Unfortunately, in the refractive surgery field, corporate
medicine has taken a foothold. This is not
a good thing. With an eye towards maximization of profitability for share
holders they have set up a system where the surgeon only operates and other
tasks are delegated with a team approach.
Sounds good.
Sounds efficient.
But
the surgeon is moved from city to city, state to state only to show up on the
day of surgery in those centers where
LASIK surgery has been scheduled in
advance. The surgeon does not examine the patient prior to surgery and is not
available locally to see the patient after surgery.
You would think nobody would ever consider
having LASIK under such circumstances, but people do every day.
In Richmond, there are two corporate operating LASIK
centers. Each uses a different execution plan for their “team” approach. Let`s
look briefly at their approach.
One of the corporate LASIK centers has a full time
optometrist. An optometrist is an eye doctor, not a surgeon and certainly not an
M.D. This person is introduced as “the doctor” who performs a thorough pre-LASIK
exam. The actual surgeon who will
perform the vision correction procedure is not even on the premises. The
surgeon actually lives in another state and travels to different states to
operate. This surgeon will review the
results of the LASIK evaluation and determine, based on that data, whether the
patient is a candidate for surgery.
While this may sound okay, the truth is that there is an
essential element missing from this flow. The surgeon never actually examined the eye. Tests were done and measurements
were made. But the surgeon did not even look at the cornea before surgery!
As a qualified, board-certified
ophthalmologist, I know there
are essential elements every surgeon should be examining his patients for. There
are things we can delegate and things we can`t, and one of them is actually examining
the patients ourselves prior to surgery. For example, say a patient has an old
superficial corneal scar. Such scars can sometimes cause complications when
making the
LASIK flap. The surgeon should be carefully and routinely searching
for such scars at the pre-op evaluation. If a scar is found, then clinical
judgment based on years of experience will determine what surgical technique
will be employed to avoid any problems during surgery. One might argue that a
very well trained optometrist could perform this function, but it is a cost
cutting short cut you need not subject yourself to.
What is even worse is what happens post-operatively. The
surgeon is not there the next day to examine you. This traveling surgeon is likely not going
to be there anytime you may call with a problem. If you do actually experience
a problem, it is possible for a trained optometrist to accurately diagnose it.
However, the surgeon is best trained for diagnosing post-operative complications
and planning a course of action. This is especially important if you need
surgical correction.
For example, let’s say your surgery was performed flawlessly
and your first day post-op check looks great. The next day you turn around and
one of your children accidentally pokes you in the eye. You feel pain and your
vision becomes very blurred. This could be because your flap is out of
position. The longer it is out of position, the more difficult it is to remove
wrinkles in the flap. This can lead to blurred vision.
The longer it is out of position the longer you feel the
very uncomfortable foreign body sensation.
You must see the surgeon for immediate repositioning of the flap. The
surgeon is in another state.
What do you do?
Good question.
Over the years I have seen several slipped flaps. I saw the
patients right away – weekdays, nights, weekends. I take the responsibility to
always be on-call for my patients; if I am out of town, then I delegate this
task to a corneal surgeon trained to perform LASIK. Otherwise, if you need me I
am there as I should be. Not complicated. Simple medical ethics based on the
best practice of medicine.
The second corporate LASIK center’s surgeon also travels
from city to city, state to state. The surgeon is only there on the day of
surgery. This scenario is different in that there is no in-house optometrist
that performs all of the pre-operative evaluation and the post-operative
care.
This center relies on a very
controversial system called “co-management”. In this system, your local
optometrist that has been caring for you over the years recommends this surgeon
for your
LASIK. Your optometrist performs the evaluation and post-operative
care.
Of course you trust the optometrist that you have seen for
ages. If this optometrist says you should see this very experienced surgeon
then you may very well take that advice, and you may feel very comfortable
being sent back to your eye doctor for the post-operative care. It all sounds
comfortable and cozy. This situation is called “co-management” because both
doctors are caring for the patient and thus it is deemed legal and fair that
both surgeons charge for this service. Usually your optometrist will get 20% of
the total LASIK fee.
What is wrong with this scenario?
Well the same things as stated above for the other
center. However, with the co-management
system, all too often the referring optometrist is very inexperienced at
managing the clinical care of LASIK. The optometrist may only refer one patient
a year. This inexperience could
certainly lead to dangerous misdiagnoses and delayed care.
So, I ask you: Why would you even consider corporate LASIK
centers? Because their marketing sounds
great? Because the itinerant surgeon has done a gazillion LASIK procedures? Or
maybe because they sound cheap (even though they are not lower in cost than
most other local centers)?
Is it really worth the health of your eyesight to take the
chance that you might be okay?
