Random Thoughts from a Restless Mind

Dr. Darrell White's Personal Blog

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Archive for the ‘Eye Care’ Category

Going To Work

One of the strongest statements yet made in support of the private practice of medicine was made this morning at 8:00 AM, EST. I went to work.

What’s the big deal? Of course you went to work. You’ve got a job and today is a work day. Ah, Grasshopper, there’s the rub. I am a doctor in private practice. I don’t have a job, I own a job. I don’t report to any centralized HR department; there’s no single supervisor looking over my shoulder. Nope, I’m a practicing physician in a private practice specializing in eye care, and this morning there are some 60 patients who’ve scheduled appointments and a staff of 14 on their way in to the office, all of whom are depending on me going in. So even though I feel like a damp campfire long past its useful life, I came to work.

If all I had was a job I’d a stayed in bed.

The dirty little secret of private practice medicine is that market-based economics works on a micro basis. There’s payroll to meet and rent to pay. The mere perception that your patients will leave your practice if you don’t go to work drives the private practitioner to work even when she feels lousy. Even more than that, the absence of a corporate barrier between doctor and patient makes the private practice doc think twice before he takes that sick day, because each one of those patients belongs to him, and vice versa. The unfiltered connection is so personal that the private practice doc thinks about what Mrs. Pistolaclionne (bonus points if you name the movie) will say if he calls off sick.

The dirty little secret in large, corporate medical practices is that market-based economics work there, too. All that talk about how your “World Class Clinic” doctor isn’t paid by how much work he does? Nonsense. In fact, the amount of money generated by any individual doctor is even MORE closely monitored and includes stuff like how many tests and procedures get done on her patients even if she isn’t doing the work herself. That doc’s compensation is absolutely driven by how much revenue she is responsible for bringing into the institution.

It’s just that the corporate Doc doesn’t own a job, he simply has a job. He has no direct responsibility for the staff surrounding him or the bricks and mortar over his head. His compensation is driven by his corporate performance, and that compensation includes time off for vacation and for sickness. Leaving time on the table is the same as leaving money there. There’s no bonus for loyalty to the institution. Points aren’t accrued for attendance. Frankly there are no real points to be won for extraordinary customer satisfaction, only demerits for egregious behavior. Unused time off, like extending your hours or taking patient calls when it’s not your turn, is simply donating your services and talents to your primary constituent, your boss the institution.

We should all be very cautious about the trend toward fewer private practice doctors and more docs employed by ever-larger institutions. Continuity of care is more than simply an always available electronic chart, it’s also a relationship forged over time between two real, live people with skin in the game. The next time you see your private practice doc and she’s a little sniffly and hoarse, remember to give her a little pat on the back and a ‘thank you’. After all, she owns this job and could have stayed home today, but she knew you had an appointment.

She knows who she works for!

An EPIC Adventure II: Training

As I posted a few weeks ago, in order to continue to use an outpatient surgery center where I have performed surgeries for 15 years or so, I am now required to use the electronic medical record EPIC. My hope had been that I would be able to continue to run “under the radar” by utilizing my pre-–dictated notes and standard orders, signing the papers as I have done lo these many years. Tragically, this was not to be. Having come to this realization about a month ago I reached out to the IT department and asked for training on the system. Being the somewhat self–involved surgeon that I am, I naturally assumed that a single phone call or e-mail would see multiple individuals leaping into action in order to help me so that I might continue to use that surgery center and generate revenue for the hospital. Silly me.

Four weeks, a dozen conversations, several e-mails, and I am assured more than several telephone calls later, I finally received a call from IT and one of the physician–advocates/trainers. I explained that I had a back log of signatures (little did I know!), and that I would be taking ER call soon, and did he perhaps have some time available to show me how to use the EMR? In the first of several remarkably positive little things in this process, Andrew did, indeed, have some time available the very next morning when I, too, could sit with him for a little bit.

Andrew himself was one of those little surprises. And ex–cop who had put himself through nursing school with the intention of using his nursing degree as a springboard to management, he informed me that he was one semester away from an MBA. It was clear he was anticipating a hostile interaction; this had been his typical experience when teaching physicians the system, especially private practice physicians. I liked him instantly, we connected, which probably contributed to the speed with which we flew through phase 1 of my indoctrination.

This can’t be all good, of course, otherwise there would be no reason to do this series! After learning how to get into the system (no, you cannot change your username), we looked at my chart deficiencies, specifically op notes that needed to be signed tracing back to November. I cleaned up all the old stuff, and then we got stuck with all of the charts that were sitting there from last week. Apparently part of the efficiency of the system allows the medical records department to put you on the “bad boy” list as soon as the case is done! We agreed to ignore these deficiencies since these would still be paper charts needing to be signed and moved on to pharmacy orders.

This was rich. I looked at about 200 orders with a “signature required” tag. Things like IV orders, and medicine injected to into the IV. Some were anesthesia orders which have no business on my list, and essentially all of the rest had already been signed. Andrew told me he’d taken a look at my in basket before we met and deleted three or four months of the pharmacy orders. I think the number he used was 800,000 orders! Whoa, maybe this isn’t going to go as well as it looks like it might. There is no connection between the electronically entered pharmacy orders and the signatures on the order sheets! 30 some odd orders per patient, each one individually entered and requiring a signature. I did 22 cases yesterday! Are you kidding me? This is what my colleagues were talking about when they mentioned the four minute per chart rule.

