"Dr. X, for every patient you send to our laser center, we'll collect the $5000 and we'll make sure you get back $2000."
"That's an extravagant amount," I said. "Isn't that a kickback?"
"So many people walk around with a meaningless life. They seem half-asleep, even when they're busy doing things they think are important. This is because they're chasing the wrong things. Morrie Schwartz, "tuesdays with Morrie"
A few years ago, I stared at the growing stack of invitations, fliers, and letters in a pending file. Fliers to LASIK seminars. Invitations to dinner with refractive surgeons and LASIK center directors. Letters to get in on the ground level and invest in LASIK centers.
Out of curiosity, I accepted an invitation to dinner. I was wined and dined. Take that back. I was WINED and DINED. Beneath the glow of dimmed chandeliers in an elegant restaurant, the compliments were blushingly effusive. I was made to feel so very special. It was seductive.
The pitch came at the end of this dinner: Dr. X, for every patient you send to our laser center, we'll collect the $5000 and we'll make sure you get back $2000." "That's an extravagant amount," I said. "Isn't that a kickback?" "No, we call it a co-management fee," was the quick reply. "You and I will manage the patient together. A "kickback" lands us both in jail. Hehehe."
That night, I told my husband, "I didn't take it personally, but now I know what it's like to be propositioned! Optometry has never been paid that well for equivalent services. Call it anything. A bribe is a bribe is a bribe. Do they really think that doctors are that easily bribed?"
Call me naive, but I was shocked, when within a year, so many doctors were climbing aboard the LASIK bandwagon. This was an experimental surgical procedure, very seat-of-the-pants, without a track record. The referral guidelines were sketchy. The scientific literature was sparse. Yet, knowing so little, they were enthusiastically referring patients to laser centers -- up the proverbial KAZOO.
With dismay, I witnessed the suspension of previously sound professional judgment, leading me to question:
Had the eye professions gone bonkers? Were they not hearing the incessant LASIK ads as sheer, unadulterated HYPE? Hype that trivialized the possible sight-impairing and sight-threatening complications? Had my peers succumbed to a selective amnesia, forgetting basic cornea knowledge? A cut and partially vaporized cornea is compromised, no matter how you slice it. Are we so easily bought? Are we that "bunch of schlocks" that a professor-mentor had exhorted us NOT to be?
Doctors are human. Oh, so human. And their inner children were being enticed with instant gratification. Some resisted. Some sat on the fence. Some yielded. LASIK coincided with a difficult time in my life. My father was gravely ill. Feeling down and vulnerable, I seriously considered leaving my profession, perhaps returning to teaching college psychology.
I felt ashamed to be a fellow member of the eye professions. A growing number of its members were failing to profess, i.e., failing to fully inform their patients. I felt embarrassed by the flagrant disregard of The Hippocratic Oath by those who were putting their own interests ahead of their patients'. I was appalled by the whole sordid "back-room" dealing that I had experienced... as if I were a hooker! So ashamed, embarrassed, appalled -- and incredulous, I avoided the subject whenever it came up among peers.
Experiencing a sympathetic reaction called "Fight or Flight," my non-confrontative, peace-loving self chose to flee. I wanted OUT! And fast.
My father loved living. His passions were reading and traveling, both sight-intensive activities. He lived life to the fullest, and at the end of it, I saw him fighting to keep every ounce of quality in his life. His valiant fight inspired me not to easily give up on what I loved so deeply:
I truly love those I serve; we have consciously cultivated a solid base of quality-minded patients who want the personalized care we offer and are willing to pay fair fees for it. It has taken years to assemble the best team of conscientious, like-minded staff members and doctors ever. Together, we have created a caring and joyful country practice in an impersonal, urban setting. High-tech, from pouring most of its profits back into it, yet beautiful and welcoming, our office is a great place to be. I love my profession, or at least I did a lot more before LASIK came along.
LASIK had become a fly in the ointment.
When my father crossed over, it was his faith in me and my faith in "I can do all things..." that motivated me to do my best to flick the fly out of the ointment and make a positive difference.
Not wishing to dwell on negative energy and resort to finger-pointing and blaming, I sought to clearly identify the fly in my ointment. If I were to flick it out, I needed to know what the fly was. Was LASIK the fly? No, it's just a procedure. Were doctors the flies? No, in an imperfect world, good and bad exist in every profession. Besides, judging others is a fruitless endeavor; I leave that stuff to a Higher Power. Not my job. And then it came to me, clear as day:
The fly in the ointment was THE FAILURE TO FULLY INFORM: the ads and infomercials were not fully informing the public; many refractive surgeons and referring doctors were not fully informing patients; and refractive surgeons were not fully informing referring doctors of their mounting failures. Real risks and complications were being downplayed, even trivialized. Financial incentives for referring patients was not common knowledge.
