1. 0 Delegation of Services & Co-management Case Studies

2. WWW.AAO.ORGAMERICAN ACADEMY OF OPHTHALMOLOGY Disclosure  The speaker has no financial interest in the subject matter of this presentation and is not representing the Ethics Committee of the American Academy of Ophthalmology with this presentation.  For questions about the material contained herein or about the Academy’s ethics program in general, please contact the ethics program manager, Mara Pearse Burke at ethics@aao.org.ethics@aao.org

3. WWW.AAO.ORGAMERICAN ACADEMY OF OPHTHALMOLOGY Why is this Topic Important?  Obligation to be Truthful  Integrity of the Profession  State and Federal Regulations

4. WWW.AAO.ORGAMERICAN ACADEMY OF OPHTHALMOLOGY Case Study 1  Dr. McDonagh has a large pediatric practice.  Levels of “staged competence” to increase volume.  Technicians, orthoptists, and fellows manage patient flow.  Dr. M involved only after complete workup is performed.

5. WWW.AAO.ORGAMERICAN ACADEMY OF OPHTHALMOLOGY Practice Innovations  Dr. McDonagh is proud of two aspects of his practice: Screening equipment. Innovation designed to make optimal use of his time.  Senior assistant manages calls and referrals.  New pediatric patients are seen efficiently and logically.

6. WWW.AAO.ORGAMERICAN ACADEMY OF OPHTHALMOLOGY Over-riding Concern  Is patient welfare served by this innovation?  Perception of medicine as only technology and information?  As ethical physicians, we must understand and define what is neglected in this scenario.

7. WWW.AAO.ORGAMERICAN ACADEMY OF OPHTHALMOLOGY Applicable Rule of the Code of Ethics  Rule 7: Delegation of Services “...An ophthalmologist must not delegate to an auxiliary those aspects of care within the unique competence of the ophthalmologist...” The auxiliary must have adequate qualifications, supervision. Alternative arrangements in special circumstances.

8. WWW.AAO.ORGAMERICAN ACADEMY OF OPHTHALMOLOGY What Do You Think?  Is Dr. M delegating eye care that falls within the unique competence of the ophthalmologist?  What are Dr. M’s motivations for “staged competence?”

9. WWW.AAO.ORGAMERICAN ACADEMY OF OPHTHALMOLOGY DISCUSSION  Delegation of authority is not only efficient, but often mandatory.  Balancing opposing values is vital.  You can delegate authority, but you can’t delegate responsibility.  The physician is always responsible!

10. WWW.AAO.ORGAMERICAN ACADEMY OF OPHTHALMOLOGY Case Study 2  Patient is 38 y/o male, Mr. F  LASIK evaluation performed by OD, patient then referred to a TLC office for surgery  Met surgeon, Dr. E, on DOS, no additional evaluation by surgeon  Poor postop outcome, “patient lacked fixation”  21 post-surgical visits with little or no improvement  Patient saw the surgeon on only 4 of those visits “Despite my repeated ignored requests to see Dr. E, I was passed around among other TLC optometrists…”

11. WWW.AAO.ORGAMERICAN ACADEMY OF OPHTHALMOLOGY The surgeon replies… “Mr. F was screened by Dr. H, an OD who is well-trained, competent, and well-respected in the community. Mr. F’s first meeting with me was on 5/17/12 and surgery was performed on the same day. Mr. F’s time at the clinic was lengthy and ample time was given for a full examination, consents, and postop instructions. I evaluated Mr. F on that day and exercised my best judgment in recommending Lasik.” (Recall that the patient denied seeing the surgeon for an eval on DOS.)

12. WWW.AAO.ORGAMERICAN ACADEMY OF OPHTHALMOLOGY The surgeon continues… “The referring doctor took over care of Mr. F on his day 1 post-op. (which was 5/18/12) We picked up care on 10/28/12 and I personally saw Mr. F on 2/15/13, 2/16/13, 7/16/13, and 11/13/13…”  The operating surgeon first saw the patient, who was having persistent postop difficulties, 9 months after the date of surgery even though the patient’s care was “picked up” by the TLC practice 5 months after surgery.

13. WWW.AAO.ORGAMERICAN ACADEMY OF OPHTHALMOLOGY Finally -  At the close of 2013, TLC nullified the patient’s “Lifetime Commitment Contract” and diverted him into an “advocacy” relationship with an in-office OD whose responsibility was to resolves patient disputes. The patient never saw his surgeon again.  Patient sought an opinion from another ophthalmologist, who determined that Mr. F had not been a good candidate for LASIK surgery.  Pre-existing conditions: Keratoconus Pellucid marginal degeneration Depression Anxiety

14. WWW.AAO.ORGAMERICAN ACADEMY OF OPHTHALMOLOGY Details…  A complete review of patent’s records from initial OD and TLC practice revealed the patient had signed every appropriate form: informed consent, postoperative co- management agreement, “Lifetime Commitment Guarantee”, and “Advocacy Agreement”.  The record revealed that an evaluation was performed in the surgeon’s office on the DOS, but there was no indication who had performed it.

15. WWW.AAO.ORGAMERICAN ACADEMY OF OPHTHALMOLOGY What Do You Think?  Was the delegation of this patient's care appropriately handled? There were internal and external delegation issues There was inadequate, if any, consent from the patient There is problematic utilization of additional health care providers in-house, especially given the patients expressed concerns.