Random Thoughts from a Restless Mind

It took exactly one week. One whole week before we had our first adverse reaction to the not-so-new new generic eyedrop. Not a one of us was surprised because we’d been here before. The branded version of this particular medicine, version 1.0, did the same exact thing. Thankfully, branded version 2.0 and 3.0 worked like a charm with pretty much no side effects. Yup…one week forward to end up 7 years in the past. Our own little front row seat for the spectacle of the subtle, cynical rationing of “good enough”.

We’ll see more, of that I am sure.

Let me share the back story here before I expand and move on. In eye surgery, specifically cataract surgery, there is a very inconvenient complication called “Cystoid Macular Edema”, swelling of the center of the retina also known as CME. As a natural phenomenon it occurs in 6-9% of cataract surgeries, and unfortunately it occurs even in people without any risk factors who had perfect, uncomplicated surgery. However, if you treat cataract surgery patients with a Non-Steroidal Anti-Inflammatory Drug (NSAID), kind of like Motrin in a drop form, you decrease the likelihood of CME by a factor of 10, down to 0.6-0.9%. Wild, huh? A real no-brainer. A classic example of that chic and trendy outcome-based medicine thing, especially since CME is costly to treat and very scary for the patient.

This 10X decrease originally came with a cost, however. The original versions of these NSAID drops stung and burned, and some 30% of patients had swelling and inflammation in their cornea which caused a temporary DECREASE in vision. So, stinging and burning which reduced the number of people who actually took the medicine, and an inflammatory side effect that decreased vision and forced you to stop the medicine. Tough call. But we live in America. Lo and behold out come versions 2.0 and 3.0 which still have a 10 times decrease in CME, only this time without any stinging or burning, and without any inflammation and decreased vision. BINGO! Another no-brainer, right? Same benefit with pretty much no side effects. Sure. Easy. Right up until a generic of version 1.0 comes out. It took exactly one week to be reminded why 1.0 was bumped by 2.0 and 3.0.

It’s like they used to say in Amish country when my wife was a kid: it’s good enough for who it’s for.

And there’s the rub, of course. Right now it’s for “them others”, but eventually it’ll be good enough for YOU. That’s the whole name of the game with this rationing stuff, you know. All you have to get to is “good enough” and then the only thing that matters is cost. No consideration for compliance, convenience, or quality of life, the only consideration on the board is cost.

Why does this matter? Isn’t the cost of medical care in the United States the single greatest fiscal challenge facing our local, state, and federal governments? Simply put, yes, the cost of caring for an increasingly unhealthy population is, indeed, getting out of hand. Rationing based on “good enough” is based on a very superficial analysis of this problem, however. This is part of the cynical aspect of this type of rationing, because a true effort at cost containment demands a deeper root–cause analysis of the “why” it’s getting so expensive. “Good enough”, by its very nature, brings healthcare to at best a standstill, and as I noted above generally involves rolling back the clock.

Reasonable people have asked why this isn’t actually, truly, good enough. In truth, what we have available to treat diseases today, or even stuff available in 2003, is at least one full order of magnitude better than that which is available in second and third world countries today, or available in first world countries in 1975. Why WOULDN’T this be good enough? Well, how do you think we got where we are today? We did so, of course, by always seeking BETTER. Not only that, but at least in America we did so by always seeking better for EVERYONE. Even “them others”.

Rationing is the great chameleon of health care cost reduction. It’s not just the forced use of generic medications (some are actually exactly equivalent to their branded counterparts) but it takes many other forms as well. The effective denial of access to both primary and specialty care for those individuals “covered” by Medicaid. The myriad, byzantine rules and regulations that are so opaque that individuals throw their hands up in disgust and dismay and fail to seek care for fear of the financial consequences of doing so. Scarcity of resources which is either real (there is an inadequate number of neurologists practicing in the United States), bureaucratic (operating room privileges for specialty surgeons are limited by governmentfFiat in Canada), regulatory (exciting new uses for established medications go undiscovered because of FDA gag rules). or arbitrary ( payment for cataract surgery is denied if the visual acuity is not decreased to a particular level regardless of how it is affecting an individual’s life). Seriously, I could go on and on.

“Good enough” is okay, I suppose, if it is used as the floor beneath which we will not allow healthcare to fall. It’s okay if that floor is constructed by carpenters whose only consideration is the real “boots on the ground” outcome from that healthcare, NOT people whose major concern is cost alone. Finally, it’s really only okay if that floor is actually the floor of an elevator, always and ever moving upward, because even “good enough” has to get better. Every example of “good enough” is actually the result of some yesterday’s healthcare breakthrough. Some yesterday’s effort at achieving “better.” Every version of “good enough” is actually trickle-down “better”.

