I feel bad for this patient, and the miss does seem egregious, as blepharitis should not cause such bad vision loss. However, the estimates of lost income seem absurd. He really couldn’t continue to do his job as a professor due to losing vision in one eye? I had an attending when I did EM residency that was able to keep working as an ER doc even after he lost his eye in a golfing accident. He was still able to do LPs and everything.
I'm with you. Bad miss, but the alleged damages resulting from the monovision seem very extraordinary. I've lived with a bad left eye my whole life and have no issues as long as my right eye is open. I don't want to assume this patient's experience and I regret his outcome, but what does a stair lift, ergonomic desk chair, and (what's portrayed as) a complete inability to teach history have to do with losing vision in one eye?
Agree. I have many patients including my own father who are monocular and can live completely normal lives. Also, the correct term is monocular. Monovision is when we make one eye for distance and one eye for near with refractive surgery, contacts, or IOL surgery.
Interesting tangent, I recently found a case in which an ophtho got sued because someone didn't like their monovision surgery. Thanks for the tip on monocular vs monovision!
Yes, I'll definitely publish it! Ophtho cases are pretty rare compared to other specialties so I only have enough to publish 1-2 per year but I'll definitely keep them coming as I find more.
I had a professor in school who had to retire due to major issues with his vision. He would max out the font size on his phone and computer screen but still require a magnifying glass to read. Eventually couldn't see students faces and felt like he was a detriment to the program. I would be a very sympathetic juror.
What was his vision problem? Someone with monocular vision that is correctable should be able to function fine, wouldnt need a magnifying glass, would be allowed to drive, etc...
I won't comment on the estimates in lost income because if I lost my vision unnecessarily, I'd be supremely upset and you can't put a price on your vision. But, this lesson is what will stick with me..."We need to maintain respectful skepticism of a patient’s ability to accurately describe their problem." Countless times I've had patients who dismiss their symptoms and respectful skepticism is best for both parties in these types of situations.
I think framing it as *respectful* skepticism really helps build a collaborative environment amongst colleagues too. I want other doctors to catch anything I've missed... when its *disrespectful* skepticism, it really creates a negative and antagonistic environment that causes burn out and probably harms patient care too.
I agree with respectful skepticism- I found my stepdaughter writhing in pain on the bathroom floor. I’m not sure *what* husband and bonus child (22 yo) told the ED doctor. Husband wanted ED doctor to talk to me - doctor obliged. “Now it sounds like we’re dealing with a chronic problem,” said the doctor on the phone. I told the story- highlighting important elements and stressing that this isn’t chronic. “Ok, now that’s different from the impression I had,” said the doctor. She got a CT scan- nothing was found to be amiss radiologically- luckily.
Ophthalmologist here. An RD presenting with HM vision would not have resulted in functional vision if it was diagnosed correctly at the first visit. This settlement is pretty ridiculous, although not dilating a HM patient is negligent and unheard of.
Unfortunately this is a somewhat common malpractice lawsuit issue... a patient has a very bad diagnosis that got missed, but even if it had been diagnosed appropriately at the first visit, the outcome would have been the same.
Both in regard to the clinical aspects of this case as well as the damages.,,
Could not agree more with all of you.
From me...
A comment on the damages...
Many years ago, in my first three years out of residency, I worked as a covering neonatologist at our local Level III NICU...
While there I worked with a delightful young nurse who was tragically killed by a drunk driver at the age of only 23.
The driver was convicted of vehicular manslaughter yet only received a one-year jail sentence.
The nurse's family filed a wrongful death lawsuit against the driver and I was deposed as a friend who was familiar with her and her family relationships.
In the process of that deposition, I was told that one of the damages being asked was on behalf of the mother...
For , literally, 40 years of haircuts once a month because that was a service which the deceased child had provided to her mother.
Med Mal Reviewer is so correct about lawyers including anything they can to "beef up claims"!
