As long as fees for refractive surgery remain at a certain level, ophthalmologists and optometrists will co-manage cases. And the very mention of this issue evokes strong emotions from proponents and opponents alike. Both have cogent arguments to support their views. Proponents, for example, point out that the practice of co-management is sanctioned and controlled by specific laws and regulations. But the issue goes deeper than that.In this month's issue, beginning on page 30, legal experts Robert Wade and Bruce Goldstein explain how to co-manage in compliance with the relevant regulations, and consultant Donna McCune offers a co-management protocol you can use in your practice. Their advice is certainly needed because violations are taking place.

Opponents of co-management complain about abuses all the time. About how some surgeons and laser centers cut checks for the care the independent co-managing O.D.s provide, which the law frowns upon. (Payment to the O.D. is supposed to come directly from the patient.) About how those payments are calculated as a percentage of the global fee, when they're supposed to be a percentage of only the surgeon fee. And about how in most LASIK cases, little post-op care is provided anyway.

Beyond the law, what does your conscience say?

We should, of course, be following the law, but we also must be able to look in the mirror and know that we're co-managing with integrity. As physicians, that should be just as important to us. For example, we should fully disclose our co-management arrangements to patients because they have a right to know how their money is being spent, not because laws make disclosure necessary.

Whether state or federal authorities swoop down on questionable co-management arrangements is only part of the issue. Doing what's right isn't easy, especially in our already busy practices, but we must choose the harder right over the easier wrong. As I tell my children: Integrity is making the right choice when no one else is watching.