Random Thoughts from a Restless Mind

There is a certain arrogance in the academy, that vaunted group of professors who opine righteously from afar about pretty much anything they study. Add to that the well-known arrogance of youth with its inherent disregard for any and all history which transpired before the youthful reached the age of cognition and you have either a toxic combination of ignorance and impetuosity, or simply a laughably vacuous collection of paper thin pontification. Such is the case with a series of statements quoted yesterday morning from a lecture given by a young academic physician on the state of population or public health in America. He posits that there is a new movement toward moving healthcare from inpatient to outpatient. There is an equally new and heretofore unseen effort to make people healthy rather than treat them when they are not. This young doctor is calling his observations Population Health v1.0.

I’m calling it Bullshit.

The lecture in question was being live-Tweeted, but that is probably the only thing about the subject matter that can reasonably be v1.anything. Instantly available dissemination of medical information to a general audience is a truly new phenomenon. With it comes the danger of the wider audience simply accepting the information since it comes from an “expert”. However, along with the relatively naive broader audience we thankfully have a small subset that is either a) informed enough on the topic to offer a “con” opinion, or b) simply old enough to remember that there is a deep and meaningful history that predates what the young expert is proposing as new. Count me as able to check c) both of the above.

Population Health is simply a better term for what historically has been known as Public Health. While Public Health typically connotes some sort of governmental involvement, Population Health is a more inclusive, more powerful concept because it includes not only government programs but also private initiatives of all kinds. Public Health typically equates to top-down implementation of global governmental policy, whereas Population Health covers everything from large for-profit publicly traded companies to the tiniest solo-practice pediatrician. In fairness to the speaker (and in a kind of peace offering for what is to come) I do think his choice of a label is spot on. The rest of his thesis and its development? Not so much.

There is literally nothing new in the entire exposition. How can you call anything v1.0, the first iteration of something that is truly new, if everything that is used as an example is simply today’s version of yesterday’s news. Let’s start with his primary assertion, that there is a new move afoot in which healthcare is only now being provided in the outpatient, rather than the inpatient, setting. This can’t be a doctor who is taking care of any patients in the real world. It is long been the exception rather than the rule that a majority of surgeries take place in an outpatient setting. Heck, 99.9% of eye surgeries have occurred in this setting since the 1980’s. So, too, for invasive testing like colonoscopy, bronchoscopy and cardiac catheterizations of all kinds. It would be much more accurate to state that we are in the end game phase of this transition, v10.0 if you will. For crying out loud, this is such a mature part of the evolution of healthcare in America that any essence of patient-centered care that would require an admission to a hospital is dismissed outright, one more nail in the coffin of that now meaningless label.

How about the assertion that we are only now engaging in a concerted effort to improve the health of our population as opposed to simply treating various maladies? This one kills me. Really? All of a sudden the entire healthcare/government/industry axis is only now finally seeking to improve the general health of our people by preventing illness? Now, in 2016, we have population health v1.0?! That’s laughable. If our young scholar is anything like yours truly, the last stop he made before making his way to the lectern was the loo. HeLOOOoh. Indoor plumbing anyone? You can make a sincere argument that v1.0 of population health efforts occurred a hundred hears ago with the introduction of the kitchen sink and the toilet.

If we confine our discussion to matters more purely medical any reasonable view must acknowledge the tremendous life-saving effect of mass vaccinations for childhood illnesses. Smallpox, polio, and measles each killed hundreds of thousands every year before the advent of widespread vaccination programs. Even efforts which we would now condemn like the sequestration of TB patients in sanitariums must be considered a type of population health program. Despite our modern day fetish with privacy issues, the near elimination of syphilis  in the Western world through mandatory case reporting and contact notification cannot be forgotten or ignored.

When we talk of Population Health in this day and age we are typically talking about mitigating the effects of modern society. Indeed, in cases such as nutrition, we are actually talking about undoing the adverse effects of prior Population Health efforts. The U.S. government either simply got it wrong, or was led awry by a cynical effort by food producers who surreptitiously funded self-serving research. No matter. We are now in possession of a sedentary, overweight population susceptible to once less common diseases that now run rampant. There is little argument that the healthcare community should engage in the effort to keep people healthy as well as treat them when they are not. The notion that this is something truly new is a fanciful notion bred of what must be purposeful historical ignorance.