“It’s good enough for who it’s for” is all well and good as long as you remember that, eventually, who it’s for is you.

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 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 phasersset 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 I 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 want Dick Lindsrom’s old job. Hell, DICK LINDSTROM  wants Dick Lindstrom’s old job! I mean, seriously, who WOULDN’T  want Dick Lindstrom’s old job? The  guy was the highest paid consultant for not one, not two, not even three, but something like FIVE ophthalmic manufacturing companies AT THE SAME TIME. Oh yeah…he was also the most famous ophthalmologist on the planet, and just happened to be a fantastic surgeon, too. He’s still got those last two things going on as far as I can tell.

Eventually someone is going to have to take up the mantle. Dick has been 59 years old for 10 or 11 years now, and he’s sure to turn the big 6-O at some point and decide to “retire early”. When he  does choose to do that, or if he is driven out of the consulting business by all of the petty new restrictions on physician relationships with industry (and vice versa) it will be a sad day, indeed. Not only for  the entrie ophthalmic community mind you, but also for the legions of patients-to-be who will NOT benefit from his influence and guidance.

Allow me to explain. Several years ago some folks in government and some consumer goody-twoshoey types all of a sudden “discovered” that doctors were consulting for companies that made medicines and things like implants and the like. They also “discovered” to their collective horror that these same companies not only paid these consulting doctors, but they also sometimes did “gifty” stuff for doctors and their staff members. Terrible stuff like, I dunno, buy lunch for the office or leave a bunch of logo pens or sticky notes around the nursing stations. Even more recently the startling discovery was made that these same pharmaceutical and medical device companies have been supporting post-graduate medical education.

The horror…the horror… (apologies to Conrad).

Dick Lindstrom has been one of the most influential clinical investigators in all of medicine for more than 25 years. By this I mean that he has suggested, launched, led, participated in, and reported on to his colleagues so many studies that led to ground-breaking clinical breakthroughs that his legacy must be considered not only in eyecare but in ALL of medicine. If you had a better medicine, or if you made a better cataract machine, chances are Dick not only had a hand in its development, but he also jumped to your better widget even if your competitors were paying him to consult on theirs. Patient first.

The guy just couldn’t be bought, in my opinion. Not only did he always choose whatever medicine or instrument was best at any given time, but his widespread, almost omnipresent involvement across the industry gave him a platform to push each competing company to outdo its competition. A continuous daisy-chain of technological advancement with Dick Lindstrom as ringleader. And now this small-minded, short-sighted movement would have Dick give up either his consulting or his clinical practice. Did I mention that he’s been among the most talented practicing eye surgeons for 25 years, too?

The food and goodies part of this stuff is inconvenient (I bought pens for the first time in my adult life this year), but really not much more. It does make the jobs of the industry reps more difficult, and frankly just seems to be mean-spirited and  petty. I mean…come on…if Dick Lindstrom hasn’t been swayed by the massive sums he’s been paid by companies for whom he has consulted, how insulting is it that the prevailing opinion in Washington and elsewhere is that MY choices can be bought for a Subway foot-long?! Seriously?

The development of new technologies and new medicines is expensive. So, too, is the post-graduate continuing education of our nation’s physicians. They can’t occur in the vacuum of the laboratory, nor can they occur in the vacuum of the boardroom. The people who do this work need the assistance of doctors who not only take care of patients but who also understand both research and business. To prevent pharmaceutical and medical device companies from supporting programs for continuing education, while at the same time allowing these same companies to market directlty to patients, is simultaneously the most cynical and naive hypocracy imaginable.

To erect arbitrary and artificial barriers that prevent people like Dick Lindstrom from making the kinds of contributions for which he is justly famous (and for which he has been appropriately compensated) is pure folly. Folly which approaches madness.

Here’s the rub…I don’t think any doctors are going to quit what they’re doing because we have to buy our own pens, and I doubt that any of us will hang up our spurs just because we now have to make our own sandwiches for lunch. I AM concerned that participation in major medical meetings will decrease if it becomes more expensive because industry support is legislated away. I AM concerned that doctors of all types will do only the minimum continuing education necessary to mantain their licensure. I AM concerned that these foolish proposals that seek to prohibit clinical educators from also receiving compensation for consulting will dramatically reduce the quality of whatever education we might be receiving.