Like I said, though, this was a surprisingly positive interaction. Andrew took a couple of screenshots and said that he was going to sit with the IT magicians and see if we might be able to figure this particular one out. Man, that’s gotta work. I mean, the whole exercise took me about 45 minutes, and I didn’t even learn how to ENTER an order.

I can sign one, though. I’ve got some ER call coming up, and I’ll have to do some–patient consultations as part of my responsibilities. I’d better polish up my “helpless look” and rehearse my supplications. Getting someone to take verbal orders is gonna be the key to salvation.

More to come…

It’s Hard To Make It Look Easy

It’s really hard to make something look easy. Think about it. The best knee surgeon takes 1/2 the time and gets twice the good results of the average surgeon. It barely looks likes he’s working at all. The very best LASIK surgeon makes the most difficult case look like a piece of cake, just like the easiest and most straight forward cases done by the average surgeon.

None of this happens without an enormous amount of hard work, practice, study, and yes, a little bit of natural ability doesnt’ hurt either.

Think about double-unders, jumping rope with two passes of the rope under your feet for each jump. A CrossFit legend named Chris Spealer did a Tabata Double-Under set (20 seconds of exercise followed by 10 seconds of rest, repeated 8 times) and got a lowest score of 40, or something crazy like that. Looked like a snap, too.  My best is 10. TEN! If you are a CrossFitter and you’ve struggled with Double-Unders (and who hasn’t, eh Jeff Martin?) you watch and you say it’s easy for him. You gotta know, though, after watching all of the Speal videos, that there were countless hours of work behind that. He just makes it look easy. It’s not.

Samuel Beckett had a run of some 10 years or so where everything he published was nothing short of brilliant, and there was a ton of it. If you are a writer and you have stared at a blank piece of paper or a blinking empty screen (and who hasn’t, eh Daigle?), you might think that Beckett was simply gifted, that the words simply poured out onto the page fully formed and prepped for posterity. Reading Beckett’s letters, though, tells a different tale entirely, one of anguish and toil, brutal hard work. He just made it look easy. It wasn’t.

We tend to discount the hard work behind any skill-based endeavor when we only see the “game film”, so to speak. The untrained eye is often unable to discern the subtleties in some performance or job that the best of the best just blow through, making it look like an everyday, ho-hum whatever. In most circumstances we just don’t have an adequate frame of reference that allows us to see how an average or “regular” surgeon, or athlete, or debater struggles with the curveball, the surprise. We don’t even get a chance to compare how the true superstar handles a truly mundane “game” in comparison with the middle-of-the-Bell Curve guy, at least outside the realm of sports.

This lack of perspective, along with a lack of awareness of how hard the best of the best have worked to get there, leads us to minimize the excellence before us. The average cataract surgeon in the United States takes more than 20:00 to complete the surgical aspects of a case. The very best among my peers take 5 or 6:00 to do the same thing. No movement is wasted, and each tiny step is literally a microscopic ballet. The complication rates for average eye surgeons are 5-10X greater than that of the top surgeons, and the best surgeons routinely achieve better outcomes by all measures.

The best surgeons make it look too easy. Our response as a nation to this is criticism that eye surgeons are overpaid for such a “quick and simple” procedure; there is a palpable, barely hidden contempt for the highest achieving physicians among healthcare policy makers. This is just wrong.

It’s really hard to make it look easy, almost everywhere and in almost every endeavor. We should be MORE amazed and have MORE respect when we see something and think: WOW…she really made that look easy!


A Great Job!

For all of the whining, moaning, and kvetching, eye Doctors have really good jobs. Especially eye surgeons. Well, at least the eye doctoring part of our jobs.  Sure, the business part of running any medical practice is hard and getting harder every day; buried under the never–ending avalanche of new and existing regulations, it’s a wonder we ever get to practice any medicine at all. But when we do, we actually have a pretty good job.

Some of the stuff we do and the successes associated with that are really quite obvious. Take an older individual who is about to lose her drivers license because she can’t see, remove her cataract, and all of a sudden you might have a 75-year-old “Mommio Andretti”! I don’t care who you are, that’s pretty cool. Add in some of the extraordinary new advanced lens implants and we have retired people who started wearing glasses in the third grade running around with bare naked faces. Seriously, you could be Genghis Khan and if you take someone’s vision from 20/100 to 20/20, people are going to like you.

It used to be that retinal surgeons celebrated “anatomic success”, the achievement of a normal appearing retina. Nowadays, with the advent of advanced micro surgical techniques and injectable medications, retinal surgeons are not only are preventing vision loss but they are improving vision in everything from retinal detachments to wet macular degeneration. They don’t really have any refractive retinal surgeries yet, but I’m thinking it’s only a matter of time. Think about it–how good is your job if you take someone with a bleeding retina and 20/200 vision, and a few months later they can drive a car? Pretty good job.

Some of the mundane things that we all do, things that are profoundly uninteresting to eye doctors, have an outsized importance to our patients. The surface of the eye has more pain fibers per unit of area than any other part of the body. If you believe in evolution, and I do, this actually makes a lot of sense. We are such visual creatures that our sensory cortex devoted to vision is dramatically bigger then any other mammal. Those pain fibers prompt us to rapidly close our eyes for protection. Ever get anything in your eye? A piece of gravel, perhaps a tiny piece of metal while doing some grinding? How about a scratch? It’s amazing how many people are assaulted by their Christmas trees in December and January. Its bread and butter for us, but making that “jump off a bridge” searing pain go away makes for a pretty happy patient. Happy patients make it a good job.