So, Population Health v1.0? Hardly. A process that arguably began with the invention of the flush toilet cannot be labeled new, no matter how good this makes a speaker, a system sound, or a concept sound. Those who fail to study history may be doomed to repeat it, though in this case there really is no need to do so. Acknowledge the past, make a sincere effort to place your idea in its appropriate slot in that history, and then make a case for your proposal. Have a little humility. There’s nothing wrong with being v10.0. Especially if it works.

Sunday musings…

It was a Tuesday. For sure. Tuesday is an OR day for me, and I was with my work people on what looked to be a pretty vanilla Tuesday morning. That’s how you like it in the OR: vanilla. A good day is no memory of the operations whatsoever. A great day is one where you remember some interaction with your teammates, something good or funny or nice.

9/11 was definitely a Tuesday. What I remember is being with one group of my people.

Everything about the day was going just like every other Tuesday. Fast cases with great results. Stories flying back and forth between doc, nurses and patients. Just a joy to be doing my job. Until, that is, one of the nurses came into my room and said a plane had hit a tower. To a person our collective response was something like “huh…that’s weird. How tragic,” and then back to work. Back to normal until that very same nurse came back and said a second plane had hit the second tower. We all stopped after that case and headed to the family lounge, a TV and CNN.

I remember being in a similar place when the Challenger blew up, surrounded by colleagues, patients and families. That’s where I was when the first tower collapsed. After that nothing was normal about the day at all. There is literally nothin in my memory banks about the rest of the morning. I know we finished the cases, but then everything came to a full and complete stop. Clinic hours were cancelled, schools let out, and the wheels of American life ground to a halt. The rest of the day was spent in tracking down my brother (traveling now by car from Chicago to Connecticut), and best friend (stranded in Brazil). The skies were empty for days.

Our new normal had just kicked in.

My parents worried about an attack on our soil from Germany to the east (U-Boats off the coast of New England) or Japan from the west (a friend posted the story of a Japanese pilot who actually fire-bomb Oregon!). As a child our politics and our lives were spent worrying about the specter of a communist attack. As an adult, a father and a grandfather, it is now the fear of Jihad unleashed. The post-Reagan/post-Berlin Wall years of relative peace and security seem so very long ago now, don’t they?

The reality, of course, is that we are far safer than we think we are. Yet our own personal realities are driven by the same psychology that led our parents to fear a coastal invasion, for us to fear Russian bombers. We march on each day, as we must. We march on so that each day’s completion becomes one more tiny victory in yet another long war fought for us mostly between the ears, so much like the Cold War before it. We seek victory once again in the daily act of living our normal lives.

We remember, though. Like I remember that it was a Tuesday. We never forget, nor should we try to forget. It is in the remembering and carrying on despite the remembering that we do our tiny part to honor those who were lost. Today is a day to take a moment away from normal to remember.

I remember.

I’ll see you next week…

–bingo

Only twice in my life have I ever noticed that I was different. That I was, or could be identified, as “other”. Now to be sure, at neither time did this realization make me uncomfortable. That’s probably because I was in a relatively familiar setting, just among a rather homogenous group of people where I was the guy who stood out. Being the only person in church or on the basketball court who is NOT of color was for me, a non-large very white male, more a case of “huh, that’s different” than a case of ” be on guard”.

More than anything else, that is likely part of the core of what is meant when we hear talk of “white privilege”: I am only at risk if I actually do something wrong.

Sitting here in suburbia, in middle-age, it’s instructive to look back at how I’ve arrived at such a place. A place where I always feel like I could belong no matter where my place takes me. The town of my earliest youth is probably most responsible for this. Southbridge was a dying mill town in Central Massachusetts, although none of us kids new it was dying at the time. Settled initially by French-Canadien ex-pats, a second wave of migration from Puerto Rico occurred before I went to grade school. 10 or 15 percent of my classmates were children of Puerto Rican immigrants, but I knew them only as kids in school or teammates on the various fields of our youth. We fought side-by-side 100 times more often than we ever fought facing each other. Sure, they were different. Their grandparents spoke Spanish while most of ours spoke French.

