DEC 01, 2009
Question: An optometrist refers patients to a “cataract specialist” from a neighboring state who flies into the community one day each month to perform a large number of prearranged surgeries. Is this ethical?
Answer: In order for this arrangement to be ethical, the surgeon must be performing appropriate preoperative assessment and postoperative care or must appropriately delegate portions of that care. Surgical and subspecialty associations (including the Academy) regard perioperative care as an integral part of surgical management. Although some aspects of perioperative care may be appropriately delegated, this scenario raises several significant concerns.
Appropriate surgical management begins with adequate preoperative assessment and a discussion that results in informed consent. A surgeon who delegates this function and does not make an independent assessment of each patient does not meet these standards. These aspects of surgical management may be considered within the exclusive competence of the surgeon and should not be routinely and/or completely delegated to nonsurgeons. Furthermore, a surgical candidate must make an autonomous decision to proceed; if the surgeon’s assessment and consent discussion occur at the operating room door, the circumstances may be considered coercive.
Postoperative care is also the surgeon’s responsibility, though with provisions for permissible delegation. Postoperative care arrangements must be discussed before surgery and consent obtained for the arrangement. Also, “routine” comanagement that primarily serves the physician’s economic interest, rather than the patient’s needs, raises both ethical and legal/regulatory concerns. While care that does not require the unique competence of an ophthalmologist may be delegated, responsibility should not—delegated services must be adequately supervised. This recommendation includes coverage for unanticipated problems requiring an ophthalmologist’s expertise. Appropriate coverage should be prearranged—not handled by referral to an uninvolved ophthalmologist or a local emergency department. Clearly, there will be circumstances in which ideal perioperative management must be modified, but these should be exceptions rather than routine practice.
Last, the itinerant surgeon risks being perceived as merely a surgical technician rather than a physician, which may compromise an adequate physician/patient relationship. If something goes wrong, the risk of legal claims against a relatively anonymous surgeon should not be underestimated.
For more information, visit www.aao.org/about and click “Ethics.” To submit a question for this column, e-mail it to ethics@aao.org.