I have found that prospective refractive patients respond to statistics amazingly well. I use my personal LASIK statistics to reassure patients about the risk and benefits of undergoing surgery. My experience has taught me how to use negative statistics in a positive light to assuage peoples’ fears about LASIK surgery, and how to use positive statistics to convince patients that refractive surgery is right for them.

TURNING NEGATIVES INTO POSITIVES
I share my good and poor operative results with prospective LASIK patients because I think doing so enhances my credibility with them. For example, I tell them that I myself underwent LASIK and now have glare. I stress that I have lived with the glare since the original surgery, and it does not interfere with my daily activities. Then, I tell them that one out of every 1,250 LASIK patients will experience some degree of this symptom postoperatively. I do not try to predict whether or not glare will affect them, although I may tell high myopes that their risk for glare is slightly higher because I anticipate having to use a small optical zone.

I also use the strategy of stating a negative and then stressing a positive action, which often puts the patient in control. For example, I may say that one out of 2,000 LASIK patients will have a slipped flap. I then explain that the most common cause of this complication is a failure to follow the postoperative instructions—such as not wearing the eye shield at bedtime.

Another example includes informing patients of the possibility of dry eye developing or worsening as a result of refractive surgery. I tell a perimenopausal female patient that she is at a greater risk of dry eye because of her risk factors and because the LASIK flap may denervate the cornea. But, I also explain that my staff and I are taking steps pre- and postoperatively to prevent and address the problem.

Bottom line: I inform patients of potential negative issues, and then either empower them to take control over their personal outcomes or reassure them that my staff and I are aware of these problems and actively work to prevent them.

I wrap up my preoperative discussion by telling patients that my number-one complication is an enhancement, and an enhancement is a glorified term for a touchup. Because patients tend to see enhancements as a failure of the procedure, I try to make them sound routine. Many people know someone who has had a postoperative enhancement. I state that between 1% and 1.5% of my refractive surgery patients need a touchup, and it is more common in those who are severely nearsighted. This discussion sets an expectation that prevents a surprise if they do need an enhancement. Ultimately, they will have confidence in my ability to fix the problem. I never tell a patient that he/she has a 100% chance of achieving 20/20 vision, because I think this sets the stage for disappointed and angry patients. I may tell them they have a 99% chance of seeing 20/20, and then if the surgery falls short of my target, I tell the patient that they fell into that 1% to 1.5% of patients who need a postoperative enhancement. We stress that the decision to undergo the enhancement is theirs, so they feel in control.

REASSURING CHALLENGING PATIENTS
Statistics can also help encourage prospective patients who are not correctable to 20/20. My partner is an optometrist who does much of the preoperative workups in our clinic. He also underwent LASIK surgery for a -8.00 D correction, and we often cite his experience to prospective patients and stress his good outcome of better than 20/20 vision. Then, to the highly myopic patient, I will say something like, “Treating your refraction with the WaveLight laser platform (Alcon Laboratories, Inc., Fort Worth, TX), there is a 35% chance that you will see better than your current vision. There is a 35% chance of your gaining one line of vision. The chance of your seeing two lines better than your current vision is 20% to 25%.”

INCORPORATING STATISTICS IN INFORMED CONSENT
Today’s LASIK technology, including the latest excimer and femtosecond lasers, has greatly reduced the amount of surgical complications. Nevertheless, statistics help patients feel that their chance of experiencing a postoperative complication is relatively remote. One of my colleagues goes so far as to include these figures in his informed consent form.

STATISTICS AND NOMOGRAMS
Nomograms are another essential component of successful refractive surgery, precisely because we can continuously improve them by tracking our personal statistics. Guy Kezirian, MD, began work on developing refractive nomograms with Charles Casebeer, MD, in the days of radial keratotomy. Later, Dr. Kezirian founded Refractive Surgery Consultants (Scottsdale, AZ) with Jack Holladay, MD, to develop outcomes analysis software. Most recently, Dr. Kezirian turned their database into DataLink (SurgiVision Consultants, Inc., Thousand Oaks, CA), which is the Web-based version of this software. Over the years, these nomograms have taught us that surgical factors we thought were inconsequential, such as the temperature and humidity in the OR, could impact our LASIK outcomes. Today’s Alcon edition of DataLink nomograms helps us harness the power of computers to improve our surgery. Today, I can use DataLink on my handheld PDA to calculate what to enter into the laser based on my personal nomogram. Practitioners may use the software on any computer and then print out the calculations for their records or to use for study and comparison.

