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January 2011

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A Judgment Call 

In “Screening for Stargardt: Choices Before Pregnancy” (Clinical Update, September 2010), Dr. Richard A. Lewis discusses his preference to leave moral judgment calls to patients. He seems to view his role as an information provider or public safety official.

With this preference as his starting point, I wonder how he might view his role in relation to a patient investigating the “best way” to commit suicide.

Had he said that he views the embryo as simply excess tissue and not a preborn human baby, I would have respected his rationale. But, then at least, he would have made an active moral judgment.

The tradition of Western medicine is intimately involved with moral judgments. The Hippocratic oath is a document about morals: how one should relate to patients, how one should view the sanctity of life, what practices one ought to avoid, etc. Stripped from an ethical framework, medicine will suffer when we simply provide whatever the patient desires. I fear this is already the case in our consumer culture with its exaggerated sense of autonomy.

Finally, it is ironic to me that I find these comments in the one publication that most emphasizes ethical behavior in our profession. Please keep up the good work in discussing what we ought to do and encouraging us to do it.

William A. Sray, MD   
Chesapeake, Va.   


The Balance Billing Debate: A Response 

I wish to thank Dr. Ginsburg and Ms. Stein for their thoughtful commentary regarding my perspective on greater patient-shared responsibility for physician services under Medicare (“Is It Time for Balance Billing?” November/December).

Unfortunately, they both misunderstood and mischaracterized my proposal as one of “unlimited balance billing.”

Surely, no one in this discussion believes that access to care will be the same if physician reimbursement is suddenly cut by 23 percent or more. My stated suggestion of cutting the Medicare allowance but not the limiting charge is a way to preserve a major benefit of the current Medicare system—that of excellent access to most physicians—without totally revamping the system.

Under my suggestion, the limiting charge would remain frozen at the 2010 level but would allow patients to essentially make up the 23 percent difference (imposed by the SGR cut in Medicare reimbursement) to see a nonparticipating physician.

This is not providing a raise for physicians and is certainly not the “unlimited balance billing” concept that Dr. Ginsburg and Ms. Stein argue so vehemently against.

Nonparticipating physicians can still take assignment on a case-by-case basis, and I believe that many physicians will do so for patients unable to afford the higher copay for necessary services. Perhaps if Congress knew that many seniors would share the burden of abrupt and arbitrary SGR cuts, they would not continue the legislative gamesmanship that continually threatens and whipsaws us with draconian cuts on an annual, and sometimes monthly, basis.

David F. Chang MD   
Los Altos, Calif.   

A longer version of Dr. Chang’s letter is available online at Scroll to the end of the November/December Balance Billing article to view it and to contribute your own comments.


Hearing Services and the Ophthalmologist 

In “A Look at Hearing Services in Eye M.D. Offices” (Clinical Update, June), Dr. Zacks stated that the Academy “can’t have ophthalmologists representing that the medical services they provide are identical to those of someone who, by training and experience, practices otolaryngology.”

I agree. I would challenge him to find any ophthalmic practice currently offering hearing services that represents itself as such.

Dr. Larkin, an audiologist quoted in the story, said she worries “about these practices that just go hire a hearing-aid salesman and put him in an eye care practice to do hearing tests.” Although other entities use this model, none of the practices working with Physician Hearing Service Inc. (PHSI) is doing this.

The audiologists and certified hearing instrument specialists are licensed professionals. A hearing instrument specialist is licensed to perform hearing testing and to dispense hearing aids—they are recruited and then retrained by PHSI to be certain that they will adapt to a strict medical environment.

The real argument is whether patients should be screened by an audiologist or hearing instrument specialist in a retail setting or in the setting of a licensed medical practitioner. After having a need brought to our attention by our patients, we identified a service that benefited seniors, a demographic that ophthalmologists deal with on a regular basis and in high volume.

With regard to Ocala Eye’s financial disclosure included in the story, the “related company” is PHSI itself. Our practice does not receive any referral fees for any practices that visit or discuss PHSI with Ocala Eye and sign up with PHSI.

Peter J. Polack, MD   
Ocala, Fla.   


Please Report All Perspectives 

The story “From Armenia to Tanzania: The Eyes of Hope and Change” (Clinical Update, November/December 2008) offers a touching account of the suffering of the Armenian victims of the Nagorno-Karabakh war (1988 to 1994) and of the continued efforts by Armenian ophthalmologists and surgeons to alleviate the pain of the Armenian war victims.

However, the article focuses solely on Armenian victims of the war, while Azeris are painted as pure aggressors. There is no mention of collateral damage visited upon Azeri civilians caught in this war.

Please remember that EyeNet is charged with the job of providing both sides of every controversial story coming from your pen.

Tural Galbinur, MD   
Arifa Mammadli, MS   
Sakina Ismayilova, MD, MPH   
Faik Orucov, MD   
Emin Alihuseynli, MD   
Toronto, Canada   

EyeNet regrets that the story did not include mention of the Azeri experience of the conflict. Dr. Roger Ohanesian, the Armenian-American physician who was interviewed for the story, recently told EyeNet: “I would see and treat patients from Azerbaijan as I have those from Syria, Iran and Armenia. Maybe diplomacy by ophthalmic care can work in this war-torn area.”



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