 Good morning, we'd like to welcome everyone out to our special grand round series. This is our ethics conference, our quarterly ethics conference. I will allow Dr. Buhi Patel to do the formal introduction of our speaker. In the back of the room though, I do want to acknowledge our resident applicants here today. Would you mind just standing up if you are here applying today and interviewing today? We're going to give you a big round of applause for coming out post-election day. Welcome, we're excited to have you and excited for your day ahead. Without further ado, turn the timer to Dr. Patel. Good morning. So it's a great pleasure for me to introduce an old friend, former fellow of mine, Ron Pelton, who is now the chairman of the Ethics Committee of No Less Than the American Academy of Ophthalmology. He's going to be the Ethics Committee Chairman for the next five years. Ron was one of our superb fellows here. He and I came up with that super-medial approach to the optic nerve. He's the man on the paper that we set up this project with and it's gone on to change the world as far as how we approached the nerve and Ron did some superb anatomy work with us in on cadaver heads. And we've gone on to do other projects just like the one you and I did. So it's lovely to see you back here again. As an Englishman, I'm not allowed to vote in this country and I don't have any strong views one way or the other. But I was watching the news till about four this morning and this just kept on coming back to me again and again. It's the one quotation that applies to the 9th of November 2016 more than anything I know. And I thought it was an introduction to Ron. And when we talk about ethics, the word ethic from the Greek, ethikos, which is the character of the human being, who you and I are and what do we do, why we do, it's very simple. You do the right thing by the other person. It's not about doing the right thing by what you believe. It's doing the right thing by the other person, irrespective of age, sex, creed, nationality, etc. Something we should remember yesterday and today as the world changes. So I thought I'd go through a couple of things. Ethics of a nation. In France, when they had the election three years ago, it cost $28 million to have the election. $93 million for Germany. In the UK, when we had it last year, it was $89 million all in dollars. And we just finished $6 billion of expense. What is the ethics of a nation in terms of expense? Why do we not discuss this? Why do we not as residents, in my case, citizens in your case, bring this up? The same thing applies to hospitals, the way we practice. I'm always railing on about the wastage I see in surgery, the things that are thrown away. I urge you to think about the ethics of the nation when it comes to such expenses. The ethics of an organisation. I just came up with these early hours of this morning. They just popped into my head. Let me just quickly go through these. You know all these names. Arthur Anderson, Enron, Madoff, Hutton, Robbins. It just goes on and on and on. And these are just ones that I remember from the last 10 years or so. And I stopped after I got to about 15 of them. So here's the thing. My niece is just finishing an MBA in INSEAD in Paris. And she said they've always had 20% of all their lectures based upon ethics. They always have. All the banks and all the organisations tell us they're there to look after us, to look after us well. And yet we see example after example after example of ethics being crossed. The line is crossed. We see it in, among surgeons, we see it in hospitals, we see it everywhere. Ethics of the nation. Ethics of the organisation. And I think it just shows from discussing what I've discussed so far, this little ditty here. We have met the enemy and he is us. We're the ones who go to ethics lectures like these, sit for an hour, discuss things, but we're not paying attention. As a nation, as an organisation, and I suggest to you even as an individual. So I'm very much looking forward to Ron presenting to us the ethics of the individual now in an impractical world. No more so is this important than today after the elections last night. Ron Pelton, thank you for coming to talk to us here. Ron Pelton. Thank you, Boobie. It's a real thrill actually to be back here. I spent four very, very, very influential years of my life here. I still have many people here that I consider to be friends, including Brad. Our kids grew up together. My son's first best friend was Brad's son. And so a lot of good memories here. I'm dealing with many of the same issues that everybody else is dealing with here, including insurance problems. I'm dealing with government problems as far as some of the mandates that are sent down that make absolutely no sense to us. And many of the things that we're being asked to do are completely impractical. Any of you that are dealing with EHR, and I assume that's probably most everyone in this room, understands what I mean. So when I was thinking about what I wanted to talk about today, I was thinking along the lines of what people think of when they think of an ethics lecture. They think they're going to be talked to about, you know, turn the other cheek and do unto others, that sort of thing. And I know when I was a resident, when someone would be discussing the fact that we're going to hear an ethics lecture, I'm thinking that's like going to your wife's best friend's daughter's wedding. I mean, who looks forward to that? Or your neighbor's 10-year-old daughter's piano recital. So I don't want this to be sort of on that plane. I want this to be more along the lines of practical everyday ethics and what the ethics committee can do to help with that. So why are ethics important? I thought this was a wonderful quote. Now many of you know who the