Whistleblowing … Softly
Treating patients like grown ups - by giving them all the information
A couple of decade ago I was a practicing optometrist with a bit of a dilemma.
I’d examined several patients who’d had what I thought was unnecessary cataract surgery.
This was being provided on a private basis (for £2,000), at a time when the identical NHS operation was available at no charge to the patient and without an inordinate wait.
There was just one surgeon involved.
His modus operandi was to recruit his patients from his routine NHS eye clinics. These were people attending for watery eyes, routine glaucoma check ups, droopy eyelids and the like.
During the course of the examination he would comment on their “cataract”.
[A cataract is a loss of transparency of the eyes’s natural lens. This lens sits just behind the pupil and naturally clouds up a bit as we age.]
Now, to be fair, you can find a little bit of cataract in pretty much any eye over the age of 50, if you look hard enough.
There is a debate though - is it really a cataract, if there’s just some reduction in the clarity of the lens? Or can you really only class it as a genuine “cataract” if the patient’s vision is compromised?
In any event, this surgeon would criticise these people’s eye care up until that point with comments like “it’s very poor that your optometrist hasn’t told you about this” and then go on to tell them how “serious” a condition it was.
Next came the somewhat overblown lament that sadly, the state of the NHS means it would be a very long time before it could be attended to… unless, of course, they would be prepared to “go private”.
There was nothing illegal in what he was doing - people were perhaps being encouraged to have a cataract operation earlier than they needed it, at a cost they could have avoided if they’d waited until there was enough cataract for the NHS to offer surgery. And, after all, most people will need a cataract operation eventually.
But he definitely wasn’t producing the best possible results - and that’s what really bothered me. Sometimes, people really weren’t seeing any better. Often, they required more complicated spectacles and/or had more problems with glare than before the operation. There were improvements too, though - which the patients would see as justifying their decision to go ahead. Things appeared brighter (because a clear plastic lens implant is more transparent than the natural crystalline lens of anyone over the age of say 45). For the same reason, pretty much any post-op cataract patient comments on how colours seem more vivid.
There are rare times when a cataract requires prompt attention - if it’s becoming hyper mature, or if there is a concern the view of the retina may soon not be good enough to monitor another condition (diabetic retinopathy, for instance). But these arguments didn’t apply to the patients of this surgeon that I’d seen.
There are other, incidental potential benefits of cataract surgery:
Removing the natural lens and replacing it with a smaller plastic one creates a wider anterior chamber (the iris has space to settle further away from the back surface of the cornea). This pretty much eliminates the risk of angle closure glaucoma (an emergency condition where the eye pressure becomes so high that the vision can be permanently damaged within a day. But it’s rare in Caucasians, who composed >95% of the local population and all of these patients).
Post-operatively, intraocular pressures are reduced by an average of about 4mmHg - so someone borderline for glaucoma may not go on to develop the condition.
These potential benefits were not, though, enough to outweigh my thinking that this chap was purely in it for the money.
So - I wrote a pamphlet to better inform people about the pros and cons of cataract surgery, under a pseudonym. The viewpoint was that of a potential patient who’s been made aware he has a bit of cataract and what he’d discovered about the condition.
It was principally for me to print out and hand to people who I knew might cross paths with this particular surgeon but I also left a copy in the waiting room for anyone to read.
The general thrust was “early stage cataracts aren’t such a big deal and usually there’s no rush about surgery”. And I pointed out there is always a small risk of visual loss with cataract surgery. It’s only about 1 in 1,000, but still, losing an eye to an unnecessary operation is a big deal.
In an attempt to demystify the condition, I called it “The Good News About Cataracts” and when I exhausted my printer ink and a couple of reams of paper, decided to put it up on Amazon Kindle where it’s stayed ever since.
The surgeon’s little racket didn’t last too long - within a year or so of me becoming aware of the situation, the hospital administrators realised he’d been using the theatre for private work, without paying the appropriate fees. He was suspended, the case rumbled on for a few years and he was eventually found guilty of dishonesty and gross misconduct and lost his job.
So - was this a potential whistleblowing situation?
At the time, I wondered if I should I have tackled this man directly, or perhaps written to the hospital authorities.
After all, these “earlier than necessary” cataract operations were an open secret amongst the local optical community. As part of any non-cataract referral to that hospital, I’d routinely warn my patients that they may be offered cataract surgery, but that wasn’t why I was sending them to the clinic, and there was no rush about even thinking about their cataracts yet.
There’s a definite hierarchy such that an eye surgeon’s diagnosis of cataract requiring surgery would carry much more weight than an optometrist’s opposing view. If I’d been specific about the exact nature of my concerns, perhaps I’d have been criticised as crossing the usual professional boundaries or perhaps even just personally disliking the man I was critical of.
So - I opted for a sort of middle ground, raising awareness of the nature of cataract and allowing patients to make a more informed choice, such that if the topic was raised with them, they wouldn’t be panicked into surgery.