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Concern about exercise advice as part of optometric care

April 27, 2013

Editor:

I would like to offer the following comments as a letter to the editor concerning Dr. Hopping’s recent President’s Column.

Consider this scenario: John, an obese patient, presents for his routine eye exam. Dr. Smith, a very caring practitioner, suggests that John should consider “exercising” in order to reduce his weight not only for his ocular well-being but also for the overall health benefits that would ensue. John goes home and tells his wife that he has never met a more concerned doctor and intends to follow his advice. The next morning John goes out for a jog and is found dead a few blocks away having suffered a massive heart attack. At the trial the widow tearfully informs the jury that John would still be with her had it not been for Dr. Smith’s advice.

Was Dr. Smith aware of John’s most recent EKG and would he be able to interpret it if he had seen it? Was he aware of the results of any cardiac stress test that John may have undergone? In his history did Dr. Smith even question John about any cardiac or other potentially dangerous conditions that might have existed at the time? Was John himself aware of any possible problems?

Although Dr. Hopping, in his President’s Column, told his patient to “take a hike,” how might that patient interpret such advice? At our hospital our doctors once gave a patient some home vision therapy exercises and the patient decided to perform them eight hours-a-day, hardly what had been intended.

I have often heard continuing education lecturers present the same recommendations as Dr. Hopping and, when presented with the above scenario, they have admitted that they have never thought their advice all the way through.

The question here is: are we practicing within the scope of our licenses when we offer such advice? And, are we culpable for any untoward results from our advice? Another consideration is whether or not our malpractice insurance carriers would consider such advice to be covered in our policies. I don’t have the answers and the answers might vary from state to state. But I think the AOA might want to consider obtaining legal opinions about these issues and informing the members whether or not they should continue advising their patients in this manner or, rather, consider appropriate referrals to other, more qualified, practitioners.

Mark S. Vogel, O.D.

Dear Dr. Vogel:

Thank you for your interest in this public health subject and for your concern for all patients. I certainly agree patients don’t always hear what we tell them and so your comments did make me think twice and I even discussed this with my legal counsel.

However, I, and my legal consult, firmly believe that the scenario you point out would not be the basis of a valid malpractice claim. Additionally, and in my mind more importantly, in the situation described in my article, I believe my not encouraging regular exercise would have been poor care of the patient and morally inexcusable.

Certainly, as part of today’s health care team, the primary care optometrist is clearly responsible for not only taking thorough health histories of our patients, but for also advising them to follow the appropriate medical advice they have been given and to encourage them to seek further evaluation whenever we feel it is in the best interest of the patient. Additionally, as primary health care providers on today’s health care team, optometrists often discuss with their patient modifiable factors that can benefit the patient’s general and specifically their ocular health, such as diet, blood sugar, lipids, cholesterol, blood pressure, body weight, smoking, alcohol consumption and regular exercise. Certainly, our patients often pay more attention to their overall health when we discuss the ocular implications of neglecting their systemic health, and I see that as both an opportunity and a responsibility we have as their primary care eye doctor. We are also encouraged, as part of the meaningful use criteria, to take a patient’s weight, blood pressure, and height (which allows a calculation of their Body Mass Index). Today’s responsibility to our patients concerns their entire well-being and has grown well beyond a 21-point exam.

Your comments remind me that it is clear that one of the important directions of health care reform is to place in our exam rooms access to the complete health history and test results of our patients. One of the purposes of this data sharing is to benefit the patient and help all practitioners avoid contradictory medical advice and drug interactions. Fortunately, AOA and AOAExcel will help our members adapt to and incorporate these significant changes and allow all of us to be more “patient-centered,” efficient, and thorough.

Sincerely,
Ron Hopping, O.D., MPH, AOA president

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