 So let's just go ahead and get started and this is, tonight is going to be mostly very informal just talking about ethics in the American Academy of Ophthalmology. All of you guys, when you become members of the academy will actually sign something that says that you will abide by the rules of ethics of the American Academy of Ophthalmology. Most people don't even remember doing that. It's interesting, I joined the ethics committee about six years ago. I became the chair in January and it's amazing to me how often I talk to senior ophthalmologists and they go, we have an ethics committee. I didn't know we had an ethics committee. I go, yeah, well, we've got a code of ethics and rules of ethics. Never heard of that. So the biggest part of what we do is to educate, just sort of help people think about how to practice ophthalmology in an ethical way. Now, one of the other hats that I wear is I'm on the board of directors for OMIC, which is the Ophthalmic Mutual Insurance Company. And I sit on the underwriting committee and also sit on the claims committee. And one of the things that we do is we give a lot of advice to people, basically how to stay out of the courtroom. And it's interesting, so much of what we tell people in ethics is almost exactly the same stuff we tell people in OMIC when we're giving advice, malpractice advice. So basically, ethical medicine is just good medicine. And if you think about, you know, we talk about living consciously, we talk about practicing consciously and think about how you do things in these situations. It's good for your patients. And in the long run, it's going to be good for you guys to help keep you out of trouble. So what I wanted to do tonight was just really just throw out some vignettes and then let you guys talk about how you've seen things handled and how you think things might ought to be handled. So one of the things that comes up from time to time with the ethics committee is how to handle residents doing surgery. So this is a little vignette that I came up with. A resident working at the VA is consenting a vet for cataract surgery. This was something I did hundreds of times. This is the resident's first cataract. Inevitably, you get asked this question. The vet wants to know how many cases the resident has done. And you kind of get that little fear that if I'm completely honest with him, he's going to go somewhere else. The resident is afraid that he'll lose the case if he's completely honest. Have any of you guys ever encountered this situation or a situation like this? Yeah. So what do you do? Well, so typically as an intern here, you know, one can second for the one with a senior surgery. So that's like, so how many of these done? How many of these, you kind of screw around. You say, well, I've been a doctor for four years and then there are a few months of training, last 12 months of training, and that's how it gets raised. And they're going to have a senior surgeon with them who's done thousands of these problems and they're going to be a big outcome. So kind of screw around and be honest. And do you always have a tending with you when you're operating at the VA, even when you're a third year? Excellent. That's not the case of a lot of programs. In fact, at my program, God, it was a wild, wild west. I mean, we were there and you could go for your entire senior year and never see it in attending at the VA. So it was sort of that, you know, the second year is teaching the first years and third year is teaching the second years. And then as a first year, you're sort of the scout monkey for the third year is doing all the, and this is back in the day. I mean, this is archaic. We used to do chest x-rays and CBCs and diffs and the whole, all that work up on all these patients. You're going to encounter this, some of you guys very soon when you get out in private practice and start seeing patients for the first time. You're in a kind of a protected position there because I think in the armed forces, we have a lot of these guys in Colorado Springs, which is where I'm from. We have the Air Force Academy, which has its own hospital, and Fort Carson, which has its own hospital. So when you go to those places, you just get what you get. You don't ask questions. But if you go out into private practice, like me, the first two patients I signed up for surgery, I'm an ocular plastic guy, called later on the same day and canceled. Because they said I didn't look like I was old enough to know what I was doing. So here's another sort of vignette. This is a vignette where the resident is staffed by an attending. So the attending talks to the vet and assures him that he will be doing the case, but a resident will assist him because he needs another set of hands. After the rex, this is made, the attending and the resident quietly changed places and the resident does the fec-o. Everything goes well. Should he tell the patient when he sees him and follow up that he did the case? Does that matter? I don't think after the fact that I think that upfront, you need to consent the patient correctly and you need to say, you know what, the people assist me and do parts of the procedure that they are able and have documented success doing, I will be in charge and