Eyeworld

Mark Packer, M.D. David F. Chang, M.D. John D. Banja, Ph.D. Nick Mamalis, M.D. EW Ophthalmology Business 55 by Jena Passut EyeWorld Staff Writer All, some, or nothing: Surgeons discuss educating patients on IOL choices W hen it comes to in- traocular lenses, cataract surgeons and patients have many more choices to con- sider and discuss than in years past. From the finer points of surgery, such as peripheral corneal relaxing incisions, to the best fit lenses, whether they be monofocal, accom- modative, or multifocal, surgeons, technicians, and counselors are spending plenty of chair time going over options with patients. Are surgeons ethically responsi- ble for giving patients information on each option available, even if they don't offer those options them- selves? What happens when a pa- tient demands a lens that is not suited for him or her? Mark Packer, M.D., clinical as- sociate professor of ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland, mod- erated a panel discussion on ethics during the 2011 ASCRS•ASOA Sym- posium & Congress in San Diego. Part of the discussion included talk- ing about premium IOLs and the fol- lowing real-world scenario: A 65-year-old cataract patient with pseudoexfoliation syndrome and 2+ soft macular drusen becomes upset after being given monofocal IOLs because he has a neighbor who had cataract surgery and is boasting that he doesn't wear glasses at all. He asks, "How come I wasn't told about these premium lenses?" He's angry. Is someone at fault here? Panelist Nick Mamalis, M.D., professor of ophthalmology, John A. Moran Eye Center, Department of Ophthalmology & Visual Sciences, University of Utah, Salt Lake City, said sometimes the direct approach is the best one, although it's best to couch those words to prevent fur- ther irritation. "What you need to do in a nice, empathetic way is to say, 'You're not your neighbor,' but you don't say it like that. Say, 'There are differences between you and your neighbor. The reason I didn't tell you about this lens in the first place is because this lens is not right for you. You have a condition where you are at an in- creased risk for problems and if we put this lens in it could cause more problems.'" David F. Chang, M.D., clinical professor of ophthalmology, Univer- sity of California, San Francisco, and in private practice, Los Altos, Calif., said the scenario could be tricky for those surgeons who do not offer pre- mium IOLs. He presented his own what-if scenario to consider. "If I don't offer premium cor- recting IOLs and the patient is close to emmetropia, do I have to tell him or her even if I don't offer them, be- cause that's going to mean that the patient will probably go seek some- one else," Dr. Chang said. "I think if I were a patient, I would want to know. It's murky." IOLs are a product and patients have become consumers of those services, noted panelist John D. Banja, Ph.D., professor, rehabilita- tion medicine department, and medical ethicist, Center of Ethics, Emory University, Atlanta. Still, pa- tients shouldn't be given complete autonomy when making this impor- tant decision. "I think the lessons that we have learned from the marketplace are that patients want to know what their choices are," Dr. Banja said. "I don't think there's anything wrong, however, with the physician saying, 'These are the possible choices' and then strongly making a recommen- dation as to what he or she thinks is best for that patient. I think that is a totally acceptable and appropriate thing for a physician to do." Dr. Packer said his patients sign a long informed consent, on which they put their initials next to their choices, for example what type of procedure will be performed and what lenses will be implanted. The patient then confers with Dr. Packer about all the possible scenarios, good and bad, that could happen with the lens he or she has chosen. "I try to air all of the key issues in the time that I feel that I have with the patient so that we're com- ing to an agreement with each other about what we are going to do," Dr. Packer said. "The technician is the one who first works up the patient and begins this dialogue. When the patient comes in to see me, I ask, 'What do you know?' In the dia- logue, my recommendation emerges." Dr. Packer said many surgeons needlessly worry about the chair time that is used to talk to patients about their premium lens choices. "I think it is very important that we eliminate that from our think- ing," he said. "It's not about the time. It's about the quality of com- munication that occurs in that room between the doctor and the patient. It doesn't take long." Surgeons who aren't comfortable taking the time to obtain a true informed consent may need to look at their pricing structure for these premium lenses, he added. "Set your prices at a level you are comfortable with so you feel you are reasonably compensated for your time," Dr. Packer said. "Get rid of that resentment about wasting time, and get the true informed consent." Dr. Chang said surgeons are fo- cused on time because third parties are in control of reimbursements. "Yes, there are economic regula- tions for Medicare, but it isn't just time," he said. "I think it's what's between your ears that really inter- ests patients, and it's the extra preparation you do, the knowledge, the time you've invested to develop your skill set, your judgment, your integrity, and your compassion. That's what the patients want, and we shouldn't forget that's where the value really is, whether Medicare can charge for it or not." EW Editors' note: Dr. Banja has no finan- cial interests related to this article. Dr. Chang has financial interests with Alcon (Fort Worth, Texas) and LensAR (Winter Park, Fla.). Dr. Mamalis has fi- nancial interests with Abbott Medical Optics (Santa Ana, Calif.) and Alcon. Dr. Packer has financial interests with LensAR. Contact information Banja: 404-712-4804, jbanja@emory.edu Chang: 650-948-9123, dceye@earthlink.net Mamalis: 801-581-6586, nick.mamalis@hsc.utah.edu Packer: 541-687-2110, mpacker@finemd.com August 2011

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