To do ANYTHING that might prevent Dick Lindstrom from being Dick Lindstrom is pure folly, and I AM concerned about that.

Wait…wait a minute. Could that be it? Could the whole problem simply be Dick? That it’s really just a Dick Lindstrom problem? Is it possible that all of these regulations, the no-pen/no-lunch rules, all of the nonsense about educators and leaders being prohibited from simultaneously having consulting agreements is all just a huge anti-Dick Lindstrom thing?

Well…why didn’t you say so? We can fix this thing right tidy-like. I want to make contributions to my field that will stand the test of time. I want to be known as a clinician/investigator/consultant who always put his patients first before any and all other considerations. I want colleagues to look at a new technology and have the first words out of their mouths be: “What do you think Darrell White thinks about this?” And not for nothing, I wouldn’t mind having those vintage consulting contracts. In a word, I want Dick Lindstrom’s old job. Who wouldn’t?

Because we all need SOMEONE who’s willing and capable of being Dick Lindstrom when he finally turns 60…

They got it half right. The jury that is. The jury in the malpractice case in which I just served as an expert witness got it exactly half right. Kind of like our whole medical malpractice court system if you think about it. A young woman had a bad outcome in one of her eyes following eye surgery, an outcome that has caused her quite a lot of unhappiness, quite a lot of difficulty. The jury was quite correct in recognizing this, and also quite correct in recognizing that this woman was going to need some financial help in order to make this difficult situation even a little bit better. In order to make this happen the jury found the doctor who performed the surgery guilty of medical malpractice.

Only one problem with that, though: no true malpractice actually occurred.

Herein lies the essential, fundamental problem with our medical malpractice tort system as it is presently constituted. Every single malpractice case is a “zero–some game” in which the only way that an individual who has been injured or otherwise suffered a bad outcome from some medical experience can receive financial help is for some doctor (or hospital) to lose a malpractice case. As an aside, the plaintiff’s attorneys, the lawyers who represent the victims of medical misadventure, must win the case in order to be paid. (The full–disclosure necessary here is that the only people who are guaranteed to be paid are the defense attorneys and the expert witnesses on both sides of the case.)

I’ve actually been up at night, literally losing sleep every night since the conclusion of this trial. That’s actually kind of odd, and doesn’t really make any sense at all because I received rave reviews for not only my testimony but also for the strategy suggestions I made over the four years it took to bring this case to its conclusion. Indeed, even the court reporter went out of her way to tell the defense team what a great job I had done. It’s kind of like getting all kinds of pats on the back for making 10 receptions for 200 yards in a football game your team goes on to lose–pretty empty feeling despite the fact that you did your part well.

What then, exactly, is medical malpractice? In the civil court system in the United States medical malpractice requires that two things have occurred. First, a doctor (or hospital) must commit an act of COMMISSION (do something) or an act of OMISSION (fail to do something) that falls below the Standard Of Care. This failure to meet the Standard Of Care must then result in some kind of harm to an individual. To be extremely technical and to–the–letter correct, the failure to meet the Standard Of Care is malpractice, and the resulting harm is malpractice liability. No need to get all tied up in that kind of detail; let’s just call the whole thing medical malpractice.

The Standard Of Care is a difficult concept. In effect, the Standard Of Care is defined as that care or medical decision-making that a preponderance of (most) similar practitioners would provide in similar circumstances at that time. Pretty nebulous, huh? Not a terribly rigid, hard, easy to put your hands around definition, and it’s a moving target on top of that. The Standard Of Care is an ever–evolving thing; new research findings, new technology, and new patterns of care will all combine to create a Standard Of Care that may be different today than it was even last year.

In this particular case there was never any question that it was a medical procedure that caused this patient to have such a bad outcome. There was never really even any question about the technical quality of the work performed by the doctor. No, what it all came down to was a question of whether or not the surgery should have been performed in the first place, and thus came into play that subtle little part of the Standard Of Care, the difficulty in describing to a jury of non-–physicians the difference between the Standard Of Care today and that of some years ago. The lawyers for the patient did a brilliant job of burying the jury with the details of HOW the complication arose, the difficulties that have arisen because of the complications, and the uncomfortable interactions that occurred between doctor and patient in the months following the surgery. They confused the jury about the difference between “could have done” (more than the Standard Of Care) and “should have done” (Standard Of Care). The lawyers were able to bury the fact that the Standard Of Care was followed by the doctor in question because at the time of surgery the PREPONDERANCE of similar physicians in similar circumstances at that time would have done the SAME THING.