I'm the captain of the ship. But just like any venture, I have people that help me and I have them do parts of the case. I think that's how you say it and you say, but I'm in charge and if they say, well, I don't like you to do the case, then that becomes an ethical dilemma of whether you do the case or not, in my opinion. Yeah, what would you do in that case? I would say I operate with residents and fellows and this is the way it is and if you don't want that system, that's the system I operate in so you can go see somebody else. You know, if it's not an emergent thing, I think that's a reasonable thing to do. If it's an emergency, I think you just have to respect the patient's wishes and go ahead and do the surgery. Otherwise, I would just say, you know what, I operate with trainees, they do parts of the procedure that I am comfortable and know that they can do appropriately and that's the way I operate. And so for me, that's what I'll do. I think that sounds pretty much ideal. I think that's exactly what you should do. Sort of the overriding theme here should be disclosure. You know, you always want to do what's in the patient's best interest and if you're always sort of thinking about what's in the patient's best interest. Now, different people have different interpretations about what's in the patient's best interest, you know. And, well, before my time, it was felt that it wasn't in the patient's best interest necessarily to give them bad news like you have terminal cancer and you would hide that from them. You might tell the family members but you wouldn't tell the patient. Of course, we all know that that just wouldn't fly today. So what if you, and when you do this, the term for this is ghost surgery and I've seen that happen in my training program back in the day where either the senior resident or the attending slides back and kind of does this to the junior resident and the junior resident slides in and sort of takes over and the senior resident or the attending keeps talking and so the patient sort of thinks that they're the one doing the surgery. So if everything goes well, you think maybe you don't need to tell them, what if things don't go well? What if something goes really south when the resident or the fellow is the one sort of driving? What do you do in that case? As a fellow or as the attending? Either. What do you do as the fellow? Your responsibility to kind of train as you're told to train and I think it's not your place to disclose anything to the patient in a, you know, but I think it would be reasonable to tell the attending, hey, we got to tell the patient that this is what's going on. But again, it's kind of, you know, I take it as like the captain, the ship approach where if you're the attending on the case, you're responsible for everything that happens in the case, whether you're doing it or not. Those two parts that you choose to delegate, you're still responsible for the outcome of that. So this is true. So, you know, so that's kind of how I like to view it. Anybody else have a different idea? I think it's still on the attending and they, you know, they're the one delegating it would be up to them to do it. What if you're seeing the patient in follow-up two weeks later and they say, what happened? You say, well, did doctor so-and-so talk to you and they go, no, no one's told me anything. Do you go to the attending and say, hey, you need to tell this lady or do you tell this lady? Any other, any other opinion? I think you disclose, if there hasn't been any discussion of the facts of what happened, I think it's completely reasonable to say X, Y, and Z happened. And I don't think you need to necessarily get into, you know, I mean, again, I wouldn't want to be put in that situation and even as a fellow, I usually try to avoid that situation. And, you know, but if they ask me straight out and it hasn't been explained that who was doing the case, they say, oh, was that your handiwork that happened just the other day and there was a patient in post-op that I was seeing and I was going to see him on a Saturday. And the husband was like, oh, so, you know, is that your handiwork? And I was like, yes, it was. The doctor testing and I were both working, but, you know, I was the one inside the eye, he was working on the outside of the eye and takes two people and this is what he was doing, this is what I was doing because I was asked, but. If things had not gone well, what would you have said? Same thing. Putting on my other hat, we had a case in Olmick not long ago which was very similar to this. And the patient only found out once litigation had started, actually litigation hadn't started, it was sort of pre-litigation where the lawyers were trying to figure out what had happened and that's when they found out that it was actually a fellow that was doing the case at the time it happened and that had never been disclosed to them. And I can tell you right there that you start out behind the eight ball when you're in that position. So again, basically the overriding idea behind most of what we talk about in ethics is just trying to find what's in the patient's best interest and sort of a good rule of thumb is what would you wanna be told or how would you wanna be