As professionals, we have a moral obligation to FULLY INFORM to the best of our ability, with the patients' best interests in mind. Especially when it has to do with our primary sense, sight.
I began a personal campaign to persuade my peers to FULLY INFORM, to think twice before casually referring their patients to LASIK surgeons. Whenever I attended meetings, conferences, or classes, I'd bring the subject up with my peers, asking them to review their basic eye anatomy and pay attention to the corneal nerves -- the "feelers" of the eye, its biofeedback mechanism -- before they sent in their next patient.
Reminding them of the neurotrophic function of these nerves (they help in the maintenance of a healthy cornea), I reviewed how the microkeratome -- "the world's smallest buzz saw" -- sliced these microscopic nerves, millions of them, that do not grow back to its original state and function.
I'd offer the reality check, "Christopher Reeve still does not walk." Bless that courageous, inspiring man who struggles with dignity and fortitude.
Quizzing my peers, I found that, for many, their knowledge was woefully lacking. They were not FULLY INFORMED themselves, yet were referring patients. Some had no idea what "Sands of Sahara" was, much less knowing what to do about it if it bit them in their face.
Bringing up consequences that might broadside their pocketbooks, I hoped to make them think twice about their casual referrals:
"The surgeon's name is on the informed consent form, is yours? You do know that the surgeons have protected themselves from lawsuits with that informed consent form, but you're left yourself wide open for lawsuit for FAILURE TO FULLY INFORM. You can be held accountable. Complications, especially corneal transplants, can be expensive. If the surgeon's consent form is "iron-clad," you're the next logical person to sue."
I'd get replies like, "Geez, I never thought of that!" Unfortunately, thought-provocation didn't seem to achieve my desired end of slowing down their rapturous, under-informed referrals. In a short time, referring doctors were insisting on having their names added to informed consent forms.
I'd toss out highly touted percentages of failure, which we belatedly know by personal experience as underestimations:
"For the one, two or three patients out of every hundred you refer to LASIK surgery, the complications are not minor inconveniences, but profound losses in vision acuity, quality and even sight itself. Are you prepared to face that patient who will need a corneal transplant? Are you aware that when surgeries fail, patients, families, networks of friends, colleagues and co-workers suffer? And all that for an elective surgery? What are you going to say to the patient who says, "Doc, I trusted you to do right by me. Why didn't you tell me this could happen to me? Why did you make the complications seem so trivial and unlikely? I would have thought twice..."
What about the losses in everyday function that are not even counted by the 1-3% statistic? Those who no longer can work as they once did. Who no longer read or travel as before LASIK? Who no longer drive safely at night? Those who are now plagued with glare, aberrations, starbursts, and halos (a combination of post-LASIK symptoms so common, it has its own acronym, GASH)? Those who suffer from dry eyes who now spend a $120 a month, $1200 a year for prescription artificial tears? Would they have chosen this surgery if they had known that these complications would be theirs for keeps?
A common response was one of resignation: "X, if I don't send them in, someone else is going to do it anyway" or "Everyone else is doing it, and I don't want to be perceived as being behind the times." I'd gently remind them to review The Hippocratic Oath and The Golden Rule.
Those overtly milking the LASIK cash cow responded with, "Hey, the money's too good not to refer," or "This is making a nice nest egg for my retirement." To them, I was unapologetically pointed, "Hippocratic is not spelled h-y-p-o-c-r-i-t-i-c."
In spite of my mild-mannered demeanor, when I smell a rat, especially a hurtful rat who has done a magnificent job of rationalization, I have no problem revealing that rat-ness to him/her self. I practice The Golden Rule; darn it, if I'm being a hurtful rat without awareness, somebody tell me, so I can snap out of it!
Carrying the "FULLY INFORM" campaign on to the Internet, I e-mailed anyone and everyone in the eye professions. I suspect my e-mails were often deleted as SPAM. I have a quick finger for it, myself. For others, I suspect my e-mails were uncomfortable, unwelcome reality checks, but not uncomfortable enough to give up hefty fees.