name Albert Schweitzer, you may not know who he is. He was a physician, a theologian, actually a very accomplished musician. And he won the Nobel Peace Prize back in 1952. And he says ethics is nothing else than reverence for life. And what I love about that quote is it sort of reminds all of us why we got involved in medicine to start with. One of the things that I enjoy doing most is international work. I do a lot of stuff with Orbis. And when I go to these trips with Orbis, it's always the best week of my life because it reminds me of why I went into medicine. I don't have to worry about malpractice issues. I don't have to worry about EHR issues. I don't have to worry about billing issues. I just see a problem and I help fix it and I teach others how to fix it. So ethics should sort of remind you of why you went into medicine. So instead of pie in the sky, we're going to be talking today more about sort of meat and potatoes issues. And then the first thing we're going to be talking about is expert witness testimony. Now everybody in this room is either an expert or soon to be expert. And I would guess that many people in this room have served as expert witnesses in a trial or deposition at some point. And if you haven't, you probably will. And what is this number? 3595. It's kind of a scary number. Statistics show that if you stay in practice for 35 years, there's a 95% chance that you're going to be sued from malpractice. That doesn't mean you did anything wrong. It just means that someone thought you did something wrong. So whether you like it or not, knowing these things about expert witnesses are important. One of the other hats that I wear is I sit on the board of directors for OMIC, the Ophthalmic Mutual Insurance Company. And one of our attorneys said this one day when we were talking about expert witnesses, an innocent doctor deserves a good one and a guilty doctor needs a better one. I thought that was a great quote. And it's very true. I've served as an expert witness on, I think, four trials. The last one was a murder trial. And this quote is very scary. When the judge is giving directions to the jury at the end of all testimony, she says you must base your decision only on the testimony of the expert witnesses who have testified in this case. That gives you an idea of just how important your testimony is. So many of you know that in addition to the ethics committee, we have a code of ethics. And there are three parts of that code, but the second part of that code has to do with the rules of ethics. There are 17 rules in the American Academy's Rules of Ethics. Now, these rules are enforceable. So rule number 16 has to deal with expert witness testimony. Now, this is the rule. I didn't put it in small print because I didn't want you to really read it. But this is the gist of rule 16. That when you testify, everything you say is going to be based on sound medical knowledge, not just your opinion. That you're going to avoid bias by non-medical factors. It doesn't matter whether you like the other expert witness or whether you like the doctor who's being sued or not. That everything you say is based upon truth and not based upon bias from non-medical factors. Obviously, there's going to be no false deceptive or misleading testimony. And last of all, what you get paid has nothing to do with the outcome of the trial. You're getting paid for your time. So the way the Ethics Committee gets involved in these situations is say that I'm being sued from our practice. And the plaintiff's expert witness gets up and gives his medical opinion of what I did wrong, and he's basing it purely on nothing that has to do with science or anything published. And if this other expert witness is a member of the academy, I can file a challenge against him with the American Academy's Ethics Committee. So the way we get involved is there's a submission made against an academy member. And then we review all the depositions and transcripts and the patient's files. And based upon that, we're either going to have a formal hearing or we're just going to make our ruling. And last of all are the sanctions. Now the sanctions can be everything from a private reprimand where you get a letter from us that says what you did was wrong and now you've acknowledged that it was wrong and please don't ever do that again. Or you may get a letter that says you're no longer a member of the academy. So there are some teeth to these sanctions. Randy. Have you actually told people that you're kicked out of the academy? So that has happened. That has happened. However, I will tell you most of the time when they know it's going in that direction and they resign. And since I've been on the committee the last six years, that's happened probably three or four times. So when it comes to expert witness testimony, we're first going to go through some don'ts. Think of this as the top ten ways on how to stay out of hot water. So number one, don't misrepresent your training. Too often we see people that have training, say as a pediatric ophthalmologist, say that they're an expert in retinal surgery. And they want to act as an expert witness because quite frankly, acting as an expert witness for plaintiff's attorneys can be very lucrative. I mean, these guys can make a lot of money. One of the things we find is quite often, it's doctors who are either retired from ophthalmology or are partially retired from ophthalmology and they're trying to supplement their vacation income. So don't misrepresent your training. Second of all, don't allow personal relationships or competitive issues to bias your testimony. So as I said before, whether you like the other doctor or not or whether you like the other lawyer or not, don't let that sway your testimony. Your testimony should be based purely and solely upon