treated in a similar situation? Here's another one, another vignette that comes up from time to time. So a young ophthalmologist is just four years out of residency and wants to start doing a new surgical technique that she's never, that she was never taught during her residency. She works out in a rural area, several hours from the closest university setting. How can she start doing the new surgery and continue to practice in an ethical fashion? So what is your, what area are you going into? And do you know where you wanna go? Let's say you end up in rural Montana and you're a general ophthalmologist and you wanna do something like DSEC comes out that a new techniques are invented all the time and this is something that you wanna start doing but you've never done it before and you've only read about it. How do you think you would handle that? I think that's exactly right. That is the original first step. What about when you get home and you're getting ready to do your first one? How do you approach that? Do you disclose the fact that you've never done it before? Yeah, I think you have to have all the reasons to do it and you just have to tell them that. Yeah, and I think a big part of that is choosing the right patients. And what you'll find is that when you probably see the same thing now, you get people that completely trust you, no holds apart. The vets are real big like that. They're like, whatever you wanna do is fine. And you're like, well, no, I get this all the time when I ask people to sign my informed consent. They go, I don't need to read a doctor, I trust you. And I tell them, I know you trust me. It's not a matter of trust. It's a matter of being informed, knowing exactly what's gonna happen and so you can anticipate or you can ask me questions and that sort of thing. So it's not a matter of trust. It's a matter, because this is another thing I hear frequently. And they go, oh yeah, the CYA paperwork. And I go, no, it's not CYA. It's to inform you about what's going on because you can sign a hundred of these and still sue me. I mean, there's no reason why you can't. But picking those patients that you have a good rapport with and maybe ones that don't have a lot of other options. You know, choosing the 24 year old who has already pretty decent vision is maybe not the one that you wanna try a new technique on. The 84 year old who doesn't wanna have a corneal graft and maybe this would be a way to avoid that. Maybe that's a good choice. Have you guys run it? We'll do that though. I mean, that's an assumption, but... You can almost kind of avoid that too. There's always people who are doing these procedures who are willing to come out to your practice for a fee, obviously. But you can get people to travel out from somewhere else and say, hey, can you come proctor me on my first three or four? And then that way when it comes up, you can say, well, I've done procedures like this, but I've never done this exact procedure. So so and so is gonna be there who's done thousands and he's gonna make sure that he's got the experience. I know how to do this, but he's got the experience to take over or do something if something were to come to that. You can usually find somebody or you can travel to them and do the same thing, proctorship or mentorship. So it's not like your training is over and you're on your own with nobody to help you in the future. There are people that are available to help. What do you guys think? And I know that Moran's sort of known now, I think for international work. What do you think about going to a foreign country as a sort of newly minted resident and doing cases on people that don't speak your language and you can't have any real communication with and to a certain degree, you're using them sort of, I don't wanna say as guinea pigs, but you're really getting your feet wet. I mean, what's your thinking about that? I think that, especially here at a lot of the international stuff, there's like us kind of learning from them just kind of how they're able to make do with what they've got and I think there are some, there are things that like our new trainees have that they can offer. They go to places where there's like one person that can't do FACO. So they're doing, they'll do like Intracal for every case and so if you have 300, that's 300 more than they have. You can probably get a better result. And it's not always just like getting a better result but sometimes it's us learning too. I know some groups will put on seminars in third world country type things, Mexico or Costa Rica or Brazil where you can go down for a week and do a bunch of cases. But this has come in front of the ethics committee. Is this ethical? Is this, you're basically using these poor people from Rio as fodder to learn how to do some new technique. Another one that has come up that has been a problem is live surgery at some of these international meetings. It was a case and I think it was Thailand where the doctor was doing live surgery and this was some cardiothoracic stuff. He was performing live surgery in an operating room but it was being transmitted electronically to this large conference. And the patient developed a problem and there was bleeding that they couldn't stop and they were