Honesty is the Best Policy When Things Don’t Go Well

By Anne M. Menke, RN, PhD

OMIC Risk Manager

Digest, Spring 2007

Faced with a medical error, patients want their doctor to do three things: explain what happened, say he or she is sorry that the patient experienced the poor outcome, and assure the patient that steps will be taken to prevent the same thing from happening to others.1 While many physicians want to talk to their patients in this way about errors and other adverse events, they may hesitate to do so for a variety of reasons. Some fear that disclosing errors and complications may prompt a lawsuit. Others may lack the communication skills necessary to respond to a patient’s anger and grief with compassion rather than defensiveness. When other health care providers or organizations are involved, some physicians may feel conflicting loyalties or be concerned about the impact of a disclosure discussion on collegial relationships, referral patterns, or credentialing.

Ophthalmologists calling OMIC’s Risk Management Hotline frequently ask for advice about revealing errors, offering apologies, or waiving fees. OMIC’s approach is founded on the principles of honesty, compassion, and fairness to both the ophthalmologist and the patient, and is designed to help minimize the risk and severity of claims and lawsuits. Over the years, articles in Argus (now published by the American Academy of Ophthalmology as EyeNet) and the OMIC Digest have offered advice on this topic. Dr. Jerome Bettman noted that “when complications arise, honesty is the best policy.” He encouraged physicians to “tell the patient what has happened as soon as possible.” Dr. Byron Demorest advised that “waiving your bill may avert a claim following a poor clinical outcome.” Paul Weber, vice president of OMIC’s Risk Management/Legal Department, reminded insureds, “don’t be afraid to say you’re sorry.”2 OMIC’s claims experience indicates that whatever the event or situation, communicating with the patient or patient’s family about the adverse outcome sympathetically and non- defensively within the shortest appropriate time period may help dispel much of the patient’s anger, confusion, and distrust. A patient’s belief that he or she is not being told the whole story, or is not being given the opportunity to ask the physician questions and vent feelings, often provokes a decision to seek the advice of an attorney and pursue a medical malpractice claim against the ophthalmologist. Indeed, studies have shown that patients who sued their physician often did so because their doctor did not help them understand what happened.

Patients who experience unanticipated outcomes are often confused about the difference between a poor or unsatisfactory outcome—a maloccurrence—and malpractice. An unanticipated outcome may or may not be the result of error or negligence, and not all errors are the result of medical malpractice. In fact, further investigation into an unanticipated outcome or allegation of negligence may reveal that what initially appeared to be malpractice was actually the result of the disease process itself or an unforeseeable or unpreventable complication of a risky, or even life- or vision-saving, treatment. To assist policyholders in dealing with patients following unanticipated outcomes, OMIC offers confidential, individual counseling through our Risk Management Hotline at (800) 562-6642, ext. 651. During these conversations, we help the ophthalmologist prepare for disclosure discussions, conduct an event analysis to evaluate the causes of unanticipated outcomes and improve patient outcomes in the future, respond to complaints, and weigh options when faced with a request for a refund. OMIC’s detailed recommendations on “Responding to Unanticipated Outcomes” are available as a document from our web site and are applied to case studies in two presentation formats, a CD and online course. This issue of the Digest illustrates many of these approaches. This article presents how an error, a complication, and unmet expectations were handled by three OMIC policyholders. Policy Issues discusses apologies in relation to OMIC’s policy coverage; the Closed Claim Study examines fee waivers; and the Hotline discusses waivers, refunds, and indemnity payments.

“Taking the High Road” When an Error Occurs

A 44-year-old man presented for bilateral LASIK correction of hyperopia. The next day, he reported significant visual difficulties, which examination revealed were due to high hyperopia and astigmatism. The ophthalmologist explained that the results were not what he expected. He told the patient he wanted to review the records and asked the patient to return the next day. The ophthalmologist contacted OMIC when he discovered that the patient had been treated with another patient’s laser settings. The physician explained that the first patient of the day had cancelled his surgery and that the second patient did not correct staff members when they repeatedly called him by the other patient’s name.

The ophthalmologist planned to tell the patient what had happened and provide treatment to address his visual difficulties at no charge. We agreed with his approach. After unsuccessful trials of contact lens and glasses, the patient underwent refractive lens exchange with implantation of a toric lens, followed by bilateral LASIK to treat residual refractive error, all at no charge to the patient. While his UCVA was 20/20 on the first postoperative day, his vision quality later deteriorated. At that point, the patient not only stopped seeing the surgeon, but sought legal advice.

