Jerome W. Bettman

Seven Hundred Medicolegal Cases in Ophthalmology

Seven hundred medicolegal claims in ophthalmology were reviewed by one ophthalmologist who served as an expert for four decades. The ophthalmologist was personally involved in 620 claims. The 700 cases have been categorized and analyzed. The reasons for the claims and some lessons derived from them are presented. Familiarity with the claims encountered by others may enable ophthalmologists to avoid similar claims.

The incidence of adverse reactions from steroid/antiinfective combinations.

Steroid/antiinfective combinations have a number of advantages over the separate ingredients, but the possibility of complications has been a subject of concern. Based on data obtained from the files of eight pharmaceutical companies and the health registry records of the United Kingdom, Australia and New Zealand for the period 1964-1973, it is concluded that the statistical incidence of adverse reactions was no greater with the steroid/antiinfective combinations than with their separate ingredients. In addition, there was no increase in incidence of the reactions during the same period with combinations. These conclusions were borne out by adverse reaction data reported in the literature and in certain unpublished prospective clinical studies. It was not feasible to obtain data from ophthalmologists who may have observed adverse reactions, but not reported them. A critical evaluation by Dr. Philip Ellis follows the review.

Ethics and the American Academy of Ophthalmology in historical perspective.

The issue of ethics has been prominent during the entire existence of the Academy. The significance of particular aspects of ethics has varied at different periods as well as have attempts at enforcement. The impact of external forces has been especially significant in the past 20 years as have the number and complexity of ethical problems. Ethical practices in our specialty have been both a problem and a source of pride to our Academy.

The Development of the Code of Ethics for the American Academy of Ophthalmology

The circumstances leading to and the process of establishing a code of ethics for members of the American Academy of Ophthalmology are recounted by the original chairman of the Ethics Committee.

Special problems in ophthalmic subspecialties.

A study of 276 medicolegal cases disclosed the number in various ophthalmic subspecialties. The medical reasons for filing these claims were usually based upon omission or commission of acts fundamental to good basic ophthalmology, not the omission of sophisticated procedures. Among the lesions were that physicians should plan for the care of emergencies, use few types of drugs, order roentgenograms if suspicions arise, use consultants, stay well within ones level of competence, and document everything.

How to Reduce Medicolegal Involvement in Cases of Trauma

The lessons learned from 52 medicolegal cases related to trauma are discussed. The role of informed consent is usually indirect. Surprise complications result in anger, and anger may provoke a suit. The emergency situation may be responsible for an incomplete examination, absence of a plan of management, or need to work with inexperienced personnel. An emergency does not preclude the need for prolonged followup in some situations. The availability of numerous devices has complicated the medicolegal problems. Recent relevant court decisions are discussed.

The Extracapsular Cataract Extraction without Phacoemulsification

The advantage of a planned extracapsular cataract extraction is that the intact posterior capsule holds the vitreous face in a more physiologic position. The extracapsular method has been improved by newer techniques and a good result has been made more certain by the following: a large microscopically controlled capsulectomy with the irrigating cystotome, aspiration of the cortex while the wound is secured with sutures, and the use of the irrigating sand-blasted cannula when indicated. The indications for the extracapsular extraction have increased because there is a greater certainty of obtaining a clear pupil with less change of secondary inflamation. These indications and the newer technique are discussed in the body of the paper.

Risk management issues in the new managed care environment.

Malpractice cases in which the defense was based on cost-containment are discussed in this article reprinted from Ophthalmic Risk Management Digest. These cases illustrate that the dollar defense is no defense.

Antitrust and peer review

An antitrust action against a physician is unlikely if the following guidelines are followed: Do not agree with competing independent doctors on any terms of price, quantity, or quality, or the patients one is willing to serve, the location from which one is permitted to draw patients, or where one will locate offices. Also, do not agree to refuse to offer services to alternate delivery systems. Generally, those who serve on peer review committees are protected if decisions are reached after effort has been made to obtain the facts of the case, after adequate notice and fair hearing procedures are afforded to the physician involved, and when the action has been warranted by the facts and is in the furtherance of health care. An attorney who specializes in antitrust should be engaged. Members of peer review committees should not be in a position to benefit from the decision. They should document all transgressions of the accused, treat the accused fairly, and give him or her the opportunity to have due process.

Ethics in Ophthalmology: A Symposium

The Code of Ethics of the American Academy ofOphthalmology was developed in response to numerous requests from our members. In May 1979, the American Academy of Ophthalmology sent a questionnaire to its members to ascertain what was wanted. A number of respondents (more than 100) thought that the Academy must develop ethical standards. The goals and priorities committee placed it high in the ratings of needed Academy programs. In response to these requests, an Ethics Committee was appointed to develop an appropriate code. A national committee was created with the thOUght that it should represent different types of ophthalmic practice, as well as different geographic areas, but should be small. A local committee was created because it could meet with little expense to the Academy, and could organize ideas for the national committee to consider, thus reducing the need and expense of many national meetings. The members of the committees are in this symposium, with the exceptions of Drs. Byron Demorest, Morton Goldberg, and Theodore Steinberg, who were not able to participate. It was evident that standards of ethical conduct varied with the individual. A consensus which represented the standards of ethics of the membership of the American Academy of Ophthalmology had to be developed. The proposed code was discussed at numerous meetings, including a symposium at the 1981 American Academy of