Patients’ shady requests: A case study in malpractice and communication

A young, healthy patient presents with a complaint of severe photophobia and requests a window-tint medical exemption—heard this one before? It’s a common enough situation for doctors of optometry, but one that requires equal parts clinical open-mindedness and professional integrity.

Such is the dilemma presented in a new case study from the AOA Ethics and Values Committee, titled “Malpractice & Communication with Patients” and describing the difficult balancing act that doctors of optometry navigate between determining medical necessity and managing patient expectations, as well as states’ legal requirements and a multi-billion-dollar automotive window-tinting industry.

A popular, trendy option for vehicle modification, window tinting is measured on a scale of visible light transmission (VLT) with a standard vehicle measuring 15-26% VLT. However, many states will permit a medical exemption for window tinting that could range from 20-70% when qualifying conditions are provided. And that’s where doctors of optometry often get pulled in, which is what happened to case study author Inrava Khasnabish, O.D.

As Dr. Khasnabish explains, a patient with regular, uncorrected astigmatism was referred for evaluation of anatomically narrow anterior chamber angles and possible laser peripheral iridotomy (LPI) treatment. Despite refusing to wear refractive error correction and previously missing other scheduled appointments for LPI evaluation, the patient demanded a medical exemption form be completed for tinted windows.

“Whenever I encounter a patient who requests the tint form to be completed, I take my time with a thorough history for all systemic and ocular conditions,” Dr. Khasnabish says. “In this particular instance, nothing was different—I maintain an open mind and try to find the source of the photophobia complaints.”

However, given the limitations of an undilated exam—due to risk of angle closure in this patient’s case and further long-term complications—the risk of peripheral retinal pathology wasn’t fully evaluated, and a state application could not be completed. Dr. Khasnabish helped the patient understand where his symptoms were coming from and the solution for these symptoms, rather than flatly dismissing the request. But the patient became incensed.

“Once he became disruptive and irate, my tone did not change,” she says. “In his unique scenario and subsequent interactions, it had crossed my mind to just complete the form to get him out of my hair. But the moment that thought entered my head, my mind immediately went to the fact that I simply cannot make up information because a patient is throwing a tantrum.”

When regular refractive error remains uncorrected due to a patient’s preference, or when a patient’s anatomical structure creates obstacles to performing a detailed examination that will yield accurate results for legal documentation, what is the patient to expect or demand from the doctor, the case study rhetorically asks.

Dr. Khasnabish emphasizes if a patient were truly able to sit through a slit lamp exam and tolerate the bright lights, then are they truly photophobic, especially when symptoms seemingly only present when driving?

“Following a thorough dilated exam to rule out all listed medical ailments per state medical exemption forms, a clinician should honor their code of ethics in practice and should not provide a tinted window authorization,” the case study concludes, further noting that the Optometric Oath states optometrists will “fully and honestly” advise patients. Likewise, the AOA Code of Ethics states optometrists will “keep their patients’ eye, vision and general health paramount at all times.”

To falsify information in order to complete a medical exemption form for a patient without qualifying conditions goes directly against the Optometric Oath and Code of Ethics, Dr. Khasnabish notes.

She continues: “Stand your ground and honor the ethical code. It is easy to give in to an irate patient to avoid chaos in the office, but doing so at the cost of your ethical integrity? Is that something you as a provider can continuously support? It comes down to the fact that you will suddenly become a provider who is always willing to bend the rules when patients throw a fit, whether or not the rules should be bent at the patient’s every whim.”

Read the full case study on the AOA’s EyeLearn Professional Development Hub.

Have questions on an ethical debate?

The AOA Ethics and Values Committee routinely produces hypothetical case studies concerning ethical challenges and how best to approach such situations based on the AOA Standards of Professional Conduct, AOA Code of Ethics and the Optometric Oath. Members may access these ethical case studies through the AOA’s centralized education portal, EyeLearn Professional Development Hub.

Have an ethical challenge or question you wish to share? Submit your idea or a case description to legal@aoa.org. The case description may be reviewed by the AOA Ethics and Values Committee and featured in future Ethics Forum discussions.