OMIC Digest Archives 2017
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OMIC Digest: Vol. 27 | No. 1 | 2017
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“It’s just a PVD.”
GEORGE A. WILLIAMS, MD, OMIC Board of Directors
This issue of the OMIC Digest focuses upon the most common reason for a medical liability lawsuit: diagnostic errors and specifically diagnostic errors associated with retinal detachment. Detection of a retinal detachment or retinal pathology that may lead to a retinal detachment requires both an appropriate and timely clinical suspicion and the correct ocular examination.
Patients may present with a variety of complaints related to the primary mechanism of most retinal detachments, a posterior vitreous detachment (PVD). Flashes, floaters, spots, visual field loss manifesting as shadows or curtains, and simple loss of vision are the most common symptoms. The well-trained ophthalmologist typically recognizes such symptoms, but sometimes the message doesn’t get through. Perhaps there is a language problem, or in the course of a busy day the ophthalmologist fails to elicit or recognize the patient’s symptoms. Patients may fail to appreciate monocular symptoms or visual loss through denial or neglect. Unrecognized or unmentioned trauma may not be described for social or personal reasons. Regardless, it is our responsibility to determine the patient’s problem.
Once a diagnosis of retinal tear or retinal detachment is suspected, the ophthalmologist must proceed with an appropriate examination. The question of what constitutes an appropriate examination is often the focus of a medical liability claim. The American Academy of Ophthalmology Preferred Practice Pattern (PPP) on Posterior Vitreous Detachment, Retinal Breaks and Lattice Degeneration (available at aao.org) is an authoritative, peer-reviewed summary of the standard of care. All ophthalmologists who see such patients should be familiar with these recommendations. I can assure you that any plaintiff’s lawyer will be.
A couple of common issues repeatedly arise. The first is the need for a dilated examination with binocular indirect ophthalmoscopy and scleral depression. Some ophthalmologists (and many patients) are uncomfortable with scleral depression. However, the PPP clearly states that scleral depression is the standard of care whenever a retinal tear or retinal detachment is suspected. The second issue involves a suboptimal view due to media opacification such as cataract, vitreous hemorrhage, miosis, or poor patient cooperation. In such situations, B scan ultrasonography is required. If the ophthalmologist fails to perform either test, there is cause for concern.
Fortunately, the vast majority of people (myself included) with symptoms consistent with a retinal tear or retinal detachment will have an uncomplicated PVD. However, even after an appropriate examination confirms the absence of a retinal tear or detachment, the treatment process is not over. The ophthalmologist must instruct the patient and, importantly, the office staff concerning the need to return as soon as possible if there is a change in symptoms or vision. An office protocol concerning how to address such phone calls or patient contacts is a good idea and an example is available at www.omic.com. It’s hard to do the right thing if you don’t see the patient at the right time.
Diagnostic errors will always be inherent to the practice of medicine. That’s why you want a company with the financial strength and unsurpassed risk management programs of OMIC. The next time you think “It’s just a PVD,” remember one of Yogi Berra’s best aphorisms: “Never make the wrong mistake.”
OMIC declares another large dividend to be paid in 2018
We are pleased to announce a 20% dividend for policyholders renewing in 2018.
Since 2007, OMIC has declared dividends totaling more than $80 Million. To put this into perspective, on average, each of our physician policyholders has received cumulative credits equal to twice their annual premium. We are thrilled that our insureds have received two of the past ten years of coverage at essentially no cost – a tremendous return on the investment in our company. This good news is a direct result of our policyholder’s commitment to good medicine, which helps lower claim trends over time.
Our consistent return of premium places OMIC significantly ahead of our peer medical professional liability companies and is in line with a long-standing commitment to fiscal conservatism. From 2012 to 2016 alone, OMIC’s average yearly dividend of 20.8% far exceeded the average of 6.6% for other malpractice carriers. And, unlike many of our multispecialty competitors, we have returned all premium above what has been needed to prudently operate the company and maintain a strong surplus; and we’ve done so at the earliest opportunity.