TRACK POSTOPERATIVE VISITS
As a profession, our enhancement rates are slowly inching down because the technology is improving and we are keeping track of the numbers. Without that, you never know. To really make use of our nomograms, we should include the data from patients’ postoperative visits. We take these data points at either the 1- or 3-month postoperative visit, because studies have shown that most refractive patients’ vision has stabilized by this time. I call these the nomogram visits, which consist of taking the patient’s refraction and topography. I do this for every patient, even those who are 20/15, because I want to know everything about their vision. Are they +0.25, -0.25, or do they have residual astigmatism? I record these numbers on a routine data collection sheet and then plug them into DataLink. Then, I can compare the data for all my patients. In this way, nomograms are one of our best tools for improving our outcomes and reassuring our patients of our commitment to success.

Karl G. Stonecipher, MD, is Director of Refractive Surgery at TLC in Greensboro and Raleigh, North Carolina. He is a consultant for or on the Speakers Bureau of Advanced Medical Optics, Inc., Allergan, Inc., Alcon Laboratories, Inc., Bausch and Lomb, Inspire Pharmaceuticals, Inc., Oasis, and Nidek Inc. Dr. Stonecipher may be reached at (336) 288-8523; stonenc@aol.com.

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Webster’s dictionary defines static as stationary, fixed, showing little change. A static environment is characterized by a lack of movement, animation, or progression. The LASIK market is static by every definition, and has been since well before consumer confidence nosedived in the latter half of 2008.

DIMINISHING RETURNS
You LASIK subspecialists have spent the last 10 years trying to tell prospective patients how you’re more experienced, your lasers are faster, your treatment indications are wider, and your technology is safer. Yet, you’re stuck. Your procedural volumes are flat.¹

During this same timeframe, the fees realized in your practices haven’t changed, although you have used incremental patient payments to invest in newer technologies.¹

In the U.S., 52 million people between the ages of 18 and 49 wear glasses. Yet, only 12% of them have had LASIK. Why not more? Every surgeon believes he/she does good work, and every practice is convinced it is delivering better results by investing in excimer and femtosecond laser advancements. But, are these beliefs accurate?

WHAT THE DATA SAY
I have reviewed and analyzed outcomes data for large numbers of eyes operated on by providers using a number of different laser platforms. I have learned that you are excellent at delivering LASIK results within ±1.00 D MRSE. You are considerably less accurate, however, at ±0.25 D MRSE. And, every provider knows that achieving 20/Happy requires ±0.25D versus the intended correction.

After years of looking at real-world results for a variety of excimer platforms, my impression is that the Allegretto Wave excimer laser system (Alcon Laboratories, Inc., Fort Worth, TX) delivers enviable consistency and accuracy. However, there is a limit to what even this technology can do without personalized input by the surgeon. Climate, the surgeon’s technique, and treatment profiles all affect results. The future success of LASIK depends on consistently and universally delivering results within ±0.25 D of the intended target.

CREATING A DYNAMIC LASIK MARKET
Question: What is required to restore energy, action, continuous activity, and positive change to the LASIK market? What would make LASIK dynamic and create real and sustainable growth for your practices? Answer: Start talking about how well you do LASIK, rather than how you do it.

Every practice must systematically incorporate outcomes tracking for every patient, every key visit, every day. You may use DataLink (provided to every Alcon user), the Refractive Surgery Consultant (both by SurgiVision Consultants, Inc., Scottsdale, AZ), or Datagraph-Med (Ingenieurbüro Pieger GmbH, Wendelstein, Germany). After you have begun tracking outcomes, you must improve surgical planning so that each treatment is developed with a living, breathing nomogram. This ensures that the effect you intend is indeed the effect you achieve. Finally, you must incorporate your results—the vision you deliver—into your consultation and marketing messages.

