Random Thoughts from a Restless Mind

“[True] innovators are on the edge of the inside.” Friar Richard Rohr

I once wrote that “if you’re not living on the edge you’re taking up too much space.” This is a bit different. Effective innovators and those who are early extenders of their ideas cannot be so far outside of present orthodoxy that their innovation is ignored, however correct they may (turn out to) be. An innovation or discovery that is too radical to even be examined might be shelved simply for being too far outside the inside, thereby denying countless individuals its benefit. Incrementalism occurs in the middle, but innovation that scales happens just barely inside the border.

Think about my fitness program, CrossFit. What would likely have been the result if step one had been the spectacle of the CrossFit Games, ca. 2017? We all know the answer to that: Constantly varied functional movement at relatively high intensity (CVFMHI)  would have been deemed ludicrous for all but the elite athletes we are seeing perform in the East and South Regionals this weekend, rather than a legitimate option as we seek a public health solution to the well-being of a broader population. The sentinel signal of the innovation was initially ever so slightly inside the outer boundary of the fitness/health orthodoxy: train consistently using irreducible full-body exercises at higher intensity utilizing proper movement patterns. Others have noted the importance and effectiveness of interval training, notably Michael Joyner, M.D, at the Mayo Clinic. While a sense of the importance of the glycolytic energy pathway existed before CrossFit, it took an innovator far enough outside the middle to realize its potential and make it the primary focus of a program.

The world of my day job is also populated by innovators who were just radical enough to nearly become outcasts. I always think of the great Charles Kelman, M.D., the inventor of what we now know as phacoemulsification. When Dr. Kelman began his research on using high frequency ultrasound to dissolve a cataract through an incision roughly 15-20% the size of what was then typical, no one could fathom why that would even matter. Fast forward to our present day ability to remove a cataract through a 2mm incision. Because of that first innovation I can now replace a cataract with an implant that allows someone to see both near and far with no glasses. Imagine!

Once true innovation occurs it moves inward, but a next wave of innovators lurks near the edge. Like so many benign Salieri’s to Mozart they build upon the original innovation within their own, smaller zones. This is no less disruptive than that original innovation; it simply occurs in a different part of the world. Shortly after CrossFit erupted in the general fitness world a second wave was brought by innovators in youth fitness by Jeff and Mikki Martin of Ramona California. Their program is now known as The Brand X Method and they lecture on their evolved programs for youth fitness all over the world. In a similar fashion Brian McKenzie, an ultra runner looking for a way to train more efficiently and with fewer injuries, used the principals of CrossFit as applied to endurance training in what was originally known as “CrossFit Endurance”. B Mack is also continuing to push the envelope in his PowerSpeedEndurance program.* It was only the growing acceptance of the original innovation that prevented these next-wave innovators from being OUTSIDE the edge of their particular parts of the fitness world.

The logical extension of CFVMHI, what we are witnessing each weekend as The CrossFit Games season is upon us, has long since passed me by. It turns out that for me all I’ve needed was an early update to the original inspiration (classic, early vintage CrossFit.com with CrossFit Strength Bias v3.3 layered on); more and more actually brings me less of everything. Others who I am quite fond of have had a different journey. One of my daughters-in-law is doing a modified CrossFit Endurance protocol for example, and is winning her age group in 5K races while pushing my granddaughter “The Nugget” in a race stroller. My grandson “The Man Cub” will doubtless train using the Brand X principles that have evolved from the original CrossFit Kids program. My friend Julie continues to push the limits of human everything as she competes on a CrossFit Games team while developing new medical paradigms, all before graduating from med school here in Cleveland. Unlike yours truly, more and more brings Julie more and more. Innovators in the world of eye care similarly bring us new techniques from the edges of our world, the latest being the once unthinkable ability to treat floaters with a laser.

CrossFit is now firmly established as both a system and a business. Small incision cataract surgery using ultrasound is the standard of care. We would do well to remember that time when this was not at all the case, a time when only one innovator sat just inside the outer edge. What is to come in any number of other areas–medicine, finance, digital, what have you–will come from the same place. Some of us caught on to CrossFit really early. Wouldn’t it be great to be out near the edge and catch something like that right in the beginning again?

*To my knowledge neither the Martins nor Mr. MacKenzie are presently associated with CrossFit, Inc.

It was the missed workouts that finally got me. That, and the fact that I was not getting to the gym after surgery because I had to RE-DO orders I’d already entered. That caused me to crack. Why I was missing workouts.

Computer Physician Order Entry went live in December at one of the surgery centers where I operate. As is my lifelong pattern, once I decided that I would remain “in the game” at that particular center I simply viewed CPOE as a new set of rules to learn, a new challenge to conquer (however involuntarily), a new game to win. Maybe it’s my first-born status, or perhaps just the result of an upbringing where everything was a contest to be won, but I learned the ins and outs of the system in less than a month. My office staff, the surgery center staff, and I then went about the task of generating a process that would minimize the depth of the “time sink” into which CPOE had tossed me. On days when I was only operating out of one OR I was only down about 2:00 for every laser done and pretty much dormie on the rest of the cases because I could enter orders during pre-existing “dead air” time.