The 2017 dividend will be payable as a 20% premium credit to insureds who renew their insurance with OMIC in 2018.
In addition, OMIC is also happy to announce that rates in all states and territories will remain unchanged throughout 2018. OMIC’s premiums in recent years remain quite competitive and we will do everything in our power to keep them as low as possible going forward.
We know that our success depends on our insureds continuing support of OMIC. Thank you for your loyalty and we hope you will spread the good news to colleagues who have not yet joined our company.
Diagnostic advice from the experts
ANNE M MENKE, RN, PhD, OMIC Patient Safety Manager
As reported in the lead article, our recent study of diagnostic error (DE) claims showed that the ophthalmologist’s care was the primary factor in the delayed diagnosis of retinal detachments (RDs). Experts evaluating such malpractice claims have the advantage of knowing the patient’s outcome and reviewing the records generated by all staff members and providers. They strive to understand the ophthalmologist’s decision-making process, and may support care they understand even if they would have handled the situation differently. They might ask the following questions to evaluate the care: How did the ophthalmologist decide which exams or tests to perform? What were the results? What determined whether to monitor a patient or refer to a retina specialist? What was the patient told? The reviews help identify breakdowns in the process of care. Here are some pearls extrapolated from these RD claims.
Q. The lead article noted that most patients in the study had RD risk factors. What caused ophthalmologists to miss them?
A. Experts reviewed the patient complaint and history provided to both practice staff members and the ophthalmologist to obtain a more complete assessment of risk factors. They noted many problems with obtaining, communicating, and documenting the presenting complaint and the history. At times, the staff member did not inform the ophthalmologist of reported symptoms or history (indicating both the need for education on RDs and a clear process for how to communicate this information). At other times, the ophthalmologist did not read the notes generated by the staff member that day, or his own notes from previous exams. It was especially difficult to defend an ophthalmologist when this key information was readily available in the medical record.
Q. When must I perform a dilated exam?
A. Experts largely based their opinion on the need for a dilated exam on the presence of risk factors for RD. Experts expected ophthalmologists to perform a dilated exam in patients with risk factors who reported a sudden vision loss or visual disturbance. For example, they felt fundus exams were required in patients with a history of lattice degeneration accompanied by a new complaint of floaters, those who complained of black spots after cataract surgery or reported recent eye trauma, before deciding that cataracts were the cause of the visual decline after trauma, and when there was no explanation for the vision loss. They often criticized ophthalmologists who did not perform dilated exams when longstanding patients with chronic eye conditions reported a recent, sudden decrease in vision.
Q. Do I have to perform scleral depression (SD)?
A. Experts had mixed opinions on the need for SD. They noted that comprehensive ophthalmologists (COs) do not always perform SD, even though the PPP from the AAO recommends it. They also acknowledged that patient complaints about discomfort often influence the decision to forgo SD. They were less critical of COs who did not perform SD if the patient was promptly referred to a retina specialist. In contrast, the experts felt that retina specialists should perform SD. They understood why an experienced retina surgeon who had a good view of the entire retina might not feel one was needed, but testified that they personally always perform one. All felt that documented SD would have significantly helped defend the care.
Q. What do I need to document?
A. Experts opined that ophthalmologists should document when dilated exams are done, whether SD was performed (and if not, why not), and the results of confrontational visual fields. They should include drawings of the retina. Positive and negative findings are both important, so ophthalmologists should include pertinent findings, such as the absence of tears, RDs, lattice, or hemorrhage. Document education about RD warning signs, including the provision of written instructions or brochures, as well as telephone advice.
