Random Thoughts from a Restless Mind

Dr. Darrell White's Personal Blog

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Posts Tagged ‘eye care’

Lessons In Doctoring Learned On The Golf Course

I’ve been thinking a lot about health care recently. Real health care, not Health Care as in “Health Care Crisis” or “Health Care Reform”, but the kind of health care that is provided by doctors and nurses and all kinds of other health care providers. You know, like making sick people better, and keeping healthy people healthy. The kind of health care that old guys like me (I’m 52, in case you were wondering) got from pediatricians like Dr. Roy in Southbridge, MA in the 60′s, or like my sons get from Dr. Gerace in Westlake, OH today.

I did a lot of thinking about this some 7 or so years ago, too, when I developed the concepts that eventually resulted in Skyvision Centers. My mini-epiphany at that time is that medicine is the ultimate consumer service business. At its core medicine is about one group of people providing a service to another group of people who either want or need that service. It’s the most intimate type of service, too. One to one. Face to face. You and me.

There is a remarkable lack of difference between doctors (and hospitals, for that matter) when you look at the outcomes that arise from that service– how many people get better after receiving medical care for their illnesses. The difference between the top 1 or 2% of doctors and the 50th percentile in terms of real medical outcomes is remarkably small, and much smaller today than it was in the days of my Dr. Roy.

Sure, there are differences in how people arrive at getting better. Some very instructive studies from Dartmouth have shown dramatic regional differences in the U.S. in how much money is spent on treating heart attacks, for instance. By and large, though, the same number of people get the same amount of better no matter where they are treated or from whom they received that treatment, and the quality of those treatments is several orders of magnitude greater and better than it was in my youth.

So what was it about Dr. Roy that people in my generation seem to have so much trouble finding in medical care today? If the treatment of diseases is so much better now why do so many people complain about medical care today? Why is it that Dr. Gerace has people lined up waiting to see him while other doctors don’t? Why do people rave about their experience at Skyvision Centers and complain so bitterly when they need to have a consultation at some of the most famous medical institutions in Cleveland?

I think it’s because Dr. Roy, Dr. Gerace, and I were all, once upon a time, caddies.

Seriously. We spent the earliest part of our working lives on the lowest rung of the service ladder, providing one-on-one service for a single customer. Because of that I think each of us realized that what really sets doctors (and hospitals) apart is what a patient experiences when they visit. The most successful doctors and the most successful medical practices are those who have realized that the central character in the play is the patient. The most successful caddies never forget that the most important person on the course is the golfer. The job of the caddy is to help the golfer perform a well as possible (maximize the health of her game) while at the same time making sure that she has a wonderful experience on the golf course.

Ben Stein wrote a column in the NY Times about his first real job; he was a shoe salesman. Imagine, at 17 years of age, selling shoes. Days filled with all manner of customers and handling the foot of each and every one of them. Customer service and sales is “learning the product you are selling, learning it so well that you can describe it while doing a pirouette of smiles for the customer and talking about the latest football scores” no matter who that customer might be. Tinker, tailor, soldier or spy, junior partner or janitor. Be they humble or haughty, gracious or grating. Totally focused on that one customer in front of you in order to provide them that service. The same can be said for any front line service job. Waitress in a diner, car mechanic, you name it.

My first summer job was caddying, and I caddied for parts of each summer through medical school. As I think about it now after reading Stein’s article it’s amazing how many parallels there are between my first job as a caddy and my career as an eye surgeon. I toted the bags for one or two golfers at a time; I usually have a patient, patient and spouse, or parent and child in the office. I was a better golfer than almost all of the men and women for whom I caddied; I know more about the eye than every patient who visits, google notwithstanding. In both circumstances my success was/is determined by my customer’s (golfer/patient) outcome, their “score”, as well as their view of the experience. Even a career-best round doesn’t feel quite as enjoyable if it took place over 6 hours in the company of a surly caddy!

I’ve told the story of how being a caddy turned into Skyvision Centers; it’s a neat story and I love telling it. For the moment, though, I have a little experiment for anyone who might be listening, and a modest suggestion for the powers that be in medical education (who most assuredly AREN’T listening). The next time you visit a doctor ask him or her what their first couple of jobs were. See if you can predict which of your doctors or dentists (or nurses) had what kind of jobs before their medical career based on the kind of experience you’ve had in their offices or institutions.

Let’s add a little time to the education of the folks who take care of our medical problems, especially our doctors. How about 6 months selling shoes at Nordstrom’s. Or a year of Sunday mornings slinging hash at a local diner. Better yet, let’s get all of those pasty washed-out interns out on the golf course with a bag on their shoulder and a yardage book on their hip, golf hat slightly askew and Oakleys on tight. Let ‘em learn how to take care of a customer without the huge advantage of all that medical knowledge. We’ll take the best of them and turn them loose in offices all across the land. Those who can’t hack it, the ones who can memorize the history of Florsheim but can’t bring themselves to touch a foot, who are scratch golfers but can’t bring themselves to congratulate the hacker who sinks a 30 foot double-breaker, those we’ll hide in the lab, or put them in huge, anonymous medical centers, one more anonymous member of an anonymous team hiding under the brand umbrella of some “World Class Clinic”  where one-on-one customer service never really happens.Because the ultimate consumer service business is medicine.

Just ask a caddy.


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…

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.