A funny thing happened on the way to happily ever after: patients we knew were scheduled were failing to show up on the OR schedule in time for me to enter their orders, and orders I’d entered started to turn up missing. That’s right…I had sucked it up, learned the system and taken my paddling like a good plebe, and the system insisted on inflicting this random form of unearned pain. The first time it happened I just re-did the orders. The second time I went off. My “Doc Whisperer” watched me put in every order for this coming week, documenting my status as a quick and accurate little Dr. Lemming. Patient lists and screen shots document my every order. All of this is to no avail. Once again, orders I placed for cases to be done tomorrow do not exist in any part of the Epic wasteland that is the EMR at World Class Hospital.

Is anybody paying attention to this? Does anybody care?!

Not only have I been forced to take time out of my day to do something I did not need to do previously, to perform acts of documentation that once took me a fraction of the time it now takes electronically, but these impositions are now compounded by the fact that work I’ve done is nowhere to be found. Lost in the ether, in a world that no longer even uses ether. This is maddening. Is there even a “Happy enough, ever after” with EMR?

Sadly, I’m afraid this is to be continued…

With the launch of SkyVision Centers 10 years ago I entered the era of EMR. Our group was certainly an early adopter, but since we had chosen this path so early we were able to make our own determinations about what we valued in the technology, and what we would not be willing to give up or compromise in order to have EMR. Our choice of platforms was one that expressly sought to enhance the efficiency of a busy specialist, while at the same time allowing us to hold on to a very personal approach to the doctor/patient interaction. That experience has informed my reaction to all subsequent encounters I have had with other EMR’s, government regulations, and the like. The launch of  Epic CPOE at my World Class Hospital ASC was just the latest example.

A tip of the hat and heartfelt thanks to the folks at the ASC who took such a personal interest in my experience. To my surprise and near delight, the CPOE intrusion in the OR during cataract surgery (in a single room) was negligible. There’s a lesson here for implementing EMR changes: do your homework. The reason my day went so smoothly in the OR is that the people who were thinking about me spent the time necessary to head off problems BEFORE I showed up that day. Two sessions with me, both of which occurred AFTER examining my pre-CPOE processes and paperwork, helped to head off predictable and preventable frustrations.

Having said that, a pox on the houses of all who created the tragedy that is the post 2008 EMR. That means both the government “know-betters” who shower all of us in the trenches with dictums on how it’s supposed to be, as well as the EMR software engineers and execs. Never mind that not a one of them could possibly have ever manned a bedpan, let alone a needle-driver, the arrogance of simply declaring what should be without looking at what is continues to be appalling. To a person every single one of my patients complained about being ignored by the ASC staff on CPOE Day One. Heck, there was literally no way for me to position my Pig, “Babe”, so that I could have eye contact with my patients when they entered the laser room; I was just like every other physician lemming with his eyes glued to a screen when they walked in. I at least have 10 years of goodwill built up with my patients so that I might be forgiven for the insult delivered by Epic.

While I’m at it, can we talk about the arrogance of the programming…ahem…experts, the Cave Dwellers at World Class Hospital? Do they work for Epic, World Class Hospital, or some outside agency? I asked for an order set for a particular type of procedure, one that would more exactly represent what and how we do it at our ASC. I was told in no uncertain terms that the Cave Dwellers had already declared that they had done more than enough for me and us, and that I should feel very lucky that they did as much as they had. Seriously. Never mind that my request would have saved me time, saved the staff time, and made for a better experience for the patient. The Cave Dwellers had spoken. These people have as much power to inflict unnecessary pain on productive folks like doctors and nurses as the pharmacists at World Class Hospital (remember a brand new bottle of eyedrops for every patient for every laser to avoid infections that had never happened in the history of laser surgery?). Here’s hoping one of the Cave Dwellers doesn’t recognize some very important name and drops that same load of attitude on that Very Important Person. Kinda makes a lie of the whole “support” part of “tech support”. This is fixable, by the way, if anyone’s listening, especially if they work for World Class Hospital.

In the end there remain two very critical problems with CPOE in general, and EMRs of the Epic ilk in particular. The first and most problematic is that at their heart they are not medical records at all, they are billing and compliance systems. The primary customer is not the physician or the patient but an accountant, and the outcome that is maximized is not a medical outcome but a financial one. These systems will always be a time suck for both doctor and patient (and nurse, and receptionist, and…), and with that will come an inevitable happiness suck. I had a full hour stolen from my day; this isn’t going to get any better. Every one of my patients had an unsatisfactory experience as ASC staff paid more attention to their Pigs than to my patients; this isn’t going to get any better, either.