An independent medical examination confirmed central irregular astigmatism that could not be corrected surgically, and BCVA of 20/80 OD and 20/100 OS. The ophthalmologist was disheartened that an error had harmed his patient but remained proud of “taking the high road” to stand by his patient and develop better patient identification policies. His honest, compassionate response was acknowledged by the plaintiff and his attorney. The case was settled for $85,000 on his behalf; the refractive surgery center paid $15,000.

Failure to Disclose Is Difficult to Defend

As sometimes happens in cataract surgery, a tear occurred in the posterior capsule, allowing a small fragment to drop into the posterior chamber. The ophthalmologist performed a minimal anterior vitrectomy and proceeded to place the IOL in the posterior chamber. Postoperative visual acuity was 20/100, with the IOP elevated at 30. The surgeon prescribed anti-inflam- matory, antibiotic, and pressure- lowering drops. Over the next ten months, the IOP fluctuated from a low of 18 to a high of 38, with VA progressively declining to LP. On the last visit, the patient expressed her unhappiness about the outcome and promised to seek a second opinion.

The patient was true to her word and ultimately filed a lawsuit, during which she learned for the first time of the intraoperative complication. Defense and plaintiff experts agreed that the surgery was indicated and that the complication itself was evidence of a maloccurrence rather than malpractice. Unfortunately for both the ophthalmologist and the patient, they also concurred in their criticism of the surgeon for neither documenting nor disclosing the complication. Furthermore, they noted that the postoperative management was negligent in that no effort was made to find or remove the lost fragment, despite ongoing problems with elevated intraocular pressure and decreasing visual acuity. They felt that an early referral to a retinal specialist could have resulted in a better outcome for the patient. The policyholder agreed, and the patient was compensated $200,000.

As this case demonstrates, physicians are often reluctant to inform patients of complications, but patients clearly want to be told. Indeed, one study showed that 98% of patients want to be informed of even a minor error, and the more severe the outcome, the more patients and families desire information. While 92% of patients thought they should always be told about complications, only 60% of physicians thought so. Similarly, 81% of patients said they wanted to know about future adverse outcomes associated with complications, but only 33% of physicians thought patients should be told about such adverse outcomes.3

OMIC policyholders who are unsure about whether and how to disclose an adverse event to a patient can discuss the matter with our risk management specialists. Had OMIC been consulted in this situation, we would have encouraged the ophthalmologist to approach the patient at her postoperative visit with the following information: “Mrs. Jones, as you noticed, your vision is not what you and I expected, and your eye pressure is high today. Yesterday, there were some problems during the surgery. Part of your lens fell into the back of your eye. If I had removed it, your eye could have been injured. I am putting you on some drops to control the pressure and swelling and prevent an infection. I’ll watch your eye closely. If the pressure doesn’t come down, or your vision doesn’t improve, I’ll want you to see a retina specialist who may need to remove the piece of lens. I’m so sorry this has happened to you. I’m going to do all I can to help you deal with this complication and protect your vision. Do you have any questions?” Such a discussion will not only strengthen the physician-patient relationship and help involve the patient in his or her care, but can also prevent an allegation of fraudulent concealment, which could open the door to punitive damages.

Some Patient Expectations Cannot Be Met

A 65-year-old presented to an ophthalmologist with a complaint of droopy upper eyelids. Examination revealed bilateral ptosis and mechanical upper eyelid entropion. After a detailed informed consent discussion, the patient agreed to a bilateral upper lid blepharoplasty and internal ptosis repair. The surgeon was pleased with the outcome; the patient was not. As she put it, she “missed the face she was born with.” The ophthalmologist responded with patience and compassion as the patient continued to express her discontent. When she wrote a letter threatening a lawsuit and complaint to the Centers for Medicare and Medicaid (CMS) if he did not pay for surgery by another ophthalmologist, the insured called OMIC for assistance. He was disappointed that the patient was unhappy but felt he had provided the best possible care. We agreed with his decision to deny her request and helped him craft a letter in which he stated that while he was sorry she continued to be unhappy about her outcome and the fact that surgery had not met her expectations, he was unwilling to pay for additional consultations or treatment. In response to the patient’s claim letter, OMIC had the case reviewed by an oculoplastics specialist, who felt the surgeon had provided excellent care. The patient’s com- plaint to CMS was similarly dismissed and the patient never filed a lawsuit.