I see an ophthalmologist regularly for a condition with my left cornea, and she routinely does dilated eye exams of both eyes at every single visit (even if sometimes I wish she didn't, especially on a sunny day!). So it seemed wild to me that the first ophthalmologist in this case didn't bother with one in the setting of an acute complaint of vision loss (and I see a comment from an ophthalmologist that this was, indeed, negligent).
This is why I dilate every new patient to my clinic if they aren't seeing 20/20 and do IOP/CF/pupils/EOMS every time they come in. Or if there's a sudden vision change from prior visit. Never know what might come up.
That being said...I am really curious at how long the patient waited before calling the clinic in the first place. If he had flashes and floaters for a week prior and didn't call till he was hand motion... waited for the vision to get "really bad"...oof. Pretty much every eye clinic schedules sudden loss of vision or flashes/floaters within 24 hours so if he called and told the staff "I have a bump on my lid and my vision is blurry", they aren't gonna necessarily schedule that within 24 hours unless there happens to be an opening.
And if he was hand motion on the first visit, odds are high the macula was already off. I'm fascinated by the claims for the assistive devices too, I actually wonder how much they will actually be used or if that was an attempt to beef up the claim demand.
The patient is presumably will be legal to drive, so why the demand for a stair lift and talking thermostat? I agree they seem excessive.
Agree. I dilate all new patients as a matter of policy. Missing an RD with HM vision is negligent but the visual outcome would not have changed for the patient.
Yep. Comes down to the fundamental question: if this person doesn't get to 20/20, why? Is it merely refractive (pinhole or quick check of the RX), or is something going on in the eye/brain? That's what makes it negligent. The OD screwed up too, because that was a second opportunity to question the visual acuity.
You hit the nail on the head in regards to the assistive devices beefing up their claims. Its just a stunt to try to get a bigger settlement. Part of the legal game.
If patients call with "blurry vision" to schedule an appointment, do you feel like your secretaries are pretty good at parsing out who needs to be seen quickly and who can come in later? Seems like one of those things where an untrained layperson is making seemingly-innocuous decisions (appointment urgency) that could have a big impact on outcomes.
I use the phrase: sudden vision changes equal sudden eye exam. Have I taken call and gone in to see the patient for what ended up being nonsense (like forgotten contacts in eyes or dry eye)? Yep.
Staff does have a decision tree to follow which cuts down on delay in scheduling care. Basically anyone in pain, sudden blurred vision or loss of vision, flashes floaters gets worked in same day, if I am fully booked they'll come talk to us and we usually work it out. Almost always within 24 hours.
When we get people that call on a Monday, and they are offered a same day appointment, and refuse it and schedule on Friday, we let them know if it's a serious retinal problem, scheduling it later can delay treatment. Basically we take an attitude if they care enough to call, we care enough to get them in.
In cases where I find something sight/life threatening, I make an effort to nail down the timeline, because if my staff messed up, I need to coach them, if it's the patient that made the delay, I need to teach them to be more cautious (especially to protect better seeing eye).
Had a case few years ago; guy had a history of a complete RD in one eye, repaired, but still left legally blind in that eye, so only had "one good eye". Sat a week on RD symptoms in the good eye, didn't get seen until Saturday. Good eye ended up being "macula involved", as in, I got an OCT photo demonstrating that there was some fluid below the macula (couldn't see macula on dilation, too much haze in my view, took the extra step to run the test since I was calling retina on a Saturday)...basically he could sneeze and it would be mac off. Got surgery Monday, thankfully got back to 20/20 vision with mild metamorphopsia. I made it pretty clear that waiting till Saturday to come in, ESPECIALLY after having the history of a RD, was part of what made his visual prognosis so rough. He basically described that the curtain got bigger and bigger each day and finally called when he woke up on Saturday and it was completely covering vision.
Yea, I've been unfortunate enough to suffer not one, but two apparent urgent ophthalmologic issues in my life. One time, it was sudden onset of floaters after eye trauma, and another time, it was eye pain and worsening blurry vision. In both cases, the secretary who took my call seemed to understand the urgency of the situation and got me in to be seen by the next day. I would hope most if not all ophtho clinics run that way.
