Risk Management

Debunking the Exploding Cataract: Why You Shouldn’t Sell Surgery

By Michael R. Redmond, MD

[Argus, March, 1992]

A patient presents to the ophthalmologist’s office with a cataract and 20/40 Snellen visual acuity. Visual acuity with medium glare is recorded as 20/100. Cataract surgery is performed and goes well, but the patient develops a retinal detachment soon after surgery. Complications ensue and the final visual acuity is light perception. The patient sues the cataract surgeon on the basis that the surgery was unnecessary in the first place.

A young father, himself postop twice for strabismus surgery, has his son in the pediatric ophthalmologist’s office for the child’s strabismus follow-up. Allegedly, the ophthalmologist initiates a discussion and tells the father that he, the father, needs additional strabismus surgery and that it can be done simply and without problems. Postoperative restrictions develop, corneal exposure with keratitis ensues and the father endures additional surgeries without total relief. He sues the ophthalmologist alleging, among other things, lack of informed consent.

Were the surgeries marketed too vigorously? Expectations set too high? Were the surgeries themselves trivialized, potential complications minimized or not even discussed? Were the patients “solicited” for surgery?

In today’s medical milieu, the ophthalmologist must avoid any hint of pressure on the patient or the family to undergo an elective procedure. Physicians are required to inform patients about the therapeutic (surgical) alternatives available and the urgency or elective nature of a procedure, but they must avoid “selling” their services. If a patient is pressured to undergo an elective procedure and a less than satisfactory result occurs, the patient is much more likely to become angry and initiate a malpractice action. Under these circumstances, the patient is unlikely to admit to recalling discussions of risks and alternatives, but will likely remember assurances, trivializations and encouragement to undergo surgery.

Documentation and informed consent are two cornerstones of risk prevention and management. An ophthalmologist can never do too much in these areas but can easily, all too often, do too little. Because what an ophthalmologist does every day may become routine, the multiple complaints the patient expresses (e.g., headlight glare, inability to read, people not knowing whether or not the strabismus patient is looking at them) are not always recorded adequately in the chart. If the records do not substantiate the ophthalmologist’s claims, a jury is likely to doubt his or her credibility and may begin to suspect a lapse not only in charting but also in professional judgment and/or ethics. The ophthalmologist should also record anything of importance, i.e., test results, consultations and family members present.

Informed consent must include an understanding between the patient and the physician, not simply discussion and signing a piece of paper. The proper relationship and rapport between patient and physician can thus be established.

Ethically, an ophthalmologist should never pressure or cajole a patient to have an elective procedure. Such pressure could turn into a malpractice liability. Communicate, document and inform but never “sell.” After all, cataracts really do not explode.