Random Thoughts from a Restless Mind

Ladies and gentlemen, we are gathered here today to mourn the death of the Age of Volunteerism. While there exist tiny spaces where true volunteers live and thrive in a bilateral exchange of freely given goodwill, by and large volunteerism has been extinguished by the actions of its historical recipients. Sunday marks my last day ever of hospital ER call, the end of 2 years of receiving token payment for making my expertise available following 25 years of doing so for free. My experience is typical, as is this denouement.

Once upon a time all of your doctors were in private practice. We all had tiny little cottage businesses, did our work, and billed you or your insurance company for the work we did. Some of us worked in tiny little groups, but it was the rare doctor who was part of a large group or business whether in a big city or out in the country. Even the slickest Madison Avenue internist was basically a country doc, just with a better, more expensive wardrobe. In addition to having a greater familiarity with our patients we also enjoyed a very clubby relationship with all of the other doctors where we practiced. There was a collegiality, a sense that we were all in the struggle together. Folks who shirked their duties, foisting them off on other docs, were quickly educated about proper protocol or left to toil alone.

Hospitals were different, too. Local or regional, they were hardly the gargantuan mega-businesses they’ve become. The org chart was shallow, and most local doctors were on a first name basis with the few administrators on the hospital payroll. You took call for the ER as a volunteer; the ER respected that you were donating your skill and your time and handled everything it could before calling you. Same thing for consultations. Your colleague only called you if they couldn’t figure out a problem or ran out beyond their scope of practice. There was a faint air of apology with each request, and a definite unspoken appreciation for the help that would be given. You helped because you were appreciated.

This is really no different from all manner of volunteerism in America. Smallish, closely knit organizations depending on the goodwill and generosity of members of their community pitching in to ensure success. Think local memorial 5K races, or CrossFit Games Regionals in the days before ESPN or the Home Depot Center. Countless small private schools that depended on the largesse and time offered by the families who sent their children there. You gladly accepted the opportunity to volunteer because you knew that without you the organization would not be able to function. You also knew that the recipient of your generosity not only appreciated your contribution, they really had no other options. Not only that, but if that organization somehow existed in your professional space you knew that it would never, not ever, abuse the trust necessary for volunteers to continue.

What happened? Money. Money and size and the distance that they create between an organization and its volunteers. Let’s go back to the hospital and the ER for a minute. Where once your efforts as a volunteer were deeply appreciated and those efforts rewarded with respect and care for your time and your expertise, the growth of employment of doctors by hospitals opened a gap between colleagues. No longer was there the esprit de corps, the shared notion that the primary target of our efforts was the patient was replaced by so very many doctors by the reality that they worked first for a business as faceless and uncaring as GM. Work that was once done by your colleague was now pushed to the volunteers whenever possible. It’s cheaper that way. Worse, boxes to be checked by the employed (to maximize revenue and minimize risk) meant demands made of volunteers, not requests. Worse, still, were discoveries that some “volunteers” were more equal than others: they were paid.

Innumerable examples are there for the picking. Some times it was just a case of laziness. Other times the insult was a clear effort to dump work on the volunteer. A critical care fellow requested a consult for acute narrow angle glaucoma. For those of you not medical this is one of the few “drop everything and go” consultations in eye care. When I arrived in the ICU I found a young patient with a black cornea who was mildly uncomfortable. I did what every highly experienced specialist does when they start a consultation, I asked the patient: “Hey, what’s up with your eye?” Turns out they had a blind, painful eye as the result of a surgical mishap, and surgery to remove the eye was already scheduled. Their discomfort was because none of the eye medications had been ordered; the fellow never asked. No doctor (or nurse) would have allowed this to happen in the Age of Volunteerism.

While this is nothing short of tragic in health care, it was inevitable once medical businesses were incentivized to grow ever larger. It is not confined to health care by any means. How do you think that volunteer at a Spartan Race feels when he learns how much his “team leader” is being paid? Have you ever “discovered” how much the Executive VP of your favorite professional organization is paid? As a people we Americans are generous to a fault. That generosity usually continues right up until we discover that we have been duped, and even worse that we have been purposely duped by the people who run the organizations for which we volunteer.

And so we gather here to mourn the passing of the Age of Volunteerism. Like so many things of wonder and goodness there remain pockets of resistance, little oases where the goodwill, honesty, and appreciation beget the kind of ebb and flow that made things so much better, kinder, more collegial at the apex of Volunteerism. My friend Tom Gardner was just named the president of the Society of Alumni of our Alma Mater. Tom has given tirelessly of his “spaces”, his timespace, brainspace and emotionalspace to help shepherd tiny Williams College as it flows on though time. Is this truly different? A tiny refuge from the Zombie Apocalypse of corporatization of all things to which we once volunteered?

We can only hope. Hope that Tom and those like him who continue to find places and causes where their volunteerism is met with what we in medicine have had to bid farewell. We can only hope that there will be places where being a volunteer means receiving the respect and appreciation and even a kind of love in return for what we have given. We can only hope that there will continue to be places where the incessant drive to grow ever bigger, size measured on a spreadsheet rather than by heart, will be resisted. For if it can happen in medicine, if volunteerism can be killed in what is arguably the most noble of all endeavors, I fear that it is doomed everywhere.

