Random Thoughts from a Restless Mind

Dr. Darrell White's Personal Blog

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Posts Tagged ‘ophthalmology’

Unshakable Belief Meets Unmovable Facts

This week I spent some time talking to a couple of folks who, unbeknownst to them, were talking about each other. Well, talking to them is not really accurate–they were having a discussion and I was having a listen. Both were talking about the effects of a particular happening on a particular person they both knew, effects that both could surely see if only they cared to remove their blinders and look.

They told wildly different stories. Their belief sets were so unshakable, so impervious to penetration by petty inconveniences like facts and reality, it was as if they wore not lenses to clarify but masks to obscure. The blind running from the blind, if you will. I’m fascinated when I see this; I see this almost every day when I am plying my trade as an eye surgeon. So much of what is “known” about medicine isn’t really known at all but “felt”. I constantly run up against an unshakable belief that is often expressed in a statement that begins “well, I think…” Indeed, I heard this from both folks telling me what was transpiring.

I’m fascinated and exasperated in equal parts by this because of how completely this unshakable belief nullifies the otherwise logical power of observable, measurable fact. If I step back and think a little more deeply about this phenomenon I am also terrified that I, too, may harbor similarly unshakable beliefs that blind me to the truths of a fact-based reality. This weekend brought me to a gathering of true experts in a particular field of my day job, one I was quite flattered to attend. There were a couple of points that I’m just convinced my colleagues got wrong, points of view it looks like I shared only with myself. Am I right? Is my insight so keen, my ability to analyze the data presented so much better, that I am just a full step ahead? Or is it rather that I am clinging to a point of view supported only by the virtual facts created by personal beliefs I am unable or unwilling to walk away from?

This simple awareness and acknowledgement–that I may suffer from “belief” bias–might be enough to inoculate me.  I certainly owe my patients (and my readers) an effort to investigate that.

Why Private Practice Survives

“I’m surprised these kind of places are still open.” –Physician employed by World Class Medical Center

“And yet, here you are, bringing your mother in for a visit.” Technician checking in mother.

In my day job I am an ophthalmologist, an eye doctor who takes care of medical and surgical diseases of the eye. Our practice, SkyVision Centers, is an independent practice, what is often referred to as a “private practice”. As such we are neither connected nor beholden to either of the large organizations here in Cleveland, both of which have large ophthalmology practices with offices near us. The mother in question was originally seen on a Sunday in my office through an ER call for a relatively minor (but admittedly irritating) problem that had been ongoing for at least a week.

That is not a typo; an ophthalmologist saw a non-acute problem on a Sunday.

Now Dr. Daughter swears that she tried to get her Mom in to see a doctor all the previous week. “She” even called our office (more in a moment) and was told all of the doctors were booked. Strictly speaking, the staff member who answered the phone was absolutely correct in noting that our schedules were full (actually they were quite over-booked in the pre-Holiday rush), and that we would not be able to see a patient who had never been to our office. Dr. Daughter works for a massive health system that advertises all over town–on billboards, in print, on the radio and online–that anyone can get a same-day appointment with any kind of doctor in the system, including an eye doctor. In fact, we saw several dozen existing patients that week for same-day requested ER or urgent visits with the urgency determined by the patient, not our triage staff.

What’s my point? Dr. Daughter never made a single phone call. She had one of her staff members call on behalf of her mother; neither I nor my staff is responsive to proxy calls from staff. I know Dr. Daughter and much of her extended family. Over 25 years practicing in the same geographic area and populating the same physician panels she has sent me barely a handful of patients, even though I care for a substantial majority of that extended family. Despite that my staff would have moved Heaven and earth to find a spot for Mrs. Mom if Dr. Daughter had called either my office or me personally.

I know what you’re thinking: Mrs. Mom would get in because her daughter is a doctor. Nope. Not the case. I may have taken Dr. Daughter’s phone call for that reason, sure, but Mrs. Mom gets an on-demand ER visit despite it being our busiest time of the year because she is the family member of other existing patients. We treat family members as if they are already SkyVision patients; we just haven’t officially met them yet.

Now you’re thinking “what does this have to do with private practice?” Without meaning to be either too snarky or self-congratulatory, this is precisely why private practice continues to not only survive, but in many cases thrive. We have the privilege of putting our patients first. Really doing it. Same day urgent visits? No need to put it up on a billboard; we just answer the phone and say ‘yes’. Lest you think we are simply filling empty slots, or that we have open ER slots we leave in the schedule just in case, let me assure you that this couldn’t be further from the truth. We. Are. Booked.