Two of the ophthalmologists discussed in this article had frank but empathetic conversations with their patients about the unanticipated outcomes, while the third chose not to document or disclose the complication. All three received written patient complaints or demands for money, two of which resulted in indemnity payments. Talking to patients in a forthright manner will not necessarily prevent claims and lawsuits, but it will help physicians feel they have responded with dignity and professionalism, in accordance with the ethical standards of the American Academy of Ophthalmology and the American Medical Association. Such an approach can also decrease the amount the physician may need to pay to compensate the patient if compensation is warranted.

1. Vincent C, Young M, Phillips A, “Why do patients sue doctors? A study of patients and relatives taking legal action,” The Lancent, 1994; 343:1609-13.

2. Bettman, Jerome W, Sr, MD, “When Complications Arise, Honesty is the Best Policy,” Argus, May 1992. Demorest, Byron H, MD, “Waiving Your Bill May Avert a Claim Following a Poor Clinical Outcome,” Argus, Nov 1992. Weber, Paul, JD, “Don’t Be Afraid to Say You’re Sorry,” OMIC Digest, Spring 2001.

3. American Society for Healthcare Risk Management (ASHRM), “Disclosure of unanticipated outcomes: The next step in better communication with patients (first of three parts),” May 2003. ASHRM website, www.ashrm.org, accessed September 2004.

Off-Label Use of ICG Dye During Vitrectomy for Floaters

By Ryan Bucsi, OMIC Senior Litigation Analyst

 Digest, Summer 2007

ALLEGATION Lack of informed consent for off-label use of ICG dye during vitrectomy.

DISPOSITION The case settled for $30,000.

Case Summary

A patient with a past history of LASIK OU and floaters OU presented to an OMIC insured complaining that the floaters were worse OD than OS. The insured noted the patient’s vision at 20/20 OU and recommended a vitrectomy. During a preoperative work up the next day, LASIK scars were discovered on both corneas. A fundus exam displayed an unusual vitreous opacity with waves of vitreous material that obscured the view of the posterior pole. The left eye displayed the same abnormal vitreous but was somewhat less significant than the right eye. A vitrectomy was performed that same day. the operative note indicated that the insured used iCg dye on two separate occasions to visualize residual vitreous and then lavaged the eye each time to remove all remaining dye. Immediately following surgery, the patient complained of a large blind spot in the center of vision on the operated eye. He was evaluated by a retinal specialist, who measured the patient’s vision at 20/300 OD with no improvement. There was no other therapy available to improve the patient’s visual acuity.

Analysis

According to the expert witnesses in this case, at the time this care was delivered, the insured’s decision to perform a vitrectomy to treat floaters and use ICG dye to better visualize residual vitreous was a controversial one. Furthermore, the insured did not have a detailed informed consent signed by the patient. Rather, he had a dictated risk/benefit note in the hospital record of a conversation with the patient in which the ophthalmologist explained and the patient understood the risks of surgery, including hemorrhage, infection, retinal detachment, loss of vision, risk of cataract progression, and the visual limitations of pseudophakia. The surgeon was careful to report the patient’s acknowledgment that some individuals are not bothered in the same way he was by vitreous opacities and that the surgery was being performed to address the patient’s unhappiness with the quality of his vision. However, the dictated note did not address the off-label use of ICG dye and the risk of retinal toxicity. Accordingly, the patient not only alleged a lack of informed consent but also contended that the ophthalmologist minimized the risks, stating that the procedure to remove the floaters was “more simple than LASIK” and would not threaten his vision. The patient re- called only the risk of infection and the doctor’s assurance that an infection could easily be treated with antibiotics. it was certainly helpful that the insured had documented the discussion in the hospital record, but the case would have been more defensible if he had also used a procedure-specific consent form signed by the patient. The absence of any documentation on the use of ICG and the patient’s poor outcome supported the decision to settle the case on behalf of the insured.