science. Number eight, don't view this case with tunnel vision. Too often we find that doctors sort of get this idea that the way I do it is the way it has to be done. I know I've trained with people that sort of felt that way, that my way is the only way. So we have to sort of resist that when we're acting as an expert witness that this is the way I do it, however this is also an acceptable way. So don't get tunnel vision that makes you miss the larger opinion. This is sort of what I was referring to, is the hired gun. Quite often the other attorney will send you sort of a little teaser and say, does this sound like a case that you would be interested in helping us with? Being an expert witness. And it seems kind of interesting. It's along your field. So you say yes. And then you start meeting with him and he's paying you for your time. And this has happened to me where the attorney said, well, you said this, but couldn't you reword that a little bit so that it says this? And sometimes you sort of feel compelled and you get in this sort of competitive atmosphere and it's almost like our team versus their team. And it can't be that way. You have to base your opinion on science and not on these rah-rah let's go team sort of attitudes. So you don't want to be the hired gun. Now here's a problem that we see frequently. Don't resist answering a truthful or objective question when it could be damaging to your side. So in fact, one of the best things to build credibility in a case is to answer a question that may not be particularly helpful to your side. It shows the jury that you can see both sides of the issue. So don't resist answering truthfully even if the answer can be damaging to the side that you're testifying for. Again, don't confuse your personal opinions or preferences with the legal standard of care. Now, every community has its own sort of legal standard of care and I think one of the reasons that people get submissions against them to the ethics committee most commonly is because they confuse their own opinion about this is the way I do things with this is the standard of care in the community and that's not the case. Number four, don't be unwilling to acknowledge possible malocurrence. Maybe now you're the expert witness for the plaintiff and there's a big difference between malpractice and malocurrence. Everybody in this room that's ever done surgery has had malocurrence. Malocurrence is when you're putting in that IOL, the case has gone beautifully, it goes in the bag and all of a sudden you see it start to drift downward and you have no idea what happened. That's not malpractice, that's malocurrence. Somewhere along the line there was a rip in the bag that you didn't see. That doesn't mean that you committed malpractice, it just means that something happened that we didn't expect. I'm an ocular plastic surgeon. Sometimes patients show up, they haven't been taking care of their wound and now they have a wound infection. It doesn't mean that I did something wrong, it didn't turn out the way we want. Now, as I always tell my patients, the difference between a good surgeon and a bad surgeon is not that good surgeons don't have problems and bad surgeons do have problems, it's that good surgeons recognize their problems, they acknowledge their problems and they deal with them. So when I see a patient that has a problem, a woundy hesitance or an infection or I see them three months post-op and it just didn't turn out the way I wanted. I tell them this, I'm not happy with this either. Let's go back and fix this. So you have to acknowledge malocurins when it happens. This is probably, again, one of the biggest problems that we see is don't be unfamiliar with the intricacies of the specialty of concern. It's doctors who came to a residency like this where you learn a lot of everything, but then you subspecialize and now you've been an ocular plastic for 16 years and yes, I see kids from time to time that does not make me a pediatric expert, that does not make me a neuro-ophthalmologist. So I don't testify in those cases, I don't get involved in those cases. Too often people see the dollar signs and they think, well, I know a lot about pediatrics because I read some stuff online, that doesn't make you an expert. If you've ever been in a courtroom sitting on the stand, you realize how intimidating it can be and even though you look up in the jury box and they all look like they just got back from an ass car race, you're thinking these guys aren't necessarily that bright. When you get 12 people in a room, there's a lot of common sense and a lot of wisdom there. Any given one of them may not be that bright, but you put 12 of them together and they're pretty smart. And the judges, even though they're not physicians and even though they may not know a lot about medicine, they're around bullshitters all day long. So they know whether you're spouting truth or something else. So don't underestimate the comprehension level of the people in the room. And I think this one again goes without stating, don't accept compensation that's contingent on the outcome of the trial. You're giving your opinion, you're being paid for your time, you're not being paid for how the case turns out. So those are some dunks. Let's talk about some do's. One of the things that we encourage people to do is to be willing to testify for both sides of the aisle. There is such a thing as malpractice. There are doctors who are unethical and are just bad doctors. And too often we're afraid to get involved, but it doesn't look credible to a judge or jury when you say, I've been involved in 10 trials and they've always been for the plaintiff. You know, they've always been for the defendant. So working for both sides of the aisle gives you credibility. Know your subject. Yes. Well, one of the