Well, it must be that we are so small that the personal touch is easy. Surely if we were huge we couldn’t get away with this. Sorry, wrong again. A bunch of my buddies are orthopedic surgeons in a massive private group on our side of town. Like 15 docs massive, with all of the staff you’d expect to go along with that many doctors. Got an orthopedic emergency? You’re in. You may not get the exact doctor you’ve seen before on that first visit, but you won’t be shunted to either an ER or an office an hour away, either. The staff members making appointments for a particular office are right there, sitting up front. The same goes for the enormous Retina practice that spans 4 counties here in Northeast Ohio. Ditto for the tiny little 3-man primary care practice up the street from me, lest you think only specialists do this.

The private practice of medicine survives because the doctors go to work for their patients, and they don’t leave until the work is done. Private practice docs bend their own rules on behalf of those patients. Every day and every night. You know what happens when private practices are acquired by massive medical groups like the two 800 lb. gorillas in Cleveland? All of those rules get made by people who don’t really take care of patients at all, and they never bend a single rule ever. Those former private practice doctors become shift workers beholden to an institution, no longer working for their patients at all.

That family doctor or specialist who was routinely asked on a daily basis if someone could be squeezed in is not only no longer asked, she doesn’t even know the question was there in the first place. Everything is handled by the institution’s call center, somewhere off in a lower rent district, with no sense of what is happening at that moment in the clinic. Your doctor might have a cancellation and a spot open to see your emergency. Indeed, if she’s been your doctor for a long time she would probably rather see you herself because that would make for better care.  But there are now someone else’s rules to follow, efficiencies to achieve so that they can be touted, and institutional numbers to hit.

“I’m surprised these kind of places are still open.”

“And yet, here you are, bringing your mother in for a visit.”

On her way out, after impatiently waiting while her mother thanked me profusely for seeing her when she was uncomfortable, Dr. Daughter extolled the virtues of her employer. Fixed hours. Minimal to no evening or weekend call duty. A magnificent pension plan that vests rather quickly. I should join up, she said. She was sure that World Class Medical Center would love to have me.

I smiled and wished her, her Mom, and the extended family a Happy Holiday Season. As I turned, shaking my head a bit, my technician put her hand on my arm.

“If you did that, who would take care of her Mom?”

Measuring Health Part 3: Emotional Well-Being “W”

2016 is an Olympic year. We will hear stories, as we do in every Olympic cycle, of the extraordinary physical accomplishments of Olympians in sports which require otherworldly amounts of what we in the CrossFit world would consider “Fitness”. Strength, speed, and agility. Uncanny feats of coordination and accuracy, some performed over distances and times that are so far beyond the reach of the average human as to defy credulity. Many of these athletes, certainly the ones we will meet through the intercession of NBC, will match our expectations of the happiness that must certainly accompany such outsized achievements. Mary Lou Retton, anyone? Indeed, what we will see on our screens will fairly scream “Healthy”.

But there will be others, too. And for all of their physical fitness, expressed so dramatically for our viewing pleasure and patriotic zeal, the lack of emotional health will make it obvious to anyone that they are not healthy. Bruce Jenner, anyone?

Remember our proposed definition of “Healthy”: Able to perform in all ways at the farthest limits of one’s potential capabilities. Health is therefore the state in which no infirmity is, or can in the future, impede this ability to fulfill a potential. It takes but a moment to think of how mental illnesses such as depression, bi-polar disease, and schizophrenia can be hidden from view when examining only physical metrics. There are examples all around us. The woman who partners with a 1400 pound horse in the rigorous, physical tasks required to compete in the three-part test that is eventing, so poised and accomplished in the arena, who retreats to solitude outside the barn because she is incapable of overcoming her anxiety around people. The outdoorsman who in his manic phase performs feats of strength and endurance others can only marvel at, and then plunges into the depths of depression from which he cannot see the noon-day sun. Much more prosaic and much more common is the individual who continually increases his or her fitness by any and all measurements due to a deeply held sense of low self-worth, perhaps even self-loathing, pursuing an unreachable ideal and always falling short.

A truly universal measurement of health must include some element of emotional well-being. Let’s call it “W”. You could certainly call it the “Happiness Factor”, and some undoubtedly will. I imagine criticism directed toward this to take the form of “Happy Face” mockery. No matter. Well-Being is a better term for this part of our equation because it encompasses more than whether or not you are happy, whatever happy may mean to you, when you are measured. Are you content with your circumstances at the moment? Do you have the ability to persevere under duress?  What is the state of your relationships? A recent study of Harvard men carried out over decades found that both happiness and longevity were tied quite closely to the quantity and quality of your relationships with family and friends. Where are you in your pursuit of your goals, your dreams, and how do you feel about that? How much stress do you perceive in your life and how are you managing that? All of these make up what one might think of when we consider Well-Being.

