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Delegated Services

Advisory Opinion of the Code of Ethics

Issues Raised:

(1) How is it determined which services can be properly delegated and which cannot?

(2) What requirements apply when services are delegated?

Applicable Rules:

Rule 7. Delegation of Services

Rule 11. Commercial Relationships

Background

Rule 7 of the Code of Ethics addresses the use of auxiliary health care personnel to provide eye care services for which the ophthalmologist is responsible. Referral to other doctors of medicine or osteopathy, even junior members of a practice group, is not such "delegation" and therefore is governed by other rules from the Code of Ethics, not by Rule 7. Also, in some cases relations between ophthalmologists and opticians might be governed by other rules that do not appear relevant in this case, such as Rule 11.

Inquiry

Facts - Dr. M, a Fellow of the Academy, has established a private practice in general ophthalmology. She employs, among others, a licensed optometrist and an unlicensed assistant. Dr. M uses the services of the optometrist to perform refractions and the assistant to plot visual fields and perform other data‑gathering functions. She has personally trained the assistant and supplemented the training of the optometrist. She supervises the activities of both on a daily basis, and knows both to be competent. In the same building in which Dr. M practices, a licensed optician has offices. Dr. M has no business relationship with the optician, but she has directed patients to the optician (as well as to other opticians) for filling prescriptions for spectacles, with satisfactory results. Dr. M wishes to know whether these arrangements are consistent with the Academy's Code of Ethics.

Resolution - The first provision embodied in Rule 7 is that ophthalmologists remain "responsible" for the eye care services provided by personnel under their supervision. Whatever the degree of appropriate delegation, Dr. M remains responsible for the quality of services provided by the optometrist and assistant as part of her practice. It appears from the facts presented that she has trained and does supervise both.

Rule 7 does not mandate a particular mode or degree of proper supervision. Under various state laws, supervision requirements may vary from required direct, onsite supervision to appropriate standing orders and telephone consultations. An ophthalmologist must comply with such laws in addition to as well as with the requirement in the rule that the auxiliary be "qualified and adequately supervised." It appears from the facts presented that the optometrist is licensed, and in the absence of any facts to the contrary, it is assumed that Dr. M has a reasonable basis for believing that both auxiliaries are competent.

Dr. M is not responsible for the professional performance of the optician, who is not under her control. Of course, ophthalmologists should not refer patients to an optician if they believe that the optician does not provide high-quality services. But in the case presented, the optician's services have been adequate.

The next important issue raised by Rule 7 is the scope of services that may be properly delegated. The rule makes it clear that it is ethical and appropriate to delegate certain functions, in conformity with state law and the Code of Ethics. Any services that under applicable state law an auxiliary is licensed to perform are therefore not within "the unique competence of the ophthalmologist" under that state system, and they may be legally delegated. Under the rule, ophthalmologists "must not" delegate those tasks that are within their unique competence. Naturally, since state laws vary, practices on delegation will also vary, and the rule's reference to the "unique competence of the ophthalmologist" does not preclude this.

However, the overriding concern of Rule 7 is to insure the best care for the patient (see also Principle 1). Therefore, ophthalmologists are not required to delegate at all; they may perform all services themselves. Moreover, the fact that a particular service under state law is permitted to be performed by others does not require ophthalmologists to delegate it to particular individuals, if doing so would not be in the best interests of the patient. Ophthalmologists may, but need not, delegate services, depending on their discretionary professional judgment about the individual's skills and the interests of the patient, among other factors.

Dr. M has delegated refractions to the optometrist and visual field plotting to the assistant. Under most, if not all, state laws, these tasks are not within the "unique competence" of the ophthalmologist; therefore, apart from any special local regulation, Dr. M is free to delegate such services under adequate supervision. Other tasks that frequently are permitted to be delegated to auxiliaries are taking the patient's history, visual acuity testing, measuring eye pressure, administration of topical medication, and nursing care. While some auxiliaries, such as optometrists, perform certain of these functions independently, when they function under the control of an ophthalmologist, the supervising ophthalmologist is subject to Rule 7 and its requirements of adequate supervision.

The final sentence of Rule 7 reflects the recognition that whatever the ideal allocation of eye care functions is, emergencies and other special circumstances may require different arrangements. However, in an emergency, for example, Dr. M would not be failing to conform to the rule's requirements of "adequate supervision" if in her absence and after her telephone authorization, the office optometrist performed certain functions that he/she might not customarily perform, provided that Dr. M reviews the patient's condition as soon thereafter as feasible.

Applicable Rules:

"Rule 7. Delegation of Services. Delegation is the use of auxiliary health care personnel to provide eye care services for which the ophthalmologist is responsible. An ophthalmologist must not delegate to an auxiliary those aspects of eye care within the unique competence of the ophthalmologist (which do not include those permitted by law to be performed by auxiliaries). When other aspects of eye care for which the ophthalmologist is responsible are delegated to an auxiliary, the auxiliary must be qualified and adequately supervised. An ophthalmologist may make different arrangements for the delegation of eye care in special circumstances, so long as the patient's welfare and rights are placed above all other considerations."

"Rule 11. Commercial Relationships. An Ophthalmologist's clinical judgment and practice must not be affected by economic interest in, commitment to, or benefit from professionally related commercial enterprises."

Other References:

"Principle 1. Ethics in Ophthalmology. Ethics addresses conduct and relates to what behavior is appropriate or inappropriate, as reasonably determined by the entity setting the ethical standards. An issue of ethics in ophthalmology is resolved by the determination that the best interest of the patient is served."

American Academy of Ophthalmology Advisory Opinions of the Code of Ethics, Postoperative Care and Employment and Referral Relationships Between Ophthalmologists and Other Health Care Providers.


Approved by: Board of Directors, June 1984
Revised and Approved by: Board of Directors, June 1992
Revised and Approved by: Board of Directors, October 1996
Revised and Approved by: Board of Trustees, June 2000
Reaffirmed by: Board of Trustees, February 2003
Reaffirmed and Approved by: Board of Trustees, June 2006