We mourn the end of the Age of Volunteerism. We wait with equal parts sadness and fear for arrival of whatever comes next.

Sunday musings…

1) Feral. Abbie the Wonder Dog was feral for the first 6 or 9 months of her life. I can’t remember exactly. She was live-trapped and rehabilitated by a Border Collie rescue organization in north central Ohio. When she frustrates me it is always helpful to remember this.

Having a formerly feral creature living in our midst is also a very good counter to the frustrations of modern life. I try to remember how far I am from true privation whenever I find myself railing agains the insanity and inherent indifference that the world clearly has toward my existence.

A quick thought of my clever (read: sneaky) pup is usually all it takes to quell my urge to explode when I encounter the tragedy of a poor internet connection…while hurtling through a mountain pass in a car going 80 MPH.

2) Test. Some 10 years ago or so I proposed that a true measurement of health should be possible. Something that combined the most basic of classic medical knowledge (weight, %BW fat, BP, Cholesterol, etc.) and the breakthrough notion that physical fitness could be measured and tracked. My theory included the necessity of including some sort of measurement of “well-being”, a mandate that was initially openly mocked but seems to have been rather meekly accepted as both logical and necessary.

Creation and launch of such a value, call it “Total Health” or something along that line, has fizzled due to the lack of consensus–nay, even interest–in coming up with a way to measure Fitness. Imagine, in a place like CrossFit where the very definition of Fitness was created, no one save me and a tiny group of equal obsessives has so much as let fly a tiny trial balloon. The original owners of CrossFit LA were the first to use a standard entry test. 500M Row/40 Squats/30 Sit-Ups/20 Push-Ups/10 Pull-ups. I suggested pulling from both traditional sources (The President’s Fitness Test) as well as CrossFit and the larger endurance communities: 2:00 each of PU/Push-Up/Sit-Up/Squat, 1RM Deadlift, 1 mile Run. We ran a competition once called the “Fittest Eye Doc” using this.

What is necessary is a test that is a) doable by the general public, and b) capable of creating a single value that can be measured and tracked. Once that is done mathematicians and statisticians can be let loose with the various factors and given the task of coming up with a formula that includes all three categories. Why bring this here, again, when thus far my previous dozen or so postings have been met with crickets? With the pivot to health and the rapid build-up of a cadre of physicians who are at least superficially interested in using high intensity exercise for the purpose of increasing health, I am hopeful of a broader dialogue that comes to an agreement on a test.

Challenge: create a test of fitness that is broadly accessible in all ways (scalable) that can be included in a definition of health. 3-2-1…Go.

3) Volunteerism. Ladies and gentlemen, we are gathered here today to mourn the death of the Age of Volunteerism. While there exist tiny spaces where true volunteers live and thrive in a bilateral exchange of freely given goodwill, by and large volunteerism has been extinguished by its historical recipients. Today marks my last day ever of hospital ER call, the end of 2 years of receiving token payment for making my expertise available following 25 years of doing so for free. My experience is typical, as is this denouement.

Once upon a time all of your doctors were in private practice. We all had tiny little cottage businesses, did our work, and billed you or your insurance company for the work we did. Some of us worked in tiny little groups, but it was the rare doctor who was part of a large group or business whether in a big city or out in the country. Even the slickest Madison Avenue internist was basically a country doc, just with a better, more expensive wardrobe. In addition to having a greater familiarity with our patients we also enjoyed a very clubby relationship with all of the other doctors where we practiced. There was a collegiality, a sense that we were all in the struggle together. Folks who shirked their duties, foisting them off on other docs, were quickly educated about proper protocol or left alone.

Hospitals were different, too. Local or regional, they were hardly the gargantuan mega-businesses they’ve become. The org chart was shallow, and most local doctors were on a first name basis with the few administrators on the hospital payroll. You took call for the ER as a volunteer; the ER respected that you were donating your skill and your time and handled everything it could before calling you. Same thing for consultations. Your colleague only called you if they couldn’t figure out a problem or ran out beyond their scope of practice. There was a faint air of apology with each request, and a definite unspoken appreciation for the help that would be given. You helped because you were appreciated.

This is really no different from all manner of volunteerism in America. Smallish, closely knit organizations depending on the goodwill and generosity of members of their community pitching in to ensure success. Think local memorial 5K races, or CrossFit Games Regionals in the days before ESPN or the Home Depot Center. Countless small private schools that depended on the largesse and time offered by the families who sent their children there. You gladly accepted the opportunity to volunteer because you knew that without you the organization would not be able to function. You also knew that the recipient of your generosity not only appreciated your contribution, they really had no other options. Not only that, but if that organization somehow existed in your professional space you knew that it would never, not ever, abuse the trust necessary for volunteers to continue.

What happened? Money. Money and size and the distance that they create between an organization and its volunteers. Let’s go back to the hospital and the ER for a minute. Where once your efforts as a volunteer were deeply appreciated and those efforts rewarded with respect and care for your time and your expertise, the growth of employment of doctors by hospitals opened a gap between colleagues. No longer was there the esprit de corps, the shared notion that the primary target of our efforts was the patient was replaced by so very many doctors by the reality that they worked first for a business as faceless and uncaring as GM. Work that was once done by your colleague was now pushed to the volunteers whenever possible. Worse, boxes to be checked by the employed (to maximize revenue and minimize risk) meant demands made of volunteers, not requests. Worse, still, were discoveries that some “volunteers” were more equal than others: they were paid.