How, then, should we go about measuring ‘W’? Remember, all of our tests should meet the dual imperatives of being accessible to pretty much everyone, and as inexpensive as possible. We could certainly use something like the classic anesthesia “smily face” pain scale, relabeling the figures, but this feels too simplistic and too momentary to be truly applicable. Our measurement should require a bit more thought than that. I have to admit here to countless hours of internet crawling trying to find a validated test of emotional well-being that has a track record in a heterogenous group that mirrors our population; most have been utilized in very specialized populations (e.g. soldiers) with a very specific research interest. Those that might apply must typically be purchased.

John Pinto is a well-regarded consultant in the world of my day job, ophthalmology. He has long had a list of clients that spans the gamut of pretty much every measurement you could think of in a group of doctors. Men and women. Young and old. Fantastically successful doctors and those that could only be described as spectacular (if unexpected) failures. As part of his quest to better understand his clients in order to better serve them, John used a questionnaire that measured emotional well-being. He found that external measurements of success such as volume of surgeries, income, and professional acclaim did not always coincide with his clients sense of success, their emotional valuation of their professional lives. These were certainly variables that mattered, but his happiest clients were not always his wealthiest, and his least happy not always those who had less. The assessment he used is the best one that I’ve been able to find, notwithstanding the fact that it is not free.

(http://psychcorp.pearsonassessments.com/HAIWEB/Cultures/en-us/Productdetail.htm?Pid=PAg511 ).

I am not wedded to the Psychcorp assessment and would happily review any alternatives. Especially if they are free! As is the case with ‘M’, our traditional health metrics like blood pressure and serum lipids, I expect a vigorous debate as to the relative weight of ‘W’ in our final Health Index. My bias is that ‘W’ is a current factor with a greater impact on health, and it should have a correspondingly greater weight in our formula. Let me start the “bidding” with double; however the final formula shakes out ‘W’ should have twice the value of ‘M’.

Mental health is an inextricable part of health. It must be included in any serious definition and measurement of health. Our variable is “Well-Being” or ‘W’.

 

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…

Leading Thoughts

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

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

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

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

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

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

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

Out front.

 

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…

Evidence Based Medicine? Preferred Practice Patterns? You Are Behind the Times

If you practice Evidence-Based Medicine (EBM), or religiously follow a Preferred Practice Pattern (PPF) such as one published in a white paper by a specialty society or organization, you and your patients can be assured of one very important fact: you are providing care that is neither up to date nor care that can be described as “Best Practices”.

You might be increasing the likelihood that your patient’s medical insurance will pay for their care, in part because insurance companies have already figured out how to make money on older treatments and protocols. I guess you can feel good about that, or at least feel good that your staff won’t be forced to fill out all of those appeals forms when state of the art care is denied. So you’ve got that going for you. What used to be considered good enough care might feel better to you if your patient isn’t avoiding the older treatment because of payment issues like they do with the newer. Adherence to some care is better than non-adherence to “Best Practices”, right?

There are certainly some of you out there in doctor land who think that citing EBM or fidelity to a PPP will inoculate you from medical malpractice tort. Sadly, nothing is further from the truth. Not only will your adversary nullify a PPP by citing a “Standard of Care” that is up to the minute when it comes to how to treat literally anything (though as we know “Standard of Care” is neither Best Practices nor EBM), but there are so many instances of EBM not allowed as evidence at trial that it’s nearly useless to try. Even the strongest body of research can be nullified at trial by introducing a single non-peer reviewed study with opposite findings to a naive jury of lay people.

EBM and PPP are the result of years of studies that were launched based on prevailing thoughts at that time. They are subject not only to what is fashionable among the medical intelligentsia, but also what is fundable. The potential ROI from the industry side of the medical pie has a direct impact on not only what is studied but what treatments are available at all. A company with a blockbuster drug that has years of patent protection remaining will be unlikely to support the study and use of its own competitor or successor until under the gun of generic competition. Governmental funding of maladies without either a popular champion or sympathetic victim is slow in coming, if it arrives at all. Both EBM and PPP enter the public arena only after months or years of time spent “in committee” with old data.

At the end of the clinic day both EBM and various PPP’s suffer from being out of date on the day they are published. Because of this they create at least as many problems as they attempt to solve. In addition to providing ammunition to insurers all too happy to avoid paying for newer, more effective care that might be more expensive, the wide dissemination of various articles on EBM or PPP’s can sow confusion and doubt in the minds of those patients most in need of Best Practices, particularly those with severe or complex problems.