You may hesitate to track your results because you fear that quantifying and sharing them somehow puts you at risk. You may worry that sharing your results implies a promise or guarantee that exposes you to liability if you do not achieve an intended result for a patient. Let’s examine potential flaws in this logic.

• Not tracking surgical results means you won’t improve outcomes, because your nomogram cannot possibly be accurate. You’ll continue to deliver 20/OK results rather than 20/Thrilled results. Such lackluster outcomes will impact your patients’ satisfaction, reduce profitability, and inhibit future referrals.
• Flat LASIK volumes are proof that simply telling people you’re good and that your technology is advanced does not compel them to action in today’s world. You promise vision. This is an analytical profession. Why would you not tell prospective patients how well you treat people just like them?

Physicians’ fear of litigation is largely unfounded. Every refractive surgeon envisions financial ruin from a dissatisfied LASIK patient. Yet, according to James J. Salz, MD, Clinical Professor of Ophthalmology, University of Southern California, Los Angeles, and a member of the OMIC board of directors,² the majority of refractive surgery claims over the last 5 years resulted from cataract surgeries. LASIK claims are comparable in number to those seen for retina and general practices. LASIK claims peaked in 2002 at 55, and they have been declining since. Dr. Salz was in the audience during a presentation I gave about this topic in October. He stated that, in 2008, the number of LASIK complaints filed with OMIC year-to-date was four! If a case goes to trial, the surgeon wins 80% of the time. When a surgeon loses, the average settlement is $125,000.² These numbers are astoundingly low. They belie the fact that 775,000 patients undergo some form of laser vision correction annually in the US, and only between five and 50 will be so unhappy that they will file a lawsuit. Yet, fear of lawsuits keeps you from sharing the miracle of how well you deliver vision with the more than 3 million people who call your practices every year asking about LASIK. It seems to me that the tail is wagging the dog!

TALKING ABOUT YOUR RESULTS
What should you do to create enthusiasm and excitement about the miracle of LASIK? Incorporate results into every laser vision correction consultation. Break results into groupings that accurately convey how well your past patients now see based on their preoperative prescriptions. In the practices I work with, focusing on outcomes focus has led to practice differentiation and financial growth.

Using outcomes in your consultation process raises the bar. Any question a patient raises about how many procedures you’ve performed, whether you offer a bladeless technique, or whether you perform customized versus traditional procedures can be answered the same way. You reply, “I think what you’re really asking me is, how will you do.” Invariably, this is indeed what your LASIK prospect wants to know. You can tell him or her, “One of the things that makes us different is that when you visit for your consultation, we’ll show you the vision we’ve achieved with people at your same prescription.”

TAKE ADVANTAGE OF THE DOWNTURN
The depressed economy gives you a unique opportunity to get your LASIK house in order. Yet, if you were achieving less that 20% year-over-year growth before the recession hit, you’re not going to suddenly experience that growth after the recovery begins. Again, you were likely telling prospects how you do LASIK, rather than how well you do LASIK. Use the next 6 months to improve how well you do LASIK, and then let people know about it. Shout it from the mountaintop. Great results — ±0.25 D results—will grow this market to 2 million procedures annually, because they will provide a real answer to patients’ fear that this surgery might make them blind. We can—and must—deliver excellence.

Kay Coulson is the President of Elective Medical Marketing (www.electivemed.com), a consulting group based in Boulder, Colorado, that helps surgeons grow their elective vision service lines. She may be reached at kay@electivemed.com.

1. Harmon D. MarketScope Newsletters. St. Louis, MO: MarketScope LLC. Available at: http://market-scope.com.
2. Guttman, Cheryl. Ophthalmic Mutual Insurance Co. refractive surgery claims experience favorable overall. Ophthalmology Times. April 15, 2008.
http://www.modernmedicine.com/modernmedicine/Practice+Management/Ophthalmic-Mutual-
Insurance-Co-refractive-surgery-/ArticleStandard/Article/detail/510885 Accessed December 12, 2008.

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