Home since childhood has been driven more by economics than any other factor. Most of my life since then has been lived in worlds that roughly track the Southbridge of my youth, roughly 80% White/20% Black or Brown. People of color were either there when I arrived (and so belonged as much as I), or arrived the same way I did (and so belonged as much as I). At this point I should confess that I’ve never given too very much thought to the color mix of my surroundings. This may also constitute “white privilege” I suppose, the privilege of not needing to be aware of color at all. What makes that kind of funny is that until the very last major move of my life, each time I’ve moved to a new place, many people assumed that I was Black prior to my arrival. Darrell White the presumably Black football player arriving at a new high school or at college? Nope. Short, skinny white guy. Darrell White the first ever Black med student or Black resident at my respective schools? Sorry to disappoint. Still, short skinny white guy. Only my voice is 6’5″, and with no accent whatsoever it is colorless.

How about those two instances where I did feel different, in church and on the basketball court? In church it was mostly humorous since the other congregants made such a huge effort to make me feel welcome. Indeed, as the only White family among the churchgoers at the Black Baptist church one Christmas it was more than comical when the pastor, my friend the Rev. Mel Woodard, introduced us from the altar (over my gentle objection) to the congregation. “Please welcome The Whites!” With a twinkle in her eye “Lovely Daughter” leaned over to me in the pew: “Duh!” No, other than the obvious pointed out by Megan, in that setting the group made sure that only the most superficial differences existed for me in that room. I would only be “other” if I chose to be.

The basketball court just down the street from Wills Eye was a bit of a different matter, and because of that more instructive when examined through the  magnification of the retrospectometer. The rules of pick-up ball are clear, and they are largely consistent in every park in America. There’s a line-up of who has “next”, and if you are not a regular you just call “next”, wait at the end of the line, and hope that you can assemble enough talent on your team to last more than one game. Here, like in church with Mel, mine was almost the only White face, but here I was “other” in every sense of the word. My turn as “next” kept getting lost on the list, the wait for that one game almost 2 hours before one of the park leaders acknowledged the tiny injustice and put my team on the court simply by joining us as our fifth guy. The other White guy was on the team, of course, and he was a stud baller. A bit to the right of average for that park, that game was the first time in my life when I was more conscious of what my game looked like than how I was playing. Who do I pass to? Do I take the open shot?

We lost the game, of course. Not so much because of anything I did or didn’t do during the game as that the other team had a guy named “Jelly Bean”  and no one could stop him (pretty decent player; I think his son was somebody in the NBA or something). In the comfort of not needing to be the least bit introspective, of not needing to learn anything at all from that morning, all I got until this past week from my encounter with Philadelphia inner city hoops was pissed off that I only got a single run after waiting two hours for my “next”. It’s only now as I look back that I realize my sense of being scrutinized, of being conscious of how I looked while playing rather than just playing, needing to be much, much better than the other “average” ballers there that day because I was White.

The events–church, a pick-up basketball game–are trivial, but the fall-out, however long in coming, is not. The fact that it is now 30 years since my non-battle with Kobe’s dad and I am just now aware of how I felt may be part of what is called “White privilege”, but moments like this are to be encouraged however long they are in coming, don’t you think? My oldest friends of color, roommates and groomsmen, as well as friends of more recent vintage will likely welcome this sense with little more than a playful “what took you so long” wink, and begin the dialogue. The Rev. Woodard’s congregants didn’t even need the comfort and cover of friendship to offer a wink (and in their collective case, countless hugs), so aware were they of how it feels to be “other” until proven otherwise.

Sympathy, my friends, is not enough. Sympathy is situational and episodic, and is therefore also transient. After all, who among us but the most hardened bigots or the most unreachable psychopaths cannot find sympathy for the family of the man killed while instinctively reaching for his wallet, or the families of the officers gunned down while on duty? No, sympathy is not enough because it is only something that we feel, and not something that we are, or even choose to be. Empathy is the magic elixir because empathy cannot be set aside. Empathy is to feel with, not simply to feel for, because it is a part of who we are. But empathy is hard, and empathy takes time. No one would wish the loss of a loved one on another in order to feel “with”. Sometimes empathy is little more than a spark, and sometimes that spark is so small that it goes unnoticed or ignored.