Risk Management Principles

As this case and the lead article demonstrate, patients often forget or misinterpret what they are told and have a hard time recalling risks that the ophthalmologist disclosed to them during the informed consent discussion. Staff can improve patient understanding by using educational aids such as brochures, handouts, and videos. Having the patient sign a procedure-specific form can also help the defense in several ways. First, it serves as further evidence that the consent discussion took place. Second, patients can be given a copy of the form, and encouraged to read it again at home with their family and to call back if they have any questions. Finally, if patients experience a complication, physicians can use the document to help them come to terms with the outcome. in this case, the insured should have modified a procedure-specific form for vitrectomy to include information about the off-label use of ICG and asked the patient to sign it following a thorough discussion of the risks and benefits of the procedure. OMIC policyholders who need assistance developing forms that are not already available on our web site may call the Risk Management Hotline.

Risk Management Issues in Failure to Diagnose Neurologic Illnesses

By Jean Hausheer Ellis, MD, FACS

Digest, Spring, 1994

 Although it occurs infrequently, failure to diagnose ophthalmic-related neurologic diseases exposes the practicing ophthalmologist to significant malpractice risk because neurologic diseases tend to be associated with permanent disability and even death.

A computer search of 3,000 ophthalmology claims in the Physician Insurers Association of America’s (PIAA) data base turned up only 15 closed claims alleging failure of an ophthalmologist to diagnose a neurologically related disease. These 15 claims showed the patients’ conditions to be distributed as follows: tumors of the pituitary gland or other endocrine tumors and surrounding nerves or tissue, 8 claims; tumors of the thyroid gland, 6 claims; tumors of the nerves or tissue surrounding the eye, 1 claim. (See box)

All 15 claims allege that the patient’s condition was not diagnosed during an eye examination. Seven of the 15 resulted in an indemnity payment to the plaintiff. The average indemnity paid in these cases ($221,071) exceeded the average settlement for all ophthalmology claims by more than $100,000.

Nearly one quarter (3 of 13) of OMIC’s large loss payments (payments of over $100,000 to the plaintiff) have resulted from claims related to failure to diagnose an ophthalmic-related neurologic illness. The following lawsuits, culled from OMIC’s closed claim files, are instructive from a risk management standpoint because they illustrate the various ways an ophthalmic-neurologic claim can arise in an ophthalmologist’s practice and the different factors that contribute to these types of malpractice claims.

Case One: Pituitary Chromophobe Adenoma

The first case involved a 50-year-old male, who held two jobs to support his wife and three children. He was referred to an ophthalmologist (Ophthalmologist ##1) after complaining to his family practice physician that he was having difficulty with his vision. Ophthalmologist ##1 found normal vision, but did formal visual fields because of suspected glaucomatous cupping. Although not definitive, the fields were interpreted as possible early glaucoma, and the patient was started on Beta-blocker glaucoma drops. He was followed up one more time, and found to have excellent IOP control with therapy. A year later, the patient left the care of Ophthalmologist ##1 and was referred elsewhere by his family practice physician.

The family practice physician referred the patient to Ophthalmologist ##2 who diagnosed bilateral pterygiae. Because of the previously diagnosed glaucoma, a screening visual field was obtained of the left eye, but the patient was unable to complete the right eye field that same day. There was no chart documentation of visual field interpretation by the ophthalmologist, or discussion of these findings with either the patient or the family practice physician. Previous visual fields were obtained from Ophthalmologist ##1 but no comparisons or record reviews were documented. Formal visual testing OU was repeated several months later by Ophthalmologist ##2, but again the chart reflected only the technician’s notes of the testing. The patient continued using the glaucoma drops, but did not keep all his follow-up appointments because of his work hours.

Six months later, the patient was seen in the emergency room for complaints of severe headaches, for which he was admitted and discharged the same day. These headaches were felt by the ER physician to be migrainous. The next morning, the patient was found unconscious at his home and was taken back to the hospital, where he died the next day from subarachnoid hemorrhage related to a large pituitary chromophobe adenoma.

Lawsuit Targets Two Ophthalmologists

A lawsuit filed by the patient’s wife and three children named the family practice physician, the emergency room physician and the two ophthalmologists. The ER physician settled out of the case and paid nothing based upon a strong causation defense that, by the time the patient came to the ER, it would have been too late to operate anyway since surgery or radiation therapy are only effective before the lesion hemorrhages. The family practice physician settled for approximately $100,000.

The main targets of the lawsuit were the ophthalmologists, primarily Ophthalmologist ##2. Ophthalmologist ##1 paid approximately $100,000 to settle the lawsuit. Ophthalmologist ##2 was felt to have greater exposure than ##1 because he had consecutive visual fields that showed the evolving bitemporal hemianopsia. Expert witnesses and consultants in the case described the visual fields taken as showing “classic” signs of a pituitary tumor. Ophthalmologist ##2 paid more than $750,000 to settle the lawsuit against him. Total settlement by all parties in this case was approximately $1 million.

