KISS: Keep it simple silly

Dr.Tandava Krishnan

One day we saw a patient who was recently given an injection inside the eye for a retinal condition. He had come for a review and examination revealed that he had developed a tear in the retina which resulted in detachment of retina, thereby causing decreased vision. Needless to say, the patient was anxious because his vision had deteriorated further after the injection. While we were struggling to explain (and failing miserably at that!) to the patient about how the two entities were different, a senior consultant reviewed his file and spoke to him thus, “Imagine you had a leaking tap in your house. The plumber has just come in to repair the problem when the power goes off in the house. Your eye condition is something similar, before the injection could rectify the problem inside your eyes; a newer more serious issue has cropped up.” Surprisingly, the patient who till then seemed to be unsure about what was happening, understood the seriousness of the situation and urged us to do whatever was needed to set things right. After the patient was ushered out, the consultant asked me rather surprisingly,” What is KISS?” While I was figuring out as to how I could answer this rather embarrassing question, he himself replied,” Keep it simple silly” and gave me a smile. I chided myself mentally for having understood the question wrong. For he had asked me “what is KISS” and not “what is a kiss”! I felt like Captain Hastings, the associate of Hercule Poirot who always ended up making the wrong conclusions prompting Poirot to quip, “Mon ami Hastings! You have the imagination most fertile, eh!”  The consultant in this incident had practically demonstrated how simple analogies in our day to day life can help us doctors explain complex medical conditions to the patients and win their confidence. The process of simplifying complex medical issues is neither new nor original. We all know the famous phrase, “An apple a day keeps the doctor away” which emphasises the need of eating nutritional food to keep us healthy.
A friend of mine after due examination, declared to a patient that he had a retinal tear which needed a barrage LASER. The patient wanted to know as to how a tear occurred in the retina. Rather than explaining the process of vitreous detachment, he said, “Sir, imagine we have joined 2 pieces of paper with glue. After some time if you were to separate them, the two pieces will not separate perfectly but in an irregular manner such that some parts of the paper continue to be stuck to the other. When such a thing happens in the retina, the defect which is formed is a tear and we would be forming a wall around that defect to prevent it from developing into a full fledged retinal detachment.” Needless to say the patient understood the condition very easily.
I too have developed my own repertoire of such simple analogies. Once while examining a patient with total cataract I advised a B scan ultrasound examination of the eye. I explained that information we got from the test was only partial and was similar to information got by listening from a closed room to the noises coming from the waiting room outside. We can estimate the number of people waiting outside, guess their gender and age but we cannot comment on the colour of their hair or the dress they were wearing. I drove home the point that a B scan would give us some information which would decide our next course of action but will not be providing the full information. In another incident a patient was reluctant to wear glasses though she was suffering a lot from asthenopic symptoms. I insisted that she wear glasses. Realising that it would be difficult convincing her to wear the glasses, I asked her,” If you had to climb up and down an office located in the 10th floor, would you use staircase or an elevator?” She indignantly answered,” An elevator obviously!” I went on to explain that the glasses were to the eye what the elevator was to the legs; that is they reduce any unwanted burden. The analogy did the trick. Once I had a bus driver who needed a surgery but was reluctant to get operated as he was scared of surgical complication. I told him, “Just like you take care to avoid accidents while driving, we take utmost care to avoid complications. Not every person who drives has an accident, similarly not every surgery ends up in a complication. Just like accidents, complications are rare.” He was convinced with my reasoning and was duly operated. Another question which I am commonly asked is, “Why do myopes have greater incidence of lattice degeneration?” My answer would be,” If you are given 2 equal lumps of dough and asked to make 2 rotis one small and the other one big, which one would end up being thinner?” When I get the answer I reply that myopes have a larger eye ball and hence the retina spreads thinner resulting in a greater incidence of lattice degeneration. Patients come to us after perfectly done cataract surgeries with less than optimal vision. Examination usually reveals a retinal problem. I explain to the patients that the eye is like a camera. The intraocular lens placed by the cataract surgeon is like the lens in the camera while retina is like the film of the camera on which the light falls. With this explanation, the patients usually understand that the retinal problem is unrelated to the cataract surgery performed. Similarly we get a section of patients who have problem in the cranial nerves and the brain with symptoms presenting in the eye. I explain that the eyes are absolutely fine but the nerves controlling or related to the eye maybe affected. To drive home the point I give the analogy of a switch which can be flicked on or off to control a remotely located light or a fan, an analogy which was taught to us by a neurologist during my under graduation.
A lot of purists might scorn at the idea of making simple analogies to the patient. They might feel that giving simple analogies would trivialise the serious medical conditions. They might suggest that these are uncharted waters and hence one must tread carefully. But if we are rigid about not using analogies, we might leave the patient all at sea!





Dr. Krishnan is a Vitreo-retinal consultant at Neoretina, Hyderabad.