There is a bridge, though, between sympathy and empathy, and it is understanding. Like a physical bridge one must look to the other side and seek to be there. Like any bridge one must have the faith that over the crest in the middle, beyond the road you can see, there lies ahead a clear path to the other side. The trip may be a difficult one, but as with all trips, it will pass much more easily if in the company of others who either seek to understand as well, or better yet others who already do. Like all those men and women who came up to me in church and hugged me after Mel’s introduction. Like the guy at the park who joined my team, made sure I got “next”, and told me to come back for a run the next Saturday.

Like Sheldon and Steve, Rasesh and Mel who will hold my hand and guide me  as I climb the bridge myself.

It was the smile Ms. DMV Lady. No question, the smile told me that you chose to ruin my day when you had a lay-up chance to make my whole weekend, that you did it on purpose, and that it made you incredibly happy. In any other circumstances I’m sure I would have smiled back at you; that’s what other human beings tend to do when they see such unbridled joy on someone else’s face.

That trip back was my third one to the DMV, but there was no way for you to know that. You did see me on the second one, though, and you clearly remembered me. I forgot my license at home so I couldn’t do what I needed to do to transfer the title for my tiny little beater of a boat. Not only that, but there was nothing you could do to help me at that point, and I totally understood that. It was my fault entirely, so I didn’t ask anything of you on that visit because I knew that there was no way that you could help me, no matter how much you might have wanted to on that particular visit. I was really frustrated for sure, but I didn’t direct any of that at you, or anyone in the DMV.

Nope, it was the return visit where you could have made my day. My wife and I hurried home, got my ID and then hustled back. Did you notice that? Did you notice that we were both there? It’s really hard to free up two people who work full-time during your hours of operation. Definitely not your fault, that. We’d already tried to pull this off the week before and been thwarted, and here we were back for a second time with you, third time total. Now was your chance. We approached the desk with obvious relief on our faces. If we were successful this time we would still have to visit the DMV one more time (you only do titles; another location would do the license), but at least only one of us would need to take off work. You took the title transfer again–you looked at it in detail the first time and couldn’t possibly have missed this–and told us that the previous owner had filled it out incorrectly. He signed it in his name alone, instead of his name as “trustee”. That’s it; he forgot to put “trustee”.  You could have tipped us off before we went home for the license. You could have just noted it and let it pass. Nope. You said that we would have to bring it to him to fix before you could transfer the title.

We were equal parts dumbfounded and devastated, and it showed clearly on our faces. Here it was again, your chance to make our day. There was nothing nefarious about the prior owner’s mistake; it was a simple oversight in how he described the ownership. God, it was such an easy fix. It was right there, right in front of you for the taking. I held out my hands and pleaded softly and quietly for mercy. No disrespect toward you or your staff or your department, and no sense of entitlement or demand for action. A very simple request and a very quiet plea that we had acted in good faith. Your response? “You forgot your ID the first time, Sir.” I simply held out my ID and very softly said “but I went home and got it without saying anything, and here I am. Please, we’re really trying hard here and really could’t know.”

It’s a legal document was all you said. You had a duty to protect the State of Ohio, you said. It was then that I responded, still quite quietly mind you. I shared that the couple you had just chosen not to help were a doctor and a nurse. That we routinely put our family second as we care for patients in need. Nights, weekends…no matter. I asked if I could fill out your customer service survey, either on paper or online, explaining that I am evaluated on the care I provide and the experience that my patients have under my care. Oh my…the look on your face was priceless. Utter shock. Not once in your life, it seemed, had it ever occurred to you that it would be possible that you would be accountable to your customers. “We don’t have anything like that, Sir.”

Then came the smile.