Q. When should I refer my patient to a retina specialist?
A. Comprehensive ophthalmologists should consider early referral to a retinal specialist if they do not have a clear view of the back of the eye (e.g., vitreous hemorrhage present). COs should refer patients with a history of trauma if no SD was performed or if a clear view of the retina out to the ora serrata cannot be obtained. COs who put RD lower on the differential should reconsider and refer patients when diagnostic studies refute the initial diagnosis, when the diagnosis does not correlate with the patient’s complaints, and when there is no explanation for the vision loss. COs should have an especially low threshold for referring any such patients if they have known risk factors for RD.
Failure to diagnose a RD by a comprehensive ophthalmologist
RYAN M BUCSI, OMIC Claims Manager
A 57-year-old corrections officer presented to an OMIC insured comprehensive ophthalmologist on referral from the emergency department. The patient reported a fall at work where he struck the left side of his head, face, and hip. He explained that his vision became blurred after the fall. His vision was 20/40 OU with bilateral cataracts. The IOP OS was 9, which was low compared to the IOP OD. The insured referred the patient back to his primary care physician. One month later, the patient returned to the insured’s office and the insured noted a decrease in visual acuity to 20/125 OS; the IOP was still 9. The insured attributed the worsening vision to progressive cataracts OS>OD and referred the patient to a colleague for surgery, which was performed two months later. On postoperative day 3, the patient’s vision had further decreased to 20/150 OS. The insured diagnosed a retinal detachment and emergently referred the patient to a retina specialist. The following day, the retinal specialist performed a pars plana vitrectomy with laser to reattach the retina. Subsequently, the patient had two recurrent retinal detachments with scar tissue requiring two additional surgeries, a gas bubble injection and the placement of silicone oil. The retina specialist noted that any return of vision OS was unlikely. The patient’s final visual acuity was HM.
Analysis
Plaintiff expert’s theory was that the patient suffered a traumatic tear of a portion of his retina OS as a result of the fall and that the initial OMIC insured failed to diagnose this detachment despite it becoming progressively more severe during the time he saw the patient. As a result of this delay in diagnosis, the ability to re-attach the retina, once the detachment was diagnosed, was significantly lessened and was a substantial factor in bringing about the permanent loss of sight OS. The plaintiff experts were critical of the first OMIC insured since the patient associated the blurry vision OS with the fall from the moment it happened; the discrepancy in IOP between the right and left eyes with the left eye pressure being much lower after the fall than for the many years preceding it; the worsening visual acuity during the first month after the traumatic incident as further evidence of continued retinal detachment; and a rather superficial initial examination and lack of a dilated and funduscopic examination. Unfortunately, our defense experts agreed with plaintiff expert’s opinions on this case. Our experts believed that the second insured (the cataract surgeon) could also potentially be criticized for not performing a dilated examination prior to the performance of the cataract surgery. The plaintiff’s case was strengthened when the retina specialist testified at his deposition that the patient suffered a traumatically induced retinal detachment as a result of the fall. The retina surgeon declared that the detachment progressively worsened over the next few months. Due to the retina specialist’s impartial position in the case and his firm statements, he became the best expert for the plaintiff. Defense counsel estimated the likelihood of a plaintiff verdict at 80%. As a result, mediation was scheduled and the case settled for $475,000 on behalf of the fist insured, as he essentially took the blame for the substandard care, thus prompting plaintiff to dismiss the second insured and the group.
Risk management principles
The first insured performed only a cursory examination. He did not appear to take the recent fall into account when evaluating the vision loss. The diagnosis of cataracts could potentially explain the blurry vision, but the reason for the asymmetrical lower IOP was not explored. According to all experts in this case, the sudden vision loss and asymmetrical IOPS should have set off alarm bells. However, the insured did not appreciate or explore other explanations for the visual complaints once he diagnosed bilateral cataracts. Furthermore, the insured did not perform a dilated examination, which was indicated based on the patient’s presenting complaints and recent history of trauma. Had this been done it is more than likely that the insured would have discovered a retinal detachment, which would have increased the odds of all or some vision being saved OS. In addition, the lack of a dilated exam prior to cataract surgery represents another missed opportunity to have diagnosed the retinal detachment.
