Promises, promises: A case study of informed consent

October 1, 2008

When it comes to LASIK, much like elected officials, physicians should never promise too much and make sure the patient is aware of all risks.

Key Points

"Read my lips. No new taxes." -President George H.W. Bush (prior to agreeing to raise taxes)

"I can promise you that when I go to Sacramento, I will pump up Sacramento!" -Gov. Arnold Schwarzenegger

"Only a governor can make executions happen. I did. And I will." -Gov. Mark White (campaigning for re-election)

Among the themes are the many promises made by candidates as they seek votes. Some fun quotes appear above.

The topic of promises reminded me of an experience with one of my patients in the early days of LASIK, when it was still "off-label." He was a VIP wealthy donor to the university where I worked, he was a captain of industry, and he wanted surgery so he could water ski and do all kinds of activities. I warned him about the risks of glare, etc.; told him there was no guarantee; quoted him reasonable odds of getting 20/40 vision but that there was a real chance he might still need glasses to see sharply (he was about a –10 D); made him watch a video and take a true-false quiz about the risks; had him read and sign a long consent form with all the appropriate disclosures about risks and benefits, and did all the things that most refractive surgeons did at the time. My tendency always has been to be careful about managing patients' expectations.

The surgery went well and he was supposed to come in the next morning for a check-up. When he did not show, I asked my staff about it. They said he had called and stated that he wouldn't be coming to see me until 6 p.m. (it was a Friday) after all the other patients and the staff had gone home.

Toast to new vision

He showed up with a big smile on his face, a wine bottle, and two fancy Reidel wine glasses in his hands. I checked his vision: 20/10 uncorrected in each eye! Everything else looked fine. He said he had never seen this well in his entire life.

The red wine was a French Bordeaux, grand cru, worth about $4,000 (I checked later). Saying that he decided to come in late so the two of us could share the wine alone, my patient opened the bottle and poured each of us a glass. While I'm usually partial to white wine, this was spectacular. We toasted his new vision, chatted about business and the university, and soon refilled our glasses.

With only coffee for breakfast and not having had time for lunch, I began feeling the effect of the wine. Being done with work for the week and not on call that weekend, I supposed it was acceptable to be slightly impaired and figured we'd both be when the bottle was empty.

My other thought was that poor boys from New Jersey like me and the guys I grew up with usually get tipsy from drinking Bud, not ridiculously expensive French wine.

"You know," said my patient, "I realize you knew all along that I would see like this after the surgery."

"Really?" I asked.