Seldom have I witnessed such a pure, unadulterated expression of joy. You had chosen to ruin my day, and having succeeded you were not just pleased, you were infused with a visceral joy. It started in your eyes as realization crept in, and then it spread to every muscle in your face. Like I said above, it was the kind of smile that is almost always returned by another human being; we are wired to share such joy, after all. Alas, ’twas not to be for you and me. It was all I could do not to vomit on your threshold when you somehow found the strength to break through the grip of your ecstasy to wish me a nice day.

You will see me again, Ms. DMV Lady. Three times we’ve tried to get our little 1971 boat licensed, and it looks like we will need to make two more stops to accomplish that. It most certainly won’t be at your particular DMV location, though. Just thinking about that makes me nauseous all over again. No, you will see me again on my turf, as a patient. Karma, if nothing else, is imbued with a keen understanding of irony, a truly wicked sense of humor. In all likelihood it won’t really be me, personally. Even karma would find that too outlandish, an irony simply too delicious to believe. In reality you will need someone who does what I do, and you will need them in a manner and a sense that is identical to how I needed you.

I noticed that you are very nearsighted, and you have an inflammatory disease of your eyelids called blepharitis that often causes an acute type of particularly unsightly pinkeye (you are not my patient; this is not a HIPPA violation). Perhaps your son is getting married this weekend like mine. You didn’t know that, did you?  No, of course not. You broke your 3 year old glasses. Your prescription is out of date and you can’t just walk in to Lenscrafters and get a new pair, and your vision insurance only covers me. It would be a shame to have to wear broken glasses to enjoy this wonderful day. Or maybe that ugly, uncomfortable pinkeye bubbled up and there you are all red and gooey, two days before the whole fam damly shows up for the wedding. Nether one is truly an emergency, and failing to take care of either one right away will not cause you any harm whatsoever.

Let’s make it even more realistic. You know, like my return trip to your office. Let’s say it’s just before closing time, and the only way to get your glasses or your medicine is if a doctor gives the OK to see you right away. No matter what you see on the billboard, you won’t get an appointment at the Cleveland Clinic or UH. No, it will be a private doc like me. We always try to help. The Doc will know your story. How? Well, through our staff we always know the story because it always makes a difference. Would it have mattered to you that the reason I so desperately wanted that boat licensed was so that my son–the one getting married–could take his cousins and his friends out on his wedding weekend? We’ll never know; you didn’t ask.

There you will sit with your non-emergent problem that is only barely even urgent except for how much it means to you personally. Do you have any idea how easily the doctor and staff can slow-roll this even now, after you are in the office? They can follow protocols to the letter, check every preferred practice pattern box and follow every single insurance billing protocol, your chart and super bill as clean and proper as the illustration of a perfect boat title as you wait for your insurance to authorize your vision care visit, or pre-approve your expensive branded medication, and ruin your weekend.

In short, they could be you, ignoring the very real person with the very real need who stands before them asking for help. Or they can see you, hear you, and so easily choose to help you. Which, of course, is exactly what they would do. They will call the insurance company to get your Rx authorized, or they will give you samples of the medicine to carry you until you get pre-approval. Because you see, Ms. DMV Lady, that’s what every single one of us is supposed to do when we are on the other side of the desk from someone who needs our help and we are truly, safely, and easily in the position to choose to help them. It’s the decent thing that decent people do for others. When they can either make your day or ruin your day, it never crosses their mind that they even have a choice. It’s funny, when they know a little more about how meaningful it is to you that they helped, they really feel good about that.

Which is why after you have been helped, after you get what not only what you need but what you really want, you will be surrounded by people with the huge smiles of joy that come from doing the right thing. You’ll undoubtedly smile back.

Will you know why?

Sunday musings…

1) Crenellate. Create multiple indentations on an otherwise smooth edge.

No reason. Just a cool word.

2) Eyelash. The normal lifespan of a normal eyelash is approximately 5 months.

Nope. I didn’t know that, either.

3) 16.6. Recovering from surgery from a non-CrossFit condition, I sorta kinda did a couple of the 2016 Open WODs. At some point over the rest of the year I will eventually do them (hopefully Master’s Rx), but for now I’m about to embark on CrossFit Open 16.6: constantly varied functional movements performed at relatively high intensity, with the intension of improving my work capacity across broad time and modal domains.