reasons people don't want to be involved with the plaintiff's bar is because they're going to be labeled as a snitch or as a bad guy. So you know if there's been malpractice and you say, but this guy practices in the same town and everybody's friends with him and if I testify against him, now everyone's going to hate me. That's hard to do. It's hard to stand up and do the right thing. But we need to be willing to do that. So you want to possess sufficient knowledge and experience so that when you're going through the qualifications or when they're discussing your qualifications, you don't want to have any doubt in the room that you're qualified or not. I testified in a case a couple of years ago that I thought was very straightforward. The plaintiffs had an optometrist as their expert who was going to be talking about an ocular plastics issue and I'm the ocular plastics guy who's fellowship trained and I've been doing this for 15 years and then when they get me up on the stand and the plaintiff's lawyer starts going through my qualifications, he made me sound like an idiot. For example, he says, did you go to medical school? Yeah, I went to medical school. But when you're in medical school, did you just study ophthalmology? No, I studied everything. He goes, so from the bottom of the foot to the top of the head? Yep, I studied every subject. He said, well, do you know Dr. So-and-so over here? And I said, yeah, I know him. Well, he went to optometry school. All he studied was the eye. So doesn't that make him more of an expert than you? You're wasting your time learning about podiatry and bones and all this stuff. And I couldn't believe he was actually saying that. But the way he said it made it sound like it made sense. So, you know, you don't want to be up there and have any doubt in your mind that you're qualified to be sitting there. Do your homework before you sign up. You don't want to be sitting up in the jury, up in the, setting necks up to the judge in your little chair, testifying before you realize that you're talking about some stuff you don't feel so comfortable about. I'm an ocular plastic surgeon and now they're talking about refractive stuff and when they use the word optics, you know, I break out into a cold sweat. So you don't want to be that guy. You want to be honest with the attorney that you're working with. You don't want to give him hope when you know there is no hope. I was involved in a case a few years back that involved an orbital abscess and a child who had a very bad outcome and the attorney that was wanting my opinion was actually working for the radiologist. And when he showed me the CT scan, the abscess in this child's eye socket was almost as big as the globe. And it was missed. It was read, unfortunately, when the pediatrician asked to get a CT scan, he asked at 5 o'clock in the afternoon and for some reason they didn't get around to doing it until like 11 o'clock at night. And then it wasn't read until midnight and somehow the radiologist read it as normal. It totally got missed. And the child ended up getting a brain abscess and did very poorly. So when he came to me and showed this to me and said, can you help me with this? And I just said, you cannot defend this. This is not a case you want to try to defend. This is a case you want to try to mitigate. You want to see if you can settle this one. Because if you go to trial, there is no way any credible expert is going to say that that could be missed. Just the first-year medical student or the janitor could call this one. So, again, provide testimony that's truthful and without bias. Doesn't matter if what you're saying helps the other side or not. Sometimes that happens. But it doesn't mean that you're going to give up the whole case just because you acknowledge that, yes, that part shouldn't have happened. Standard of care, that's a big issue. Now, we recently dealt with a case in which the standard of care was the entire case. So the expert for the plaintiff was saying that this patient should have gotten anti-Vedjeff. That's the standard of care. It should have been done right away. And I'm sitting on it. That's malpractice. Well, this was in like the case happened many years before. And actually, Vedjeff was not the standard of care. In fact, Vedjeff, anti-Vedjeff, was just coming out in the early trials. And so it wasn't yet the standard of care. So even though it may be the standard of care now, was it the standard of care at the time when the supposed malpractice happened? You need to be aware of what the standard of care was when this issue happened. So you want to answer questions that are asked well and you want to ask for clarification of poorly asked questions. And sometimes you will get questions that almost sound like a riddle. When they ask you and at the end of it, you kind of shake in your head and I'm not sure what you just said. Can you rephrase that? And sometimes one of the things the most credibility to the jury is just to say, I don't know. I don't know. I have no idea. Dr. Wooden, it would have been better if he had done this. I don't know. I don't know what the outcome of that would have been. And so if you decide to get involved in this, this is one of the things you're going to be asked about. When you're up giving your testimony, you're going to be asked what percentage of your time you serve is your goodness, what's your hourly fee? How much are you being paid for this particular case? How many times have you testified for a plaintiff? How many times have you testified for a defendant? And then, last of all, you better be willing to submit your transcripts of your depositions in your trial testimony to the ethics committee because if you testify in a way that's unethical, there may very well be a submission made against you and then