The second issue reflects the end of my first day with “Babe” and it is the only issue that could possibly get better: computers and software of any sort are only as good as the people using them. Despite all of our planning, all of the preparation that happened before I arrived at the ASC, everything came to a screeching halt when I tried to plug in my orders for next week. The poor woman whose job it was to enter the patients into the system was simply overwhelmed with work. On top of her regular job and her regular duties she was now not only responsible for the additional task of putting patients into the Pig Pen, but she also had a very hard deadline to beat. At the moment of truth it was her failure, but just as it isn’t the waitress who is at fault when she delivers the overcooked steak, neither was it the poor clerk’s fault that I sat and stewed while she completed her task under the baleful glare of her boss. Just as it is the chef who is at fault for the burnt steak, so too is it the fault of management upstream for failing to give a frontline worker the time necessary to feed the Pigs.

Here, at last, is hope. Faint hope, but hope nonetheless. Someone, somewhere in the chain of command at World Class Hospital may realize that they can make this whole CPOE mess a little bit better for at least some of the folks who are affected by it. It won’t be me, or anyone like me; it’s clear that physicians are just interchangeable cogs in this machine–the noisy ones will be replaced. It surely won’t be patients; that ship left port way before Epic arrived, no matter how many ads World Class Hospital takes out declaring fealty to “patient-centered care”. My hope, and my new crusade, is that the non-physicians on the front line who are taking a beating from this will be acknowledged and given the resources necessary to NOT be the fly in the oink-ment (couldn’t resist). They don’t deserve to end up in the crosshairs of a doc looking for a place to put his unhappiness.

Now, the Cave Dwellers on the other hand…

Boy oh boy, was it crowded in the Ambulatory Surgery Center on Tuesday. The place was crawling with techie types in outfits that looked an awful lot like Walmart uniforms, bumping into a cadre of Suits who were there doing…well…I’m not sure what the Suits were doing. They were mostly in the way of productive people doing useful stuff. My day started off with an almost immediate case of miss met expectations as the tech support person who’d promised she would be there to guide me on Day One, since she’d spent so much time personally preparing both me and Epic for our first CPOE date, was nowhere to be found. Sadly, it was apparent that the otherwise quite lovely and very talented woman who was there instead, let’s call her my “Doc Minder”, was going to need some catching up on what had gone before, despite her assurances that she’d been fully prepared by Top Tech, the Doctor Whisperer.

“Dr. White, I was led to believe that all of your pre-op orders have already been entered into the system.” Uh oh. I spent 2 hours the prior Thursday afternoon with the head honcho “Doctor Whisperer” entering all of those orders. My first thought was “why don’t you know this already, since you have access to all of my charts today and could have looked?”, followed by “How is it possible that you didn’t look so that you could head off any problems before I got here?” What I said was: “they’d better be.” Ugh. Was this a sign? Given my state of mind heading into this day you can imagine the kinds of thoughts going through my head when the first mobile computer brought to the OR for my use didn’t work. Like, not at all. Rough start.

Turns out that I have some history with these mobile computers and World Class Hospital. They were originally called “Computers on Wheels”, which I instantly renamed “COWs”. Makes sense, right? Easy. Cute. Man, did that get shot down fast. Something about cultural sensitivity, or, really, I have no idea, but calling them a “COW” was verboten. I’ve been using that “Lipstick on a Pig” analogy when discussing everyone’s sensitivity to my unhappiness about Epic in general and CPOE in particular. My new four-wheeled “Pig” arrived and to my surprise things actually started to look up. The computer worked so well that I found myself calling it “Babe”.

Having all of my pre-op orders already in the system turned out to be a critical step in giving the day a fighting chance to succeed. All of the orders had, indeed, successfully made their way from the chart to the nurses in pre-op, and from there to what seemed to be a fairly regular implementation for my surgical patients. This is important because patient preparation starts well before I arrive in the morning for surgical patients, and begins for lasers while I am toiling away in the OR. The fact that it took some 2 hours to get these orders entered last week (total of 19 cases), a process that had heretofore occurred entirely without needing me to engage, was momentarily lost in the euphoria that I didn’t need to put out any pre-op order fires (hmmm…would that be a Pig roast? Sorry.).

Although this was day one for implementing CPOE in this particular ASC, the fact that the main campus of World Class Hospital, as well as several other WCH ASC’s had already made the transition, meant I really wasn’t truly a guinea pig (too much?). Standard order sets already existed for eye surgery, and it was relatively simple for the behind-the-scenes cave-dwellers to create both order sets specific for our ASC as well as templates for my op notes (more on the cave-dwellers in Part III). As I noted in Part I our turnover time in a single OR for cataract surgery is ~7:00. With some gentle and kind prompting from my “Doc Minder” I was easily able to do everything “Babe” asked of me between cases in addition to my usual duties (chat with the family, etc.). My kindly “DM” agreed that “Babe” would probably slow me down on busier days when I hop between two OR’s, but for today at least there was no time suck for cataract surgery. I even did one fewer dictation because the “Doctor Whisperer” had helped me create a template for “Complex Cataract Surgery”.

I may or may not have said “That’s some Pig!” out loud.