The jury got it half right.

There, in a nutshell, is everything that’s wrong with our present medical malpractice tort system. In order for this woman, obviously harmed by this procedure, to receive some award so that she can do certain things that will make her life easier, she and her team had to “beat” a doctor and win in court. And oh yeah, she’ll also have to give 40% of whatever her award might have been to her lawyers. I think that’s a big part of why I’ve been having trouble sleeping. Not the lawyer payment thing, but the fact that a doctor who (in my opinion) practiced within the standard of care must now have a black mark against his name so that a patient can get some money that I frankly think she deserves.

Maybe a better analogy of my role in this “competition” would be something more like this: I was the consulting coach brought in to suggest an additional element to a figure skater’s program. Assuming that everyone in the competition was as conversant with the subtleties of the rules involved I suggested that the skater add an elegant, understated movement that would be obvious to any experts on the panel of judges, the jury as it were. Unfortunately, in our American system of medical malpractice, that’s not the case, and the opponents eschewed subtle elegance in favor of multiple quad jumps. The skater I assisted performed totally within the letter of the rules, but was penalized because the jury, the panel of judges, was not really an expert panel and missed the added element. And so he lost.

I DO wonder though what my reaction would have been if the opposing skater who landed all those quads had been the one who lost. Would I be up at night over that, too?

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

I’m not sure if they still use these terms, but I take full credit for the original use of “target” to describe the victims of violence who came to the Bellevue Hospital emergency room. As an ophthalmology resident I was on call every fifth night, and because I lived outside of the city I actually have to spend each on-call night in the hospital. The bad news, of course, is that I didn’t get to sleep in my own bed. The good news was that I developed a more friendly relationship with the ER attendings, fellows, and residents, as well as the nursing and clerical staff. I also developed a very easy relationship with the prison guards from Riker’s Island. The term was coined, and the game was set when I sauntered into the ER in the wee hours of some morning and asked out loud to no one in particular: “okay, where’s the target?!”

Whether it was primary care or specialty care clinics like our ophthalmology division, Bellevue Hospital was where people who fell through the holes in the safety net went for their medical care. Pretty much everyone received care that they couldn’t receive anywhere else, so it was easy to feel good about the contribution that you were making, even as a resident. It would be difficult to pick out the person I helped the most over my three years in New York except for young Jean, the target from France who I saved one night while covering the ER.

It was around midnight and I was seeing an older woman who was complaining of flashes and floaters. A Latina, my patient spoke not a word of English, so I was delighted to make the acquaintance of her daughter, a lovely woman roughly my age who accompanied her mom and acted as translator. I excused myself when the phone rang. “We gotta target from Rikers for ya Darrell. Not a word of English.” Send ’em right up was my response, pretty confident that my new friend the patient’s daughter would be able to translate for what I expected to be a Riker’s Island prisoner who spoke nothing but Spanish. Imagine my surprise when a rather thin, soft, artsy looking boy of 20 or so from France shuffled into our waiting room, his right eye black and blue and swollen tight.

The target part was pretty much standard fare, punched in the eye, but everything else was totally out of place. The visual was just wrong on more levels than I could describe. My new best friend said she knew little bit of French so I sent her out to chat with Jean while I examined her mother’s retina. Our French lad was clearly not much of a threat; the unwritten communication between the doctors and the writers Island guards told us as much, the guards chatting between themselves at the other end of the room. These two particular guards, a man and a woman who were not part of the normal Bellevue Hospital crew, would actually become a pretty important part of saving this target.

I finished up with my older woman, reassuring both her and her daughter that the flashes and floaters were nothing to be alarmed by, and that they would eventually go away. I asked her daughter what she had discovered, and with a sad, slow shake of the head she started to tell the story.

Jean, our target, had been in the United States for less than 24 hours. He was to visit friends, and had arrived a day earlier than a bilingual friend, another young Frenchman who would be the tour guide and connector for a group of kids in New York City. Rather naïve and not the least bit street–savvy, Jean decided that he would go on a walking tour of the city around Penn Station. This was back in the mid-1980s, and Jean came from a very fashion conscious family. It was cold in the city and he was wearing a fancy, team logo jacket, the kind the gangbangers in the city were wearing at the time. Sure enough, he happened upon a group of gangbangers very early in his travels.