Whenever I get a little down or blue, overwhelmed by all of the minutia of running a business, or borderline depressed at the thought of ever more government intrusion into the space between me and my patients, I remember just how good my job is when I can get to doing it. I don’t really think about all of the high-tech things, the LASIK, the cataract surgery, the fantastic medicines I have at my disposal to treat things like infections or glaucoma. No, what think about is the oldest, least fancy, most routine part of my job: prescribing that first pair of glasses to a kid who can’t see. Seriously, you should see the look on their face when they realize just how poorly they’ve been seeing. Even better, the “AHA! moment” when you put that prescription in front of their eyes and all of a sudden there’s a 20/20 line on the eye chart. I’ve been at this for 25 years or so, and that moment, that simple, low–tech moment never fails to make me smile. When the simplest, tiniest thing you do can make someone that happy, well, you’ve probably got a great job.

Like me.

EMR and Underpants

Skyvision Centers has a subsidiary company called the Skyvision Business Lab. We do business process research for pharmaceutical companies, medical device companies, and other medical businesses in the eye care arena. One of the companies we have worked for is a very cool company that produces animated educational videos for a ophthalmologists and optometrists. I had an interesting experience while talking to their chief technology officer. It was interesting because the conversation proved our basic reason for existence at the Business Lab, that it is impossible for any company to develop, sell, and install any kind of product in our world without understanding the ins and outs of every day activities in an eye care practice.

Of course, I always find it extremely interesting when I’m right!

It was a tiny little point, really, but how could you know something this small and seemingly insignificant unless you had spent time on the “frontline” of medical practice? The chief technology officer for the video company was frustrated because doctors and their staff were not using this really cool product that they had purchased. Furthermore, because they weren’t using it, they were failing to buy downstream products from the video company. As it turns out the salespeople for this company were telling the doctors that this particular product should be “turned on” by the staff at the front desk of the office. This is exactly the wrong place because the front staff personnel simply have neither the time, nor the understanding, nor any incentive whatsoever to do this! The product actually works beautifully if it is “turned on” by the back-office staff. Bingo! Problem solved.

So what does this have to do with Electronic Medical Records (EMR), and for heaven’s sake what does this have to do with underpants? It’s simple, really. When was the last time you bought a totally new type of underpants, underpants that you had never seen before, and underpants that you had certainly never worn before, without trying them on? Furthermore, what’s the likelihood that you would allow someone else to design, fit, and choose a style  of underpants for you if that someone has not only never met you but has never even seen a picture of you?!  That’s the image I get every time I read an article about EMR.

In theory the concept of an electronic medical record that would allow permanent storage of every bit of medical information, with the ability to share that information between and among doctors and hospitals involved in the patient’s care is so logical and obvious that debating the point seems silly. If you have ever seen my handwriting, for example, you’d realize that the entire field of EMR was worth developing just to make doctors stop using pens and pencils! Trust me on this… the doctor hasn’t yet been trained who is also a specialist in penmanship.

I actually trained at  two of the pioneering hospitals in the use of electronic medical records, and indeed in the use of computers in medicine in general. Dr. Larry Weed and Dr. Dennis Plante at the University of Vermont were pioneers in the concept of using computing power to make more accurate medical diagnoses. Both the University of Vermont Medical Center and the Maine Medical Center were among the very first institutions to develop and implement digital medical records for the storage and use of clinical data like lab reports and radiology reports. In theory both of these areas make sense, but in practice the storage and display of clinical data is all that’s actually helpful in day-to-day practice.

If this is the case, if the acquisition, storage, and retrieval of critical data is helpful, the next logical step must be to do the same thing with the information obtained in doctor’s offices, right? Well, in theory this makes a ton of sense. The problem is that nearly none of the EMR systems now in place have been designed from the doctor — patient experience outward; they’ve all been designed from the outside in, kind of like someone imagining what kind of underpants you might need or might like to wear, and making a guess about what size would fit you. With a few exceptions, tiny companies that are likely to be steamrolled in the process, every single EMR on the market is the wrong fit for a doctor and a patient.

Why is this? How could this possibly be with all the lip service that is being paid to the doctor — patient relationship and the importance of getting better care to patients? It goes back to that same tiny little problem that the medical video company tripped over: it’s really hard to know how something should work unless you spend some time where the work is going to be done. Electronic medical records in today’s market are responsive to INSTITUTIONS, insurance companies and governments and large hospital systems. System before doctor, doctor before staff, staff before patient. Today’s EMR’s have been designed with two goals in mind: saving money and reducing medical errors. Should be a slamdunk at that, right? But even here the systems bat only .500, producing reams of data that will eventually allow distant institutions to pare medical spending, but neither capturing nor analyzing the correct data to improve both medical outcomes and medical safety. Fail here, too, but that’s another story entirely.

So what’s the solution? Well for me the answer is really pretty easy and pretty obvious. Send the underwear designer into the dressing room! Program design, programs of any type, are one part “knowledge of need” and one part plumbing. How can you know what type of plumbing is necessary unless you go and look at the exact place where the plumbing is needed? How can you know what size and what shape and what style of underwear will fit unless you actually go and look at the person who will be wearing the underwear? It’s so simple and so obvious that it sometimes makes me want to scream. Put the program designers in the offices of doctors who are actually seeing patients. Set them side-by-each. Make them sit next to the patients and experience what it’s like to receive care.

THEN design the program.

I’m available.The  Skyvision Business Lab is available. I have a hunch that the solution will hinge on something as simple and fundamental as my example above — front desk versus back office.  It doesn’t necessarily have to be me, and doesn’t necessarily have to be us, but it absolutely is necessary for it to be doctors and practices like Skyvision Centers, places where doctors and nurses and staff members actually take care of patients. Places where patients go to stay healthy or return to health. Places where it’s patient before staff, staff before doctor, doctor before system.