While this is nothing short of tragic in health care, it was inevitable once medical businesses were incentivized to grow ever larger. It is not confined to health care by any means. How do you think that volunteer at a Spartan Race feels when he learns how much his “team leader” is being paid? Have you ever “discovered” how much the Executive VP of your favorite professional organization is paid? As a people we Americans are generous to a fault. That generosity usually continues right up until we discover that we have been duped, and even worse that we have been purposely duped by the people who run the organizations for which we volunteer.

And so we gather here to mourn the passing of the Age of Volunteerism. Like so many things of wonder and goodness there remain pockets of resistance, little oases where the goodwill, honesty, and appreciation beget the kind of ebb and flow that made things so much better, kinder, more collegial at the apex of Volunteerism. My friend Tom Gardner was just named the president of the Society of Alumni of our Alma Mater. Tom has given tirelessly of his “spaces”, his timespace, brainspace and emotionalspace to help shepherd tiny Williams College as it flows on though time. Is this truly different? A tiny refuge from the Zombie Apocalypse of corporatization of all things to which we once volunteered?

We can only hope. Hope that Tom and those like him who continue to find places and causes where their volunteerism is met with what we in medicine have had to bid farewell. We can only hope that there will be places where being a volunteer means receiving the respect and appreciation and even a kind of love in return for what we have given. We can only hope that there will continue to be places where the incessant drive to grow ever bigger, size measured on a spreadsheet rather than by heart, will be resisted. For if it can happen in medicine, if volunteerism can be killed in what is arguably the most noble of all endeavors, I fear that it is doomed everywhere.

And so we mourn the end of the Age of Volunteerism. We wait with equal parts sadness and fear for arrival of what follows.

I’ll see you next week…

–bingo

“It’s better to full-ass one something than to half-ass a bunch of things.” Anonymous

Soon enough I will be living another week of on-call coverage for one of the largest hospitals in Ohio. When asked recently by colleagues why I still do hospital coverage I had to admit that I really didn’t have an answer. I don’t really have to do it, and yet it doesn’t really seem like it feels right not to. There’s a kind of “pay it forward” debt to the giants who came before me that still lingers, I suppose. That debt’s been paid, with a bundle of interest, many times over, and it may be time to close the ledger.

Why now? Well, it has very little to do with the work itself because that hasn’t really changed all that too very much over the years. No, it’s more about the work that’s NOT being done by others, work that they own and are responsible for and don’t do, that will ultimately drive me away from this part of my day job. It’s really no different than any other job or workplace anywhere. The lazy and the shiftless, the incompetent and the entitled all see it as just fine to kick the can downstream to whomever they can get away with kicking it to.

I’ll bet you just had a dozen images of this from your own life flash by, right?

Boy, there are a thousand reasons you will hear to explain and rationalize why they feel it’s perfectly reasonable to get you to do their work. After awhile it gets really old. The first thing you should do when you encounter this is to look within and make sure that YOU aren’t doing this anywhere to anyone else. Gotta make sure that your virtue is intact before you saddle up the high horse! Once you’ve ascertained that all is right and proper with your own work ethic you then have a bit of a choice to make: rock the boat or sail along. Sadly, though you know the consequences of the latter (you continue to do that slacker’s work), be prepared for the possibility of not being thanked for pointing out reality to bosses and co-workers. It’s entirely possible that you will be the one criticized. Totally fair, right?

In the end there is no best answer to this dilemma. All you can do is use the feelings generated in you by being on the receiving end of this work-shifting to make yourself a better worker, no matter who it is you do that work for. If you do, indeed, reach that point where you just can’t look at yourself in the mirror any more because the injustice is simply too much to accept, it’s OK to call it as you see it. That’s where I am today, and that’s what I’ll be doing while on call. To be sure, all of that “pay it forward” I’ve done will get me an audience, though it may not mean I will be able to effect change. Other than workload, that is. In this tiny part of my day job, I will continue doing the very best job I possibly can, as I always do, for each of my patients each time I see them.

What I won’t be doing is picking up the other half an ass that someone else missed before I full-ass my part of the job.

The late, great Larry Weed, M.D., Professor of Medicine at the University of Vermont predicted both the age of EMR as well as the advent of IBM’s Watson, “Big Data”, and machine-learning in the practice of medicine. With the problem-oriented medical record in the form  of the SOAP note (Subjective -> Objective -> Assessment -> Plan) he codified a universal approach to essentially any medical problem evaluated in any patient. What was then called the Medical Center of Vermont implemented a data warehouse which allowed instant viewing of test data by computer throughout the institution in the early 1980’s (the first “EMR” if you will), and sister institution the Maine Medical Center solved the problem of the handwritten orders by adding computer order entry (CPOE) in 1984 or so. Despite all of the hoopla surrounding the Accountable Care Act’s carrot and stick drive to digitize the medical record, the horse was already out of the barn and slowly walking in that direction in the 1980’s.