Close review of the formal visual fields show combined arcuate glaucomatous changes and bitemporal hemianopsia, as typically seen with pituitary tumors. The past history of glaucoma may have contributed to the misinterpretation of the visual field changes which, when compared with previous bilateral fields, clearly showed the progression of the bitemporal hemianopsia. While Ophthalmologist ##2 testified that he reviewed the fields and compared them, there was no record or documentation to support his testimony. Nor was there any communication to either the patient or the family physician regarding test results or contemplated follow-up.

Another problem in this case related to the patient being lost to follow-up. No system existed in the ophthalmologist’s practice for tracking patients who missed appointments, such as a recall card, telephone call from a staff member, or other form of communication to the patient or the referring physician, to inform them of the need for return testing and examinations.

Case Two: Giant Cell Temporal Arteritis

The second case involved a 67-year-old female who presented with complaints of extreme fatigue, loss of appetite, nausea, febrile illness, nasal congestion and purulent rhinorrhea. She also complained of migraine-like headaches across the forehead, and bilaterally down her face. She was treated for a viral syndrome and briefly hospitalized by her internist, who noted only slight improvement of the symptoms upon discharge.

The headache, fatigue, loss of appetite and nasal congestion persisted for another month, which the internist attributed to a prolonged viral illness. After experiencing these symptoms for six weeks, the patient went to the emergency room where she was treated for sinusitis, and given instructions to see the internist for follow-up. The patient returned to the internist as instructed with complaints of nausea and vomiting, persistent headache and neck pain as well as shoulder and calf pain. She was admitted to the hospital by the internist the same day for an ENT consultation, which confirmed acute sinusitis. Sinus surgery was scheduled for the next day.

During her hospitalization, the patient complained to her nurse of blurred vision in her left eye and a loss of vision for 2 to 5 minutes on the left side, immediately following the sinus surgery. Neither the patient nor the nurse informed the doctors of the 2 to 5 minute loss of vision and the nursing notes reflected only the persistent complaints of blurred vision and headache throughout the patient’s stay.

A routine ophthalmology consultation was obtained the day after surgery for “blurred vision.” The ophthalmologist took the history of blurred vision in the left eye, and obtained the patient’s description of seeing a “tree” in her left field of vision. No one explained to the ophthalmologist that the patient had been hospitalized at a different facility a month earlier, or that an elevated sed rate measuring 72 had been drawn at that time. Vision was found to be 20/80 in each eye at bedside, with normal IOP OU, and dilated fundus examination showed mild bilateral macular edema, which the ophthalmologist attributed to the recent sinus surgery. He recommended follow-up in his office upon discharge four days later.

Once at home, on the day of discharge, the patient told her husband she could no longer see out of her right eye. They immediately called the ophthalmologist, who instructed them to come in. He correctly diagnosed temporal arteritis.

At first, the patient refused to travel to a neighboring academic facility in another city for treatment. She was immediately started on 80 mg of oral prednisone and photographs were taken to document the fundus findings. The next day, the patient finally agreed to go to the recommended academic facility. Upon arrival there, she was placed in the Trendelenburg position and started on a high dose of I.V. methylprednisolone in an effort to salvage vision. A temporal artery biopsy confirmed the suspected diagnosis of giant cell arteritis.

Treatment was of minimal effect and the patient remains legally blind with Count Fingers vision OU. Unfortunately, there was no communication back to the referring ophthalmologist by anyone at the academic facility, nor did the referring ophthalmologist follow up with the patient.

A lawsuit was filed, naming the ophthalmologist, the primary care physician and the hospital nurse. The nurse settled out of court for $50,000, with the internist mediating for a total of $250,000. The ophthalmologist settled for $100,000, for a total settlement of approximately $400,000.

The nurse in this case was an important party because she claimed she had never heard of temporal arteritis before. At the time, it did not particularly concern her that the patient complained of a temporary loss of vision and continued bilateral blurred vision.