For whatever it’s worth I’m 5’8″ tall, I weigh 150 pounds, and I’m relatively lean for an old guy. I guess it’s a little embarrassing to admit this… I still wear “TightyWhiteys”, but I’m open-minded. I’m willing to change.

Just take a look at me first before you choose my underpants for me.


Unnecessary Care? Says Who?

It’s become one of those trendy phrases, “unnecessary care”. When you hear it on television or talkshow radio it’s usually said with a sneer. Indeed, the speakers almost spit the phrase out–“Unnecessary care”–like it tastes bad.  It’s almost always accompanied by “fraud and abuse”, or a not so subtle accusation that some doctor is profiting off this “unnecessary care” at the expense of some poor patient. But is this true? Is this always the case? Are there no longer any circumstances whatsoever where the doctor really DOES know best?

I’m an ophthalmologist, an eye surgeon.  Every single day in the office I see several patients who have enormous cataracts which have dramatically affected their vision, and yet they are not only totally unaware of this decrease, they are militant in their rejection of surgery to improve their vision. Some of them have vision which has decreased to a point where, not only would they fail their drivers license test, they are nothing short of a menace to society behind the wheel. Because cataract surgery is an elective procedure, the patient gets to choose whether or  not to proceed with surgery. In other words, operating on a patient with a cataract who does not feel he has a problem would be “unnecessary care”.

The opposite version of this happens every day, too. In about 25 states there are strict, numerical guidelines that insurance companies (including Medicare) used to determine whether or not cataract surgery is “medically necessary”. Not a day goes by when I don’t see a patient who is bitterly unhappy with her vision, and yet her measured visual acuity is better than the threshold for “medical necessity”. Despite the fact that this patient feels handicapped by decreased vision caused by a cataract, operating on her is considered “unnecessary care”.

It kinda tricky. Sort of a damned if you do, damned if you don’t thing. I know it seems like a rather fine distinction, but cataract surgery is actually a big deal when it comes to the economics of medicine in the United States. Did you know that there are almost 3,000,000 cataract surgeries performed every year in the United States? Could some of these surgeries have been “unnecessary”? I dunno. I’m really struggling with the definition of “necessary”, frankly. Is cataract surgery in my two patients unnecessary? Says who?

You can achieve the same relative mortality rates for atrial fibrillation with either a cardiac ablation, or a cocktail of medications. Maybe you are medicine–free with the ablation, and therefore free of not only the yoke of your daily medicine schedule and side effects, but also the considerable burden of navigating your health insurance-approved medication list. The ablation might be 10X the cost of the medicines, but does that make it “unnecessary”? Too much? Says who?

So how do these two cataract patient scenarios play out at Skyvision? Well, the very unhappy patient with a cataract of any size whose vision does not reach that threshold level of “medical necessity” always chooses to wait until her insurance will pay for the cataract surgery. Always, whether she is a retired schoolteacher or a wealthy heiress worth tens of millions of dollars. She leaves the office unhappy, frustrated, and frightened. She cannot enjoy her daily activities because she cannot see well enough, and she is frightened by the prospect of normal activities like driving.

The other patient? Well, this patient typically has a monstrous cataract, so brown and cloudy it’s like looking through beef broth, or even beef gravy. This patient gets angry, too, but he is angry at me. He’s angry and offended that I would have the audacity to suggest that his vision is poor, too poor to drive, for example. He doesn’t understand what 20/50, or 20/80, or 20/100 vision means, and frankly he doesn’t really care. He’s got a drivers license, dammit, and he’s legal to drive. These visits almost always end something like this:

Me: “What kind of car do you drive?”

Patient: “A crown Vic.”

Me: “What color is your Crown Vic?”

Patient:” White. Why?”

Me: “Because my wife and kids are driving on the same roads as you, and I’m going to tell them to stop and pull over every time they see a white Crown Victoria.”

I say THAT’S “necessary care”!

The Answer Is…

Alex, the question is: What is the one thing that ASCRS, the American Society of Cataract and Refractive Surgery, can do for its members that it isn’t already doing?

ASCRS, AAO (American Academy of Ophthalmology), AMA (American Medical Association), and the various and sundry other organizations of letters are all of the same ilk. Each one was founded with the idea that physicians as a general group, and more tightly defined specialist groups, needed some sort of representation. Some sort of trade group that would present our needs and desires to other groups like the government, insurance companies, and the public. You know, someone to take OUR side in a discussion, to support US in a debate.

So, how’s that working out for you, Doctor? How well are your trade organizations doing, you know, carrying the flag, supporting you and your issues, the things that matter to you? Like protecting your relationship with your patients? Protecting you from frivolous lawsuits and the incessant threats that make you add “cover my ass” to every treatment plan? How are they doing taking up the cause of preventing yet another government program from gumming up your day with more useless, purposeless paperwork? How’s all of that going?

Yeah…thought so.

Once upon a time organizations like the AMA stood for something. The AMA in particular was the ethics referee for all physicians, as powerful as a FIFA ref in the World Cup, and frankly just as impervious to outside influences and criticism. To be censured by the AMA was a serious thing, the only thing worse being the loss of your license to practice medicine. Now? Do you remember reading the histories of the eunuchs who waited on the Chinese emperors of antiquity, emasculated and with a veneer of power that they brandished with a flourish. They lived for the intrigue; they thrived on the daily ebb and flow of palace life, content to be AROUND the tables of power, though they were not really AT the table. It’s like that now.