As a (now retired) emergency physician, I find this case especially concerning. A sudden change in vision, even with a style, is the equivalent, in my mind, of an ocular stroke, and would mandate not only an ophthalmologist referral, but also a phone discussion directly, including “should I dilate and do a slit lamp exam or will you when you come in today to see the patient?” Also,I would be concerned about vicarious liability about referral of an urgent patient and having the specialist miss the diagnosis. The defense obviously found the ophthalmologist care indefensible and should just write a (reasonable) check.
I work in telemedicine- I see patients in hospitals all over the country- in the vast majority- ophthalmologists do not see patients in the emergency room. Granted- a lot of these hospitals are rural. When I was “on the ground” in a more urban area- still- most of the hospitals did not have ohptho available.
As a practicing emergency physician, your recommended course of action doesn't reflect reality. Would that making a phone call and urgent referral to an ophthalmological subspecialist was that easy.
I recently had a patient presenting with hemianopsia that developed on a Friday evening. He waited until Saturday to come to our rural emergency department. No ophthalmologist staffs our hospital or the closest tertiary care center. Ophthalmologists at university hospital 2.5 hours away refused to give advice since patient was not in their facility and would not accept transfer because "not an EMC." Other university hospitals with ophthalmology services did not have ophthalmologists who would take calls. Spent hours on phone trying to find care.
It would be nice to have an available ophthalmologist before "mandating" care.
Exactly my point, which is why I think we should all be careful about what care is "mandated." Standard of care is what a reasonable physician would do under the same or similar circumstances, not what would happen under ideal circumstances.
I feel bad for this patient, and the miss does seem egregious, as blepharitis should not cause such bad vision loss. However, the estimates of lost income seem absurd. He really couldn’t continue to do his job as a professor due to losing vision in one eye? I had an attending when I did EM residency that was able to keep working as an ER doc even after he lost his eye in a golfing accident. He was still able to do LPs and everything.
I'm with you. Bad miss, but the alleged damages resulting from the monovision seem very extraordinary. I've lived with a bad left eye my whole life and have no issues as long as my right eye is open. I don't want to assume this patient's experience and I regret his outcome, but what does a stair lift, ergonomic desk chair, and (what's portrayed as) a complete inability to teach history have to do with losing vision in one eye?
Agree. I have many patients including my own father who are monocular and can live completely normal lives. Also, the correct term is monocular. Monovision is when we make one eye for distance and one eye for near with refractive surgery, contacts, or IOL surgery.
Interesting tangent, I recently found a case in which an ophtho got sued because someone didn't like their monovision surgery. Thanks for the tip on monocular vs monovision!
Can you publish the mono vision case? We need more ophtho cases on here, I read them with great interest.
Yes, I'll definitely publish it! Ophtho cases are pretty rare compared to other specialties so I only have enough to publish 1-2 per year but I'll definitely keep them coming as I find more.
Stye. One of my best residents (you know who you are, Bert) was monocular, and got a pilot’s license.
I had a professor in school who had to retire due to major issues with his vision. He would max out the font size on his phone and computer screen but still require a magnifying glass to read. Eventually couldn't see students faces and felt like he was a detriment to the program. I would be a very sympathetic juror.
What was his vision problem? Someone with monocular vision that is correctable should be able to function fine, wouldnt need a magnifying glass, would be allowed to drive, etc...
Looks like a bad miss.
I won't comment on the estimates in lost income because if I lost my vision unnecessarily, I'd be supremely upset and you can't put a price on your vision. But, this lesson is what will stick with me..."We need to maintain respectful skepticism of a patient’s ability to accurately describe their problem." Countless times I've had patients who dismiss their symptoms and respectful skepticism is best for both parties in these types of situations.
