Risk Management

Practicing Beyond One’s Expertise: The Road to a Lawsuit

By Richard A. Deutsche, MD

Argus, November, 1993

Practicing beyond one’s experience and expertise is a not uncommon cause of medical malpractice lawsuits. Prior to performing a surgical procedure for the first time, an ophthalmologist has an ethical obligation and a legal duty to possess the necessary skill to safely perform the procedure.

The Academy’s Code of Ethics states: “An ophthalmologist should perform only those procedures in which the ophthalmologist is competent by virtue of specific training or experience or is assisted by one who is.” (Emphasis added.) The legal duty is set forth in jury instructions, which state that a physician must “use care and skill ordinarily exercised in like cases by reputable members of the profession.” Careful preparation and forethought prior to performing new surgical procedures is necessary in order not to breach either of these standards.

To gain the necessary expertise, most surgeons first acquire the relevant scientific and technical information by attending oral (didactic style) presentations, studying the scientific literature, and using interactive videotapes, which are becoming a popular and effective learning method. The second step is to attend courses offering hands-on laboratory practice. The number of wet lab courses a physician should take depends on the complexity of the procedure and the surgeon’s prior experience. The lab course should be designed to give each ophthalmologist sufficient time to learn the necessary surgical skills while in the laboratory under the instructor’s direction.

The next step is to observe and assist a surgeon experienced in the procedure. After the ophthalmologist has assisted a few times, it is strongly recommended that the physician be proctored on the first few procedures he or she performs. Studies have shown that beginning surgeons who operate under an experienced surgeon’s supervision can obtain excellent results with their first few procedures.

Certain procedures lend themselves to learning in steps. For example, phacoemulsification can be learned in several stages, making one change at a time. An ophthalmologist accustomed to performing extracapsular cataract extraction (ECCE) who wishes to convert to phacoemulsification should perform 10 cases of capsulorhexis prior to ECCE, progressing to 10 cases of phaco sculpting only, followed by ECCE. The physician can continue adding one system change at a time until he or she has mastered the entire procedure.

Many surgical procedures are now performed in the ophthalmologist’s office. Patient safety requires that before an ophthalmologist performs a new surgical procedure in the office, he or she conduct a careful analysis and inventory of necessary medical equipment and medication. Certain surgical procedures may require that the physician be trained and certified in CPR and have access to a crash cart. Sterilization equipment in the office may need to be upgraded to comply with regulatory standards. Office personnel may need to take additional training to improve their skills and obtain certification demonstrating they can assist during the new procedure.

Eventually, the ophthalmologist will be ready to perform the surgical procedure without a proctor. Physicians should bear in mind that ethical and legal issues may be evolving concerning the informed consent process when the surgeon is performing new procedures. Ophthalmologists should stay alert to any new legal requirements in their states concerning what information, if any, should be disclosed to patients about a surgeon’s limited experience with a procedure.

We need to remember how we learned new techniques during our residency. The same principles apply when we are in practice and are learning new techniques. By approaching new procedures carefully, complications can be decreased, and both the patient and the ophthalmologist will benefit.