The leader of this street corner group told Jean that he admired his jacket. He admired it so much, in fact, that he thought Jean should give him the jacket. Jean, of course, had absolutely no idea what the gangbanger was saying;  he only spoke French. The gangbanger pulled a knife and threatened Jean. Amazingly, Jeann took away the knife and stabbed the gang banger! When the police arrived and asked what had happened Jeann stood mute while the gangbanger screamed that John had tried to kill him. Unable to tell his side of the story–the street cops didn’t speak French– he was arrested for attempted murder and sent to Riker’s Island.

Now jacketless but still otherwise fully clothed, our target found himself in a holding cell at Rikers. It turns out that he was also rather fashionably shod, wearing brand-new leather sneakers that were all the rage at the time. You know, the kind of sneakers the gangbangers wore. Not too surprisingly his cell mates, at least some of them, were gangbangers. One of them approached Jean and proclaimed his admiration for these brand-new sneakers. Jean, of course, had no idea what he was talking about, seeing as he still didn’t speak a word of English. When it became clear that the gang banger was demanding his shoes Jean refused. The gangbanger cold-cocked him in the right eye and another target was off to the Bellevue Hospital emergency room.

With the exception of this fascinating story taking care of Jean was otherwise standard target fare. After prying open his swollen eyelids I was able to determine that his eye was intact and that no damage to his vision would ensue. But now what? What do I do with this thin, soft, French speaking 21-year-old all alone in New York City. I decided that I would help this one. If I ever made a difference, I would make a difference for this one.  This target, the recipient of violence he neither deserved nor sought, this was the one target, that one patient I would help outside of the professional help I gave everyone else.

How? What could I do? What did this young man need? There it was! What this young man needed was help telling his story. I was in the middle of the biggest hospital in the biggest city in America. Surely I could do this. Little did I know…

We’ve had lots of new people around Skyvision Centers recently. Two sets of consultants have come through at our invitation, our hope being that they would help us improve our patient education process. While they certainly had lots of really good ideas, systems and protocols that have been tested and found to be quite helpful in typical eye care practices, we found that they didn’t really translate terribly well “off-the-shelf” at Skyvision.

Why? It turns out that we have a very different culture at Skyvision, and that the management structure we use to foster that culture is so foreign to traditional medical care that we had to eat up some of our consulting time teaching the consultants who we are and how we work. Oddly enough, the question that set this process off was one that probably seems to be ridiculously basic to these two groups of consultants, but one that turned out to be nearly impossible for us to answer. “Who is your office manager?” Um… well… Gee., we don’t really HAVE an office manager. “Well, who should we talk to , then?” The answer to this question turned out to be just as difficult for them to understand: “everybody.”

I should start, I guess, with a word about our culture. I described the Skyvision culture to a new employee yesterday as a group of adults behaving like adults and treating each other like… adults. I told her to think of us as a Tribe of Adults! This is all I really wanted from my staff five years ago when I founded Skyvision. My most enjoyable part of management has been “blue-sky thinking”, setting priorities, charting a course, and allowing my people to work to the absolute limits of their capacity and ability in order to bring us home. Employee relationship monitoring and management is beyond boring and only barely tolerable. Hence, a Tribe of Adults.

Unfortunately, the typical management structure in small businesses in general and medical businesses in particular is not really conducive to fostering this kind of culture. Pretty much every other medical practice that I’ve ever been involved with, either as a physician, a patient, or a consultant has been set up as a steep management pyramid. Very strict top–down management in a command and control environment. Lots and lots of rules and regulations with an equally dense layer of middle management whose prime objective appears to be applying discipline to everyone who falls below it on the pyramid. Individual initiative is totally suppressed, and even the task of managing your relationship with a coworker is given over to a manager. Yuck.

But a Tribe of Adults clearly needs to be managed in a totally different way. A group of people who are willing to take responsibility, not only for the outcomes of their work product but also for their own personal behavior and relationships within the organization is best managed with as flat a management structure as possible. The ultimate flat organizational chart would be one in which literally no management existed. This is impossible, of course, because at some point someone has to chart the course, lay out priorities, and designate goals. After that  a Tribe of Adults shouldn’t need much management!

Enter the “Pond Theory of Management.”  Unlike the top–down management of a pyramid, if you look at an organizational chart set up according to Pond Theory from the side, what you will see he is a very thin layer on the surface of the pond and a few tiny flowers sticking up a bit above the surface. The magic, though, is looking at this organizational chart from above. If you look down on the pond what you see are a number of lily pads which flow on the surface of the pond, one for each employee in the business. The flowers above the lily pads represent a small number of individuals responsible for big picture issues and those very few instances where the Tribe of Adults cannot work through an issue on its own.

