RADIAL KERATOTOMY

RADIAL KERATOTOMY

194 therefore help them to choose an appropriate doctor and well stimulate false hopes of a cure. It could lead to might or even depreciation of one...

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194

therefore

help them to choose an appropriate doctor and well stimulate false hopes of a cure. It could lead to might or even depreciation of one doctor by claims competing another. As the General Medical Council’s booklet on Professional Conduct and Discipline weightily puts it, "Publication in any form of matter commending or drawing attention to the professional attainments or services of a doctor may if the matter was published in a manner likely to attract patients or to promote the professional advantage or financial benefit to the doctor amount to serious professional misconduct". The wide range of services that can be provided by a large group practice is more likely to attract patients than the limited range of a single-handed practitioner, and publicity on this score could certainly be construed as to the professional advantage and financial benefit of the group. Single-handed doctors and small partnerships would be within their rights under such rules of professional conduct to report the group practice to the General Medical Council for misconduct. A spate of reports of this nature would lead to adverse Press comment about medical ethics, pointing out that they are a code of conduct written by doctors for doctors and questioning whether such a restriction as the veto on advertising was in the public interest. It might well be in the best interests of established doctors but not of patients. Should not society as a whole provide the moral and ethical framework within which doctors may legitimately use the technical and clinical skills for which they have been trained, 1 as Ian Kennedy asserted in 1981? Patients in general would welcome much more information about health and disease than the medical profession has hitherto allowed them, as the BMA representative meeting has belatedly recognised. Advertising is accepted by the general public as a useful way of buying goods and services. In medical matters people are not concerned with the niceties of doctors’ ethics so long as they do not interfere with doctor/ patient relationships. There is a precedent for advertising. Solicitors and accountants have been allowed for some time to advertise and there is no evidence that their professional status or relationships with clients have suffered or that they have taken to denigrating each other. Many people neither know nor care whether their solicitor advertises or not. Advertising, then, is a dead duck so far as the general public is concerned. Only doctors, or at any rate their representatives, are against it. Is it a reasonable stance? Provided that the present restrictive rule about what constitutes ethical advertising is modified to allow health authorities to publish factual details about doctors-such as family doctors’ surgery times, professional qualifications, special interests, clinics, and the like-it seems unlikely to do much harm. It might, on the contrary, Practitioners’

Royal College of General improve the quality of general

augment the

campaign

to

practice. The present method of paying family doctors encourages and inertia to such an extent that many of them restrict their role to responding to patients’ symptoms and illnesses. They recognise no need to promote preventive medicine, to exhort their patients to stop smoking and eat sensibly, to point out the dangers of too much alcohol, or indeed to make any effort to educate their patients. The patients are, in general, satisfied with the family doctor service. They do not understand the advantage of early recognition of such conditions as hypertension which far too few doctors specifically look for. The only general

mediocrity

1 Kennedy

I. The

unmasking of medicine.

London

George Allen

&

Unwin, 1981.

practitioners whose performance is at all assessed are trainees and their trainers. The rest can, if they wish, do a minimum of work and quietly stagnate. Lists of services provided by more progressive practices and published by health authorities and perhaps exhibited in Post Offices, Citizens Advice Bureaux, and other public places are likely to have a stimulating effect on stagnant practitioners, especially when the current Royal College initiative with its avowed intention of assessing all general practitioners gets under way. Advertising within reasonable bounds would be in the interests of patients and profession. RADIAL KERATOTOMY AN operation that can be done under local anaesthesia in 5 min and can yield$2000 an eye has become one of the most fashionable surgical ventures in the United States. Radial keratotomy, for treatment of myopia, consists of about eight radiating cuts into the substance of the cornea. The results are rather unpredictable, but usually it does reduce myopia by a

few dioptres; very occasionally it is damaging; and its longterm sequelae are unknown but cause apprehension since the corneal endothelial cells are irreplaceable, and their depletion below a certain threshold is followed by a blinding

keratopathy. Early this year, some American keratotomists sued a group of academic physicians for many millions of dollars in lost earnings because they had declared radial keratotomy an experimental procedure, therefore not covered by insurance. The case was focused on academics in Georgia, who were threatened with an outlay of$40 million (including costs) should the case succeed. This they could not risk, and they were allowed to settle for$250 000, including a statement that the operation is "effective" and not "experimental" (although its clinical trial has still two years to run). In the United Kingdom the public taste for surgical innovations is less well developed, but lately the Press has been very active in the cause of radial keratotomy. The initial reaction of most eye surgeons is a disapproval of such surgical interference with a healthy, albeit mildly myopic, eye, combined with a distaste for the brash (and often irresponsible) publicity with which it has been launched; and this is augmented by an alarm at its social and economic consequences, since one in six of the population is myopic and therefore a potential candidate. Of the few UK surgeons who have obtained the necessary equipment, only one (it seems) is ready to operate on selected cases under the National Health Service; despite careful exposition of the risks and reminders that a touch of myopia is a blessing after middleage, demand is growing. We are left with too many uncomfortable and unanswerable questions. Will this operation become a divisive issue, both in politics (only the rich being able to afford it) and in ophthalmology (between the few who specialise in this profitable surgical foray and the others who carry the load of genuine eye disease). Since most of the aspirants are youngmany seeking to remove a myopia that precludes employment as policemen, firemen, pilots, athletes, and so on-could we be sowing the seeds of widespread corneal damage in their middle age (a notice has just been issued precluding service in the US Army, Navy, or Air Corps for those on whom a keratotomy has been performed). How indeed are we to assess surgical procedures that, unlike drugs, require no official

blessing? 1.

Anonymous. Clinical

trial

stirs

legal battles Science 1985;

227: 1316