Alas, everyone involved knew that the happiness was fated to be short-lived. The efficiency bar is so high when we do ophthalmic lasers that there was simply no way that “Babe” was going to be able to keep up; he was back to being a Pig as soon he moseyed over to the laserium. Because every patient’s chart must be completed before they are allowed to leave the facility–images of armed guards wearing Google Glass running Epic and manning the exits filled my head–I had to attend to all of “Babe’s” needs before starting with the next patient. This process took 1.5-2X as long as usual, increasing the time it took me to do my lasers and making it a bit less convenient for my patients.

Then everything went off the rails.

Computers are computers, and software is software. They are both heroes or goats depending on how well they fulfill whatever task they are assigned, but they are prisoners of the people who operate them. The plan that all stakeholders had agreed on was for ASC staff to schedule all surgeries booked by SkyVision as of Monday by the time I finished lasers on Tuesday. I would then do all of the pre-op ordering for the following week before leaving for the day. Under the best of circumstances every minute I spend doing this is both a time and a happiness suck for me because, as I noted above, prior to CPOE I didn’t have to do ANY of it. Naturally, more than half of next week’s patients had not yet been entered into the system making it necessary to not only stick around to pet my Pig (I know) but also wait for the overworked WCH staff to complete their tasks. All in all it cost me about an hour, stealing my workout and rushing my lunch so that I could be in the office and start clinic without making my patients wait.

What’s the take-home? Tune in for Part III. For the moment let me just say…that’ll do Pig, that’ll do.

It’s really quite flattering, all the attention. The cynic would say that it’s all really just an attempt to keep my business, and I’m sure there’s a bit of that going on. After all, even though my surgical volume is down since my I left my original practice to start SkyVision, I still do a rather high volume of surgery at a very low cost/case. Still, the sheer number of folks, not to mention who they are, who have gone out of their way to try to make my CPOE transition go smoothly is impossible to ignore. Folks really do seem to be sincerely concerned about me as a person, someone they know and have come to like enough over many years, not just a surgeon bringing business. If only it wasn’t all so…so…useless.

I know, I know, I sound a bit petulant, but I’ve watched this movie before. I know how it ends. It may sound somewhat ungrateful, what with the head of physician training, Chief of Surgery, and Head of Outpatient Surgery and local administrator among those taking an open interest in my journey. It’s just that the story only ends one way, with a great big time suck that undoes a decade and a half of ever increasing efficiency (and with it patient satisfaction) and the associated assault on my emotional well-being.

All these people walking around with lipstick thinking…hoping…maybe just one more coat and he’ll smile when the pig kisses him.

It’s my own fault, really. I admit that I had allowed myself to believe that the uneasy peace I’d made with Epic, the EMR utilized at World Class Hospital, would be a lasting one. A peace for all time. I would interact with the beast on a quarterly basis, signing verbal orders that kindly nurses had accepted and op notes for surgeries that deviated just enough from the routine that they needed to be dictated fresh. In return I would be allowed to simply sign orders, op notes, and other sundry paperwork as I had been doing for the last 24 years. Simple. Everyone wins. My OR days run efficiently saving me, my patients, and the institution countless hours of wasted time, and I continue to bring the majority of my cases to one of the outpatient surgery centers owned by World Class Hospital. (It should be noted that I am the lowest cost eye surgeon in the entire system, thereby generating the greatest per/case profit for WCH). I truly believed that I would still find sanctuary in the OR from the thousands of chickens pecking away at my professional satisfaction and by extension my general degree of happiness.

BzzzzzzPfffffTttttt…sorry Doc, that’s the wrong answer. Johnny, tell our contestant about his lovely parting gifts.

For the first 16 or so years of my post-residency career literally every process change in which I’ve been involved has had a direct, positive effect on outcomes or safety, patient experience, or my efficiency. About 8 years ago tiny little negative things started to creep in, some of which chipped away at that efficiency. A few more forms to sign. More pre-op checkpoints for my patients to pass on their way to the OR. Along with this came the madness that arises when a huge organization plays defense against an unregulated regulator like CMS (medicare) or JCHO (the hospital regulator). Not one, not two, but three personal checks by the surgeon to confirm the surgical site. A pharmacy either running scared or run amok that demanded a brand new bottle of eye drops for every laser patient despite an industry-wide infection rate on lasers of 0.00000001%. It was mostly piddly-diddly stuff, and the OR staff did their very best to run interference and preserve our efficiency.

Now? Oh man. The introduction of the Epic EMR into the OR has turned our 2-nurse room into a 2.5-3 nurse set-up. There is so much dropping down and clicking necessary to fulfill the beast’s demands (man, would this analogy be perfect if they still let us call them Computers On Wheels?! Feed the COW!). Previously, one circulator could do all of the paperwork, prep the patient, and have time to spare to facilitate room turnover. Admittedly I move pretty quickly as I do cataract surgery, but it’s impossible for just one person to do all of these tasks now that Epic must be served, without all of the rest of us sitting on our hands and waiting. The local administration and the staff have rallied around me and my patients and for most cases an extra pair of hands is there to keep things moving. Heck, I do my part as well by taking the trash out of the room and bringing the used instruments back to the sterilization room.

