Viewpoint

Risky business

FROM THE CHIEF MEDICAL EDITOR

Larry E. Patterson, MD

At an ASCRS meeting last year, I met two young optometrists who shared a surgical comanagement arrangement that was new to me.

Comanagement itself is not new. Optometrists and even nonsurgical ophthalmologists routinely refer patients to surgeons for evaluation. I receive more than 80% of my surgical candidates this way. I evaluate the patient, talk options, risks and benefits, and if everyone agrees, we schedule the surgery.

NO SURGEON’S INPUT

What these ODs were doing went beyond that. Besides postoperative care, they actively participated in preoperative decision-making. They saw the patient and, if all agreed that surgery was necessary, the optometrist conducted the informed consent, biometry, IOL decisions and calculations, and scheduled the surgery for his contractor-ophthalmologist.

My jaw dropped. “So the surgeon never examines or sees the patient until the day of surgery, right before the operation?” “Correct” they answered. “Aren’t you or your surgeon worried about liability?” I asked. Seeing their puzzled look I continued. “Let’s say something goes badly. Do this long enough, and it will. That patient sues, and you’re in court. When the prosecutor has your surgeon on the stand and asks him, ‘Doctor, are you telling us you operate on your patients without examining them at all?’ how will he respond? That he is just too busy to see patients?” It was obvious they had never considered this.

Last month, the AAO and the ASCRS released a joint position paper entitled “Ophthalmic Postoperative Care,” and wrote that “the ... ophthalmologist has the ultimate responsibility for the preoperative and postoperative care of the patient, beginning with the determination of the need for surgery and ending with completion of the postoperative care contingent on medical stability of the patient.” (See our comanagement story on page 26.)

NO COPPER

I don’t want to patrol your practice — I want to keep you out of trouble. OMIC mandates the surgeon personally performs an independent evaluation and then obtains the surgical consent. I would think most medical boards would feel the same. This legal duty cannot be delegated. Deep down, I suspect those doing it know they are on shaky ground. While we know of specific practices doing it, nobody will go on the record.

But beyond legal reasons, why would you perform elective surgery on someone you’ve never examined? Are you that busy? What happened to that whole doctor-patient relationship? If you only see patients under the microscope, you may have become nothing more than a glorified technician — albeit a rich one. There are a certain percentage of referred patients, after a careful exam, I conclude surgery is not indicated. Patients are often thrilled and thankful to hear my decision.

We went into medicine to help people. While there’s nothing wrong with making money or loving how we earn it, letting dollar signs obfuscate The Hippocratic Oath will invite injury: maybe to the patient, but most likely the doctor. OM