1. 0 Case Study Conflict of Interest Learning on the Job What your Patients Should Know

2. WWW.AAO.ORGAMERICAN ACADEMY OF OPHTHALMOLOGY Case History  75-year-old male  POH significant for: Fuchs endothelial corneal dystrophy Cataracts  Status post CE with MFIOL OU UDVA 20/25 OU; UNVA J2 OU Trace corneal stromal edema OU Referred to a cornea specialist for DMEK OU

3. WWW.AAO.ORGAMERICAN ACADEMY OF OPHTHALMOLOGY Case History  Patient is referred to Doctor Guttae Cornea specialist at a major academic institution Performs a large number of endothelial keratoplasties each year (DSEK) Has not performed DMEK previously but wishes to primarily so that he will continue to be viewed as a leader in the field of EK surgery

4. WWW.AAO.ORGAMERICAN ACADEMY OF OPHTHALMOLOGY Case History  Doctor Guttae advises the patient He is an experienced EK surgeon DMEK is a newer form of DSEK that provides better visual outcomes Although he has not performed DMEK previously, the surgical technique is essentially the same as DSEK, and thus he feels comfortable performing the procedure The risks of the procedure include donor dislocation and primary graft failure, which are the same as DSEK

5. WWW.AAO.ORGAMERICAN ACADEMY OF OPHTHALMOLOGY Case History  Doctor Guttae does not advise the patient Dislocation rate and primary graft failure rate for DMEK are higher than DSEK Dislocation rate and primary graft failure rate are higher for inexperienced DMEK surgeons compared to experienced DMEK surgeons

6. WWW.AAO.ORGAMERICAN ACADEMY OF OPHTHALMOLOGY Case History  The patient has an uneventful DMEK procedure  Donor Descemet membrane is dislocated on POD # 1 and requires repositioning

7. WWW.AAO.ORGAMERICAN ACADEMY OF OPHTHALMOLOGY Case Discussion  What ethical issues, and corresponding Rules of the Code of Ethics, are involved in this case?

8. WWW.AAO.ORGAMERICAN ACADEMY OF OPHTHALMOLOGY Case Discussion Ethical Issues  Rule 1. Competence Obligation to provide patients with the highest quality care possible Necessarily involves “learning curve” while acquiring new skills  Surgeon obligated to learn as much as possible about the procedure and outcomes before deciding to perform the surgery  Surgeon should consider obtaining certification or training in the procedure, if possible

9. WWW.AAO.ORGAMERICAN ACADEMY OF OPHTHALMOLOGY Case Discussion Ethical Issues  Rule 2. Informed Consent Accurate description of surgeon’s experience if likely to affect the patient’s decision to proceed with surgery  Should include discussion of complication rate for beginning and experienced surgeons, if significantly different

10. WWW.AAO.ORGAMERICAN ACADEMY OF OPHTHALMOLOGY Case Discussion Ethical Issues  Rule 9. Misrepresentation of Procedures Truthful, accurate description of procedures  Should avoid giving the patient the perception that newer necessarily means better

11. WWW.AAO.ORGAMERICAN ACADEMY OF OPHTHALMOLOGY Case Discussion Ethical Issues  Rule 15. Conflict of Interest Recognition of factors that can influence treatment recommendations  Desire to perform new surgical procedures – Perceived superiority to current surgical procedures » Surgical difficulty » Surgical time » Postoperative management » Visual outcomes – Interest in expanding surgical repertoire

12. WWW.AAO.ORGAMERICAN ACADEMY OF OPHTHALMOLOGY Case Discussion Ethical Issues  Rule 15. Conflict of Interest Recognition of factors that can influence treatment recommendations  Potential financial benefit – Ability to perform more surgeries in the same time – Marketing advantage over competitors  Desire to be seen as an innovator or leader – Increased notoriety among peers – Generation of data for presentations/publications

13. WWW.AAO.ORGAMERICAN ACADEMY OF OPHTHALMOLOGY What Do You Think?  Is Dr. Guttae obligated to tell the patient that he has not performed DMEK previously?  Is Dr. Guttae obligated to tell the patient about the potential benefits that he will receive for performing DMEK (including generation of data for presentation) ?