you may end up in our court and it's just not a place you want to be. So staying along these lines of practicality, this is the last thing I'm going to talk about here, and this is informed consent. And this is important because every single patient that we deal with surgically or procedurally, we have to get informed consent. So these are the dos and don'ts of informed consent. Now this, let's see here, I don't know... It's informed consent and a decision of the proposed manual treatment. It's not acceptable if your doctor necessarily asks if she has information to perform medical procedure. You must be able to understand reasonable and foreseeable consequences of giving permission and consent or not giving permission for the medical procedure. It's generally accepted that in order to provide proper permission for medical treatment, your doctor must explain, number one, the nature of the proposed medical procedure or alternatives to the proposed medical procedure. And number three, the relevant risks, benefits and uncertainties related to each alternative. No permission or consent to be expressed in words or implied by your actions. For example, when you're undergoing a surgical procedure, your doctor will usually get you to sign a consent form as part of the consent process to confirm your permission to perform the medical procedure. Any medical procedure without proper informed consent is deemed to be an assault. I would encourage you at some point to go into YouTube and just type in informed consent and there are tons of these plaintiffs' attorneys' videos discussing informed consent and how even though you signed a document, we can still win your case. I encourage you to understand what informed consent is because these guys know it inside and out. And when you're playing in their field, you're in foreign territory because they know what they're doing and when you're in a courtroom, you totally fill out a place. They fill out a place in the operating room. You're going to fill out a place in the courtroom. And if you just go onto YouTube and start flipping through, look, there's tons of these. So rule number two in the 17 rules of the Code of Ethics is dealing with informed consent. It says the performance of procedure shall be preceded by appropriate informed consent. That can't be so confusing. Well, I think that informed consent basically goes and get permission for what the doctor's going to do. They want to trust the doctor. So when you want to trust the person, you're not really looking to say, would you please be sure to talk to all the risks, all the benefits and all the options. That's kind of what you might do with a lawyer or someone you felt was trying to say a used car. It's not exactly the same as dealing with a physician. I love the fact that he put lawyers or salesmen in the same sentence. So studies have shown that after people sign their informed consent and sign up for surgery, 40% of them can't even tell you what they signed up for, exactly. That 50% of them can't tell you any of the major risks of the surgery. They show that 60% don't really understand the wording of the informed consent that they just signed. And 70% of them don't even read the informed consent. This happens to me on a regular basis. As I was discussing with the residents last night, I sit down and talk with the patients. So this is how the surgery goes. This is why we're doing it. And you don't have to do it. And if you don't do it, this is probably what's going to happen. You don't sign up for the DCR. Your eyes just going to continue watering. Yeah, there's a chance it can get infected. That doesn't happen very often, but it can happen. It happens. We can still do the DCR. And quite often, this is what I get. I trust you, doctor. I'll sign it. I go, no, no, no. It's not a matter of trust. It's a matter of being informed. I know you trust me or you wouldn't be sitting here. You need to read the document. You need to ask me any questions. Or another thing that I get quite often is I'll say, I'll go through everything with them. I'll say, do you have any questions for me? And they'll inevitably say no. If they happen to have a family member with them, a daughter or son or spouse, quite often they will raise their hand and they'll say, yeah, I got a question. How many people have you killed doing this? Or how many people have gone blind when you were doing this? And so if they're there by themselves and they say, no, I don't have any questions, I say, well, here's what you should ask me. And I'll list three or four questions that they should be asking me. So informed consent is something that patients misunderstand because they think most of the time that it's a CYA thing. When in actuality it's what we're doing as a physician, where I'm trying to treat you, I'm trying to teach you about your problem and then what can be done about it. So here are some of the don'ts of informed consent. Don't confuse signature on a form with informed consent just because there's a signature on the form, just because you got them to sign a consent form does not mean that they have informed consent. And again, all the lawyers understand this principle very well. It doesn't mean that it's not important to have them sign the form, it just means that that in and of itself is not gonna save you. Don't misunderstand what I'm saying here. It says don't allow anyone other than a surgeon to consent the patient. What do I mean by that? Anyone can get the patient to sign the document. In fact, in my practice the nurse is the one that hands the consent form to the patient. But she's not the one who gives informed consent, I am. So when the patient comes in and I evaluate them for a problem, I say here's what you have. What you have is called ectropion. And here's why you have it. Here's