As I See It

Remember Your Priorities: Patient First, Money Later

An exam room is not a bully pulpit.

By Paul S. Koch, MD, Editor Emeritus

"No offense, doctor," she said, "but you were not my first choice. The surgeon I thought I wanted didn't make a good impression on me, so I came here to check you out."

How could I pass up such an interesting opening? I sat back and gave her leave to continue. I have no idea whether the events she recounted took place as described or if she embellished them. It doesn't really matter. Whatever happened, she wasn't one bit happy about it. I could tell by the way her voice got louder and faster.

Several friends had recommended this other doctor. I know him. He's really good. The patient had no cause to question his surgical skills.

After the technician's workup, the patient waited for the doctor. She saw him pause at the door, studying her record. He walked in and said, "You need a toric lens implant. It costs me $500, so I'm going to charge you $600."

She was infuriated. What, no "Hello?" No "How do you do?" No "How can I help you?" No "What is your problem?" No "Yes, I can help you?" Not even a "Here's what your problem is?" And what the heck is a toric lens anyway and why do I have to pay for one?

Dollars and Sense

Why was this doctor more interested in money than in her? He talked about money before introduction, history, examination, diagnosis and recommendation!

How did he get this way? In this case, I knew immediately what happened because I had lunch with this surgeon only weeks before. This warm and compassionate doctor had taken a course in premium IOLs and bought into the conclusion that his primary job was to assess each patient for one of these lenses. And so he did, even before meeting the patient to learn about her problems and her needs.

One speaker at the course had said he could probably be sued if he didn't inform patients about their options for new lenses, whether he used them or not. Faced with this declaration, our friend developed a paranoia that offering a premium IOL took precedence over explaining cataract surgery. He felt he had no choice, because failure to discuss lens options could be a violation of someone's pronounced standard of care and he could end up in court.

Standard of Carelessness

Let me digress. A procedure performed in fewer than 10% of cases may be a perfectly good option, but it is not the standard of care and it is wrong to bully someone into thinking that it is.

Let me digress again. Informing patients about lens options is appropriate, but if you believe that a discussion about premium lenses is mandatory, do you already inform your patients about existing lens options, telling them about alternatives that lack the potential for glistenings, dysphotopsias and aberrations? Or do you not because there is no money riding on the outcome of the discussion? Come on, be honest. You don't discuss these things now, do you? I didn't think so.

I like using premium lenses and I would have one myself. I have a counselor who discusses them with every surgical candidate. However, just like offering phacoemulsification and lens implants a generation ago differentiated my practice from others, offering premium lenses is a differentiator, not a standard of care.

You can embrace them, or you can ignore them, but no one should make you feel you have to use them any more than a corneal surgeon could be forced to do a DCR, or a retinal surgeon a trabeculectomy. Surgeons may offer whatever services they are comfortable with — not services someone else tells them they must. OM

Paul S. Koch, MD is editor emeritus of Ophthalmology Management and the medical director of Koch Eye Associates in Warwick, RI. His e-mail is: paulkoch@kocheye.com.