Why, then, is the EMR landscape such a mess in 2018?

Our American healthcare landscape is blessed with a number of very large, prestigious institutions. They are self-professed and incessantly self-promoted as leaders in both thought and action when it comes to the advancement of medical care in all ways in the United States. It is right here in the laps of the leaders of those famed institutions that blame rests for the debacle that is the modern EMR. As early as 1990 and as recently as 2008 the opportunity to lead presented itself to our most august institutions. When given this opportunity to develop a new, better type of medical record that would aid in every aspect of caring for patients, our most important medical institutions punted.

When you think of the best medical care in the country, who do you think of? Pretty easy to answer that, I bet. The Cleveland Clinic, The Mayo Clinic, Yale, Stanford, the hospitals that made up what has become Harvard Pilgrim Health like Mass General, Brigham and Women’s and Beth Israel, Johns Hopkins, Baylor. Household names, all. Every single one of these institutions seeks to portray itself as the ultimate example of excellence in medical care, devoted above all else to the development and provision of care better than any and all competitors. Not only that, each wishes to project the most pious of images, one that espouses their monk-like devotion to doing what is best for their patients before all other considerations. With a building consensus that record keeping the old pen and papyrus way was hindering both present and future care, and indeed might be contributing to harmful care, the era was ripe for any or all of these presumably noble, altruistic non-profit institutions to answer the call.

When American healthcare was ready to look to any of these institutions to lead us into the digital information age, each and every one of them abdicated. The leaders of these and other great institutions had the chance to develop a true medical record in digital form that was first and foremost a tool to be used to improve the care that was provided in their institutions. They had the resources. Any one of them could have taken a leadership role in its development, not unlike the kind of leadership many of them have taken as the first institution in on cutting edge medical care such as organ transplantation or new generation cancer care.

Instead, both early and late, the leaders of each one of these major institutions chose a path with an eye not toward how the EMR would engage in the care of a patient, but in how it would engage with accounts receivable. Each institution opted to prioritize the growth of revenue over improved care. Everything is about maximizing the income of the institution, while at the same time minimizing the risk associated with billing.

J’accuse.

Think about that second part for a moment. EMR’s are not designed to promote the safety of an individual patient as she goes through her care experience (despite what the marketing brochures may tell you); for safety they are designed to limit the likelihood that a payer audit will find a lack of documentation that supports the charges. The bigger the company making the program, the greater is this emphasis. In the early 00’s any one of the above institutions (and Texas, and Ohio State, and Dartmouth, and…) could have launched a program that met all of the MEDICAL criteria for a good record. If they wanted to make a profit they could have sold the rights to use it.

Why don’t EMR’s communicate with one another? Were you aware that even institutions that run software from the same vendor do not have the ability to simply put notes from one another into a universal chart? Crazy, huh? Frankly I’m not really all that sure who is to blame for that particular bit of nonsense, but the obvious answer as to why your Epic chart can’t communicate with, say, Nextgen lies with that abdication of responsibility I spoke of above.

By not taking control of the process of EMR development at the outset all of our major medical institutions learned that 1) they never really bought an EMR, they just rent it which means that 2) they no longer really own their own information. What better way to remain in control if you are Epic than to prevent The Cleveland Clinic from banding together with The University of Pennsylvania as a bargaining unit than to prevent them from sharing patient information ON THE SAME DAMN PLATFORM?

J’accuse.

To their collective shame our most prestigious medical institutions and their leaders sold their souls by prioritizing their role as commercial entities rather than as leaders in medical care on behalf of patients. In the process they allowed themselves to be enslaved by the commercial interests that now control the medical record. Worse than that they created an additional barrier between a patient and his own medical record.

There has to be a bright spot, right? Some shining beacon, a last bastion, someone willing to stand against toute le monde and defend the honor of academia, to not become the next rhinoceros?  Certainly some institution was willing to stand up and do the right thing by saying “screw it”, we’re gonna make a killer EMR that does everything that Larry Weed said it should do first, and then figure out the billing crap later, right? Perhaps the medium sized Intermountain Health in Utah is on the right track, but all of the really big institutions turned belly up to submit to the demands of payers, hoping for a treat and a  belly rub. Surely UVM, the home of Larry Weed didn’t cave, right? The University of Vermont must surely have been driven by its early entry into the world of digital information management and created its own EMR that both houses information in a clinically relevant way, as well as allowing for computer-guided decision making, right? RIGHT?

Nope. Sorry. The University of Vermont runs on Epic.

Man, what a place Bellevue Hospital must’ve been back in the day. It was crazy enough in MY day in the mid-1980’s. Bellevue is arguably the most famous hospital in the world, famous mostly for the treatment of psychiatric patients, and made all the more famous by the Christmas movie “The Miracle on 49th St.” in which Santa Claus was institutionalized in one of Bellevue’s top floors. For those of you who don’t know Bellevue Hospital, the top six floors of a 30 floor tower were (are?) reserved for psychiatric patients, at least one of them for psychiatric patients who hail from Rikers Island.

