Random Thoughts from a Restless Mind

Dr. Darrell White's Personal Blog

Cape Cod

Posts Tagged ‘ophthalmologist’

Doc or Trainer: Owning Your Own Job

We are starting to see some turnover among the OG CrossFit Affiliate owners. Some, like Skip, were in literally on the ground floor, and a successful Box rode them into the sunset (enjoy your retirement!). Others, like Steve and Kelly, have nearly 10 years into ownership as they approach both mid-career and mid-life. They turn over a highly successful business and take on the role of “Founder” (can’t wait to see what’s next for you!). Some owners have left the CrossFit fold and changed the name and structure of their gyms. There have certainly been some closings, typically folks who either didn’t really know what it was they were getting in to, or found that being the owner of a job is more than they bargained for.

As such, the successful CrossFit Affiliate is much like every other small business where the owner is also operator. My day job is like that: if I don’t show up for work no revenue is generated. A huge percentage of small businesses run just like this. What you own is not so much a business as it is owning your own job.

With all of the talk of exercise as medicine lately, it’s interesting to compare and contrast the megatrends at work in the fitness industry and medicine when it comes to practitioners. In medicine we are in the midst of what is nothing short of a diaspora with physicians leaving the private practice of medicine for employment in ever-larger organizations. It should be noted that this phenomenon is in direct response to government action. Men and women who once owned their job, with all of the responsibilities (payroll, rent, etc.) and freedoms (hours of operation, client experience, etc) now work is settings where process and protocol is dictated to them, and fidelity to the organization has primacy.

Thanks to CrossFit and the CrossFit Affiliate model, the megatrend in fitness is exactly the opposite. Trainers have been unleashed from the corporate environment where salesmanship is the most highly regarded skill, and put in charge of a job where outcomes drive the business. Affiliate owners are the new private practitioners of fitness, in charge of everything from programming to toilet paper.

A certain tension has always existed between large medical organizations and smaller private practices. It should come as no surprise that similar tensions exist between CrossFit and its Affiliates and large fitness businesses and their partners. Large organizations crave control and abhor independent competition. Indeed, for those behemoths the only thing worse than independent competitors is being shown up by them. You know, like getting better surgical outcomes or having clients who look like the crowd at the Games. Large organizations often turn to government to suppress this type of competition and make the megatrends flow their way.

There are several important points to be made from this comparison. First, of course, is that every Affiliate owner and every member at every Box should fight alongside HQ is this battle. Trainers get better with more experience, not with more certificates.
Trainers who own their jobs also own not only their outcomes but everything about the experience of their clients. Just like a private physician. I’m biased, of course, but this is well worth fighting for.

For those fortunate enough to train people for a living the reality is that you don’t, and likely never will, own a business. There are very few large CrossFit businesses. For every CrossFit NYC or CrossFit Eado there are 3 or 4 hundred boxes run primarily by the owner. What you own is your own job. You’ll need initiative, passion, and resilience. A thick skin is helpful, too, because you’ll get plenty of feedback on that job. With a little luck you, too, may one day leave behind something significant enough that there is someone there to carry on when you leave.

There’s some turnover in Affiliates. At the moment nothing like a trend exists. Owning your own job is not for the faint of heart, and some will find it not their cup of tea. Others, like the OG’s above, will leave for that next thing on the horizon. What mattered is that they had the opportunity to own a job and took it, creating something that will live after they have gone.

The best boss is the client (or patient) who chooses you. The chance to work for them is worth fighting for.

I’ll see you next week…

Medicine is a Harsh Mistress

“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.

 

CPOE, An Epic Misadventure: Update

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

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

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

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

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

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

Another Epic Misadventure: Interlude

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

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

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

 

Tarnishing a New Technology

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.

Lessons In Doctoring Learned On The Golf Course

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

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

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

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

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

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

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

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

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

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

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

Just ask a caddy.

 

It’s Hard To Make It Look Easy

It’s really hard to make something look easy. Think about it. The best knee surgeon takes 1/2 the time and gets twice the good results of the average surgeon. It barely looks likes he’s working at all. The very best LASIK surgeon makes the most difficult case look like a piece of cake, just like the easiest and most straight forward cases done by the average surgeon.

None of this happens without an enormous amount of hard work, practice, study, and yes, a little bit of natural ability doesnt’ hurt either.

Think about double-unders, jumping rope with two passes of the rope under your feet for each jump. A CrossFit legend named Chris Spealer did a Tabata Double-Under set (20 seconds of exercise followed by 10 seconds of rest, repeated 8 times) and got a lowest score of 40, or something crazy like that. Looked like a snap, too.  My best is 10. TEN! If you are a CrossFitter and you’ve struggled with Double-Unders (and who hasn’t, eh Jeff Martin?) you watch and you say it’s easy for him. You gotta know, though, after watching all of the Speal videos, that there were countless hours of work behind that. He just makes it look easy. It’s not.