doing something laparoscopic using like Da Vinci sort of instrumentation. Anyway, the patient ended up dying. And the question was, was this truly informed consent? Did this patient really understand what was going on? And the thing is the doctor who was doing the surgery was not from that country. And so it became a big issue. So this has come up in front of our ethics committee and what are our recommendations concerning live surgery in situations like this? Is that ethical to allow someone to do that? Is that an ethical way to train? It's a fair amount different situation. One is, so I'm pretty involved with Orbus. One of the differences is that with Orbus we're working with the local doctors and so they're the ones who bring the patients and so the way an Orbus week works is when you basically say on Monday you're in a room like this with some of the local doctors and then they start bringing in the patients. And you have an idea of what it is you want to teach that week. You wanna teach them how to do DCRs. And so you say that's a good, that will be a good patient. That's not a good patient. She has too many heart issues or this guy has uncontrolled blood pressure issues. So you go through and you pick them out and then with the local people you translate you go through the consents and the risks and the benefits and all that. Now when you do the surgery there's two ways of doing the surgery. Sometimes you're doing surgery in their hospital and sometimes you're doing it on the plane. And when you do it on the plane you're scrubbed in with one of the local doctors and this is his patient. He's gonna take care of this patient when you guys leave. So it's kind of like a, almost like an attending resident sort of scenario. And true it is being videotaped and have you guys ever been on the Orbis plane? Orbis is a phenomenal program to be involved with if you get a chance I highly recommend it. But in the front area where first class is they have all those first class seats are still there and then they have a big screen TV like this and everyone sits there and then there's a moderator who stands up with a microphone and they're watching you live and you're back say behind that wall in a little operating room back there in the coach area. And the operating room is just absolutely amazing because they have every instrument you could possibly want and they have cameras everywhere so they can see you and you're wearing a mic and then there's a camera on the microscope and all that stuff. So as you're doing the surgery the moderator's asking you questions and so when you talk everyone in the room does it, why are you using that suture or why are you tying it that way, that sort of thing? So it's, it is live surgery but it's a different situation as opposed to imagine like one of these big academy type meetings and there's just some patient somewhere that's being piped in and he doesn't know that he's being piped in front of all these people and he doesn't understand necessarily that it's gonna be a foreign doctor operating on him alone. So these are kind of questions that come up in front of us on a regular basis. So we talked a little bit about informed consent. This is one of the bigger issues that we deal with. Both on the Ethics Committee and with OMIC is informed consent. I'll talk more about informed consent tomorrow but if you read the academies, it's rule number two when we talk about informed consent it says that the surgeon has to be the one obtaining informed consent, right? Not the resident, not the nurse, not the first year, the surgeon, whoever that surgeon is. And I know back in when I was training both when I was a resident and when I was a fellow I think I did basically 100% of the informed consent for the, you know. So how about this one, in attending does the fellow see and work up the patient including going over the risks and benefits of cataract destruction? The attending steps into the room takes a quick look through the slit lamp to evaluate the cataract and notices some zonular dehiscence. He then discusses the case quickly with a fellow and asks the patient if they have any questions. Was informed consent obtained? Now, one of the things that happens to me frequently I say, do you have any questions? You know, when you kind of get this deer in the headlight look and they go, no. And I go, well, you should. In fact, question number one that you should ask me have I ever done this before? Question number two is what's my worst outcome? Question number three is, has anyone ever died or gone blind from, you know, these are questions you should be asking me. And then that'll often stimulate. And sometimes what you'll find is that grandma comes in with her daughter and grandma says, no, I don't have any questions. And the daughter goes, well, I have some questions. And in fact, quite often the family members are brave enough to ask you how many people have you ever made blind with this sort of surgery, where the patient is too embarrassed to ask you that. So what do you think? Was that informed consent? Case all ready. So when the patient has questions or as you're telling the patient, this may be a little more difficult on the counteract surgery than just a straightforward