Risk Management

A Medical Board Investigation Handled Perfectly

 By Ryan Bucsi, OMIC Senior Litigation Analyst

 Digest, Winter 2007

ALLEGATION: Complaint to state medical board of loss of vision following laser treatment for diabetic macular edema.

DISPOSITION: Medical board did not pursue investigation following defense attorney’s letter of response.

Case Summary

 A patient presented to an OMIC insured’s office with a visual acuity of 20/40 in the right eye and 20/60 in the left eye. The physical examination revealed clinically significant diabetic macular edema in both eyes with foveal lipid in the left eye. The ophthalmologist subsequently performed laser treatment on each eye on separate dates. At the follow-up examination, the patient did not exhibit any change in visual acuity or complain of any loss of vision. The diabetic macular edema resolved in the right eye but persisted in the left eye, so the surgeon performed another laser procedure.

The insured’s associate evaluated the patient at her follow-up visit two months later. Although the patient had never called to report any visual acuity loss, she now said that she had not been able to see well since the second procedure. Her visual acuity was 20/400 in the right eye and count fingers in the left eye. She was diagnosed with severe diabetic macular edema in both eyes with possible macular ischemia. The associate recommended a repeat fluorescein angiography to assess the perfusion status of the maculae and to evaluate the vascular status of the retina in each eye.

 The patient chose not to return to the insured. The insured then advised her in writing that the advanced state of her condition required that she either come in for a follow-up appointment or see another ophthalmologist; he warned that lack of care could further jeopardize her vision. The patient reportedly sought care with another ophthalmologist as advised.

Analysis

The patient filed a complaint with the state medical board alleging that her compromised vision in both eyes was a result of the second laser treatment. The insured and his attorney worked together to craft a response to the medical board complaint and an expert witness was retained to evaluate the care. The physician’s letter to the medical board started out by admitting that the laser treatment did indeed cause destruction of the macular retinal tissue responsible for central visual acuity but that it could do so only in the treated eye. Notably, the patient had complained of delayed bilateral visual loss, for which another cause needed to be found.

The retained expert supported the physician’s care, opining that the procedures were indicated and appropriate for the patient’s macular condition and that there was no objective or significant change in her visual acuity immediately following either of the treatments. The expert felt that the most likely cause of the patient’s vision loss was her underlying diabetic retinopathy, which had progressed rapidly due to other factors such as duration of her diabetic condition, degree of blood sugar control, underlying vascular disease, compromised renal function, and anemia. This worsening of the patient’s diabetic retinopathy may have led to macular ischemia and progressive leakage of fluid and lipid from incompetent diabetic macular blood vessels.

Risk Management Principles

This case exemplifies how a medical board investigation should be handled. Even though the ophthalmologist was confident that he had met the standard of care, he immediately reported the matter to OMIC’s claims department. The OMIC litigation specialist for the insured’s state promptly referred the case to an attorney, who in turn retained an expert. Within one month of the date of the medical board letter of investigation, the OMIC attorney had worked with the insured to draft a response. Furthermore, the expert signed an affidavit supporting the physician’s care; this affidavit was attached to the letter of response. The medical board decided not to pursue the matter and concluded its investigation. The insured’s willingness to cooperate and work with the OMIC-appointed attorney to craft an effective response was a key factor in averting a potentially costly and time-consuming medical board investigation.