With the introduction and implementation of CPOE (Computerized Physician Order Entry) all of our efforts to improve efficiency, with all of the wonderful things efficiency brings, will be for naught.

How can I possibly know this before experiencing it even once? People talk, and doctors are people. I’ve chatted with a score of surgeons about how long it takes for them to do what Epic and World Class Hospital requires of them, and I’ve got a bit of experience just signing stuff after the fact. It just simply takes a lot of time. Add to that an institutional indifference to the psychological effect of hoovering  time out of a surgeon’s day and you’ve created the world’s biggest, most frightening chicken peck.

Tell you what, let me share a few numbers with you before we make the switch, memorializing them here, dated, before the transition, so that there’s no possibility that I made stuff up after the fact. The baseline numbers I am about to share admittedly are rosy in part because everything that can be done to/with the paperwork by someone NOT me happens as part of well-established routine. Details such as start/stop times, IOL serial numbers, etc. are filled in by support staff; there is little to no chance that this will be the case when everything moves from paper to screen judging by other surgeon’s experiences.

95+% of my cases are either cataract surgeries, post-cataract lasers, or lasers to treat dangerously narrow anterior chamber angles. Through a combination of fortunate genetics and hard work I have become very good, and very fast, at all of these procedures. My team and I achieve enviable outcomes and microscopic complication rates despite the fact that we move very, very quickly. A patient having cataract surgery spends approximately 15 minutes in the OR. For comparison sake, a study from a prestigious eye hospital recently posted an average time in room of ~33 minutes for its top three cataract surgeons. Turn-over time (patient out/next patient in) is 6-7 minutes. On average it takes me 26 seconds to complete ALL of the paperwork that must be done in the OR. It takes another 9 seconds to sign the op note when it is returned from transcription; this is important because Epic will require either finding, editing, and signing an op note in the OR, or dictating one on the spot.

Our team of nurses and doctor has achieved an even more enviable efficiency when doing lasers. The average time it takes for a patient to have the entire laser experience–enter the laserium, be seated at the laser, have the laser successfully performed, and leave the room–is 3 minutes. That is not a typo. The average set-up in the United States is closer to 15 minutes or more for this procedure. At the conclusion of the laser it takes me on average of 17 seconds to complete all of the paperwork that is required, and again 9 seconds on average to sign the op note when it becomes available.

You’re probably thinking why this is a big deal, aren’t you? That I should stop whining and just get on with it. Here’s the rub: I do lots of these procedures each time I go to the OR. Any additional clerical time must be multiplied by the number of cases done that day, and all of that time will be stolen from my day. When I finish in the OR I then do other stuff that’s pretty important. Sometimes I go back to the office and see patients, patients who may have had to wait a long time for their appointment. On really good days I get to go to my beloved CrossFit gym to get a workout in. An even better day is one on which I get my WOD in and then sit down in front of the computer to write. These latter things, especially, make me happy. They make it worthwhile to work as hard as I do. Every extra minute it takes me to do something I already have to do not only brings frustration in the OR itself but also keeps me from parts of my life that bring me happiness. A happier doctor is generally a more effective doctor.

We are establishing a baseline today, and that baseline includes a certain degree of happiness. What do you think the chances are that CPOE will increase my happiness? Stay tuned for Part II.

The technology is fabulous. I mean, Femtosecond Laser Cataract Surgery (FLCS) is really, REALLY fabulous. It deserves a full roll-out. It is nothing less than the logical next step in a progression of medical treatments that extends back in time to the days of the Pharaohs and Cleopatra. Yet we debate its merits (Is it better? Is it safe?) in a sad and tawdry replay of the introduction of its predecessor technology, a chapter in the august history of ophthalmology that is still cringe-worthy among the vanishing actors still alive from that tragicomedy. That original sin, the denigration of the technique of cataract removal called Phacoemulsification (Phaco) by the establishment could at least stand on technical grounds;  Phaco 1.0 was rather rough stuff. Here we have no such ground on which to stand; the new technology of FLCS at launch is at LEAST as safe and effective, and promises to become more of both as it develops.

Why, then, my obvious angst?

The problem lies not with the technology but with the business model, and by extension how that is dividing the community of cataract surgeons. You see, what was really tragic about the the response of the ophthalmic community during the transition to Phaco for cataract surgery was the outright character assassination of those on the forefront of adopting Phaco by those still entrenched in the status quo. In my opinion the same is starting to happen now, only it is those who are adopting the new technology who are subtly smearing those who have yet to do so.