counteract surgery. This is kind of one to expect. But these are also some higher risks with your case than just your typical everyday counteract. So I think that needs to be discussed and made out at that point, rather than we're signing up for a counteract surgery, you know, everything should go well. And what do you think about the fact that the attending's interaction with that particular patient was simply, do you have any questions? No, okay, bye. Yes, I think the attending needs to have more input in that discussion initially, but they should be probably the one presenting most of the information about the actual surgery, potential complications. There is a complication you've gotten that from that. They're gonna be the ones answering that the only need to build that rapport as the attending from seven days later when something has happened and now trying to scramble it. Well, so one of the things we're gonna talk a little bit about tomorrow with informed consent is the fact that informed consent is not the piece of paper. Informed consent is a discussion you have. That piece of paper that you sign only says that informed consent was done. That's all it is. So too often when I was a resident, I'd just say you just need to sign this right here. And of course they're gonna sign it. And I don't think anything near or even close to informed consent was obtained in so many of these surgeries that I did because I didn't really know. All I was told is that they're supposed to sign this form. So one of the things that we see in ethics, one of the sort of challenges that's brought up frequently is when a case where you have a cataract surgeon who's very busy and he has hired X number of optometrists to work for him. And the optometrists see all the new patients and they work them up for cataract surgery. And then the only time they actually see the surgeon is on the day of surgery. And fairly often the scenario is the patient's laying in the operating room, getting ready to pull the microscope over and the surgeon leans over and says, do you have any questions? No. And then they do surgery. And I can tell you that when things don't go well and sometimes they don't go well, I mean, that's just surgery. Those patients tend to be very unhappy if I'd have been told this or this or this. And as far as omic is concerned, that's a hard case to defend. That's a hard case to defend. Have you guys ever seen or heard of situations like this? Some, you know, sometimes we do not necessarily that exact thing, but even as fellows here, when we see patients after hours, especially as a second year, you know, second year fellow, typically the attending is not coming in to evaluate that patient. And they say, okay, yes, they've got a Mac off attachment, sign them up for Thursday, and they meet them in the pre-op area. So they usually don't, I mean, they're not hiding from the patient, but a lot of our patients come from a long ways away and they're not coming in at 1 a.m. to see a Mac off attachment that they're not gonna do anything about. So a patient's not gonna stay around, so they meet them on the day of surgery and most of them are very darn good about talking to them. Going, you know, I go over the full informed consent and then they usually go back over and say, hey, here's all the risks, here's what we're talking about doing, here's why, you know, I know you had all this explained already, but do you have any questions? Yep. And you know, that's kind of a gray area where it's in between. It's still the day of surgery, higher stress time, you know, they're already in a gown, laying on the table, their eyes starting to be dilated, you know, in the pre-op area and so. It's not ideal, but they're granted their situations. And in fact, that's kind of the, one of the fun things about ethics is there's no cut and dry way of doing everything. You know, you're doing what's in the patient's best interest. And sometimes with patients that are coming from far away, you know, you do what you have to do or patients that are in the middle of the night, you know, we've all operated, I've certainly, I do a lot of trauma and I've operated on a lot of patients where there was no family member around and we couldn't get informed consent, you know. So we get what's called three dot consent, where you have three doctors sign the consent form and say, this guy needs surgery, he's gonna go blind or don't die or something like that. So, yes, there are always mitigating circumstances. And again, if it's in the patient's best interest in situations like that, then that's what you do. But I think, again, we're in the omicat, it's always good to cover yourself to be able to say, you know, yes, this isn't my standard way of doing things, but your situation's different. Is there anything, any questions you'd like to ask me? And it's always good. I always like to have the family members in the pre-op area next to the patient. And I say, do you guys have any questions about what's gonna happen? And so one of the situations we've seen in cases like this with omic is that when a patient has only been talked to the doctor on the day of surgery, the plaintiff's lawyer, the patient's lawyer, in that case that's gone bad, makes