The controversial clinical issue in this case was the elevated sed rate. Expert opinions noted that a slightly elevated sed rate perhaps one in the 20’s or 30’s could be expected in anyone recovering from influenza. It was felt that the patient’s original sed rate of 72 probably would have been found to be elevated to 115 by the time of her second hospital admission, had it been repeated. Elevated sed rates should be followed and repeated to evaluate their rise and fall, to clinically correlate their course and to evaluate their suspected cause.

A second point of contention in this case concerned the role of the consulting ophthalmologist, who was expected to evaluate the overall clinical picture as well as the specific reason for being called in to see the patient. In addition to evaluating an ophthalmologist’s specialty training in the diagnosis and treatment of diseases of the eye, juries will consider whether a defendant-ophthalmologist’s overall training as a physician (i.e., medical school and internship) was applied to treating and assessing the causes of the patient’s ophthalmic illness.

Risk Management Suggestions

Both cases raise several liability issues and point out steps an ophthalmologist can take to reduce liability exposure to these types of claims. These measures include:

• Have a system for reviewing incoming records and making notations in the chart. Consider reviewing incoming records in detail and outlining the crucial elements, making comparisons with your own records. Document that you did so in the patient record.
• Always record interpreted visual fields in the patient record. Consider calling the patient back with the test results, or send a quick note. Include follow-up and medication schedules. Send the results to the referring physician.
• Develop a system for follow-up of missed appointments, making sure that all “no shows” are brought to the physician’s attention. All follow-up efforts should be documented in the patient’s medical record.
• Set aside all patient charts from the day’s appointments for quick review at the end of each day. Flag charts that you want to take a closer look at or to discuss with your partner or colleague. This is a good time to review missed appointments and prescription refills for that day.
• When in doubt about a clinical finding, consider bringing the patient back for a “second look” when you are able to set aside time for an extended appointment to review the situation in greater depth.
• Establish and maintain good patient communication skills. If a problem does develop, keep in contact with the patient and referring physicians. Be as caring, concerned and compassionate s possible. Do not give false assurances or guarantees, but take the time to be a good listener.

Conclusion

As observed in the above cited cases, the ophthalmic neurologic claim can be fairly complex and difficult to anticipate, and can arise in a variety of settings and circumstances. These patients could have entered any practicing ophthalmologist’s care. Although, in retrospect it may be easy to identify the problem areas contributing to these claims, neuro-ophthalmic diagnosis and correct management often remains an enigma. Unfortunately, the consequences of delay are uniformly severe.

Reduce the Risks of Mapping the Visual Field

By Ralph Z. Levene, MD

Argus, May, 1993

Next to acuity, the visual field is the most important determinant of visual function. Mapping the field has become increasingly complex during the past decade. The variety of instruments, methods and strategies to choose from, as well as the sea of numbers, can be overwhelming. Confusion over which instrument to buy and how to set up a visual field protocol may be eased by talking to an expert.

Even before technology offered so many choices, visual fields often were the source of many malpractice suits. Faulty technique, misinterpretation of results, failure to test or to follow up on tests often were to blame. The following risk management considerations can help you avoid these and other liability problems related to visual field testing.

First, ask yourself how your office performs in technique and interpretation. Do you or your technician need a refresher course? Are fields interpreted shortly after they are done? Are all interpreted fields filed together in the correct chart? An unread or misplaced field is not a legal defense.

What is your protocol on routine screening? Some ophthalmologists perform a screening on all new patients and periodically on regular patients, following up with a definitive field if the screening is suspicious. Others prefer to perform a definitive test when there are suspicious clinical circumstances. Both strategies can be legally and ethically correct.

However, delaying or failing to follow up on suspicious or puzzling clinical circumstances is a frequent factor in malpractice suits involving visual fields. In a case from the OMIC files, a physician notes a suspicious pale optic disc and an acuity of 20/20, but misses a pituitary tumor. He schedules the patient for a return visit in one year by which time the tumor has become inoperable.

In another case, a physician notes a suspicious cupped optic disc, visual acuity of 20/20, and pressures of 16. He schedules the patient for a return visit in six months. The patient fails to keep the appointment and the physician does not follow up. When the patient finally returns two years later with frank glaucomatous disc and visual field changes, the diagnosis of low tension glaucoma has been significantly delayed.

Does the defect fit the diagnosis? An ophthalmologist takes over the care of a patient being treated with a topical beta-blocker for glaucoma. Many of the patient’s visual fields have a vertical midline defect and pressures of 10 to 12. Relying on the previous diagnosis of glaucoma, the ophthalmologist misses a brain tumor.