I think framing it as *respectful* skepticism really helps build a collaborative environment amongst colleagues too. I want other doctors to catch anything I've missed... when its *disrespectful* skepticism, it really creates a negative and antagonistic environment that causes burn out and probably harms patient care too.
I agree with respectful skepticism- I found my stepdaughter writhing in pain on the bathroom floor. I’m not sure *what* husband and bonus child (22 yo) told the ED doctor. Husband wanted ED doctor to talk to me - doctor obliged. “Now it sounds like we’re dealing with a chronic problem,” said the doctor on the phone. I told the story- highlighting important elements and stressing that this isn’t chronic. “Ok, now that’s different from the impression I had,” said the doctor. She got a CT scan- nothing was found to be amiss radiologically- luckily.
Ophthalmologist here. An RD presenting with HM vision would not have resulted in functional vision if it was diagnosed correctly at the first visit. This settlement is pretty ridiculous, although not dilating a HM patient is negligent and unheard of.
Unfortunately this is a somewhat common malpractice lawsuit issue... a patient has a very bad diagnosis that got missed, but even if it had been diagnosed appropriately at the first visit, the outcome would have been the same.
Pediatrician here...
EXCELLENT comments all...
Both in regard to the clinical aspects of this case as well as the damages.,,
Could not agree more with all of you.
From me...
A comment on the damages...
Many years ago, in my first three years out of residency, I worked as a covering neonatologist at our local Level III NICU...
While there I worked with a delightful young nurse who was tragically killed by a drunk driver at the age of only 23.
The driver was convicted of vehicular manslaughter yet only received a one-year jail sentence.
The nurse's family filed a wrongful death lawsuit against the driver and I was deposed as a friend who was familiar with her and her family relationships.
In the process of that deposition, I was told that one of the damages being asked was on behalf of the mother...
For , literally, 40 years of haircuts once a month because that was a service which the deceased child had provided to her mother.
Med Mal Reviewer is so correct about lawyers including anything they can to "beef up claims"!
What a sad case!
Extremely sad. The entire NICU staff and all of the physicians were devastated. Over 50 of us attended her memorial service.
I see an ophthalmologist regularly for a condition with my left cornea, and she routinely does dilated eye exams of both eyes at every single visit (even if sometimes I wish she didn't, especially on a sunny day!). So it seemed wild to me that the first ophthalmologist in this case didn't bother with one in the setting of an acute complaint of vision loss (and I see a comment from an ophthalmologist that this was, indeed, negligent).
This is why I dilate every new patient to my clinic if they aren't seeing 20/20 and do IOP/CF/pupils/EOMS every time they come in. Or if there's a sudden vision change from prior visit. Never know what might come up.
That being said...I am really curious at how long the patient waited before calling the clinic in the first place. If he had flashes and floaters for a week prior and didn't call till he was hand motion... waited for the vision to get "really bad"...oof. Pretty much every eye clinic schedules sudden loss of vision or flashes/floaters within 24 hours so if he called and told the staff "I have a bump on my lid and my vision is blurry", they aren't gonna necessarily schedule that within 24 hours unless there happens to be an opening.
And if he was hand motion on the first visit, odds are high the macula was already off. I'm fascinated by the claims for the assistive devices too, I actually wonder how much they will actually be used or if that was an attempt to beef up the claim demand.
The patient is presumably will be legal to drive, so why the demand for a stair lift and talking thermostat? I agree they seem excessive.
Agree. I dilate all new patients as a matter of policy. Missing an RD with HM vision is negligent but the visual outcome would not have changed for the patient.
Yep. Comes down to the fundamental question: if this person doesn't get to 20/20, why? Is it merely refractive (pinhole or quick check of the RX), or is something going on in the eye/brain? That's what makes it negligent. The OD screwed up too, because that was a second opportunity to question the visual acuity.
You hit the nail on the head in regards to the assistive devices beefing up their claims. Its just a stunt to try to get a bigger settlement. Part of the legal game.