At the turn of the most recent century a company called Eyeonics (since purchased by Bausch & Lomb) and its CEO Any Corley ushered in a new era in cataract lens implants. With these new implants came an equally revolutionary new business model. Through the tireless work of Corley and his associates patients were given the option of paying an additional charge to add an UNCOVERED service on top of a medically necessary service that was otherwise fully covered by insurance. While the costs of the basic aspects of cataract surgery (remove the cataract; replace the removed natural lens with an artificial implant) would continue to be paid by health insurance (including, most importantly, Medicare), a patient now had the option of paying to add an additional service such as the treatment of astigmatism or presbyopia (the ability see up close as well as at distance) without the need to wear glasses.

Mr. Corley and Eyeonics did the grunt work of convincing the bureaucrats in what is now CMS that this was OK, and this  success launched some of the most vibrant technological advances anywhere in medicine. We now have no fewer than 6 “premium” lens implants, with at least another 6 in development. This is really exciting stuff and it is the direct result of the lobbying work done to create this new business model: extra charges for services that are beyond the basic, standard services necessary to accomplish the treatment of a medical necessity, in this case the removal of a cataract.

So what’s the problem? In a nutshell, the industry that has given us the FSLC is conflating this advancement in the fulfillment of the basic aspects of  cataract surgery (FSLC) with the provision of additional services that are not medically necessary (treatment of presbyopia). Indeed, such luminaries in my world as Eric Donnenfeld, Dan Durrie, and Steve Slade are on record as saying that FSLC is already safer than traditional Phaco, and that it already produces superior outcomes in ALL circumstances, specifically including the implantation of a standard lens implant. How then is this a “premium” service? Why is FSLC not being sold as the next development in the long line of successful improvements in cataract surgery for the masses? For Heaven’s sake, if FSLC is truly safer than what industry and industry consultants have taken to calling “manual cataract surgery” (despite the inconvenient fact that FSLC still involves some pretty tricky manual steps), how can one justify calling this a “premium, non-covered procedure” for which a patient must pay more? Seriously, pay more for safety? Pay more for better outcomes?

THAT my friends is the problem. In order to get what may turn out to be the safest surgery, for the first time in history patients must now pony up. Think about how this would play in, oh, heart surgery. “Well Mrs. Jones, your heart surgery can be done with the older technique and covered by your insurance, but for $2000 extra we can do the better, safer laser version for YOUR heart.” Nice, huh?

Our ophthalmic device manufacturers, including interestingly the same Andy Corley I previously lauded, have taken the easy route. Rather than “man up” and go before Medicare and the other insurers to justify a request for insurance coverage of the additional cost of what the podium speakers are calling a safer, better procedure, they have instead opted for the cynical, cowardly route of mis-applying the “Corley Rule” and having the patient pay. Worse than that, there is a very clear message coming from the podium (though not necessarily Donnenfeld, et al.)  and various editorials that those of us who have achieved stellar visual outcomes with spotless safety records are somehow now failing to provide our patients with the new “standard” if we opt to wait at this stage of development. Really. That’s what they are saying. Indeed, even some who are old enough to have been the targets of this kind of behavior in the 70’s and 80’s  say that out loud.

Listen, I get the excitement about a new technology that will probably win out as both better and safer. Heck, new often wins just because it’s new, or because people THINK it’s better and safer even if it’s not (read: Femtosecond laser LASIK  flaps vs. modern mechanical keratomes). I’m good with that. At 53 years of age I will almost surely perform FSLC for a significant part of the rest of my career once I begin. But don’t try to tell me that this is anything other than the latest step in a progression of procedures that began with “couching” in ancient Egypt. Don’t expect me to feel OK with the cynical decisions that everyone in the pipeline have made in order to avoid having the battle on insurance coverage for something they are already calling a “standard”. You simply can’t have it both ways. You can’t say that this is a safer surgery with better outcomes and then say that the regular Joe or Jane should reach into their pocket and pay EXTRA for the next better version of regular surgery that has always been covered by insurance, and then expect me to get in line and salute the “Jolly Roger” you’ve just hoisted.

The technology of the Femtosecond Laser Cataract Surgery is great. The cynical business model is not. Let’s not tarnish this wonderful new technology by repeating the bad behavior of the 70’s during the transition to Phaco by speaking ill of our colleagues who may not be as willing to jump on the bandwagon of a cowardly industry unwilling to do the right thing in support of of its own creation. It is our job as ophthalmic surgeons to demand that the device industry do the hard work to come up with a more appropriate business model if they want to sell their lasers.

As far as I’m concerned it is also our duty as colleagues to not forget the trauma we inflicted upon ourselves in the Phaco transition by smearing one group or another, however subtly or quietly that might be done. Both sides of this controversy must do whatever it takes not to repeat that tragic history as we move inexorably toward the universal adoption of the newest heir in the cataract surgery lineage. In general I’m a fan of our industry partners, but they created this issue by abdicating when it came time to support their invention.

It’s up to us to force them to own up to that and fix it.

You’ve heard this before: the more solutions you have for a single problem, the less likely it is that the true solution has been discovered. Once a real, conclusive solution is discovered it is accepted and implemented by essentially everyone who is presented with that particular problem. This process occurs unfettered in an open market or open system, and the cost of a particular solution depends on a combination of need for the solution and the economic incentives that exist to solve the problem.