I’m not really sure why, but I’ve been thinking a lot about Bellevue recently. My experiences as an ophthalmologist in private practice in the suburbs of Cleveland, Ohio really have exactly nothing in common with my experiences as an ophthalmology resident on the lower East Side of New York City. Nonetheless Bellevue has been on my mind. Since I’ve been thinking about it I thought I’d share some stories about Bellevue and about my time as a resident at all of the NYU hospitals. This will also give me an opportunity to introduce you to some very special, very interesting characters whose lives crossed paths with mine.

Irwin Siegel was an optometrist with multiple roles at Bellevue Hospital. His most important role for me and my fellow residents was to teach us about optics and refraction, the science and technique of prescribing glasses and contact lenses. Dr. Siegel was also a noted researcher in the diagnosis and treatment of retinal diseases, specifically diseases of the macula or center of the retina; there is actually a syndrome named after Dr. Siegel and two of his partners.

Dr. Siegel was a fascinating man, especially fascinating to a child of suburbia like me. The prototypical New Yorker, Dr. Siegel lived his entire life in Brooklyn and Manhattan. He did not own a car, and used some form of public transportation for more than 95% of his travels. You got the sense that any forays outside the island of Manhattan were viewed as akin to a ride on the “Heart of Darkness” express. The guy simply reeked of New York, and he spent his entire professional career at Bellevue Hospital.

Recall that my life’s memories are wrapped up in eyecare, optics, and the optical industry. My father’s first job was at American Optical in Southbridge Massachusetts, at the time the largest ophthalmic manufacturing company on the planet. The very first lasers were actually developed in the laboratories of AO. In the early 1960s Dr. Siegel and his partners were doing research on lasers at Bellevue. Now, as you can imagine, something as powerful as the energy of the laser light had also come to the attention of the U.S. Military. So comes the story of the Bellevue Death Ray!

Dr. Siegel and Dr. Ron Carr were doing laser work somewhere in the bowels of Bellevue. This would have been in the early 1960s, and the laser they were working on was an enormous mechanical monstrosity, a piece of equipment that took up more space than most upper East Side kitchens. Not only was it physically enormous, but the generation of a single pulse of laser took well over a minute, a minute filled with a crescendo of sound not unlike what one would experience when a jet engine is engaged . Imagine a room, half filled with this exotic piece of near–science fiction equipment, surrounded by white–coated scientists all wearing goggles that look as if they had been spirited away from a Mount Everest expedition. Add in a few very senior military officers in full dress regalia and the scene is set.

The officers visiting from the Pentagon really had no idea what to expect. They were intrigued by this new technology, interested to see if there might be some military application. Dr. Siegel noted that he and Dr. Carr were mostly bemused by the presence of the officers, although he did admit being a little bit impressed by the two-star general in their midst. The  experiment/demonstration was set up, on one end of the room the monstrous laser, on the other end of the room a rabbit in a box, his head poking through a hole, the laser aimed at his left eye. Goggles were donned and the switch was flipped.

The laser came to life, slowly building energy in the rudimentary laser tube, the whine and the clang and the clatter growing in intensity with each passing second. Dr. Siegel and Dr. Carr stood calmly to the side, ignoring the laser and concentrating on the rabbit. The officers, on the other hand, slowly crept back away from the laser, trying to melt through the wall, and failing that trying to become as small as possible. Two-dimensional, if possible. The wail of the laser grew… the sound filled the room… the wail, the clatter, a crescendo… BAM!

And then, silence. The doctors and the officers took off their goggles. They walked over to the  box and discovered that the rabbit was dead. Immediately one of the colonels started doing a jig. “We have a death ray! We have a death ray!” He began to run for the door, headed for the telephone (no cell phones or sat phones in those days). “Well, hold on a minute,” said Dr. Siegel. “Let’s just take a closer look.” It turns out that rabbits are not terribly bright creatures, and that when they are frightened they tend to forget how to move backwards. This poor bunny, the only creature in the room without Ed Hillary’s goggles, had been so frightened by the noise of the laser that he literally suffocated himself, pushing against the rim of the hole in the rabbit box in an effort to escape.

When Dr. Siegel looked inside the rabbit’s eye there was a single perfectly round burn, approximately 2 mm in size in the middle of the rabbits retina. There,  in the space of approximately 5 minutes, was born and died the Bellevue Death Ray.

The epilogue of this story is rather interesting, though. About 10 years later, after numerous refinements of both the production of laser energy and the focusing of that energy, one of the most important trials in the history of medicine took place using focused laser light to prevent vision loss from diabetic retinopathy. The Diabetic Retinopathy Study was the very first prospective, double–blind, randomized clinical study done on a cooperative basis across the entire country, the type of study that is now considered the ‘gold standard’ for medical research. The results of that study have saved countless individuals from a life of blindness due to diabetes.

This is where I trained, and men like Dr. Siegel who told us this tale from Bellevue Hospital as part of our optics classes, is one of the men who trained me.

As I mentioned, I’m on call for our large semi-suburban hospital for the month of July. I was consulted for a patient who has monocular vision loss that is unexplainable, at least given the capabilities we have as ophthalmologists when we see patients at the bedside in the hospital. The consult brought back memories of Julys past as a resident on call.