When did it happen? When did this group of “all-powerful” become a collection of empty sacks? It probably started whenever the AMA lost its great battle over its prohibition of advertising, a case of free speech and restraint of trade in which the AMA was thrashed. It’s never been the same since then, just one small defeat after another. Indeed, the very nature of the game was changed at some point, whether it was the advertising defeat or some other tipping point.

I’ve looked very hard, called into play my most powerful google-fu, looking for the answer. Who led us to this point? Could it really have been a Dr. Chamberlin? No…to0 easy…can’t be. It would be just too perfect if the 3+ decades of universal appeasement as the modus operandi for all of the medical alphabet organizations could have been started by someone so named. Nevertheless, appeasement is precisely what organized medicine has all been about for decades.

Surely, if we agree to accept Medicare payment as our payment in full, they will trust us to do what is right for our patients. If we just agree to label our charts with these treatment and billing codes they will assume that we are doing what we say we are doing. Hey, they’re going to pay you a BONUS for faxing your prescriptions with a computer system. Well, you know, a computerized medical record is theoretically best for our tapped out payment system, and if we do everything just like they say there’s a possibility that they might pay a little bit so you’ll lose less money on it. Well, you know, there are some docs who have cheated the system, so we’ll have to accept the “guilty until we can’t find any way to not find you innocent” policy of regulatory enforcement.

Drip…drip…drip…the slow torture of seeing the next drop come…drip…each tiny capitulation labelled as “cooperation for the common good”…drip…the willful, purposeful blindness of the appeasers…drip…well, certainly THIS time they will reward us for being good team players…drip…no lesson ever learned…DRIP.

Well, Dr. Chamberlin, here’s what I’ve learned. It doesn’t work, this appeasement thing. It never does. It’s never enough, all that you’ve given up, all the times you’ve decided that we would “take one for the team.” Appeasement never works because those you wish to appease do not respect you, and because of that they do not respect US, the physicians. Indeed, they view us with barely concealed scorn. It doesn’t matter whether they are Republicans or Democrats, government or private, Aetna or the Blues, they know that you don’t have what it takes to ever take a stand. You don’t know what it is to use leverage, wouldn’t recognize it in your pocket, and would turn away from it if you did.

What to do…what to do? Believe it or not there are still some physicians out there who have neither emptied their (figurative) sacks, nor become so jaded and angry that they can no longer muster the empathy necessary to be a doctor. What should we do? Should we retreat to some nirvana, some mythical place like the mountain hideaway built by John Galt to house those who would traffic in excellence in a world where success is born of merit? Ah, would that we could. The closest that any might come to this is to retire, withdraw their services from the system and become conductors. Or provide their services to all comers for free; that would shake things up. Not many of us can afford to do that, and if we could not many of us are willing to walk away from that which has defined our very beings for so long.

So, what? Well, for me, I have gazed too long on a system built on the cynical abuse heaped on the followers of the appeasers to avoid becoming just a little bit cynical myself. It’s a game, you know? Games have rules and regulations, little battles that can be won even though the war might already be lost. Perhaps an extra patient at the end of the day. A perfect chart with every preferred practice pattern item covered. Who knows? The rules ebb and flow as the alphabet organizations push a little, pull a little. There’s always a game, a little battle, rules to play by, rules to follow, a way to win within the rules today. A cynical approach to a cynical battle, with hopes for no collateral damage. 10 years of that kind of today, and then…

Alex, the answer, apparently, is nothing, because that would be better than what they are doing now.

When A Conflict Of Interest Isn’t

“I’m sorry, Doctor, but we can’t have you give that talk; you have a conflict of interest since you’ve been paid to do research on that medicine.”

“Well, Senator, it’s a conflict of interest for a doctor to sell those crutches in his office.”

“It is the opinion of this newspaper that physicians should declare to each patient any ownership interest they might have in a surgery center so that the patient is aware of any conflict of interest.”

And on and on the drums beat, droning incessantly and insistently about the dreaded “conflict of interest”.

In a world now run by the terminally attention deficited, with multi-tasking and synergy-seeking all the rage, we apparently have one domain in which nothing but the purest, most antiseptic, monastic and single-minded devotion to a single task and goal is acceptable: the provision of health care in America. Think about it…the simple existence of OTHER interests is de facto evidence of some nefarious CONFLICT of interest. The underlying assumption appears to be that it is impossible to have any additional interest–ownership of a business, a consulting agreement, stock or stock options–without the ability to devote your primary attention to the best interests of your patient. Any other interest is automatically bad, and every physician is guilty and can’t be proven innocent. How did we come to this?

There are issues and examples both substantial and trivial, and yet each of them is addressed as if they are one and the same. I bought pens last month for the first time in my professional career (I graduated from med school in 1986). It was weird. Who knew that there was a place called Office Max and that this huge store had not one but TWO aisles of pens to peruse?! I think it was Bics in a KMart the last time I bought a pen. Somehow this fact means that I have been making decisions for my patients based on all those pens I DIDN’T buy all these years. There’s only one problem with that: I don’t remember a single thing about even one of those pens.

And yet somehow accepting those pens is a “conflict of interest”. Seriously.

Why is it that if I somehow get something from someone, big or small, even if I perform some service or even buy something from them, that it’s a “conflict of interest” if some company or other might make money from what I do for my patient? Why is every peripheral interest that exists around the little silo in which I practice medicine–a space occupied by me, my staff, and my patient–why is that automatically a “conflict of interest” with some sort of negative connotation? That I must be doing something bad? Why not just “another interest”? Why can’t these things be a “convergence of interests” between what is best for my patient and any of the other stuff that might be going on around us?