what's going on. And here's how I fix it. And if we don't fix it, here's what's gonna happen. Here are the risks of surgery. Here are the risks of not doing surgery. That's the informed consent. And then anyone can get them to sign the document. It can even be the secretary. So the surgeon needs to be the one that talks to the patient. The one that's gonna be cutting on the patient needs to be the one that talks to the patient and informs them so that they can ask the questions of the person that's doing the surgery. Don't coerce. Well, none of us are gonna hold a gun to a patient and say you have to sign this. If you never consent someone except right before surgery, that can be construed as a form of coercion. They feel under the gun, they feel intimidated that if they don't sign this very quickly, you're not gonna help them, you're not gonna do surgery for them. So what I learned when I joined OMIC is to have the patient sign the consent form in my office and then make a photocopy of it and send it home with them. And then when they come back for surgery, one of the first things I do is, so I sent you home with that consent form. Did you read it? Did you have any questions about it? So no one could ever say that they weren't informed. Not only did you talk to them in the office, but you sent them home with a consent form. And one of the other things that I started doing when I joined OMIC was procedure specific consent forms. So I have one, the top of the consent form says DCR, another one that says ectropion, another one that says ptosis. So we don't like the ones that say, I give Dr. Blank permission to do blank and the risks are in a big, long list and you go through and circle them. What I did was I took the brochures at the academy and Ace Hoppers puts out that sort of list. This is what ectropion is. This is what ptosis is. This is what nasal ectomoduct obstruction is. And I made my consent form sort of based on them. So my consent forms are very friendly to laymen. I don't use a lot of doctor words in there. Again, if you didn't catch what the last thing that that lawyer was saying was, is that if you do a procedure or surgery on somebody without their consent, that can be construed as battery. That's kind of a scary thought. One of the biggest cases that we lost on OMIC was a Shalazian case. Oh, I'm sorry. OMIC stands for the Ophthalmic Mutual Insurance Company and I think it's probably the largest malpractice insurance company covering ophthalmologists. Now most academic programs have their own, they're involved with the university and they're sort of self insured, but many, many doctors out in private practice are insured by OMIC. So again, you don't want to ever be accused of battery because you did something to somebody without telling them what the risks and benefits are. The Shalazian case that OMIC paid out on I think was somewhere on the order of a million dollars. Shalazian for you guys that are applying for residency here. I don't know if you know what a Shalazian is but just sort of think of it as a big zit on your eyelid and to think that you could be sued for a million dollars for that is kind of a scary thought. So here are some of the do's. Your discussion with the patient and the consent form should tell the patient what their diagnosis is. If it's known, sometimes you don't know what the diagnosis is. It should include the nature and purpose of any proposed treatment or procedure. We should talk about the risks and benefits of the surgery that I'm proposing. You should outline the alternatives to the surgery that I'm proposing. Then you explain the risks and benefits to the alternative. So maybe I'm saying you can have TOSA surgery or you can get glasses with crutches on them and these are the risks and benefits of either one. Then you want to talk about the risks and benefits of doing nothing. So one of the things I always talk about patients with, you know, you've got four options here. You can do this or this or you can just leave it like it is. And sometimes when they hear that, they'll say as long as you can promise me that this isn't cancer, then I'm happy to just leave it like it is. And then you want to send the patient's home with a signed copy of the consent. So just to re-emphasize, the discussion process is the informed consent, not the signed piece of paper. And not only is it an ethical obligation, it's a legal obligation spelled out in statute and in case law in all 50 states. So for those of you that have interest, many of you I think will be out in private practice before long, you don't have to be insured by OMIC to go onto their website and look for their consent forms. There's a big long list of consent forms that cover almost all areas of ophthalmology. So we encourage people to go on to the website to download the consent forms and then you can put your own logo on there and make them so that they work for you. So stay ethical and avoid this guy. He says, well, what if my bliss happens to be suing people? So if there are any questions, this is how I can be reached. And I know quite often people will come up to me after a lecture and they'll say, I'm asking for a friend, but what if such and such happened? I gave a talk at the academy this year and I said, are there any questions at the end and no one raised their hand? And then I said, thank you. And as I came off the podium, like eight people approached me and said, well, I didn't want to say this in front of everybody, but one of the other hats that I wear is a member of the state affairs committee. And I just want to encourage us, especially in the atmosphere that we're in right now with the elections going on and everything, if you don't think that your vote matters, you are very, very wrong. So how do we protect ophthalmology? Get involved with