but I can tell you exactly what you need to do, so that ten years from now when you ask the same question, I can answer the same way."  What is really important is knowing what to do.

On September 28, Dr. Wilson discussed "Glaucoma Medications" in the Chat room. Click here for highlights of that meeting.

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