Malpractice Management
Comanagement Conundrum
For your patients and yourself, document everything -- even if you're referring.
BY J. James Thimons, O.D.

K.T., a 45-year-old Caucasian female, first presented to Dr. R for evaluation of a complaint of irritation and redness when wearing her contact lenses. She had been experiencing this problem for the last two years and had followed the advice of different practitioners but had found no consistent answer to her dilemma.

Getting the whole story

At K.T.'s initial examination with Dr. R, her history revealed a steady increase in symptoms with lens wear that had caused a decrease in comfort and wearing time over the last six to eight months. Additionally, K.T. indicated that other practitioners had prescribed various drops. These drops helped somewhat, but had never resolved the problem completely. Also, as soon as she discontinued their use, the symptoms would return in several weeks to months. Recently, the symptoms occasionally appeared even when she wasn't wearing her contact lenses on the weekend.

Taking a look

Physical examination showed visual acuity of 20/20 in each with contact lenses and spectacles. Manifest refraction was �4.50D OD and �4.00 �0.75 x 180 OS. External examination revealed mild hyperemia. Pupils, extra-ocular movements (EOMs) and confrontations were unremarkable.

Slit lamp exam showed good lens position and movement, but the tear prism was reduced and tear quality was poor. Lids showed mild inflammation with some telangectasia and 2+ posterior lid disease. Lissamine staining was mild on both conjunctiva and NaFl staining showed no corneal involvement. Dr. R did notice a decreased tear film breakup time (less than seven seconds). The patient showed minimal allergic response. The remainder of the slit lamp exam was normal and the dilated fundus exam showed 0.4 cup-to-disc ratio OU with mild peripheral retinal changes without holes or tears.

Tackling the problem

Dr. R instituted a change in K.T.'s contact lens material and solution system to address the symptoms. He also recommend-ed artificial tears p.r.n. and scheduled K.T. back for follow up in two weeks, at which time she showed moderate improvement. Dr. R advised her to undergo punctal occlusion, which she did, one week later.

Dr. R saw her one month after occlusion for follow up. At this visit, K.T. indicated that her daily comfort was improved but not resolved, and that she wanted to consider refractive surgery because she was tired of all the "hassle" she was experiencing with her lenses.

A second opinion

Dr. R advised K.T. that he would be glad to evaluate her but that the dry eye symptoms she was experiencing might make her a less-than-ideal candidate. (Unfortunately, he didn't note this suspicion in the medical record).

K.T. returned in one week, having been out of her lenses for that time. Her symptoms had improved and the clinical evidence of inflammatory dry eye had decreased, but not vanished.

Dr. R was hesitant to recommend the procedure, but agreed to refer K.T. to a local refractive surgery center to obtain a second opinion. At that visit (two weeks later), she showed minimal change in any of her basic ocular refractive or clinical findings from initial exam. The surgeon who evaluated her advised that she might have dry eye symptoms after the procedure but that her success without contact lenses was encouraging. He recommended a course of topical steroids for two weeks before the treatment and advised K.T. that she may need to continue treatment after her surgery.

Going forward with surgery

K.T. elected to undergo a LASIK procedure bilaterally and achieved excellent refractive results at plano OD and �0.50D OS, both resulting in 20/20 + visual acuity. Unfortunately, Dr. R noticed at the one-week post-op visit that K.T. had 1+ diffuse superficial punctate keratitis and 2+3, Lissamine staining of the conjunctiva.

She also was symptomatic of dryness and irritation. The surgeon initiated treatment and started K.T. on topical cyclosporine 0.05% (Restasis) b.i.d. OU, as well as doxycycline 100 mg p.o. b.i.d. in addition to topical prednisolone q.i.d. Dr. R followed her at weekly intervals and the operating surgeon also saw her during the first three months of the post-op period. K.T.'s symptoms improved somewhat and a visible decrease in clinical findings was evident, but she remained unhappy with the overall level of comfort.

Trouble surfaces

At six months post-op, Dr. R received a request for medical records because K.T. had sought a second opinion from a local M.D. In the period following that visit, K.T.'s attorney contacted Dr. R and submitted a request for K.T.'s complete medical file. The operating surgeon also received a request for medical and surgical records regarding the case.

Reviewing the facts

What went wrong and who's at fault? In the area of refractive surgery, the issue of post-op dry eye is a significant concern and is the cause of numerous lawsuits. While it's possible for patients who have this presentation pre-op to eventually undergo a refractive procedure, it's imperative to establish that the symptoms and clinical signs had completely resolved before surgery.

In this case, while Dr. R identified and treated K.T.'s initial symptoms, he was unable to resolve them. This certainly increases the risk of post-op complications and should have been an indication to delay the surgical procedure indefinitely until the resolution of these issues.

Additionally, Dr. R elected to refer K.T. to a local surgeon for a second opinion. While this isn't an inappropriate decision, it in no way relieves him of his primary responsibility for the patient's welfare. In fact, in this case, it placed him in a more difficult position because the surgeon elected to proceed with a surgical procedure while the patient had clinically active dry eye.

In a co-management situation, the responsibility for the patient's welfare belongs equally to both clinicians. In this instance, the referral did not relieve Dr. R of legal liability nor did the decision on the part of the surgeon to proceed with the case change the issue. However, had K.T. sought the consultation on her own, then the circumstances would've been different. Additionally, had Dr. R documented his opposition to the procedure in the chart at the time of the initial exam or had he voiced his concerns at the pre-op visit, then his culpability on this issue would've been substantially less.

Know your responsibility

Both of the defendants have been deposed and the case is awaiting a trial date. Still, the lessons are clear: Co-management works well when both clinicians understand that they both bear responsibility for the patient and that the referring practitioner doesn't forfeit his liability by making a referral. Clinicians need to support the patient's best interest regardless of the opinions of others involved and, when necessary, actively counsel the patient regarding her options.

Dr. Thimons is a nationally and internationally acclaimed speaker and serves as medical director at Ophthalmic Consultants. He was awarded Optometry's Top Educator in 1999.