Bellevue Hospital, and the Bellevue Hospital residents provide medical care for the New York City prisoners who are housed at Riker’s Island. This is actually quite an opportunity, especially for a child of suburbia like yours truly. It’s not as if I had never come across people in the criminal justice system prior to my Bellevue days, it’s just that I didn’t have such routine and regular contact.I don’t remember exactly, but there are at least three or four entire floors at Bellevue dedicated to the care of Riker’s Island inmates who have medical problems. One or two are for the criminally insane, and others who have some degree of mental illness. The remaining two floors house prisoners with problems as varied at coronary artery disease and pink eye. As disconcerting as it was for someone like me to enter a locked ward, the accommodations at Bellevue were at least a full order of magnitude nicer than those at Riker’s Island. This provided an interesting opportunity for Riker’s Island inmates to create a medical reason to leave The Rock, and created a very interesting learning opportunity for all of the residents  to discern real from not so real.

This  might have been the most fun part of my entire residency experience.

People who have something to gain from having an eye problem all seem to have the exact same complaint: “I can’t see.” Sometimes it’s “I can’t see out of my right (or left) eye,” and sometimes it’s simply “I can’t see.” The savvier the patient, the more subtle the symptom. The trick as the doctor on call is to simply demonstrate that their vision is substantially better than what they are describing. Oh yeah, it’s important to do so in such a way that you don’t make them too very angry; you don’t want to become a Bellevue Hospital “target” yourself!

Every resident develops a repertoire of tricks that he or she will use, a go–to list that tends to work for the majority of the malingering patients. To be truthful, especially when caring for children, sometimes the patient is actually convinced that he or she really CAN’T see. The kids are really pretty easy, though. I found, and frankly continue to find, that even with my limited attention span (often described as being slightly shorter than that of your average gnat) that I have more patience than almost any child under the age of 18. Most eye charts will start with a 20/10 line, and then move through 20/12, 20/15, and then several to many 20/20 lines. If you start at 20/10, by the time you get the 20/25 or 20/30 that line looks absolutely enormous! I think I’m batting about .997 in kids with 20/400 vision in the ER who “miraculously” and up with 20/25 vision in the exam room.

Folks who have something to gain from being diagnosed with visual loss weren’t always wards of the state or city. Occasionally there would be people who stood to gain from being diagnosed with profound visual loss for other, less existential reasons than wanting a ticket out of Riker’s Island. My favorite was a Hispanic woman who came with an entourage of family members, her complaint being complete and total loss of vision in both eyes from some vague and poorly defined trauma suffered at the hands of a landlord who was trying to evict the her from a rent–subsidized apartment. Her examination was totally unremarkable. Everything about her eyes was so  normal it was eerie. My suspicions were high because she just didn’t seem all that distraught over her new blindness, you know? There’s an instrument called an indirect ophthalmoscope which is used to examine the peripheral retina. The light we use can be cranked up to a level which is quite frankly rather painful. I explained to my patient through her translator that I was terribly sympathetic, and very concerned about how she would ever be able to survive if she was  evicted, what with her being totally blind and all. I just had this one last test to do, to look at her retina. With phasers set on stun I started to examine her eyes with the light cranked up. She started screaming in Spanish. What’s she saying? What’s she saying? Remember, now, this is a woman who has no light perception, everything in her world is black. Her son grabbed my arm and started yelling at me. “Turn that light off. It’s too bright. It’s hurting her eyes!” Yup, just another satisfied patient.

The prisoners really were the most fun, though. You had to be on your toes because some of them were actually quite dangerous. If the corrections officers were chatting amongst themselves in the waiting room you could be pretty sure that the patient in your exam chair was nonviolent. If, however, there was a corrections officer standing roughly 1/2 inch from each arm of the patient, well, that was one you had to worry about. But the prisoners got it, they got that this was a game. If they could beat me they got a stay at the Bellevue Hilton. On the other hand, if I got the best of them, it was back to Riker’s Island. The guys who complained of decreased vision in just one eye were actually not too difficult to fool. Again, all I had to do was prove that the vision and the supposedly “blind” I was normal. We quote discovered” all kinds of sight threatening needs for a new pair of glasses at two o’clock in the morning in the Bellevue consultation room.

The guys who complained of decreased or lost vision in both eyes were more challenging and therefore more fun. Can’t see anything at all? Piece of cake. All I have to do was prove that they had locked on to some image. There must be three dozen prisoners who complained of total loss of vision in both eyes who headed back to Riker’s Island one minute after entering my consultation room after they leaned over to pick up the $10 bill that I put on a footstool of the exam chair. Did you know that your pupils constrict when you focus on an image inside arm’s-length? You can imagine how handy that three-year-old Sports Illustrated bathing suit issue came in, and how many prisoners learned about accommodative pupillary construction after looking at THAT picture of Christie Brinkley.

