Random Thoughts from a Restless Mind

Thomas Sowell, an American sage, laments the “huge degeneration” in America toward “the grievance culture”. Indeed, I have written on this before. The near reflex response to be aggrieved, to be offended first, and to ponder and reflect later, if at all. There is a certain and definite lack of goodwill, a reluctance or refusal to extend goodwill, or the assumption of goodwill, on the part of others. Rather, the culture of grievance mandates that we impugn malintent in the deeds and actions of others, especially if in some way those others (them others) have values or beliefs that don’t completely and consistently line up with those of the aggrieved.

On CrossFit.com, especially in a prior “Wild West” era, this phenomenon could be seen every 4th day with the publication of a libertarian-leaning article, or something that ran counter to the progressive drumbeat in the halls of academia or government. The simple act of speaking against the orthodoxy of a group sent said group into a paroxysm of aggrievement. This is no different from what we see in the now limitless wilderness of the internet and social media. Context is irrelevant. Intent is irrelevant. The provenance of the offering is irrelevant. Once unleashed the only thing that matters is the bleating of the aggrieved, however large or small their numbers might be, however trivial the insult, if it can even be called an insult at all.

While away at a professional meeting this weekend a new ad campaign for a product in my professional world dropped. It is irreverent and funny, and it was conceived and created by members of the same group that is on the receiving end of the joking. There were three reactions, as is probably typical of something like this. One group thought it was clever and funny, and realizing that it was the first in a series this group looked forward to seeing where the campaign was headed. By far the largest group saw the humor, realized what the intent of the campaign was, acknowledged that the humor was harmless and without intent to harm, but cringed at what was a rather large misstep. Seemingly in love with the joke both the creators of the campaign and the company that authorized its launch failed to see that, while funny, it was in very poor taste. This second group shook its collective head at how tone deaf the company was.

The third group was mortally wounded by offense. The aggrievement was existential. A firestorm was unleashed upon the company. The agency and its employees were excoriated despite their inclusion in the group supposedly aggrieved, saved only by their anonymity as individuals from a very public shaming among an influential cadre of the advertised company’s customers. That ire was directed at the CEO of the company, an exec known quite personally by a majority of his/her customers. The attacks were pyrrhic and personal despite an obvious lack of malintent. There appears to be no amount of shame that can possibly atone for the sin of humor without intent to offend that misses its mark and does just that, regardless of the size of the cohort offended.

The grievance culture allows progressively smaller and smaller numbers of individuals who care about narrower and narrower issues to hijack larger and larger institutions and paralyze them. One need only look at the tragicomedy that played out 2 weeks ago at Middlebury College in Vermont to get a sense of what this means. A (pseudo-) scholar was invited by a conservative student organization to speak. Mind you, this speaker’s ideas have been so roundly disparaged that even the members of that conservative club did not support them; they invited him in order to have an opportunity to debate the ideas. Alas, other members of the Middlebury community were offended by the mere presence of on campus of one who could hold ideas that are so antithetical to their own. This group declared that their grievance superseded any and all rights and privileges of every other individual or group, including the group that invited the speaker and whose members largely shared the opinion (but not the aggrievement) of the offended.

This small minority drove the speaker from the stage. They attempted to drone out an internet broadcast of his speech with repeated pulling of fire alarms. In the ultimate expression of their grievance they assaulted a faculty member who was driving the speaker out of town after the event, sending her to the hospital. It is particularly instructive that the group of the aggrieved chose this course because the speaker’s ideas and positions have been so roundly and completely debunked that it would probably have taken less effort and have been more effective to simply simply hoist him on his own petard on the stage and watch him swing.

I find myself in group 2 in my professional example (amused but somewhat astonished that experienced business people could be so tone deaf) and similar to the group that invited the faux-controversial speaker (contemptuous of pedagogy that cannot be supported with anything other than belief). Mr. Sowell is a true A-list man of ideas and letters, while I am a C-lister with B-list aspirations. Nonetheless I share with him his sorrow at this degeneration of American culture, this insistence that a difference of ideas begets a grievance that supersedes not only the rights of those who disagree, but also the very possibility that other ideas might exist. Replacing a culture of ideas and ideals with a culture a grievance is a step backward for society, perhaps for civilization.

The tyranny of the minority begins with a tyranny of ideas, waged with the weaponry of grievance.

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.