EyeWorld Asia-Pacific September 2013 Issue

26 EWAP CATARACT/IOL September 2013 Dissonance in a femtosecond by J.C. Noreika, MD, MBA Dialectics in femtosecond laser cataract extraction T he term “cognitive dissonance” was coined by social psychologist Leon Festinger in 1956. he concept is as old as mankind. Consistency in thought, i.e., consonance, is necessary to maintain a psychological equilibrium. Inconsistencies cause dissonance. I found myself cognitively dissonant at this year’s ASCRS•ASOA Symposium & Congress in San Francisco. The reason? The dialectic enveloping femtosecond laser cataract extraction. Successful new technology promises speed, safety, economy, and ease of use. In one scientific paper session, the moderator stated the femtosecond laser had moved quickly beyond “proof of concept.” This is important if intraocular surgery wasn’t the subject and money didn’t matter. But, since I am more likely to need a femtosecond cataract extraction than to perform one, I remain blissfully immune to the pressures of its adoption. This laser fashions precise incisions, near-perfect corneal flaps, exquisitely engineered capsulorhexes (if it weren’t for those pesky tags and tears), and preps the nucleus for more rapid emulsification reducing ultrasonic energy. Internationally, eye surgeons seem eager to remove cataracts using only irrigation and aspiration after pretreatment with the laser. Parlaying decreased phaco time against greater fluidic volume, data suggests that corneal endothelial cells may be preserved, postoperative inflammation decreased, and posterior capsular opacification reduced. Surgeons can manage some high-risk eyes more safely. Surgical liabilities? There is a significant learning curve, complications occur, refractive surprises and astigmatic errors happen, small pupils are challenging, dysphotopsia remains problematic, applanation lends anxiety to patient and surgeon, and a second procedural step extends the surgical time. Informing the audience of his paper’s methodology, a presenter showed that a cohort of patients had an average surgery time of ninety-plus minutes while a second cohort’s was longer because transportation to a different facility was necessitated. Eye surgeons will resolve these growing pains through discoveries such as gentler applanating technique and more efficient intersurgical process. The ASCRS Lecture on Science and Medicine featured Jerome Groopman, MD , and Pamela Hartzband, MD . They discussed topics culled from their book Your Medical Mind: How to Decide What’s Right for You. They intimated that advertisements about drugs, diets, and treatments often contain doublespeak purporting to provide information while promoting an unfalsifiable message. For example, a television commercial reports that a specific statin medication reduces the risk of heart disease by 30%. However, after considering the patient’s overall risk of heart disease due to age, weight, genetics, and medical history, the true hazard of a cardiac event may be only 2% over the next five years. The statin drug mitigates the likelihood from 2% to 1.4%. Statisticians may deem that significant; patients incurring the drug’s expense and potential side effects may not. Dissonance? Insurers are not going to pay additional dollars for femtosecond lasers. Patients, many on fixed incomes, must ante up scarce out-of-pocket dollars for imaging or limbal relaxing incisions, which may provide outcomes that may not be functionally superior to manual surgery. Former CMS administrator and Brookings Institution doyen Mark McClellan, MD , followed the dialogue of Drs. Groopman and Hartzband. He stated that the demise of fee-for-service medicine is inevitable, that accountable care organizations are expanding more rapidly than Starbucks, and bundled payments for clinical “episodes” are coming to a surgery center near you. Then came the bad news: Reimbursement for cataract surgery is not going to increase, the 2% sequestration cut in Medicare fees won’t be restructured anytime soon, and policy wonks don’t know how to derail the inevitable sustainable growth rate train wreck. Cataract surgery has been victimized by its success. Dissonance? Insurers are not going to pay additional dollars for femtosecond lasers. Patients, many on fixed incomes, must ante up scarce out-of-pocket dollars for outcomes that may not be functionally superior to manual phacoemulsification. And the federal government, committed to “fairness,” must bless the evolution of a two- or even three-tiered healthcare system. My final encounter with cognitive dissonance occurred at the “Ethics Surrounding Marketing of Femtosecond Laser Cataract Surgery” presentation. Addressing the issue of informed consent, its theme supported the thesis of Drs. Groopman and Hartzband that there is no single right answer when advising patients. The age- old question “Doctor, what would you do?” is immutably shaped by the clinician’s mindset firmly based on formative experience. A prominent femtosecond laser surgeon stated that if he needed cataract surgery, he would choose the laser. Drs. Groopman and Hartzman might ask if his choice is justified by the procedure’s substantive benefit. Dr. McClellan might ask how it provides economic value. Ethicist John Banja, PhD, might ask how a surgeon best guide patients’ decisions without concession to financial motivation. The patient might ask if there is potential for buyer’s remorse. I’d ask who is the surgeon and which machine does he use. Psychologists propose that several defense mechanisms can reduce dissonance and effectively restore consonance. I hope to find one soon because rationalization isn’t working. EWAP Editors’ note: Dr. Noreika has practiced ophthalmology in Medina, Ohio, since 1983. He has been a member of ASCRS for more than 30 years. Contact information Noreika: JCNMD@aol.com