There is one story out of all of my adventures with the Riker’s Island prisoners that stands apart. It was July, and I was doing my duty helping out the new first-year resident on one of his first nights on call. We got a call from the ER about this terrified patient who had lost vision in both of his eyes; he was defenseless. Dave, now a world famous pediatric ophthalmologist, was really unsure of how to proceed so I told him that we would do it together. We sat back and watched very carefully as the prisoner entered the room. He was totally on his own, not assisted in the least by the corrections officers. He managed to navigate around all of the little articles I had placed between the door and examination chair, not hitting a single one. He found the chair, turned just like you or I would, and sat down. His examination was perfect, naturally. After putting drops in his eyes to dilate his pupils this is what I said: “I can see that you are terribly frightened sir, and frankly I can’t blame you. I’m very concerned about your vision, and I’m going to do everything I possibly can to make sure that you are alright. I just put some drops into your eyes so that your pupils will dilate. Dr. Granet and I will then examine your retinas once the drops have worked. We are going to talk about what we’ve seen so far. Please go back into the hallway and take a seat in the blue chair, and we’ll come and get you in just a few minutes.” The prisoner left the room, once again navigating the “mine field” without incident.

Dave bowed his head, a little tiny twitch at the corner of his mouth as he shook his head. “There’s only one blue chair out there, isn’t there?” He smiled as he strolled over to the door. Sure enough, there was our patient, very calmly sitting in the single blue chair, surrounded by a dozen empty red ones!

We had to invite the corrections officers into the exam room when we explained our findings.

I am on call this month for the largest community hospital on the West Side of Cleveland. Covering a semi-suburban ER is quite different from covering a true big city ER, especially when the semi-suburban hospital has gutted both its trauma and eye services. My on-call role now is little more than that of foot servant, covering the loose ends of other people’s arses in the pursuit of a perfect chart. Bellevue, at least the Bellevue I knew in the 80’s, was quite a different story. Although it was July it was July in New York, pre-Guliani New York, and it was Bellevue Hospital.

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

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

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

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

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

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

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

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

My Dad has been hospitalized for many, many weeks now. My siblings, a couple of the daughters-in-law (including my wife) and I  have taken turns either keeping my Mom company or spelling her and just hanging with my Dad alone. We have tried mightily to keep each other abreast of a day’s events, and we have made yeoman’s efforts to help Mom communicate with all sorts of members of the medical community involved in Dad’s care. Man, has THAT been a challenge. The differences in understanding the lingo of medicine, not to mention the vast gulf between the frame of reference that exists between  “civilians” and medical workers on the front line create communication barriers that can seem impenetrable.

Where does the responsibility lie when we enter into a conversation? Let’s define a conversation as the interaction between two people during which there is a purposeful transfer of some kind of information. Let’s refine that by saying that in this day and age we cannot define a conversation as simply as two people talking with one another. We have email, texts, FB chats and PM’s, Twitter @’s and PM’s, phone calls and Skype, and of course plain old face-2-face talking. Any and all of these have been, or yet might be used when we go forward with Dad.

So where does the responsibility lie to ensure effective transfer of information? Upon whom does it rest to make sure that facts or ideas have been successfully transmitted and received? How about the emotional content, the feelings that ride along with the data? Sometimes the emotional content is really the data that’s intended for transfer and is quite obvious, like the color guard accompanying a General. Oft times, though, the feelings attached to the words are as carefully and craftily hidden as a stowaway on a cruise ship. What exactly does it mean when a nurse greets Mom in the morning with the fact that Dad “struggled” the night before?

Here’s my bid: the responsibility lies on BOTH sides of the conversation. Active listening is key. Engaging in the conversation means engaging the individual on the other side. It starts at the very choice of vehicle: to whom am I sending this message? On the receiving end the vehicle should also be evaluated: who sent this to me? Think about it…the universe of topics you would engage with your 75 yo grandparents via text is awfully darned small, and if you are a grandparent who texts you can’t “receive” disrespect in a message filled with contractions and lingo. By the same token, both sender and receiver must be actively conscious of the frame of reference of any “other” in the conversation.

A Facebook status update is like a billboard, meant to be one-way, neither demanding nor expecting a reply. A conversation, on the other hand, is by definition bi-lateral. It requires active listening and anticipatory listening on the part of both people. It requires a shared understanding of the power as well as the limitation of each method one might choose to utilize. The smaller vehicle (text, Tweet) creates the greater distance and so must transfer the more basic information. More nuance or emotional content requires a different vehicle, at once larger (to include the details) and smaller and more intimate (so that everything can be seen as well as heard). Closer.

In the end we are social creatures, driven always to connect. The rules of communication have not really changed despite our ever-increasing ability to communicate, to connect. The more important the interaction the closer we must be to the other. Communication, no matter what vehicle we choose, requires that we listen better. Listen to what is said to us; listen to what we say; listen, especially, to what the other hears.

The responsibility for a successful communication is shared equally by both or all involved. Despite our newfangled world filled with different ways to communicate the most effective strategy hasn’t changed in a few thousand years:

Listen better.

CrossFitters have taken up the cause of health, given the charge of improving health and preventing decrepitude. There will always be a need for what we can call “real medical care” or sickcare (you know, rather than healthcare). After all, stuff happens. I’ve been plunged into the abyss of American sickcare as I help shepherd my Dad through a prolonged exposure.

Much has been made of the tremendous costs of the most modern medical care. There was a 20 page article (20 pages!!) in Time magazine about this last week, about inflated charges and financial gamesmanship and whatnot. True enough. Indeed, I’ve read the theory that sickcare in the U.S. was pretty darned good 10, 20, 30 years ago, and we spent much less money for it back then. Why not just use, say, 1980′s sickcare as our standard? Weren’t we pretty healthy then? It sure seemed like we could at least afford sickcare then, both on the personal and societal levels.