Any specialty in medicine could provide examples, but since I’m an eye doc let me offer one that illustrates most of the nuances involved. We’ve long known that elevated tear osmolarity (salt content) is a component of dry eye (DES). Prior to 2009 testing the osmolarity of human tears required a complex, time-consuming process that also suffered from the twin-blade cut of being both expensive and not covered by any insurance plans. Consequently the use of tear osmolarity as a core diagnostic test in the care of DES was pretty much a non-starter.

In 2009 TearLab introduced a much simpler, much less expensive test that could be done in the course of a regular office visit, and in 2010 the company received a waiver from the FDA which allowed doctors to use the test in an office setting without being certified as a clinical laboratory. Approval for payment by insurance companies, including Medicare, came shortly thereafter. As with any new test that becomes widely available it took a couple of years for clinicians to figure out the full extent of the meaning and application of the results. The short version of this part of the story is that tear osmolarity testing has become an integral part in both the diagnostic work-up and ongoing follow-up of DES patients in any advanced DES clinic due to its clear therapeutic value. It also fits into the prevailing financial model and patient mindset in which diagnostic testing is an insurance covered benefit.

What’s the problem then? Our largest professional organization, the American Association of Ophthalmology (AAO) publishes a series of PPP’s addressing many common entities in eye care, and DES is one of them. The latest version was published in 2013 after more than a year of discussion in committee based on practice patterns  and publications from 2011 when Tear Osmolarity was not yet in widespread use. The PPP made much of the fact that this at the time new test had not yet been widely adopted and that there was still some discussion about its true clinical worth. BOOM! In rushed a Medicare administrator in January 2015 with a proposal to withdraw payment for this “non-essential” test of “unproven” value.

The problem, of course, is that Tear Osmolarity is now widely and quite rightly accepted as a part of today’s “Best Practices” of DES care. Ironically, the use of Tear Osmolarity is actually an example of EBM, but that evidence has emerged subsequent to the initiation of the PPP process. Removing insurance payments will erect a barrier between patients and their best chance at treating their disease.

Thought leaders in my field as well as other, more nimble professional organizations than the AAO have offered assistance to TearLab to prevent a change in the insurance payment for tear osmolarity testing. Both eye doctors and their patients will likely survive this misguided attack on an extremely useful technology. It does make one wonder how many other instances exist where a seemingly good idea (PPP, EBM) is misused in the eternal battle between those who provide medical care and those who are charged with allocating the monies used to pay for that care. Funny, isn’t it, how the medical powers that be, professional organizations like the AAO, are always a bit behind the times, and the payment powers that be (and often plaintiff’s attorneys) use that to their advantage?

Preferred Practice Patterns and many examples of Evidence Based Medicine need to come with an expiration date, or at least a warning that using them cannot be construed as either “Best Practices” or cutting edge. Even at the time they are first published.

 

 

CPOE: Another Epic Misadventure Begins I

It’s my own fault, really. I admit that I had allowed myself to believe that the uneasy peace I’d made with Epic, the EMR utilized at World Class Hospital, would be a lasting one. A peace for all time. I would interact with the beast on a quarterly basis, signing verbal orders that kindly nurses had accepted and op notes for surgeries that deviated just enough from the routine that they needed to be dictated fresh. In return I would be allowed to simply sign orders, op notes, and other sundry paperwork as I had been doing for the last 24 years. Simple. Everyone wins. My OR days run efficiently saving me, my patients, and the institution countless hours of wasted time, and I continue to bring the majority of my cases to one of the outpatient surgery centers owned by World Class Hospital. (It should be noted that I am the lowest cost eye surgeon in the entire system, thereby generating the greatest per/case profit for WCH). I truly believed that I would still find sanctuary in the OR from the thousands of chickens pecking away at my professional satisfaction and by extension my general degree of happiness.

BzzzzzzPfffffTttttt…sorry Doc, that’s the wrong answer. Johnny, tell our contestant about his lovely parting gifts.

For the first 16 or so years of my post-residency career literally every process change in which I’ve been involved has had a direct, positive effect on outcomes or safety, patient experience, or my efficiency. About 8 years ago tiny little negative things started to creep in, some of which chipped away at that efficiency. A few more forms to sign. More pre-op checkpoints for my patients to pass on their way to the OR. Along with this came the madness that arises when a huge organization plays defense against an unregulated regulator like CMS (medicare) or JCHO (the hospital regulator). Not one, not two, but three personal checks by the surgeon to confirm the surgical site. A pharmacy either running scared or run amok that demanded a brand new bottle of eye drops for every laser patient despite an industry-wide infection rate on lasers of 0.00000001%. It was mostly piddly-diddly stuff, and the OR staff did their very best to run interference and preserve our efficiency.

