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March 2013 EW MEETING REPORTER 153 Ethics and admitting when mistakes occur Winter Update's interactive format allows attendees to become part of the educational process. tivities. He said he is open with his patients when a case is difficult and tells the patient if he thinks he may have to go for another treatment plan than what was originally decided on. Don't undersell the importance of talking to the patient properly, Dr. Donnenfeld said. The question of whether a monofocal or multifocal lens should be used also came up. But the major point again was that patients' needs and demands are what come into play when choosing between a monofocal or multifocal lens. Dr. Steinert said, in his opinion, it is a personality choice between multifocal and monofocal lenses. He said originally with multifocal lenses it was the common opinion not to try to use them in younger people. "Over time, my experience has been the reverse," he said. Dr. Steinert said he has found that younger people adapt better than older people. Dr. Donnenfeld agreed with this point and said results have shown a better ocular surface, a healthy macula, and minimal astigmatism. A variety of treatment options for further correction after cataract surgery The panel also discussed what Dr. Donnenfeld called a fairly straightforward case, involving a 72-year-old woman who was unhappy one month after her cataract surgery. She was +1 a month following surgery, and Dr. Donnenfeld wondered what others would have done given the choice between a variety of treatment options. Jonathan Rubenstein, M.D., Chicago, said he would most likely choose a piggyback IOL and would stay away from surface ablation. He said surface ablation may not be the best option for an older female because of possible dryness and surface irregularity. He also said it would depend on what the refractive error was beforehand in choosing the technique. With a variety of other preferences in favor of surface ablation or piggyback IOL, Dr. Donnenfeld expressed his differing opinion. "I would 100% do an IOL exchange," he said. He said advantages of this procedure are that the patient does not have to be billed for it, and the IOL exchange is a fairly straightforward procedure. He said if the patient was coming back after around six months to a year, he then might prefer a piggyback IOL. Ethical dilemmas in treatment pose issues for ophthalmologists Difficulties can arise in treating patients based on what their cases need and the patients want, complicated by Medicare rules for reimbursement and the addition of marketing to practices, among other key ethical issues facing ophthalmologists. Dr. Bakewell discussed sample cases that pose ethical dilemmas for ophthalmologists, including ones involving femtosecond laser use. In his first case, a 70-year-old female Medicare patient had significant bilateral cataract formation and wanted surgery. The treating physician had a femtosecond laser and had educated the patient on the "merits of using the laser" in assisting surgery. The patient then wanted a monofocal IOL and for the physician to use the laser, but the only way for compensation in the case would be to charge for limbal relaxing incisions (LRIs). However, the patient had only 0.12 D of astigmatism in one eye, and zero astigmatism in the other. Dr. Bakewell said the dilemma lies in whether the physician should tell the patient that she has only minimal astigmatism, less than usually treated, but that charging for astigmatism is the only way to pay for the use of the laser. Physicians should be aware, he said, of how to deal with such ethical dilemmas, and that guidelines are in place to assist in these cases. "The big deal is that we don't want to get in trouble," said Dr. Bakewell. "Guidelines have been established by ASCRS and the AAO jointly in terms of femtosecond laser use." Dr. Stulting shared an experience where he made a mistake in a procedure and admitted it to the patient. Dr. Stulting said that when finding an IOL power for a procedure, it was accidentally calculated on a setting for a piggyback IOL rather than for the IOL that was going to be implanted during cataract surgery. In this case, Dr. Stulting said that he admitted his mistake and apologized to his patient. He told his patient that he understood if he wanted a second opinion but also explained a treatment option that he would use to try to fix his mistake. Medical ethicist John Banja, Ph.D., Atlanta, said he could not think of an instance when a physician honestly and truthfully admitted to a mistake and had it turn into a nightmare. He said a patient is more likely to get angry when an error is concealed and he or she finds out without being told. "When an error occurs, you cannot apologize enough," Dr. Banja said. He said a doctor is often upset and embarrassed about a mistake but that it is important to think about the patient rather than yourself. If you are being compassionate with a patient and you're projecting the attitude that you care about your patient and are embarrassed it happened, the patient might pick up compassion and empathy from you and project it back, Dr. Banja said. Roundtable discussion lively addition to meeting In the faculty roundtables and wrapup session, faculty from the meeting, including Dr. Steinert, Dr. Donnenfeld, and Dr. Cionni, met with attendees and discussed topics broached over the four-day meeting. At each table, faculty and attendees spoke about differing topics, from ethical dilemmas for ophthalmologists to consulting on individual patient cases from attendees. EW Editors' note: The doctors have no financial interests related to the day's discussions.