a really good case for this patient was never, they signed a piece of paper, yeah, but they were never understood, they were never told what was gonna happen. And it's amazing if you go on the internet, go on YouTube and type in informed consent, you'll see lawyer after lawyer after lawyer after lawyer who's trolling for business with these YouTube videos, talking about lack of informed consent. Just because you signed a piece of paper doesn't mean that you got informed consent. One of the things that, again, we'll talk about this tomorrow as well, omic is real big on and something that I do with all my patients now, I didn't do this before, but after I joined to omic and learned about this, I do this with every patient is I have them sign the consent form in the office and typically what happens is I sit down and talk to the patient, we're gonna be doing a DCR on you and this is what's involved in a DCR and this is what's gonna happen on day number one after the surgery and then I'm gonna see you at two weeks, et cetera, et cetera. And then my nurse comes in with a consent form and we have them sign the consent form, then we make a copy of that consent form and we send them home with it. So it'd be really hard for that patient to say, I didn't really know what was going on. Really, because the doctor talked with you and then he actually sent you home with a piece of paper and we're also, omic is real big on procedure specific consent forms as opposed to the, I allow Dr. Blank to do blank, the following risks are and then you just circle all that stuff. That's probably not a great way of doing it. So what I did was I took some of these little brochures that you get from the Academy that explain, this is what a retinal detachment is, this is what nasal icon reductive obstruction is and I sort of use that to write out my consent form and so it's in fairly plain language. Let's move on. So, yes. I want your video. I don't think so, because at that point they can't, you say do you have any questions? If you then sit down with them and say, you saw the video, do you have any questions about the video? And yes, I think that's probably, that's educational material. That's good. But I think if they don't have a chance to actually answer your, you know, ask questions and get them answered, that's probably not really informed consent. I'm on a concert next door. Who doesn't like the Beatles, right? Minor complications. So you're operating on a patient for left cataract extraction as you put in the lens, you inject just a little bit too fast and you rip the bag, okay? So you evaluate very closely and you notice that the rip's really small and very carefully you maneuver the lens and get it in the bag. No vitreous is seen and the rest of the case goes easily. What do you do? Do you tell the patient? Tell the patient about the rip? What do you think? What would you tell him? We had a case very similar to this. And the problem was the patient wasn't told. And then a couple of weeks later they come in and now the lens is sunsetting. And they're like, what happened? Doctor at that point kind of felt like, well, I can't really tell them that I saw it happen. And then the case ended up with lawyers involved and then there it was in the operative report. But the patient was never told. So most of the time you're not ever gonna get in trouble by disclosing or over disclosing. And I think you worded it perfectly. You explained to him, this is what happened and this is how I handled it. And this is not the first time I've seen this problem. And one of the things I tell my patients frequently is that any doctor that tells you he's never had a complication is either a liar or someone that's too stupid to know that he's having complications and either one of those is equally bad. So the difference between a good surgeon and a bad surgeon is the good surgeon handles his complications. So you just closer than what happened and this is how I handled it. And if there's any problems were, we're gonna keep a close eye on it. That's a good one, okay? Next one, referrals. Okay, so you guys are gonna be out, some of you are gonna be out really soon in private practice. You're seeing a patient that was very hesitant about doing her surgery with you because you're the new doctor in the practice and she wasn't really thrilled about having the new be-do-her surgery. But you've assured her that you're well qualified so she finally consents. And the surgery turned out to be a lot more difficult than you kind of expected. And she has severe corneal edema that seems to last for several weeks. In the beginning you sort of think you know what's going on but after two or three weeks you're kind of losing confidence in yourself like I don't think I really know what's going on here. But you're kind of afraid to refer her because if you do you're sort of proving her point that you're the newbie and you, number one, caused a problem and now you don't know how to fix it. So what do you do? So what if you're, again, what if you're in rural Idaho and the only guy around is the guy who did everything in his power to keep you from coming into that town. And so he doesn't really want you there and he's not happy that you're there and he