The CrossFit Games Open 2016 is an interesting and fun diversion, one that gives us a common experience across time zones and geographic variance. For me, though, the real magic happens in the other 47 weeks, the 47 week experience that you could call “16.6” and heading into “17.0”.

That’s why I’m here.

4) Easter. Does it strike anyone else as odd, or something like odd, that it is only the two major Christian holidays (Christmas and Easter) that have superimposed, widely followed non-religious traditions? Try as I might I find no such superimposition on such equally important annual religious observations like, say, Ramadan or Yom Kippur . More so, if you do a little digging into the Easter Bunny’s origin you find that in his original incarnation he, like Santa Claus, kept a ledger of “good and bad”, with the good receiving eggs/candy/gifts. While I have no insight into why this might be, I find it odd.

In the Christian world there is no more important celebration that Easter. Indeed, the very concept of Easter is as difficult and complex as that of the Trinity. Judaism and Christianity share the Old Testament, and presumably therefore share a belief in the same Deity. It is in the interpretation of the Messiah that most people understand the difference between the religions (interestingly, the Koran recognizes J.C. as a significant prophet), but the more profound difference between Christianity and all other religions as far as I can see is the chasm that faith must leap to accept both the Trinity and Easter miracle.

While I am best described as having faith in a deeper, greater Presence, I am not a very religious person any longer (this makes Grambingo very sad). However, not unlike the CrossFit we all practice here, it is instructive to note the secular attempts to nullify the religious aspects of both Easter and Christmas, while noting how hard it is to hold tight the two beliefs that are the crux of Christianity.

For those who do the hard work of Christianity I offer a heartfelt and sincere Happy Easter.

I’ll see you next week…

–bingo

“You can have anything. You can’t have everything.”

A rather unlikely combination of players got me to thinking about “having it all”. You know, the perfect job, marriage, home, life. Like Streisand when she sings “Everything”, the life of “I don’t want much, I just want more”. Friday night and Saturday morning were spent in the company of 5 or 6 physicians who  can only be described as “Alpha Females”; this morning’s reading included a piece on Michigan’s football coach, Jim Harbaugh.

What do Harbaugh and my young professional colleagues have in common? Well, they are in the midst of trying to have it all. While these ridiculously successful eye surgeons are more aware of the costs of their quest than Harbaugh, when pushed they are no less apologetic, no less committed to seeing it through to its logical conclusions.

On the surface it would seem that Harbaugh is poised to live a comically outlandish exmple of a successful coaching life. A winning record at a traditionally over-run college program (Stanford) followed by a Super Bowl game in the NFL (losing to his brother’s Ravens), and now head coach at his Alma mater. It’s all so very believable if you read the article quickly, but there it is in the fine print: “…his 14 year old daughter remains in California with her mother, Harbaugh’s first wife.”

Rut roh. A little bit of Heinlein creeping in here.

Much has been written about the plight of the “successful woman”. Indeed, I’ve written on women in medicine and the fallacy of “having it all” (and been quite enthusiastically eviscerated for having done so). My female colleagues sat with me around a table and over wine we talked at length about their lives. How busy they are in their day jobs. How the added time requirements of being acknowledged super-experts in parts of our shared field add to the challenges of being mothers and wives in nearly direct proportion to the gravitas it adds to their professional stature. We were all away from home on a Friday night for a meeting Saturday morning and the privilege of flying home that afternoon.

“N”, a colleague nearly 15 years younger who is also (I hope) becoming a friend, opined that she felt like she was “half-assing” everything except our shared endeavors as subject experts. That she only felt fully successful, comfortable, and in some way validated, in the company of her expert consultant peers. The moment, shared with knowing nods by each woman present, was brief.

Personally, I am late to this consulting game, roughly at the same “level” as colleagues in their mid- to late-30’s (I am 55). Barring some unlikely stroke of good fortune (e.g. I might actually be as smart as I think I am, and someone might actually agree), I will end my career rising no higher than the middle of the pack. Why is that? Well, let’s spend a moment with Heinlein, as my wife Beth and I did when I was ~34.