At first, the positive, supportive replies were a trickle; now, it is a steady stream. This has been a faith-restoring and heartening experience. I am in honorable company after all; there are many who have refused to make light of our professions' duties and obligations. Thanks to the Internet, we are finding each other. I especially like the replies that go: "I thought I was the only one who felt like you...You're right. We did take an Oath, "First, do no harm... What can we do?... Let's work on this together."
A grassroots effort to FULLY INFORM was born.
Many of the refractive surgeons were not talking up their complications. There was a FAILURE TO FULLY INFORM referring doctors who were feeding them patients. Staying mum about their less than stellar results was good for business. Using the Snellen eye chart worked in their marketing favor. A post-LASIK patient may have a significant decrease in visual acuities under low light conditions, but still be able to handily read a high-contrast eye chart, i.e., stark black letters projected on a stark white background.
Case in point: In March 2000, back in my home state, I interviewed a post-LASIK patient, Mary Doe, who related this experience to me:
"I'm not going to talk about me. But I do have to be out of here by 5 o'clock, as I can't drive at night anymore. I want to tell you about my friend, John Doe. I'm talking for him, because he's not ready to talk about it yet.
I owe it to him to let you know what happened to him, because I persuaded him into doing the surgery with me. From the get-go, I was doing great. I was out there telling everyone, "Do it, do it, do it." He was being quiet about it. Some time later, I asked John how he was doing. He said, "Mary, I'm not doing so well. "Go back to the surgeon," I urged. "We have a lifetime guarantee on this. They can do a touch-up, an enhancement."
John said: "I did already. The technician had me read a line on the chart. I read it. The surgeon came in and said, "What are you doing here? You're doing great. You just read the driver's test without glasses or contacts. What's the problem?" I said, "Doc, like right now, how come when I reach down to tie my shoelaces, I can't see my shoelaces for my shoe?" The surgeon shook his head and said to me, "You need to see a psychiatrist."
Hearing John's story, thanks to Mary, gave me the push to do more. With crystal clarity, I had a moral obligation to FULLY INFORM her, FULLY INFORM him. I know, as any eye professional knows, the following: John's and Mary's refractive surgeon knew darn well that LASIK surgery had decreased John's ability to see in low light conditions, i.e., there was a reduction in contrast sensitivity. No only was the surgeon being a complete a**, he was being totally dismissive of the patient's accurate reporting of a very real and common symptom of LASIK. Yet, he led John to question his sanity.
A CONSCIOUS FAILURE TO FULLY INFORM.
Like Mary, John no longer drives at night. Just as John can no longer see his white shoelaces on his white sneakers in a dimmed room, both can't easily see dark-colored cars and objects on dark roads (your kid hurrying home on a bike? your pet? your spouse jogging? your parent taking an evening stroll? you crossing a street?). Forget looking for matching socks in the morning. He no longer sees numbers well (print on colored paper is difficult), which is essential to his job. He's thinking about going on disability, and taxpayers will be paying to support him. John's life has been complicated, let alone his eyes and vision. But that surgeon will count him and Mary as unmitigated successes. And the failure rate will remain under-estimated, deceptively misrepresenting the true numbers to the public, a failure to fully inform.
These days, we are busily FULLY INFORMING one another and the FDA. We write, share, and collect our case reports on the LASIK failures. We're sending copies to one another, as well as forwarding copies to the FDA, along with our individual accounts of our personal experiences of backroom deals-making.
These days, we share tips on how to help post-LASIK patients who now seek our care. We learn from them and from caring doctors (like leukoma and DavOD) who generously and anonymously give of their time and expertise to answer questions and contribute to a growing resource of fully informative accounts at http://surgicaleyes.com.
Whenever one of us has access to the media, thanks to the power of the Internet, we strive to FULLY INFORM the public, e-mailing summaries of case reports, existing studies, and articles on complications. We suggest interviews with complicated post-LASIK patients (with their permission and willingness, of course) and refer to actual patient accounts at http://surgicaleyes.com.
The national, state, and local media are reading, listening, and using our information to FULLY INFORM the public in their articles, newscasts, and magazine shows. I am pleased to see that a number of my peers who were initially tempted are finding their way back to what attracted them to our profession in the first place: the caring and helping of people and the preservation of sight. My faith in my profession is being restored.
Many are no longer sending their patients in for LASIK, realizing first-hand that LASIK is not ready for prime time. We are all seeing more and more LASIK failures. Sobering failures. Many are discovering true "bigness," admitting to the casualness of their early-on referrals and now educate their patients with the intent to FULLY INFORM. They are apologizing to their patients, and are doing all they can to assist traumatized post-LASIK patients.