Here’s the rub: I saw 2013 vintage care this week, and I saw something that approximated 1985 or so. The “time travel” between 1985 and 2013 was a real eye opener. No one in their right mind would trade the best of what we have today for “1985 is good enough”. Trust me. That particular “time travel” trip was a nightmare.

Do we as a society, country, and/or economic ecosystem need to find some way to bring some sanity, some rational economics to how we buy and pay for our “sick care”? You bet. We here in the CrossFit world are on the right track as we seek health, seek to avoid the need for sickcare. But man, I gotta tell ya, if you are sick and you need to be cured, you want to be right here in North America.

And you want to be be here today, in 2013.

It’s the jobs, Stupid. That’s what should be on the office wall of every legislator at every level of government across America. Say what you will about Bill Clinton, but did anyone ever get it more than that first Clinton presidential campaign? A simple sign in their campaign war room reminded everyone of the central message: “It’s the economy, Stupid!”

It’s more than that, of course. Now, you could say, “It’s the jobs, Stupid!” What can you do to stimulate the creation of jobs now? Sure, you can take a page out of Rahm “Never Waste a Crisis” Emmanuel’s book and combat our crushing unemployment by pumping money into grand public works. Who doesn’t agree that our bridges, roads, sewers and subways are in dire need of repair? But everyone was enticed by President Obama’s promise of “shovel ready” public projects into which stimulus funds could be pumped, followed instantaneously by the hiring of willing hands to man those shovels. Stimulus I didn’t really turn out that way, so why would we embark on Stimulus II? Or III? Return on this investment was pretty much zero.

Nothing will get our economy moving faster and restore our national spirit than employing more people, and at a higher wage. Let’s take a quick look at the kind of job sector that would be most desirable.

Any industry into which we might pump money should have the ability to ramp up employment at the first dollar of public investment, or the first loosening of a needless regulation. OR BOTH.

Any sector targeted should be able to create and fill jobs across a broad range of salary, experience, and skill levels, and it should be relatively gender-neutral. It should reward achievement and educational advancement. Any jobs created should be domestic, although any hard products created must be attractive for export. It should be an American business sector that is expanding now, and poised for additional growth.

Pretty ambitious list of criteria, huh? Where will we ever find an industry or economic sector that could fulfill all of these criteria without some new genius discovery or mega-bureaucratic mischief?

Easy. Healthcare.

Think about it. Right now our country is fixated on cutting the money flowing into healthcare businesses such as hospitals, nursing homes, and doctors’ practices. Government regulations make it more and more difficult to make a profit while providing healthcare. Perhaps more frightening is the fact that similar regulatory agencies make it nearly impossible to bring new medical products to the market or build the sales of existing products.

Despite that, healthcare and related industries (pharmaceutical manufacturing, medical device manufacturing, health insurance administration and sales) continue to grow in all ways that we can measure, except the most important one: jobs.

I know your reaction. “We’re gonna go broke paying for healthcare as it is; how could we possibly pump MORE money into that?”

Hear me out before you dismiss my theory out of hand.

Every new regulation, every new requirement, every cut in payment for an office visit or a medicine or a hospital stay results in a net LOSS of jobs. And worse, pretty much no one in the entire healthcare and medical sector is hiring now, partly because of declining pay for services and products, and partly by the gloom caused by an assumption that the future holds nothing but more of the same.

We should try to identify regulations to remove. Start with removing the prohibition on drug companies marketing so-called “off-label” use of prescription drugs when it is clear they are beneficial. More sales of existing drugs means more jobs. More sales of existing drugs — along with fewer barriers to approving new drugs — means even more jobs.

People in healthcare and related businesses make a good wage, and there are jobs available across a broad wage scale. These folks buy houses, employ skilled trades, go out to eat and the like. As they advance, they earn higher salaries, and then they do the American thing: they spend it!

Pump more money into healthcare rather than less. Stop all of this talk of cutting payments to hospitals and doctors and instead index fee increases to inflation. Stop reducing Medicaid rolls and give doctors and hospitals an incentive to care for these people by increasing Medicaid payment to the levels of Medicare. That would create more jobs.

Education matters in all things medical, whether you are a doctor or someone working in a pharmaceutical factory. Generally, the more education you have, the better you fare economically. There is no systemic gender or race discrimination in healthcare. With doctors, nurses, hospital administrators, academicians, the only requirement is to be good at what you do. Same thing in related industries like medical device manufacturing; ambitious people of all types, men and women, young and old, can advance in their careers. Advancement means more job openings.

And guess what? More jobs means generating more income that can be taxed! More jobs create more spending and more sales that can be taxed! You could even encourage more of this by decreasing income taxes on those people most likely to spend that money, which would then create…wait for it…more jobs!

Oops. Sorry. Politicians are involved. Decrease taxes? That’s just crazy talk.

The next thing you know someone will propose some really crazy thing, like increasing the money we spend on healthcare.

*Credit for the idea to William J. Petraiuolo, M.D.