your state society and I'm the regional rep for Utah and one of the beautiful things about Utah is you guys are dialed in. Almost everybody in this state is a member of their state society and that's a wonderful thing. Get involved with your state IPAC. I was recently the president of our state society in Colorado and what I used to preach to people all the time was help. And they'd say, I don't have time to help. And I go, I don't need your time, I need your money. I can hire the help, but either give me time or give me money. Get involved. One of my good friends, Jeff Maltzman, is now the chair of the surgical scope fund. He's down in Arizona and surgical scope fund has won many battles for the academy and I will encourage all the residents to get involved with this, even $20, even $10. But what it does is it sends a message that I know about this and that I care. And then of course, Opth PAC. And if you guys read the little blurbs that the academy puts out on a regular basis, you can see that what we say, what we do, how we contribute actually matters. Medicare Medicaid sends mandates down on a regular basis. I got audited last year for blepharoplasty codes. I got audited 100 charts. And I just found out yesterday that about 20 of those charts came back deficient and they want their money back, which floored me. I thought I was flawless. So I started reading through each one of these cases one by one and the first one said, you didn't put the patient's name or the date on the H&P. I couldn't believe it. So I pull out my H&P and there it is, the name and the date. First of all, the name and the date on the H&P has nothing to do with CMS requirements for whether I should be able to do a blepharoplasty on this patient or not. There's nothing in the LOC that discusses the H&P. They don't even say that you have to have an H&P. So I'm getting geared up to do some battle with these guys. And luckily I have the academy that I can work with because they can give you pointers because they can hire the people to look into this. I know most of you in this room know who Sue Vicorelli is and she now works for the academy and is a huge proponent of coding initiative and can give a lot of good advice. So get involved. That's all I have and if you have any questions I would be happy to try to answer them. Randy. So very timely and as you say, essentially everybody is going to face this at some point if they have a busy practice. And what I can also add is that no matter how right you feel you are these are emotionally, you know, they are emotionally extremely disturbing and difficult things to be in. And it's good to have people that will kind of be there and help and support. And again we got to remember again that a complication is not a practice. So I mean those of us, nobody wants a complication particularly with a bad outcome but I've seen people who essentially give a line of initiative and I say wait there is a new assignment on practice that people have already essentially said. I mean saying you're sorry that something happened I think is actually important to do but saying that you did something wrong when clearly you had a complication that anybody could have at some time and that there is no evidence that you did something wrong to create that. So our mindset has got to be much better at how we handle that. The other one is that you realize when you get to trial there are websites out there where plaintiffs, people do this almost as a business plan and I had one that I'm involved in right now where the plaintiffs expert is currently involved in 24 active malpractice cases and has been involved in 150 as a plaintiffs attorney over the last couple of months. And I can almost guarantee you I know the name of this person because we see them on a regular basis. And one of the good things about the ethics committee that we do is that finally someone will stand up against someone like this if they're a member of the academy and file a challenge against them and we've got one of those going on right now and interestingly enough it wasn't the defendant doctor that stood up it was the defendant doctor's lawyer that said this expert witness is a bad apple you need to get him out of the academy because what we say is we're a club we're a great club and if you want to be a member of our club this is how you got to act and if you're not willing to act that way or if you're going to do these things we don't want to be associated with you. So I'll also tell you that I just had a friend an ocular plastic friend who was involved in a lawsuit and it just finished and it took a total of about five years and he was actually he was on trial for I forget the exact terminology but it involved initially involved with a patient that lost vision after trauma but then somewhere during the whole trial process she tripped one night and fell into a swimming pool and drowned and then they elevated it to like unintentional homicide or something like that and he knew that he had done nothing wrong but at the last second when they wanted to settle for X amount of money he considered settling he said I knew I was absolutely 100% right but I was so emotionally devastated and drained by all of this and the thought of having been told I'm a bad person for the last five years and now sitting up in front of a courtroom where all attention is upon you everyone in that room is there because of you everyone's looking at you everyone that's testifying is testifying in some way about you he said I just didn't think I could do it and he talked to his lawyer and his lawyer said if you settle this I am going to start crying and she talked him out of it and he ended up going and luckily he had a wonderful expert witness who's a member of ASOPPERS and he said this guy came in and he was like the Calvary