Many have come to realize, the hard way, that they "bit off more than they could chew," especially when their post-LASIK patients returned with unexpected complications, some irreversible. Many more are taking classes like "How to Treat Post-LASIK Complications." A hardbound text on the subject is now on the market, filled with photos of complicated REAL cases. Nothing hypothetical or maybe about those damaged-for-life eyes. We are also preparing ourselves for the long-term effects that will arise for many with age. For some of us, it's Humpty Dumpty time again. We wrangled with the down-the-road problems of RK -- remember that failed "miracle" eye surgery? Been there, done that. And here we go again.
Many more are finding out that, when they consciously strive to FULLY INFORM, a common phenomenon occurs: Patients do think twice. Consciously thinking about what their sight is worth to them, patients make more carefully thought-out decisions, instead of headlong, emotionally-charged ones. Pondering the risks and the gamble involved with a cautious eye to the future, they come to a full awareness that this is an elective, experimental surgery with the possibilities of significant eye- and life-complications and long-term problems...
They take that critical look before leaping.
AND once FULLY INFORMED, most patients are willing to wait for a less risky procedure, which will happen! It's just not here quite yet. For a certain percentage when conventional means do not correct impaired vision, LASIK may make perfect sense. Remember, this is not about a procedure; it is about FULLY INFORMING.
There are those occasional patients who have been brainwashed by the hype and do not wish to be fully informed, period. They are those who will listen and still decide to do it. We wish them nothing but success and well-being, and let them know that our door is always open for them.
Patients ultimately make their own decisions. And we respect that right. This is America. There will always be those who live on the edge, sky-dive and climb Everest. The difference is they do so with full knowledge of the possibility of injury or death, no matter what the safety precautions. Nature has its unforgiving quirks, its vagaries.
Not FULLY INFORMED with the knowledge of the possibilities of injury or (sight) death, LASIK patients are not as prepared. Eyes are Nature's masterpieces. Even with the best equipment in the most experienced of surgical hands, eyes can also be as quirky as Nature.
Common laments of those hurt by the FAILURE TO FULLY INFORM include: "Why wasn't I FULLY INFORMED that this could happen to me?" "Why were the complications trivialized, glossed over?" "I had no reality on the complications." "I trusted my doctor to have my best interests in mind, and since, I've learned about the financial incentives to refer. Why was this incentive-to-refer not disclosed to me? I would have thought twice!"
Fully informing the patients is simply the right thing to do!
Those of us who are choosing to FULLY INFORM are making a difference, one person at a time. One reporter at a time. One news article at a time. One web page at a time. You will see more and more websites like this one, as more and more of my peers are recognizing the need to be heard, to FULLY INFORM.
But all of this is not enough. And not in time for many.
The irresponsible TV and radio ads, paid by those who wish to sustain their $100,000/day incomes, continue to lure, day in, day out. A percentage of under-informed patients WILL pay the steepest of prices with their sight and well-being by those who FAIL TO FULLY INFORM.
Sadly, those with complications who were casually referred and/or poorly informed are the most embittered. Their primary sense has been compromised, serving as a daily reminder of a broken trust -- a sacred trust -- for the rest of their lives.
You are invited to join us. Please join us in being proactive in FULLY INFORMING the unwary public. We need your help. We share the same public. They need us to help. They are us.Writing this, I have done my best to keep my word impeccable. I am not too proud to beg on behalf of the gift of sight. Thank you for your attention.
P.S. For those who have already done it, stay positive. We do not wish to rain on your parade. We wish you no ill, ONLY continued success. Be aware. Stay informed, as several long-term problems are avoidable with early intervention. Many of us doctors are back in school, taking classes to stem the tide of LASIK complications. Much of what we learn is news to us as doctors, and therefore news to you, as patients. Success has been attained in containing the sight-devastating "Sands of Sahara," which can "melt" the cornea. Success has been attained with aggressive dry eye syndrome treatments to avoid corneal scarring, abrasion, and erosion, but better results are obtained when started early, when the symptoms may seem subtle and non-threatening. Sight is a cherished gift; do your best to preserve it the best way you can.
P.P.S. Feel free to publish this. Make copies, hand out them out. Share its URL. No permission is needed. Posted without a motive to derive financial gain, this is a public service to FULLY inform, plain and simple.
This is a grassroots effort that's worth getting involved with, as it's about sight. For Heaven's