Listen, I get it. There have been instances where docs have pushed inferior products on their patients because they had a significant financial incentive to do so. I’m reviewing a med-mal case right now where the plaintiff had an eye problem which resulted in cataract surgery. The cataract surgeons are not being sued, but I looked over the surgical record and saw that they put an inferior POS lens implant in this guy’s eye, and I KNOW they did that because they own the surgery center and that lens is dirt cheap. THAT’S a conflict of interest. But for every surgery center owner like this putz I know 50 who put in state-of-the-art implants because that’s what’s best for their patients. Those docs still make a profit, but it’s smaller because they are putting the patient first. Why is THAT a conflict of interest?

It’s not.

Three different companies make 3 versions of the same kind of medicine, all of which have identical efficacy and safety, and all of which sell within pennies of each other. How does one choose among them if one needs to be prescribed? Is it such a heinous insult to humanity to choose to prescribe the product from the company that pays the doc to consult on some other project? Or the company that brought in lunch? Or (GASP!) the one that left a couple pen lights in the office? Tell me, how and why is this a “conflict of interest”?

This trivialization of the concept of “conflict of interest” is actually weakening the protections that we should have against REAL conflicts that cause real harm. Pushing unproven technology (artificial spinal discs, anyone?) on unsuspecting patients prior to definitive proof in return for obscene “consulting” agreements, for example. Applying the same degree of moral outrage to a ham sandwich as we do to conflicts which truly pit the best interests of our patients against some profound interest on the part of the physician that prevents him/her from centralizing the patient is farcical moral equivalence. I think it is actually harming our patients.

Our most renowned medical editors, innovators, inventors, and teachers are withdrawing from public positions that require a monk-like aversion to these “conflicts of interest”. Who will replace them? Will the ascete cocooned in the conflict-free zone and unaware of what developments are on the way contribute? How about the teachers? Will we be taught by “specialists” who put together the purest power-points from the latest scrubbed articles, priests who are not stained by the sins of the those who are touched by the commerce of medicine by actually touching, you know, patients?

Here’s my bid: a true “conflict of interest” is one in which there is an essential tension between what is best for a patient, and some other ancillary benefit that might accrue to the physician. Something that makes the doc think about that other benefit first, before the patient. Everything else is an “additional” benefit. We should stop this silliness; stop trivializing the concept of “conflict of interest” through the dumping together of all other interests in the same gutter. We should all be allowed to ignore all but the truest of conflicts as we continue to put our patients’ interests first.

We should be allowed to seek a “convergence of interests.”


Tales From Bellevue Hospital: 4th Of July

There are only two kinds of people in New York City: Targets, and people who hit Targets. At Bellevue we took care of the Targets.

It’s the first weekend in July. For most people in America that means the 4th of July and everything that goes along with that. Barbecues. Fireworks. Festivals and ballgames of all sorts. And beer. Lots and lots of beer. But in that curious sub-culture of medical education the first weekend in July means the first time on call for newly minted interns and newly promoted residents and fellows of all sorts. Everyone and everything is new, just in time for July 4th and its aftermath.

Funny, but I ended up on call for every 4th of July in my four years of post-med school training. I’m not sure which, or how many, of the residency gods I offended, but whatever I did I apparently did in spades ’cause I hit the first weekend jackpot every year. I have no memory of my first on call as an intern, but the “Target Range” was open for business those first couple of years at Bellevue, for sure! In fact, if memory serves, the phrase “Target” was coined that very first weekend of that very first year as an ophthalmology resident.

“Hey Eye Guy! We got a John Q. Nobody who got shot in the temple just standing on the subway platform. Says he can’t see. Whaddaya want us to do with him? By the way…welcome to Bellevue.”

Crowds and beer and heat and stuff that explodes. Welcome to Bellevue, indeed. Some poor schlub survives the bar scene after the parade, makes it through pickpocket alley intact, gingerly stepping over detritus living and otherwise, only to get shot in the head as the A Train approached the station in a random act of anonymous violence. The bullet entered through the right temple, destroyed the right eye, and wreaked havoc in the left eye socket before coming to rest against the left temple. Right eye gone and malignant glaucoma in the only remaining left eye. And there I was, all of 3 days into my opthalmology residency, backed up by a chief resident of similar vintage. Whoa…

There’s no way to avoid it. After all, med students have to graduate and residencies have to start some time. There’s just this unholy confluence of weak links in the system all coming together in time for the second (after New Year’s Eve) most difficult ER day in our big, academic hospitals. Get sick or injured on June 4th? Everyone’s on top of their game and everyone’s in town. July 4th? The fix is in, and the game is as rigged against you as any carnival game attended by a dentally challenged carnie.

As I sit here, an Attending on call for the 4th of July weekend, covering the ER and cowering each time the phone rings, the Tweets and Facebook posts heralding the arrival of a new crop of interns and residents send me back to Bellevue. Year 2, cursed again, covering the spanking new 1st year ophthalmology resident (was it Dave?) as he got his welcome “gift” from the ER. “Hey Eye Guy. We got a Target down here for ya. 10 year old girl. Some dumbass tossed a lit M80 to her and she caught it. Went off before she could get rid of it;  blew off her right hand and looks like her right eye is gone. You from NY? No? Welcome to Bellevue, pal.” Yup…there’s something about the 4th of July in every teaching hospital in the U.S., and just like everything else, whatever it is, there was more of it at Bellevue.

