LASIK advertising: We should not sell procedures

Iread the editorial on advertising in ophthalmology1 with great interest and wholehearted agreement. The seemingly progressive tendency to irresponsible advertising, particularly of laser in situ keratomileusis (LASIK), is becoming an embarrassment to all of us who wish to practice ethical medicine and do no harm to our patients. There are no national boundaries to modern Internet advertising or to medical ethics. This is not only a problem in the United States. I would like to add to the editorial and make a suggestion. One problem that has ensued from LASIK advertising is the emergence of a new type of patient—one who presents demanding a procedure rather than complaining about a medical problem and inquiring about suggestions for amelioration of the problem. The difference may appear subtle, but it represents a very significant and dangerous shift in the doctor–patient relationship, expectations, and, sometimes, the actual delivery of care. I will cite the example of a recent patient, a 47-year-old woman who reviewed the advertising of a few laser centers in southern Ontario, Canada, and then presented to a few of them asking about LASIK for +5.0 diopters (D) of hyperopia in both eyes. She received different recommendations, sometimes a guarded prognosis, and the statement from 1 center that it would not offer its usual guarantee of persisting good vision or a complementary retreatment. She came to me seeking clarification of her position and my advice. It turned out that similar to many confused potential laser patients, this patient actually presented because she had noticed her distance and near vision getting worse and not because she actually wanted LASIK or even cared whether she would require glasses after surgery. She had worn glasses her entire life and had accepted it, but a younger friend–colleague had told her how the magical laser had improved her vision and allowed her to be spectacle free. Indeed, my examination revealed that the cause of the problem was not only hyperopia and presbyopia but early cataractous lenticular changes that restricted her best corrected visual acuity to 20/25. It was clearly wiser for her to consider cataract surgery or refractive lens exchange, depending on which problem was considered greater, but resulting in essentially the same operation that did not involve the use of the excimer laser. She was shocked to be told that she required cataract surgery after 2 laser centers had reviewed the various laser options with her but did not mention the cataracts or lenticular surgery. She went home to discuss the issue with her family as she was more confused than before. Fortunately, she decided to trust my assessment and eventually had cataract surgery. Her acuity declined during the subsequent year before she returned, accepting that perhaps my assessment had been right. My point is not to accuse the laser centers who gave her advice. I had seen many other patients who had gone to receive the magical curing laser, some of whom were referred for cataract surgery by the laser center and some who unfortunately had laser surgery and then had the cataracts “discovered” when they complained of inadequate improvement after LASIK. The real issue is that we should not be selling procedures. I cannot imagine presenting to a cardiologist saying, “Could I please have a bypass of my LAD and circumflex arteries. I am feeling a little low and achy today.” Until patients are able to diagnose their medical problems, they are poorly qualified to decide on the appropriate therapy. So, it follows that selling treatments to patients is unethical and will result in harm to some portion of the targeted audience. It is the sale of the procedure and not the quality of its performance that has resulted in inappropriate treatments. I have, on occasion, attended other LASIK surgeons and noticed patients who I thought were not well suited for LASIK. When I questioned the surgeon, the typical response was something like, “Dr. X refers many patients. He told this patient that she would benefit greatly from LASIK, and he will be doing all the follow-up after I see the patient on the first postoperative day. If I refuse to do LASIK for this patient's 2.0 D of myopia after Dr. X has already charged for the postoperative care, it will present a great problem for him. She should have reasonable uncorrected vision for 6 months to a year, after which he will refer her back for the cataract.” Is this good patient care and ethical medicine? No wonder our colleagues in other branches of medicine are beginning to lose respect for ophthalmology. Can we do anything about this predicament other than complain to one another? I think we can. It would not be difficult for the American Society of Cataract and Refractive Surgery and the American Academy of Ophthalmology to jointly mount a small advertising campaign opposing procedure advertising. No other organizations in the world are large enough to do this efficiently. Humorous ads, such as the patient presenting to a cardiologist or a gynecologist, proctologist, urologist, or gastroenterologist demanding procedures that are obviously idiotic could be created and used to eliminate the value of procedure advertising and, by doing so, bring ophthalmology and medicine back closer to “real medicine.” We live in a worldwide, essentially single society with respect to medical procedures and patients' awareness of these procedures through the Internet and advertising. We cannot blame individual LASIK centers for advertising to ensure their survival. But we can take steps to change the level of the playing field by educating people that procedure advertising is simply unacceptable. After all, it is the people who are our patients. We should help them make educated decisions about their health care. We can only win by choosing this option. Steve Arshinoff FRCSC Toronto, Ontario, Canada

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