As part of a session on "Hallway Controversies - The Business of Refractive Surgery" at the recent 2003 ASCRS?ASOA Symposium & Congress, San Francisco, Holladay won a debate against defense lawyer Jeffrey J. Campbell, JD, of Phoenix, about whether plaintiffs are adequately served by physician witnesses.

Plaintiffs are not adequately served because physician witnesses likely not respected by their peers might offer blanket testimony supporting claims such as de-centered flaps, foreign material in the eye and dry eye - regardless of specific facts related to each case, Holladay said.

"First of all, plaintiff lawyers usually get a hired gun - someone who is a spin doctor, basically, who tries to fit the findings of the case to fit the desired outcome for the plaintiff," Holladay said. "It's often a retired physician who is not really up-to-date on facts, who has a reputation as a plaintiff's witness and who is not considered an expert by his peers."

Campbell, who defends physicians in medical liability cases, said refractive surgeries tend to be targeted in lawsuits because they are elective procedures with patients expecting "perfect results." For this reason, Campbell said, the number of lawsuits against ophthalmologists has increased significantly since 1998.

"To some extent, I will agree with Dr. Holladay that the plaintiffs are underserved, but they are actually in my opinion over-served by a limited number of unqualified physician experts - the 'hired guns,'" Campbell said.

Campbell urged qualified physicians to serve as expert witnesses to provide objective testimony. But he conceded Holladay's point that plaintiffs' lawyers tend to shop around until they find a witness, qualified or not, to serve as an advocate.

"An expert witness is not supposed to be an advocate for either side," said Campbell, who added that he favors tort reform in that area.

In another session on whether or not refractive surgeons should engage in aggressive external marketing, the winner was Terrence P. O'Brien, MD, associate professor of ophthalmology, Johns Hopkins School of Medicine, and director of refractive surgery, Wilmer Eye Institute, Baltimore. O'Brien opposed extensive external marketing, while Jonathan D. Christenbury, MD, in private practice, Charlotte, N.C., took the opposite side.

"It's very important to communicate your message to potential clients," Christenbury said. "At the least, you want to communicate how your services are better than your competitor's."

Calling himself a "friend of marketing," Christenbury said advertising the types of services offered is far less expensive than comanagement.

But O'Brien warned that inappropriate marketing, particularly with mention of cut-rate deals, trivializes the procedure and loses patient trust. He said patients also become confused about pricing.

"Other trends we will see are discount open heart surgery or budget brain surgery," O'Brien said.

O'Brien gave examples of extremely bad advertising that has given laser vision correction an unfavorable public perception of procedures. In several cases, competitors offering "blade-free" refractive surgery have depicted razor blades as visuals that O'Brien said add to the fear factor.

He showed a clip from a CBS television sitcom, "King of Queens," in which a wife is wearing heavy sunglasses after an implied botched procedure after her husband gave her a gift of a bargain laser vision correction procedure offering "one-half off" for the second eye.

"Anything you have printed will later be put into billboard size and placed before a jury," O'Brien said.

But laser refractive procedures can be advertised, as long as the message is delivered tastefully and emphasizes excellence of care and service, Christenbury said. He conceded, though, that, for quality assurance reasons, it probably would be best to have any advertising claims reviewed by an attorney before they are published or aired.

"You want to emphasize your experience," Christenbury said. "Avoid negative marketing where you are trying to say something bad about a competitor. I think some of those low-cost laser centers (responsible for negative advertising) have gone belly-up. Eventually, as some of these low-cost centers go away, we probably won't be advertising pricing."

But O'Brien said internal marketing or word-of-mouth is far more effective than external marketing.

In another debating session, Paolo Vinciguerra, MD, chairman, Department of Ophthalmology, Humanitas Institute, Milan, Italy, advocated LASEK as the preferred surface ablation procedure over PRK. He said LASEK is superior because patients experience less pain, faster recovery, lower infection risk and no delay in re-epithelization.

But Vance M. Thompson, MD, assistant clinical professor, University of South Dakota, Sioux Falls, won the session with his argument that PRK is the preferred surface ablation procedure because epithelial healing is more consistent.