If patients call with "blurry vision" to schedule an appointment, do you feel like your secretaries are pretty good at parsing out who needs to be seen quickly and who can come in later? Seems like one of those things where an untrained layperson is making seemingly-innocuous decisions (appointment urgency) that could have a big impact on outcomes.
I use the phrase: sudden vision changes equal sudden eye exam. Have I taken call and gone in to see the patient for what ended up being nonsense (like forgotten contacts in eyes or dry eye)? Yep.
Staff does have a decision tree to follow which cuts down on delay in scheduling care. Basically anyone in pain, sudden blurred vision or loss of vision, flashes floaters gets worked in same day, if I am fully booked they'll come talk to us and we usually work it out. Almost always within 24 hours.
When we get people that call on a Monday, and they are offered a same day appointment, and refuse it and schedule on Friday, we let them know if it's a serious retinal problem, scheduling it later can delay treatment. Basically we take an attitude if they care enough to call, we care enough to get them in.
In cases where I find something sight/life threatening, I make an effort to nail down the timeline, because if my staff messed up, I need to coach them, if it's the patient that made the delay, I need to teach them to be more cautious (especially to protect better seeing eye).
Had a case few years ago; guy had a history of a complete RD in one eye, repaired, but still left legally blind in that eye, so only had "one good eye". Sat a week on RD symptoms in the good eye, didn't get seen until Saturday. Good eye ended up being "macula involved", as in, I got an OCT photo demonstrating that there was some fluid below the macula (couldn't see macula on dilation, too much haze in my view, took the extra step to run the test since I was calling retina on a Saturday)...basically he could sneeze and it would be mac off. Got surgery Monday, thankfully got back to 20/20 vision with mild metamorphopsia. I made it pretty clear that waiting till Saturday to come in, ESPECIALLY after having the history of a RD, was part of what made his visual prognosis so rough. He basically described that the curtain got bigger and bigger each day and finally called when he woke up on Saturday and it was completely covering vision.
Yea, I've been unfortunate enough to suffer not one, but two apparent urgent ophthalmologic issues in my life. One time, it was sudden onset of floaters after eye trauma, and another time, it was eye pain and worsening blurry vision. In both cases, the secretary who took my call seemed to understand the urgency of the situation and got me in to be seen by the next day. I would hope most if not all ophtho clinics run that way.
As a (now retired) emergency physician, I find this case especially concerning. A sudden change in vision, even with a style, is the equivalent, in my mind, of an ocular stroke, and would mandate not only an ophthalmologist referral, but also a phone discussion directly, including “should I dilate and do a slit lamp exam or will you when you come in today to see the patient?” Also,I would be concerned about vicarious liability about referral of an urgent patient and having the specialist miss the diagnosis. The defense obviously found the ophthalmologist care indefensible and should just write a (reasonable) check.
I work in telemedicine- I see patients in hospitals all over the country- in the vast majority- ophthalmologists do not see patients in the emergency room. Granted- a lot of these hospitals are rural. When I was “on the ground” in a more urban area- still- most of the hospitals did not have ohptho available.
As a practicing emergency physician, your recommended course of action doesn't reflect reality. Would that making a phone call and urgent referral to an ophthalmological subspecialist was that easy.
I recently had a patient presenting with hemianopsia that developed on a Friday evening. He waited until Saturday to come to our rural emergency department. No ophthalmologist staffs our hospital or the closest tertiary care center. Ophthalmologists at university hospital 2.5 hours away refused to give advice since patient was not in their facility and would not accept transfer because "not an EMC." Other university hospitals with ophthalmology services did not have ophthalmologists who would take calls. Spent hours on phone trying to find care.
It would be nice to have an available ophthalmologist before "mandating" care.
Hemianopsia should be a neuro consult, not an ophtho consult.
One can only work within the milieu where he/she/they practice(s). Rural practice is trebly hard, but you do the best you can.
Exactly my point, which is why I think we should all be careful about what care is "mandated." Standard of care is what a reasonable physician would do under the same or similar circumstances, not what would happen under ideal circumstances.