doesn't like you being there. But he's got 15 years more of experience than you. You're gonna refer to that guy or you're gonna refer down to Salt Lake City. I can learn from you. So I'll tell you my experience. I left here and I had a, I was set up to join a guy in Colorado Springs and about six months before I was finishing my fellowship here in Oculele Plastics, I called him one night, just on a weeknight just to ask him some questions about some real estate questions actually. And he said, yeah, I kind of wanted to talk to you about that. And I said, so about what? He goes, you know what? I've kind of decided I don't really want a partner. I'm like, well, dude, we already bought a house. I mean, he goes, well, there's no room for you here and I don't think you wanna come here because no one really wants you to come here. And I said, well, I don't have a choice now. I mean, we're coming. My in-laws live there and we're set. I mean, kids, they're set for school. And he said, you won't come. You'll get an academic job somewhere. And so I went and I went around, he was the only guy in town. So I went around introducing myself to the other practices and virtually everyone I met said, well, I've been sending my stuff to him for the last 15 years. I don't really have any reason to switch. I said, I'm not asking you to switch. What I'm telling you is now there's a backup quarterback. So when he's out of town, you don't have to send him to Denver anymore. Or if it's 4.30 on a Friday and he doesn't really wanna see the patient or he's not in the office, then I'm here. And so I had some patients that I didn't know what to do with. So I started referring them over to him. So that started a little bit of a dialogue. And then one day about a year after I got there, I got a phone call from him and he said, would you have a drink with me? And I said, sure. So we went to this place and we're having a drink and we're just talking about nothing. And after about an hour, I said, so what is it that you wanted to talk about? And he said, I was just wondering how you'd feel about me joining your practice. And I said, wow, that's something to think about. And I went home and my wife said, so did you have a drink with Dr. So-and-so? Yeah, I'm like, well, what did he want? And I told her and she said, absolutely no way in hell. If you join practices with him, we're divorcing. So that actually never happened. But so it was one of these contentious situations. And I think by coming in and trying to be humble, he didn't do any trauma. And I did a lot of trauma here. And he didn't do any cosmetics. And I did a lot of cosmetic stuff here. So we were both ocular plastics, but we didn't do the same stuff. So it ended up working out very well. So there's actually one of the rules of ethics has to do with referrals. Believe it or not, we get complaints from patients who say Dr. So-and-so won't refer me. I wanna go to this other doctor, but he won't send any of my paperwork or any of that stuff. So just because you're not in elementary school anymore, doesn't mean that you're not childish. We see that frequently. Here's one I bet you guys have talked about quite a bit. So you have a case that's very perplexing and you want to get another opinion. You text all the information, including the picture and the name of the patient to a colleague to ask their opinion. Is this okay? What do you think? I think if we ask to run this by somebody in the net for me to send your information. Did you guys ever do that? Usually not via text. We have outside providers who want, I mean, I guess I haven't had a right to send someone else, but we'll get. Do you guys text each other information? If you identify, it needs to picture if an FA or something, something that I guess you can theoretically identify something. What if it's just a close-up of the cornea? That's okay. I think so. If I take a picture, though, I usually tell the patient like that. We always ask, is it okay if we take a picture and like send it to one of the other doctors and they're like, yeah, sure. That's number like, I guess, I mean, sometimes they're like unconscious, like in the trauma they would do it, but I think that's like, for cognitive care, you kind of have to. So other than unconscious patient, in a situation like that, do you need to like create some kind of documentations that's aligned with patient three to allow you to take a photo and then send it off to another college for non-useful and encrypted phone? Yeah. Well, that's a legal question and I'm not really qualified to answer that. I know I have a friend who's at UCLA and I mean, they are radical, radical about that. They can't even text a picture of the cornea of a patient. You're just not allowed to do that ever. I'll tell you, I'm in private practice and I get pictures from patients all the time. Every single day, patients text me pictures. What I do is we go back and forth answering each other and then when it's all done, I forward the entire conversation to my assistant who then prints it out and puts it in the chart. But this is sort of one of those situations. Colorado, Southern Colorado is a bit like, sort of like the rural parts of Utah where if I do surgery on a patient and then two days