Just like my very impressive young colleagues, when I was in my early 30’s I was approached to offer insight into the needs and desires of my generation of physicians. Being a male physician I acknowledged the advantage of fewer societal expectations regarding responsibilities outside my career, and the massive leg up from a spouse who left her career behind to run the domestic side of the team. Good, bad, or indifferent, what my wife and I did then was explicitly calculate the cost of that success.

In “The Moon is a Harsh Mistress” Heinlein’s lunar society is run as a nearly pure libertarian experiment, fueled by a single philosophy: There ain’t no such thing as a free lunch. Your mother told you the same thing: there is a consequence to everything you do (or don’t do). What Beth and I did, what Harbaugh didn’t do and what my colleagues only later have done, is prospectively calculate the costs of success in one domain paid out from the accounts of the rest of a life’s domains. Gains in one almost always come at a cost or loss in others. Certain of the effect on our family (despite my gender-driven advantages), the costs to be paid at home, Beth and I opted to forgo the opportunity. For 10+ years the only place I went was home for dinner.

What was the cost to me for having taken myself off the consulting carousel? Who knows? I might have been a certifiable big deal in the world of my day job. For sure, the White family left a lot of money on the table. Harbaugh chose differently and left a 14 year old daughter, and all that represents, in California. My young colleagues, the Alpha Females who are quite rightfully sitting at the table of experts despite their tender years? What will be gained, and at what cost? We shall see…they shall see.

In the end, Heinlein (and your mother) continues to be right, no matter what currency we use to calculate cost: TANSTAAFL.

Twice a year I travel for my day job as an ophthalmologist to a large trade show dedicated to a combination of continuing education and commerce. Part of what I do when I am attending these meetings is provide services as a “leader” to the companies that sell stuff to people like me. The term that is used to describe me in this setting is a “Key Opinion Leader”, or KOL.

I used to think this was very impressive, to be a KOL. Frankly, I was very impressed with myself having “achieved” such a presumably lofty status. I’m not so sure about that anymore. Oh sure, I’m still plenty impressed with myself–I am my own biggest fan, and for whatever it’s worth you should be your own biggest fan, too–but as I think a bit more about what it really means to be a KOL it becomes something a bit more of, I dunno, less I guess.

To be a KOL one must certainly be seen by some kind of audience that is moved by your opinion; I get that, and I still get that the mere fact that one has reached a stage in career or status where your opinion is sought is a kind of stamp of “OK’ness”. No question about it, that’s flattering. Dig a little deeper, though, and you begin to realize that perhaps the only reason why your opinion is out there at all in its quest to be key is because it aligns with the worldview of someone who is telling folks what you think. With few exceptions, even in our modern day of enhanced access for the everyman to tell you what he or she thinks, your opinion is only pushed out there if it is key to someone else’s commercial well-being.

Looked at through that prism at least, it’s a little less impressive to be called a KOL, isn’t it?

The goal all along for me here, in my day job, and pretty much everywhere, is to somehow be a Key Thought Leader. To trade in a marketplace of ideas, hopefully contributing at least some degree of refinement to another’s true genius if I’m unable to generate any true genius of my own. This realization, too slow in coming to be called an epiphany but rather disruptive to my worldview nonetheless, has forced me to re-think a big part of my place in the world of ophthalmology.

Are you interested in what I think only because it aligns with your established objectives? Well then, you’d like me to be a KOL for you, someone who will knowingly or unwittingly move only your needle and not mine. That’s called commerce, and it’s a perfectly legitimate exchange for which we can negotiate value.

Or rather are you interested in what I think while you are in the process of creating those objectives? Ah, now, that’s quite a different story, isn’t it? In this case you are really and truly interested in what I actually think as something that has stand-alone value because you’ve yet to even determine what the dial looks like on your meter, yet to even know what moving the needle looks like. In effect what you have done is put my thoughts out in front of your product or service. In the end I might not actually have what it takes to be one, but if do I know where a thought leader stands.

Out front.

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 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.

“I suppose I’m sorry I missed my appointment on Thursday. So, anyway, here are the ground rules for how this phone call is going to go and how you’re going to give me the appointment I want.”