Now? Oh man. The introduction of the Epic EMR into the OR has turned our 2-nurse room into a 2.5-3 nurse set-up. There is so much dropping down and clicking necessary to fulfill the beast’s demands (man, would this analogy be perfect if they still let us call them Computers On Wheels?! Feed the COW!). Previously, one circulator could do all of the paperwork, prep the patient, and have time to spare to facilitate room turnover. Admittedly I move pretty quickly as I do cataract surgery, but it’s impossible for just one person to do all of these tasks now that Epic must be served, without all of the rest of us sitting on our hands and waiting. The local administration and the staff have rallied around me and my patients and for most cases an extra pair of hands is there to keep things moving. Heck, I do my part as well by taking the trash out of the room and bringing the used instruments back to the sterilization room.

With the introduction and implementation of CPOE (Computerized Physician Order Entry) all of our efforts to improve efficiency, with all of the wonderful things efficiency brings, will be for naught.

How can I possibly know this before experiencing it even once? People talk, and doctors are people. I’ve chatted with a score of surgeons about how long it takes for them to do what Epic and World Class Hospital requires of them, and I’ve got a bit of experience just signing stuff after the fact. It just simply takes a lot of time. Add to that an institutional indifference to the psychological effect of hoovering  time out of a surgeon’s day and you’ve created the world’s biggest, most frightening chicken peck.

Tell you what, let me share a few numbers with you before we make the switch, memorializing them here, dated, before the transition, so that there’s no possibility that I made stuff up after the fact. The baseline numbers I am about to share admittedly are rosy in part because everything that can be done to/with the paperwork by someone NOT me happens as part of well-established routine. Details such as start/stop times, IOL serial numbers, etc. are filled in by support staff; there is little to no chance that this will be the case when everything moves from paper to screen judging by other surgeon’s experiences.

95+% of my cases are either cataract surgeries, post-cataract lasers, or lasers to treat dangerously narrow anterior chamber angles. Through a combination of fortunate genetics and hard work I have become very good, and very fast, at all of these procedures. My team and I achieve enviable outcomes and microscopic complication rates despite the fact that we move very, very quickly. A patient having cataract surgery spends approximately 15 minutes in the OR. For comparison sake, a study from a prestigious eye hospital recently posted an average time in room of ~33 minutes for its top three cataract surgeons. Turn-over time (patient out/next patient in) is 6-7 minutes. On average it takes me 26 seconds to complete ALL of the paperwork that must be done in the OR. It takes another 9 seconds to sign the op note when it is returned from transcription; this is important because Epic will require either finding, editing, and signing an op note in the OR, or dictating one on the spot.

Our team of nurses and doctor has achieved an even more enviable efficiency when doing lasers. The average time it takes for a patient to have the entire laser experience–enter the laserium, be seated at the laser, have the laser successfully performed, and leave the room–is 3 minutes. That is not a typo. The average set-up in the United States is closer to 15 minutes or more for this procedure. At the conclusion of the laser it takes me on average of 17 seconds to complete all of the paperwork that is required, and again 9 seconds on average to sign the op note when it becomes available.

You’re probably thinking why this is a big deal, aren’t you? That I should stop whining and just get on with it. Here’s the rub: I do lots of these procedures each time I go to the OR. Any additional clerical time must be multiplied by the number of cases done that day, and all of that time will be stolen from my day. When I finish in the OR I then do other stuff that’s pretty important. Sometimes I go back to the office and see patients, patients who may have had to wait a long time for their appointment. On really good days I get to go to my beloved CrossFit gym to get a workout in. An even better day is one on which I get my WOD in and then sit down in front of the computer to write. These latter things, especially, make me happy. They make it worthwhile to work as hard as I do. Every extra minute it takes me to do something I already have to do not only brings frustration in the OR itself but also keeps me from parts of my life that bring me happiness. A happier doctor is generally a more effective doctor.

We are establishing a baseline today, and that baseline includes a certain degree of happiness. What do you think the chances are that CPOE will increase my happiness? Stay tuned for Part II.

 

Who Talks to People Like That?

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

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

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

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

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

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

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

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

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

Sometimes, the answer is “no”.

Tales from Bellevue Hospital: On Call 4th of July

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.