later, they're having a question or an issue, for me to ask them to come in is a real hardship. Now there it's two or three hour drive and for them to text me a picture so that I can say, no, no, no, that's not infected. That looks fine. I mean, they're thrilled and I'll get, I do a lot of international work with Orvis and some other places and I was in India this summer for two weeks and I would get texts from patients almost every day. It was just okay. From the legal standpoint, I sort of stand on the hope that if what I'm doing is in the patient's best interest and I'm trying to help the patient by making them not wait on me or not go to the emergency room, et cetera, et cetera, then that's a pretty good argument, I think. Others might disagree and if you get super legal about it, you shouldn't probably ever do anything like that. But my own personal opinion is that with certain things, I think we've gone way too far the other way. When I first started practice, patients, this whole hippo thing first came out like around 2000 and we had this form and everybody, we gave it to everybody and patients, especially the older people, were like, oh my gosh, you're not gonna make me read that hippocrap again, are you? Just whatever. Yeah, and patients didn't want it. So I don't think, and it was a big problem too when you would call another doctor that sent the patient over, can you send over there? Well, they have to come in and sign a piece of paper and I go, no, they don't. Not from one doctor to another. Well, there's a lot of misunderstanding about it. So I think in the long run, some of the mandates from a higher ups have not been in the patient's best interest. Here's our last little thing to talk about. Social networking. A patient wants to friend you on Facebook. Is this okay? Has this ever happened to anybody? It's like it's a policy here at the university. Is it? What about when you're not here and it's not, there's no policy, you know? Do everyone think that way? I know some doctors that use on Facebook and they have a professional Facebook page for their, that's kind of becoming, that's probably a little bit different, yeah. I've had a couple of patients. I've had several patients, as a matter of fact, find me on Facebook and try to friend me. And I don't know, that seems like it's a boundary to me. Your professional life versus your private life. Here's another Facebook issue that I've seen is people posting pictures of patients on Facebook. And a tech that I work with, she works with a lot of doctors and she was working with a podiatrist. And this was a foot that got caught in some kind of machine, just mangled all the bits. It was just like from the knee down. But you think that's okay? Yeah, I don't think that's okay either, in fact. I think that's a fairly clear violation of hip-up. Because if that's your mom or dad, you don't want people. And you know how people can, I don't know, screenshot that or whatever. The next thing you know, it's on Reddit and everywhere else. So, well, let me, one nice thing before we leave. Well, I think that's all. It's just about seven o'clock. And I know you guys have a lot of other things that you need to do, but I hope that you'll, number one, realize that when you join the academy, that you are signing a form that says that you will abide by the rules of ethics. And I hope that at some point you'll take the time to look at those rules. Because they're there for a reason. They're there to help you practice in a way that's in the patient's best interest. And if you do that, now wearing my omicat, I can tell you, you go a long way toward protecting yourself. When patients realize that you're doing things, not for CYA purposes, but you're doing them because you truly want them to turn out well, it's amazing how people will, even patients that you've harmed, not on purpose, will go out of their way to protect you. We've had several cases where the doctor who actually caused the harm was not sued, but the anesthesiologist was sued, the nurse was sued, the tech was sued, the surgery center was sued, but they refused to sue their doctor because they felt like their doctor was their friend and their doctor had their best interest at heart. So when you practice ethical medicine, you're just practicing good medicine. And the ethics of any given situation are not always clear cut. But if you always sort of have in the back of your mind, I'm trying to do what's in the patient's best interest and think about that logically. I think you're gonna go a long way toward protecting yourself in doing good medicine. So tomorrow morning at Grand Rounds, we're gonna talk about some other common things that we deal with on the ethics committee a lot. Interestingly, they sort of overlap a lot with OMIC, and one is expert witness testimony. You guys are all soon gonna be considered experts and especially when you're kind of newbies. The lawyers really like to have you because one, you have time. And two, I think they often feel like you can be manipulated more than old guys. And three, you don't know what to charge. So you grossly undercharge them. And then we're also gonna talk about some more about informed consent stuff. So anyway, I hope you have a good evening.