Unfortunately, in healthcare in the U.S. this “rule” is not always the case.

Here’s a story about a solution that is NOT being used to the extent it should because private surgery centers are punished financially if they do the right thing. This example is truly a case of perverse economic incentives violating what we think of as a law of nature, that the discovery of a solution for a vexing problem will be adopted by all who suffer the problem if it is shown to be superior to all other solutions. Let’s look at the “Floppy Iris Syndrome” (AFIS) in cataract surgery.

The iris is the colored part of your eye, and the pupil is simply an opening in the iris, much like the shutter of a camera. The pupil is dilated prior to cataract surgery so that the cataract, a clouding of the lens that sits in back of the iris, can be reached and removed. Six or Seven years ago cataract surgeons began to be ambushed by pupils which spontaneously constricted or shrunk like a pursestring closing, or by an iris that started to billow like a parachute placed over a fan. Dubbed the “Floppy Iris Syndrome”, it turned out that it was caused by exposure to a certain class of medicines used for the seemingly unassociated problem of urinary retention in men with enlarged prostate glands; it has since been found to be caused by an increasing number of other medicines. It was a disaster. The complication rate for surgeries with AFIS was 10X or greater than those with a normal iris and pupil.

The search for the cause was important because cataract surgeons could now be forewarned that they might encounter AFIS during surgery if their patient had ever been on one of the medicine culprits. Once the cause and the extent of the problem were known the race was on to find a solution. Unfortunately, all of the intra-operative tactics we’d used in the past to handle small pupils were largely ineffective against AFIS. In fact, some of the standard ways to address a small pupil actually made the surgery MORE difficult because of the floppy, flaccid iris. Every week brought one or two new ideas to add to the dozens already on the table, proving the rule that many solutions means that no true answer has been found.

Enter Dr. Maluygen and his marvelous eponymous ring. The Maluygen Ring essentially solved the entire problem by simultaneously expanding the pupil and stabilizing the iris, and it was both vastly superior to all other solutions available and technically within the capabilities of pretty much every cataract surgeon. Bingo. QED. Kudos, heartfelt thanks, and a bit of profit to Dr. Maluygen and the company that marketed his Ring, right?

Not so fast there, Cowboy. Every week we STILL see articles on how to deal with AFIS in surgery despite the fact that not a single surgeon has stated, on or off the record, that there is anything that is as good as the Maluygen Ring. Here is where the perversity begins. It turns out that only hospital owned surgery centers can bill insurances for additional or special items used during surgery, and the $125 that the Maluygen Ring costs is extra and therefore not reimbursed. The majority of cataract surgeries in the U.S. are performed in private surgery centers, mostly owned by surgeons who operate in them. To begin with, private surgery centers are paid roughly 60% of what hospital-owned surgery centers are paid. $125 represents in most cases 50% or more of the gross profit (before interest, taxes, depreciation, etc)  generated in a case.

That’s right, there is a 50% financial penalty for using the best and safest method to avoid a preventable complication.

It’s no wonder that the owners of surgery centers continue to look for an alternative solution to the problems cause by AFIS. In a misguided attempt to save money, Medicare has led the charge to pay independent surgery centers less than hospital owned centers, and along the way has stripped the independent centers of the ability to pass on the cost of items that represent the “best practices” for certain situations. Rather than use the acknowledged superior solution (the Maluygen Ring) we continue to see inferior techniques utilized despite the fact that they often prolong the surgical case and fail to completely solve the problem. All because policies are created by non-clinical personnel who are only  empowered to save money.

We should be mindful of these perverse economic incentives as our American system of curing disease undergoes an historic upheaval. Do we really want doctors and others considering the economics of utilizing true, proven best practices? Do we really want non-clinicians creating policy that turns medical decisions into economic ones?

Incontrovertible data does not always lead to the expected outcome. Take for example the much-trumpeted call for “evidence-based medicine”, choosing courses of action or care patterns that have been shown to be beneficial with regards to outcomes, reduced complications, or reduced cost when no benefit has been proven. The recent movement in which several national physician organizations have been asked to identify procedures or tests that should be eliminated for lack of proven efficacy is a presumed “no-brainer” way to reduce the cost of healthcare. In my eyecare world routine pre-admission testing for cataract surgery has been singled out as unnecessary, a waste of time and money for almost everyone involved. A New England Journal of Medicine article from 1990 is cited which unequivocally  shows no benefit to the patient or the cataract surgeon. The data comes from the NEJM. From 1990. This is only a tiny bit removed in both historical context and gravitas from a couple of stones and a guy named Moses. Why are we even talking about this in 2013? Why isn’t this already a done deal?