Only two kinds of people in New York, Targets and people who hit Targets. At Bellevue we took care of the Targets.


The Surgeon Has No Clothes

I stand by the side of the road, wide-eyed in amazement, alone despite the fact that I am surrounded by other spectators. We are watching a parade, a great spectacle to celebrate the apparent dawning of a new age in cataract surgery. One after the other they pass me, the great and famous experts, the Emperors of ophthalmology. Each one sits upon a throne surrounded by bags filled with the coin of the land, the thrones built upon the newest fashion, a femtosecond cataract laser. The rest of the crowd is dazzled; they stand in silent awe as these men with such magnificent reputations usher into the kingdom the latest fashion.

I blink once. Twice. I cannot believe what I am seeing.

Over the millennia there have been thus far three truly revolutionary advances in cataract surgery (a cataract is a clouding of the natural lens in our eye). The ancient Egyptians, and for all we know Ancients of many other sorts, “cured” cataracts through a procedure known as COUCHING. Using a thin bamboo reed the “surgeon” punctured the eye and simply pushed the opaque lens into the gel–filled open cavity in the middle of the eye. Not terribly elegant, but if the eye did not become infected it actually dramatically improved vision in the days of the Pharaohs. This was the original cataract surgery.

The advent of very fine suture material and magnifying glasses brought with it the development of intracapsular cataract surgery. The eye was entered through a large sterile surgical incision and the cataract was removed as a whole. After the incision was closed with these rudimentary sutures it was necessary for a patient to remain stationary, her head held still by sandbags for a week. As barbaric as this sounds today, this procedure, along with cataract glasses, dramatically improved both the safety and the visual results of cataract surgery. Revolutionary change number 1.

Intracapsular cataract surgery was followed by extracapsular cataract surgery, the procedure made necessary by the creation of intraocular lenses. These tiny implants, less than half the size of a dime, are implanted in the capsular bag left behind after the inner workings of the cataractous lens had been removed; think of it as filling an empty grape skin. Better vision, greater safety, and with the addition of mechanical assistance extracapsular cataract surgery also brought efficiency and speed to cataract surgery. Clearly superior, the extracap supplanted the intracap, and during a time of transition both procedures received identical financial coverage from all forms of health insurance. Revolution number 2.

What followed next in ophthalmology was probably the predecessor of all that we have come to know about the intersection between commerce and care in American medicine. A certified genius who was so sure that he was right that he simply did not care what any of his colleagues– indeed what any ophthalmologist at all–thought about him or his invention, introduced  phacoemulsification. Charles Kelman discovered that you could remove a cataract of any size through an extremely small incision by first dissolving it inside the eye with high–frequency ultrasound. Kelman was initially viewed as a heretic, and early adopters of phaco technology were scorned by the ophthalmic orthodoxy. In response they marketed phacoemulsification as the superior procedure that it was, further enraging the establishment by becoming wealthy and famous through the efficiency and efficacy of this surgical revolution.

Once again, during the time of transition from extracapsular cataract surgery to phacoemulsification, both procedures were treated equally in the eyes of health insurance, and every patient’s surgery was paid equally with either technique. Revolution number 3.

As phacoemulsification gradually ushered extracapsular surgery into extinction in the 1980′s there began an era of relative tranquility in the world of cataract surgeons. There was very little to distinguish one surgeon from another save for gross incompetence, a complication rate so far outside the norm that it could not be ignored. How could this be, you ask? Well, all of the intraocular lens implants during the initial part of this era were essentially the same. Each lens development, each evolutionary step however big or small, was quickly adopted by the overwhelming majority of surgeons, and pretty much every cataract surgery patient received a state–of–of the–art implant for her surgery. The SURGEONS surely knew who among them was better. They knew who was faster, slicker, more elegant, and dramatically less likely to have any complications whatsoever. But even the most astute patient was incapable of knowing the difference between a 20-minute cataract surgery and a five-minute cataract surgery, one plodding and clumsy, the other elegant and quick, so powerful was this new technology. Every cataract surgeon in America could, and did, look their patients in the eye and say their outcomes were essentially the same as every other surgeon; they, themselves, were just as good as every other cataract surgeon.

This happy time of peace, love, and tranquility came to a screeching halt in 2003 with the introduction of an implant called the Crystalens. Here, for the first time, the cataract surgeon was able to give his patient excellent vision at any and all distances WITHOUT WEARING GLASSES. The problem, though, was that the Crystalens was actually rather tricky to insert. You really DID need to be more equal then your surgeon peers in order to get this extraordinary outcome. Not only that, but the implant was almost 10 times as expensive as what now became known as standard implants, it required roughly 3 times as much work preoperatively and postoperatively to achieve this outcome, and all of a sudden there was a very clear division between cataract surgeons. There were those who did what became known as premium surgery because they could, and there were those who didn’t.

Surgeon Emperor’s rode on their thrones through the throngs of what once were their peers, adorned with wondrous capes and crowns they so deservedly wore for they were truly better surgeons, and they were paid more to do this premium surgery. For you see, a great change had occurred:  the health insurance companies did NOT view these new implants as equal to those in present use, and in their wisdom they allowed patients to pay with their own money for these more expensive lenses. This they did, though not in great numbers, just enough that it started to become clear that some surgeons were more equal than others. This was not a true revolution in cataract surgery itself, only the economics of cataract surgery.