“I know it’s been two years and the doctor said my son would need glasses for school and that it’s really busy during back to school time. Yah Yah…I get it. I don’t care that everyone with after school appointments called weeks ago. School has started and he needs an appointment RIGHT NOW. I demand to talk to the doctor.”

“What do you MEAN the doctor’s 5:00PM appointments are all filled? I told you she wants new contact lenses RIGHT NOW! 10 AM tomorrow is totally unacceptable. You tell the doctor I’ll be coming in with her in 2 weeks and you can be SURE I’m going to tell the doctor how unacceptable this is.” CLICK

Seriously, who talks to people like this? These are all near exact quotes from established patients calling to make appointments for routine, non-emergent visits. All three had received explicit instructions at the conclusion of their previous visits, and all had been sent recall reminders that it was time to make their next appointment. Remember, we are a very busy eyecare practice with 3 doctors that sees emergency patients on a same-day basis, including nights and weekends. We are not averse to working hard or seeing extra patients, and we counsel our patients that we will sometimes run a bit behind because of this ER visit policy. Philosophically it doesn’t seem right to over-book our schedule, making the conscientious have to wait longer in the office during their visit, in order to accommodate those who make little or no effort to respond to our instructions and reminders.

Let alone those who talk to my staff like these three. Sheesh. Trust me, the tone in their voices was exactly as you’d imagine it as you read it, equal parts incredulous and offended that anyone could possibly not understand how much more important THEY are than everyone else on the schedule. It got me to thinking, though. What would it be like if people talked like this in other walks of life?

For instance, you are the Registrar at, oh, how about Harvard. You pick up the phone and somebody’s Daddy is calling about Econ 101 taught by N. Gregory Mankiw. The class is full. Actually, it’s oversubscribed and there’s a waiting list with 125 kids already on it. The registration deadline was 2 weeks ago, a deadline that the young scholar just blew off and a deadline that Daddy doesn’t even acknowledge. ” You’re not listening to me. I told you that my son will be in that class. He has a spot waiting for him at Goldman Sachs and no one is going to  keep him from getting what he deserves. I demand to speak with Mankiw.” How do you think that turns out for Sonny?

Or how about this? The flight to Chicago is full, and since it’s about an hour before takeoff no more folks are coming off the standby list. Standing at the United desk is a very well-dressed professional addressing the agent. “I suppose I’m sorry that I didn’t make it to the earlier flight I was booked on. Here are the ground rules for how this discussion is going to go, and how you are going to escort me onto this flight.” I can definitely see some sort of escort coming, can’t you?

Imagine what it would be like if you could listen to a call coming to a judge’s bailiff from someone who talked to everyone like my three patients. “Really? I said I needed to get this ticket taken care of right away but I’m only available late in the afternoon. 2 weeks from now is too long to wait. 10 AM tomorrow for court? That’s just unacceptable. Why aren’t there more times at the end of the day? I will be there at 5:00 in two weeks and you can be SURE I will tell the judge what I think of this.” What would you give to see that one play out?

When I hear the way people talk to folks who work in health care it makes me wonder how far they take it. Does it go so far as to extend to Church? “Listen Father, it’s football season. The Buckeyes on Saturday and the Browns on Sunday, ya know? This whole Saturday and Sunday mass schedule doesn’t line up with the season at all. I can’t believe you don’t get that! Why can’t we just move mass to Monday until after the Bowl Games and the Super Bowl. Tell you what…just forget about it. I’ll be here on Sunday and I’m going right to God on this one. You just make sure he’s in Church this weekend so I can tell him directly.” Well, we know that God is always in Church, and that He does, indeed, hear every petition a member of His flock makes. Like Danny Meyer, the great restauranteur in NYC who holds that the customer is NOT always right, but does have a right to be heard. Actually, this example gives me some comfort, some direction in how we might deal with patients who talk to our staff in such a brassy, entitled manner. We are definitely not God, or even the least bit God-like, but like Danny Meyer and God, we can always listen, as we know they do, and we will always politely offer them an answer.

Sometimes, the answer is “no”.