Preconceived notions are commonly seen when treating patients with venous disease. Physicians need to learn how to deal with these, especially when they are not compatible with what you believe is the right decision for treatment. The treatments in this field have often been patient-driven, and the patients have usually done a good amount of research before coming into your office. For new patients, I generally leave a good amount of time for introduction, conversation, and education. Our new patient appointments are usually at least 30 minutes in length, and most of this is face time. Often, patients have a specific treatment in mind (eg, laser of the ankle spider veins), but they do not want any evaluation or treatment of the varicose veins in their knee or thigh area. When dealing with more demanding patients, I have developed several strategies to help change their opinions about what might be best to treat their condition.


Here are a few tips on how to convince patients that what they wanted when they walked in might not be what is really best for them:

1. Listen to Your Patients

Establish what their real goals are and what their reasoning might be for wanting one particular procedure over another.

2. Know the Literature

You should be the expert, and you should be able to quote statistics from some of the landmark articles. Read the venous journals every month and participate in studies if possible.

3. Attend the Venous Meetings

These meetings will help you get the most up-to-date information and to hear and discuss different opinions with other experts in the field. This can help to arm you with the proper arguments if you really do not want to proceed with what the patient wants. The American Venous Forum and the American College of Phlebology have meetings that are rich with up-to-date information about all aspects of venous disease.

4. Educate Your Staff

Make sure they understand the principles of venous disease and have them reinforce the instructions for the patients. Pre- and postprocedure instructions should be verbally reinforced by your staff. The typical course following procedures should be described by the clinical staff, and they should offer to answer any other questions. Written instructions should be reviewed with the patients. Both the clinical help and the front desk secretarial staff should be familiar with the routine pre- and postprocedure instructions, and they should be fluent in their discussions with the patients about the expected course. Patients are reassured by the consistency of the office staff explanations, and it further reinforces your medical judgment.

5. Use Objective Materials to Make Your Point

For instance, these might include before and after photos. Show the patient’s actual ultrasound images, magnetic resonance venography, CT venography, or worksheets documenting the areas of reflux, obstruction, diameters, depths, etc. Literature or pamphlets explaining the procedures and the indications and contraindications for the procedures can be useful. I also put the patients into a room with several informational posters before they see me, which helps to lay the groundwork for my explanations.

6. Work Through a Decision Tree

This will help patients understand the algorithm of how we choose various treatments. Draw diagrams of their anatomy, and make notations of your observations on the diagram (and give the patient a copy to review later on).

7. Take Small Steps

If the patient seems to be uncomfortable with your approach, try to find a compromise, or stage the procedures, if possible, to help reassure the reluctant patient.

8. Give the Patient a Choice

If it seems reasonable, I will give the patient a choice, as long as I am sure that he or she understands the risks and benefits of all the treatment choices.

9. Make Sure Not to Rush

Sit down and look your patients in the eyes. Take a thorough history, and perform a careful exam, explaining why you need that information. I often try to make them feel more comfortable during the exam by mentioning what I am looking for and what I am seeing or not seeing as I proceed.

10. Explain the Natural History of Venous Disease

You might say that it is often like tending a garden. They need to be aware that there will likely be some recurrences, and that you will be there to help them if this occurs. Eventually, they will develop a trust in your judgment if you do all of these things. If they remain skeptical, I will remind them that most of these situations are not emergencies. They can think about their options, do some more research, and return for a follow-up and re-examination at certain intervals if we cannot find an agreeable solution.

11. Be Honest With Them

Let patients know which tools you feel comfortable with and which ones you do not use on a regular basis. Refer them to someone else who may perform the procedures that you do not personally do, and be up front about this. They will respect you and trust you more if you are honest. You may even get more referrals from this patient, just by referring them to another expert for the procedure they originally wanted.


Do not let the patient talk you into something that you are not comfortable doing. This can be a recipe for disaster. If you compromise and change your protocols, you may find that the results are not what you would like. Managing patient expectations is key, and if you cannot reach an agreement, I recommend that you tell these patients that they may want to get another opinion.

Julianne Stoughton, MD, FACS is with Vascular Surgery, Massachusetts General Hospital and Harvard Medical School in Boston, Massachusetts. She has stated that she has no financial interests related to this article. Dr. Stoughton may be reached at