Comanagement is a Medicare arrangement that allows for the orderly transfer of patient care between equally trained physicians. Ophthalmic comanagement is a unique twist as its meaning incorporates eye surgeons transferring care to paramedicals not trained in eye surgery. Equally as important is the inclusion of financial reimbursement as the basis for this transfer of care.

Dr. Elliot Kirstein's comments (June, Letters to the Editor, p. 26) are evidence that he takes the responsibility of selecting a surgeon for his patients seriously. Unfortunately, most appear to consider their Medicare check first. In our area, optometrists subject their patients to one hour cataract surgeries because the surgeon pays his "kick-back." Another favorite is the patient sent out of town to the "better surgeon" so that the postop visits become a burden and thus a better opportunity for a comanagement "arrangement." These are just two of the many scenarios we and other ophthalmologists see play out in our communities across the country. Should we really applaud Dr. Kirstein's referral pattern of sending patients to the best surgeons when he is really just providing the best care for his patient?

The comments about other MDs referring to their friends seems to try to justify one wrong for another. Prior to "therapeutic legislation," optometric referral patterns were very much based on the same principles Dr. Kirstein decries. Now that money is involved, the "kick-back" referral pattern cannot hide behind the same "ignorance" or "cronyism." In light of optometrists now using financial gain as their basis for making referrals, "buddy referrals" don't seem so bad.

There will always be that surgeon on the take from optometrists who tries to justify his "unique" comanagement situation. There will always be optometry trying to justify their presence in medicine. But, isn't it interesting how everything worked out before "legislation, not education" became common place. Referrals were based on the referring doctors' knowledge of the surgeon. Surgical patients were cared for by a physician at least trained in eye surgery.

It is time to stop trying to justify ophthalmic comanagement and just recognize it for what it is. This abandonment of responsibility of patient care by operating surgeons is clearly unethical in every sense. Every ophthalmologist knows this; our colleagues in medicine know this. Even optometry recognizes financial gain as unethical in the patient care decision-making process.

Practicing ophthalmologists have been forced to make a decision. Succumb to blackmail for referrals or uphold the higher ethical standard of patient care. I believe most choose the latter. It is truly a shame though, that we have had to fight this battle without the support of the American Academy of Ophthalmology. Clearly there is hypocrisy when the same Academy that requires three ethics credits to maintain certification has not supported its members in forbidding this most unethical of practices. It appears that we as members need to force them to make a stand either for or against their own ethical code and end this needless and unnecessary inflammatory debate.

To those trying and Dr. Kirstein, thank you for caring about your patients. 

Editor's note: Name and location withheld at author's request. Though we prefer that our letters carry identification, given the topic we granted the author's request.