So here I find myself, one of these Lesser Surgeon Emperors of the premium implant era. I stand among the crowd as this very small group of self–proclaimed Greater Emperors glide by, pulled along on their grand femtosecond chariots. They are declaring, loudly and to anyone who’ll listen, that laser cataract surgery is the fourth great revolution in the long history of cataract surgery. “It’s more accurate,” they declare. “It will make cataract surgery safer!” They cry. “It’s the next, mandatory step in premium cataract surgery. It’s well–worth every penny of the additional $1000 the premium cataract patient will pay,” they state as they preen on their perches.

I blink as I stand there. Something’s not quite right. The rest of the crowd cheers these magnificent creatures but still something seems wrong. A better, more accurate and uniform capsulorhexis (the initial opening into the cataract)? That doesn’t seem to be a problem with premium cataract implant surgery today, at least in the hands of the best surgeons. Better sealing wounds to decrease the number of post–operative infections? Again, the busiest, highest volume, best cataract surgeons already have the lowest infection rates in America. A simpler, more reproducible and accurate limbal relaxing incision (a technique to treat astigmatism)? Well, I HAVE heard that an inability or unwillingness to handle astigmatism IS a barrier to implanting premium cataract implants, but that doesn’t really seem to be much of a problem for those surgeons who are successfully using them now.

I blink once again and then it hits me: the Emperor Surgeons have no clothes! They are parading right in front of us, declaring the femtosecond laser the proverbial silk purse to be utilized as part of a premium service, carried only by those cloaked in the finery of the court as they have been told by the industry courtesans.  Femptosecond laser cataract surgery is a revolutionary step, but it is a premium service like the Crystalens, and is properly utilized only by Emperors.

They are right but they are also so very wrong.

Blinded by the hype, blinded by the glow of their reputations, by the industry courtesans as they wave their empty clothes hangars, the naked Surgeon Emperors are trying to MISS the fourth great revolution in cataract surgery, because femtosecond cataract surgery is not a silk purse, it’s actually just a better backpack! Femtosecond laser cataract surgery is the technology that reestablishes real equality among cataract surgeons. It is not the scepter of the Greater Surgeon Emperor, it is rather the butter knife of the common surgeon.

Think about it. The best cataract surgeons in America are not having any difficulty making a proper capsulorhexis, and they are obtaining over–the–top outstanding outcomes with literally every single type of intraocular lens available. These are not the men and women who are having outbreaks of endophthalmitis (a total eye infection) because of poor technique creating their incisions. We are not seeing an epidemic of untreated astigmatism in the population served by these extraordinarily talented surgeons, especially in those eyes that have received a Crystalens or other premium lens implant. The femtosecond laser as a necessary, mandatory tool to improve the outcomes in THIS group of surgeons performing premium service cataract surgery? Please. The incremental improvement in outcomes will be infinitesimally small in this group, and I will go out on a limb and say that any of the Emperor Surgeons in the parade who are truly among this group of noted surgeons would tell you just this.

No, femtosecond laser cataract surgery is the next great revolution in regular, garden-variety, standard implant cataract surgery performed by the middle–of–the–Bell Curve cataract surgeon. Here is a quick story to illustrate my point. An 80-year-old man had cataract surgery performed in his right eye by one of the most deservedly famous cataract surgeons in the United States. Perfect incision. Perfect capsulorhexis. Limbal relaxing incisions that reduced astigmatism to 0. Every single aspect of the operation that would have been impacted by the femtosecond laser was performed flawlessly. The outcome? Not so great, actually. The patient had a poorly positioned implant causing blurred vision, which was not discovered for approximately 9 months due to postoperative inattention. This caused him to be greatly unhappy with his result and ultimately causing him to seek another surgeon for his left eye even after the blur was fixed.

This new surgeon simply could not be more different from the world famous surgeon. A very kind and gentle soul with a lovely and caring bedside manner, he was at best deeply buried in the middle of the surgical Bell Curve. The outcome? Not so great, actually. A poorly done capsulorhexis prompted him to default to a much older lens implant, a clear technological backward step, and a surgical problem that would clearly be prevented with the use of the femtosecond laser.

So my friends, the femtosecond laser actually IS the fourth great revolution in cataract surgery, but the Greater Surgeon Emperors are failing to see that, like intracapsular to extracapsular, and extracapsular to phacoemulsification, phaco to femtosecond is a revolution for the masses. The femtosecond laser will make an average cataract surgeon a good one, a good cataract surgeon a very good one, and a very good cataract surgeon potentially a great one. It will do very little for the outcomes of the already great cataract surgeon. Oh, there may certainly come some new type of implant where the outstanding surgeon will require a femtosecond laser in order to properly use it, but as of this moment that particular widget doesn’t exist. The femtosecond laser is a technology looking for a use, an investment looking for a market. Will it find its place only with the Emperors, those who should be leading, now instead just riding behind?

The greatest of Emperors lead.  If I am right, if this is actually a technology which will make regular cataract surgery safer and more predictable, Surgeon Emperors and their industry minions should be pounding the streets of Washington to make this fourth revolution just like its predecessor: available to all. They should call it as it is, the average surgeon’s pathway to greatness. They should lead on behalf of every 80-year-old man who deserves a perfect capsulorhexis and a perfectly created wound to go along with his most modern standard implant. They should lead their surgeon brethren on behalf of their people. The greatest among these Emperor Surgeons will see nothing that is negative happen to them if they fight to make femtosecond laser cataract surgery just the next revolution in every day cataract surgery.

I blink. I wait for one of these Emperors to put on some clothes, get out in front, and lead.


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