Do not let a patient’s proxy sway the premium surgery process
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This topic may be a bit far-reaching for premium surgeons, but it seems my recent daily cataract surgical evaluations have at least one patient simulating Munchausen syndrome by proxy.
In 1977, Meadow used the term Munchausen syndrome by proxy (MSP), now known as factitious disorder imposed on another, to describe when parents produce histories of illness in their children and support such histories by fabricated physical signs and symptoms or even altered laboratory tests. The person with MSP does not seem to be motivated by a desire for any type of material gain.
Why does MSP have any relevance to the premium refractive cataract surgeon? How many times in our daily consultations does the person who attends the preoperative and/or postoperative visit with the actual patient try to become the patient and speak on their behalf? As premium surgeons, we know this conflicting situation can become uncomfortable, and here are a few tips from my personal experience.
Ignore the proxy
Remember the informed consent for the premium surgery is with the actual patient and not the proxy. Legally, if the situation is getting out of hand in the exam lane, the surgeon can ask the proxy to leave and then refocus on the actual patient. Specifically, if this occurs at the preoperative exam, the surgeon can kindly deny the desire to operate on the actual potential patient in the first place. And the most disturbing situation is when the proxy thinks they have more knowledge than the premium surgeon. My response is to have them provide objective peer-reviewed literature of their “n = 0” experience as a surgeon.
CYA
For most of you reading this column, no explanation is needed for CYA, but make sure you do the proper due diligence preoperatively and/or postoperatively with a second person from your clinic in the exam lane. Also, have a low threshold to refer out the patient for a second opinion from your preferred retinal/corneal/glaucoma expert so the proxy can hear the same story more than once before operating on the actual patient.
Perform objective testing
No matter what premium IOL technology is used (PanOptix/Vivity, Alcon; Crystalens/Apthera/Aspire, Bausch + Lomb; Symfony OptiBlue/Synergy/Eyhance, Johnson & Johnson Vision; Light Adjustable Lens, RxSight; SBL-3, Lenstec), all require proper objective testing preoperatively. Topography/tomography/epithelial mapping will help decide if an enhancement can be performed postoperatively if needed with laser vision correction (LASIK, PRK, SMILE) or limbal relaxing incisions at the slit lamp. OCT macula will find an underlying epiretinal membrane, for example, in up to 10% to 15% of my premium population, which changes my decision-making process. Ocular surface evaluation with tear osmolarity (Trukera) and/or dynamic meibomian gland imaging (LipiView, Johnson & Johnson Vision) will help avoid poor biometry readings and incorrect IOL power selection. Objective scatter index makes it much easier postoperatively to decide if a YAG capsulotomy is needed earlier than later to help visual recovery. Objective testing negates anything and everything the actual patient and/or proxy deems to be erroneous in the exam lane discussion findings.
OK to walk away
Ultimately, politely deny the proxy their glorious moment and simply refuse to operate on the actual patient even if objective evidence says they are good to go. It is OK to walk away even as one of the best premium surgeons.
Premium surgeons have a tough daily schedule of surprise patients, but when that MSP shows up, try to follow some of the advice in this column and keep yourself from becoming a proxy for yourself.
Until next quarter, safe travels and keep up the great chatter in the hallways of meetings, where I actually learn the most these days. Stay healthy and have a great holiday season.
- Reference:
- Meadow R. Lancet. 1977;doi:10.1016/s0140-6736(77)91497-0.
- For more information:
- Mitchell A. Jackson, MD, of Jacksoneye in Lake Villa, Illinois, can be reached at mjlaserdoc@msn.com.
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