Ah…there it is…”a waste of time and money for ALMOST everyone involved.” Some very powerful someone has an economic incentive that does not rest on either an outcome or on safety. Someone is getting paid for all of those EKG’s and blood tests for pre-admission testing prior to cataract surgery (I am a cataract surgeon; it isn’t us),  and they have found a way to interpret various and sundry Medicare and OR accreditation documents in such a way that pre-op testing is mandatory. This blatantly ignores the evidence because the evidence ignores the economic incentives: a hospital is getting paid for pre-admission testing. All those patients are being robbed of their time, and every one of them who has an “abnormal” test result is then directed down the rabbit hole to chase a “cause”.

I know, I know…you’re shocked. SHOCKED! As bad as that example may be, and as perverse as it is that the champions of evidence-based medicine ignore the evidence when money is on the line, a story of a hospital doing something extra to get paid more is kinda boring; it just seems to happen all the time. In the private world of free-standing surgery centers that are not associated with a hospital pretty much everyone gets the joke about pre-admission testing and would do pretty much anything to be able to quit. You see, the private surgery centers don’t get paid the same way and pretty much lose money on pre-op testing. If they could get away with it they would all drop pre-admission testing for cataract surgery. The barrier is the economic incentive for the hospitals that own surgery centers and their influence on how regulations are interpreted.

In the face of data that provides a pathway to cost savings in healthcare, evidence-based medicine will only be utilized if the incentives are such that the invested players stand to gain, or if lights bright enough and cries loud enough arise to point out the perversity of the economics at hand.

We’ve lost the ability to be amazed. As a society, as a people, North Americans not only fail to be dazzled by things that are downright amazing, we have actually become quite blase about, well, pretty much everything. That sense of wonder at the new we celebrate in children is leached out of our kids at ever younger ages. Our ability to be awestruck has atrophied, and any sense of awe, wonder, or amazement that we DO experience is so fleeting that it’s almost as if it was never there.

How did this happen?

This idea, this observation has been stewing in my subconscious for a couple of months now. It popped its cork yesterday after a couple of experiences I had starting last week. The first, interestingly, actually involved seeing people who actually WERE amazed. I flew to and from Providence to visit my folks last weekend. On the way out I sat in the last seat in the plane (doorman to the restroom), on the way back in the very first seat (Walmart greeter). On both legs of my trip I was seated next to 45 year old men taking their very first trips on a plane. Imagine! 45, and never on a plane. These guys were simply awestruck at the notion that they were drinking a Coke inside an aluminum tube that was cruising at 35,000 feet. One of them took about a hundred pictures of the clouds out the window. Those guys were amazed! I let myself get swept up in their experience; it really IS cool, and not even just a little bit amazing, that I could get to my folks 750 miles away in less than 90 minutes!

Experience #2 occurred in my office on a one-day post-op day. Medicine in general, and certainly my field of ophthalmology in particular, is a victim of its overwhelming success. Indeed, this is not too different from the airline industry. We deliver the goods time after time, on time, without a hiccup. So frequently, in fact, that in those rare instances where things are rocky, or there is a complication, we view the outcome as only slightly less horrific than an airplane crash. Even a fantastic outcome, one that would have been so unlikely just a few years ago, is now viewed as some kind of a disappointment if it fails to meet the outlandish expectations of an audience that has been numbed by routine success.

Take, for example, cataract surgery. I had a patient with a very large cataract, a very small pupil, and a flaccid iris–a set-up for a very challenging surgery, one that a few years ago had a 10X increase in complication risk. Per our protocols the patient was offered several choices of lens implants, and the expected outcome (visual acuity, need for glasses, etc.) for each of these was discussed and explained multiple times by multiple staff members and doctors, all according to our protocols. Some of these implant choices were entirely covered by insurance, and others included fees for which the patient was responsible. These, too, were covered in detail several times by several staff members. In this particular case there was even a second, extra (no charge) visit to the office specifically to discuss these options and the associated expectations following surgery.

So how’d it turn out? The staff and doctors were turning cartwheels when we discovered that the one-day post-op distance vision was 20/20 without any glasses! Imagine our surprise and chagrin when patient and spouse sad glumly in their chairs at the news, not the least bit excited. In fact, the majority of the visit consisted of patient and spouse grilling doctors and staff about the fact that the patient could no longer see up close without glasses. This despite the many counseling sessions about implant choices and post-op expectations in a patient who could not pass a driver’s test with or without glasses prior to surgery. Not a word about how amazing it was that such a challenging surgery resulted in the ability to now pass a driver’s test without glasses!

You might fairly ask if I was amazed by this? Sadly, no, I was not. It’s not enough for the airline to bring you in on time and safely. Nope, now you had to be flown first class on a free ticket and arrive early to simply be satisfied. To be amazed one would need to have somehow been transported to and from the S.S. Enterprise by Sulu personally.

Manned flight, up and down with nary a hiccup each and every time. Cataract surgery that improves your vision 99.9% of the time with nary a hiccup. Joint replacements that allow you to play tennis. GPS in your car that directs you to within a foot of your destination. Neurosurgery while you are awake. Cell phones, for Heaven’s sake! Sometimes you fly first class or see 20/20 without wearing your glasses! Come on…that’s amazing! Right?

Amazing…