coming in on a horse and he got up there and was so well spoken and so credible that the jury came back in an hour with a not guilty verdict but after five years but he said it changed my life it was devastating so you want to stay away from that each state is different we have a pre-litigation hearing that is mandatory but it's not but you know it's been very effective it's not binding it's been very effective and I can think of a lot of different cases that people involved in were clearly there was no they sensed they almost always were a complication with an outcome that was not good some type of complication that something happened that wasn't right that's almost always most of these things that go along but a unanimous decision by our pre-litigation is a pretty far-off statement and I can think of a whole series that died right now I can tell you with OMIC we've had cases like this and I don't know about this state Judith but in cases like that we've had cases that we thought were going to go and then when they came back unanimously said there's no case here the lawyer just dropped it so yeah Colorado has a law I forget exactly what it's called but it's you can say I'm sorry without that being used against you in court and I'll tell you this one of the things that we see all the time at OMIC is if your patient likes you even if they're suing for malpractice you may very well get dropped we had a case recently where there was a bad outcome and the lawyers got involved and they were suing for malpractice but they sued the surgery center they sued the nurse in the room the circulator the scrub tech and the anesthesiologist but the woman said I love Dr. Olson I will not name him in this suit I've seen that many many times where they maintain a good relationship and therefore they say I'm not even though potentially the person they dropped is just as involved sometimes even the most involved in that great relationship so it's often an angry patient and a lot of anger can occur and when nothing is wrong where people are being avoided or people aren't addressing the issues these are all the kinds of things that often set a patient that has had a complication and a problem we're all going to have complications there's only one way to avoid complications don't argue you can have outcomes that you don't like but if you can maintain a relationship with the patient it's pretty rare it's when you haven't or you're clearly not being honest or open with the patient about this and they're angry you set that up and you can always count on the fact that you're going to be sued in our system we're not like in the system if you have tort law in England and the plaintiff side loses they pay all attorney's costs in our system you lose just being sued trust me the process itself is punitive even if you never make it to court even if it never goes to court it can be devastating it can be devastating to your practice so the things you can do to try to avoid that personally and we asked this question at the cataract session and a lot of people I think telling people that you're sorry but how you say no one wants a complication and I'm sorry that this happened to you I think that goes a long way to maintain this but let's talk about this is something that's a known complication here are the things that we're going to do own it own it for the institution as well I think that is extremely powerful in maintaining that relationship not always but again it's a person who feels upset and abandoned and angry their odds that they're suing have now probably gone 50-60 maybe 80% when I first started in practice and a patient would voice some sort of displeasure with something that wasn't a big deal I would often times get defensive because a patient has more swelling on their left side and they're like what did you do wrong and all of a sudden I get defensive I've just learned through the years that if I look at something I go wow that looks terrible I'm not happy with that but we're going to fix it let me tell you what we're going to do and you can see them they just get they just all that anger just sort of seeps out of them like you just popped a balloon and they're like oh so you think it's bad too because they're just waiting for me to live and start an argument when I go man that looks horrible or I'll walk in the room and they've just got major bruising and I'll go good lord what happened to you you know quite often I can get them to smile or laugh and I go that's a lot of bruising man they go wish you would have told me this was going to happen I wish I would have known that was going to happen one other remember this to tell a patient well this is a very rare which indeed could be the case I mean endothelmitis here's probably like one in three thousand so that's a rare complication that's a common malpractice suit is a bad outcome with endothelmitis after surgery remember for the patient who has a complication what's their personal incidence 100% they don't want to hear it's rare it happened to them as far as they know that's all that happened admits that this is happening to you 100% even though we rarely see this I understand that obviously doesn't help you at all but here's what we're going to do to fix it or here's what we're going to do to mitigate it it's really rare so you should be upset about it that again sounds defensive and it sounds like we're not owning it Jeff times about it I just want to make two quick comments one remember do you see someone young, vibrant not beat down by madison or malpractice you still have chosen a great professional even though it's a pretty heavy topic remember for some of the residents we'll need to be excused today to be prepared for the clinic Ron thank you one more time and jupy again thank you for the introduction thank you