Do you recognize artifacts and evaluate the reliability of each field? Some patients never yield a reliable field and others do so intermittently. The newer static methods are more sensitive to detecting defects but probably are more prone to artifacts. When in doubt or in unusual circumstances, repeat the field.

Is the defect progressive? This is a critical point in patient management. Apart from artifact, variations from test to test often are underestimated with consequent errors in interpretation. Case in point: an ophthalmologist has been treating a patient with an advanced case of glaucoma and a stable field defect. On a recent visit, a visual field, performed with reasonable reliability, shows an apparent change and is incorrectly interpreted as a significant progression. The ophthalmologist suggests surgery. The patient seeks a second opinion. A repeat field shows a previous stable defect. Unnecessary surgery, with the potential for a lawsuit, is avoided. The change interpreted by the first ophthalmologist as significant was actually a normal variation from one test to another.

Another factor to consider when evaluating results is whether there has been a change in technique. Switching from tangent or Goldman instruments to newer computer assisted methods can skew results. Discuss ambiguous results with an expert or refer the patient for a second opinion. Don’t be afraid to ask for help.

Don’t Defer Emergency Cases When Covering Calls for a Colleague

By Richard A. Deutsche, MD

Argus, August, 1992

Weekend, night and vacation call scheduling presents potential risk management problems if the on-call ophthalmologist does not see emergency cases in a timely manner. A review of ophthalmic claims reveals instances in which the operating surgeon and the on-call ophthalmologist were sued for failing to treat postoperative complications in a timely manner.

One case involved an elderly man who had an uncomplicated extracapsular extraction with a posterior chamber intraocular lens performed on a Thursday. The eye was doing well when the operating surgeon saw the patient the following day. On Saturday, two days postop, the patient developed pain and decreased vision. After failing to reach the surgeon, who had signed out to another ophthalmologist for the weekend, the patient was eventually able to contact the covering ophthalmologist by phone. He relayed his symptoms and was told to take Tylenol.

The next day, still complaining of pain and decreased vision, the patient was referred to another on-call ophthalmologist. When the patient was seen that evening, a diagnosis of enophthalmitis was made. On Monday, the patient was seen by a retinal specialist who did a vitreous tap followed by the appropriate treatment for enophthalmitis. Despite these best efforts, the eye was lost. The patient sued the operating surgeon and both on-call ophthalmologists for abandonment and delay in diagnosis.

Another case involved a middle-aged woman who had an uncomplicated retinal detachment repair with intravitreal gas performed on Friday. That evening, she developed pain and blurred vision. She called the retinal specialist, who had gone out of town, and was referred to the on-call ophthalmologist who prescribed Empirin with codeine No. 4 for pain. The severe pain continued and her vision worsened.

When the on-call ophthalmologist saw the patient the next day, her intraocular pressure was 70. Although the ophthalmologist immediately began appropriate treatment for intravitreal gas and control of the glaucoma, permanent damage to the eye had occurred, presumably from the prolonged elevated intraocular pressure, and the eye was lost. The patient sued the retinal specialist and the on-call ophthalmologist for failure to respond to the emergency.

In both instances, the claims may have had stronger defenses or been avoided altogether if the ophthalmologist on call had seen the patient in a timely manner.

Ophthalmologists are strongly advised to adhere to these risk management principles when arranging or accepting weekend, night or vacation coverage:

• When signing out, be sure to inform the ophthalmologist who is taking your calls of any recent surgical cases or any problem patients.
• When on call, keep your home telephone line open as much as possible so the answering service can reach you.
• If you are taking calls for a colleague, be readily available and willing to see patients regardless of the time of day.
• Keep notes of telephone calls you take while on call, and place these notes in the proper charts when you return to the office.
• Inform your colleague of any patients who contacted you during his or her absence.
• Remember that certain general ophthalmic emergencies such as a chemical splash in the eye, perforating eye injury, recent bulging of the eye, rapid onset of vitreous floaters, curtains or veils across the vision, photopsia and foreign bodies in the eye must be evaluated immediately.
• Postoperative patients who complain of pain, acute complete or partial loss of vision, infectious discharge or increased redness of the eye must be seen by an ophthalmologist as soon as possible. Do not delegate this duty to a non-ophthalmologist.

By following these guidelines, you can provide your patients with optimal ophthalmic care and decrease your exposure to litigation.