Samuel Beckett had a run of some 10 years or so where everything he published was nothing short of brilliant, and there was a ton of it. If you are a writer and you have stared at a blank piece of paper or a blinking empty screen (and who hasn’t, eh Daigle?), you might think that Beckett was simply gifted, that the words simply poured out onto the page fully formed and prepped for posterity. Reading Beckett’s letters, though, tells a different tale entirely, one of anguish and toil, brutal hard work. He just made it look easy. It wasn’t.

We tend to discount the hard work behind any skill-based endeavor when we only see the “game film”, so to speak. The untrained eye is often unable to discern the subtleties in some performance or job that the best of the best just blow through, making it look like an everyday, ho-hum whatever. In most circumstances we just don’t have an adequate frame of reference that allows us to see how an average or “regular” surgeon, or athlete, or debater struggles with the curveball, the surprise. We don’t even get a chance to compare how the true superstar handles a truly mundane “game” in comparison with the middle-of-the-Bell Curve guy, at least outside the realm of sports.

This lack of perspective, along with a lack of awareness of how hard the best of the best have worked to get there, leads us to minimize the excellence before us. The average cataract surgeon in the United States takes more than 20:00 to complete the surgical aspects of a case. The very best among my peers take 5 or 6:00 to do the same thing. No movement is wasted, and each tiny step is literally a microscopic ballet. The complication rates for average eye surgeons are 5-10X greater than that of the top surgeons, and the best surgeons routinely achieve better outcomes by all measures.

The best surgeons make it look too easy. Our response as a nation to this is criticism that eye surgeons are overpaid for such a “quick and simple” procedure; there is a palpable, barely hidden contempt for the highest achieving physicians among healthcare policy makers. This is just wrong.

It’s really hard to make it look easy, almost everywhere and in almost every endeavor. We should be MORE amazed and have MORE respect when we see something and think: WOW…she really made that look easy!

 

A Great Job!

For all of the whining, moaning, and kvetching, eye Doctors have really good jobs. Especially eye surgeons. Well, at least the eye doctoring part of our jobs.  Sure, the business part of running any medical practice is hard and getting harder every day; buried under the never–ending avalanche of new and existing regulations, it’s a wonder we ever get to practice any medicine at all. But when we do, we actually have a pretty good job.

Some of the stuff we do and the successes associated with that are really quite obvious. Take an older individual who is about to lose her drivers license because she can’t see, remove her cataract, and all of a sudden you might have a 75-year-old “Mommio Andretti”! I don’t care who you are, that’s pretty cool. Add in some of the extraordinary new advanced lens implants and we have retired people who started wearing glasses in the third grade running around with bare naked faces. Seriously, you could be Genghis Khan and if you take someone’s vision from 20/100 to 20/20, people are going to like you.

It used to be that retinal surgeons celebrated “anatomic success”, the achievement of a normal appearing retina. Nowadays, with the advent of advanced micro surgical techniques and injectable medications, retinal surgeons are not only are preventing vision loss but they are improving vision in everything from retinal detachments to wet macular degeneration. They don’t really have any refractive retinal surgeries yet, but I’m thinking it’s only a matter of time. Think about it–how good is your job if you take someone with a bleeding retina and 20/200 vision, and a few months later they can drive a car? Pretty good job.

Some of the mundane things that we all do, things that are profoundly uninteresting to eye doctors, have an outsized importance to our patients. The surface of the eye has more pain fibers per unit of area than any other part of the body. If you believe in evolution, and I do, this actually makes a lot of sense. We are such visual creatures that our sensory cortex devoted to vision is dramatically bigger then any other mammal. Those pain fibers prompt us to rapidly close our eyes for protection. Ever get anything in your eye? A piece of gravel, perhaps a tiny piece of metal while doing some grinding? How about a scratch? It’s amazing how many people are assaulted by their Christmas trees in December and January. Its bread and butter for us, but making that “jump off a bridge” searing pain go away makes for a pretty happy patient. Happy patients make it a good job.

Whenever I get a little down or blue, overwhelmed by all of the minutia of running a business, or borderline depressed at the thought of ever more government intrusion into the space between me and my patients, I remember just how good my job is when I can get to doing it. I don’t really think about all of the high-tech things, the LASIK, the cataract surgery, the fantastic medicines I have at my disposal to treat things like infections or glaucoma. No, what think about is the oldest, least fancy, most routine part of my job: prescribing that first pair of glasses to a kid who can’t see. Seriously, you should see the look on their face when they realize just how poorly they’ve been seeing. Even better, the “AHA! moment” when you put that prescription in front of their eyes and all of a sudden there’s a 20/20 line on the eye chart. I’ve been at this for 25 years or so, and that moment, that simple, low–tech moment never fails to make me smile. When the simplest, tiniest thing you do can make someone that happy, well, you’ve probably got a great job.

Like me.