How does this Pond Theory of Management really work? The key, critical difference between a business run based on Pond Theory and one that is run on traditional command-and-control principles is in the allocation of tasks. In command-and-control theory some manager assigns a worker to a task, and might even assign that worker responsibility to direct other fellow workers in the accomplishment of that task. In the Pond there are areas where lily pads overlap, tasks that could be performed and responsibilities that can be shared among two or several workers with similar skills or job descriptions. Where these lily pads overlap the responsibility and the accountability for completing this task or achieving this goal is determined by mutual affirmation of all the workers whose lily pads overlap.

The individual who now has accountability and responsibility for this task retains them as long as he or she is able to deliver the desired outcome; all of the other workers whose lily pads overlap accept this individual as their leader for this particular task. In a similar and related manner, those workers who have affirmed this individual give up any “right” to criticize how this outcome is achieved. There are certain rules and regulations that might apply, of course. In our medical world HIPPA and other government regulations are unavoidable. National, state, and local laws apply, too! Beyond this what we achieve in “The Pond” is outcomes with minimal managerial oversight,  interference, or necessity.

After two full days with us I’m still not sure the consultants really got what I was talking about, and if they did I’m pretty sure they didn’t really believe me. How about my new hire? She came from an extremely rigid practice with rules and regulations to account for pretty much every minute of her day, and a manager who monitored each one of those minutes to make sure that there was 100% compliance with all of those rules and regs. What was her reaction when I explained to her the culture of a Tribe of Adults working in an extremely flat organization, working on the Pond?

“Wow! We’re all BIG girls here!”

Uncle. I give up. Full surrender. Total capitulation. I cannot beat the takers.

It’s funny because my first three drafts of this missive started out “stop the madness”, but I can’t. It won’t stop. The “Do-Gooders” and “We Shoulders” who make the decisions because “they think” or “we feel” have beaten me. Beaten everyone like me. The white flag is up. Turns out the windmill is really a dragon, and contrary to what it says in all the fairy tales the dragon always wins.

You see I, Dr. Quixote as it turns out, thought that being right made a difference. I thought that data, precedent, FACTS would rule the day. Silly me. Silly, sorry sad little me. I thought it was about patients, patient outcomes, statistics, but all along it’s been about the system and protecting the system, protecting it from the very possibility of theoretic risk, protecting it from…patients.

Here I was looking at yet another cost being added to the experience of my surgical patients and asking why a change was being made. Why were we opening a new bottle of $13.00 eye drops for each laser patient, when each bottle held enough medicine for 100 patients? Why were we using a new vial of antibiotic to be injected into the infusion bottle of each case, when each vial held enough medicine for 5 cases? Why, indeed, when there had never…not once…been a reported case of acquired infection, ever, from using one bottle or one vial. Ever. When eye doctors in their offices use and have used, bottles of eyedrops until they can’t squeeze our a single extra molecule. Why?

I blanched at the waste. Plastic baggies of bottles full of drops carted to the trash. Vials of man’s best antibiotics less the microliters used for one surgery crowding the sharps buckets. It was unconscionable, an insult to Puritan and non-adherent alike. The amount of waste nothing short of vulgar.Did no one else see this? I mean, here we are in the supposed throes of a healthcare crisis born of excess and waste, and yet I, Dr. Quixote, flailed alone?

Data…surely data would prevail. Look at the cost, I cried. Never mind the insult to the Puritan ethic, simply look at the cost! You can’t bill the patient, though Lord knows you’ve “mistakenly” done so innumerable times. It’s a cost. It decreases “revenue in excess of expenses” (you’re a non-profit…I get it…we can’t call it profit). I even understand why you’ve spurned my entreaties about Pre-Admission Testing even though there was an article in the New England Journal of Medicine that said PAT is unnecessary. The NEJM is the only medical journal that God reads, and even SHE knew I wouldn’t win THAT one because you can get PAID for PAT. I get that one.

You’ve beaten me. Today I see it. You sent in the REAL decision maker, one of the people who make the decisions in this new age of medicine. I was still under the illusion that maybe I, a doctor, was a decision maker. That I, a doctor who looked at and liked real data, had a vote, some skin in the game. No, today you sent in The One From Pharmacy. I have seen the One With Power and now I know that I am beaten.

The One From Pharmacy has all the words. He has all the weapons. “It’s only fair that each patient receive the same freshly opened bottle/vial.” “What if we have an infection and we re-used a bottle? How could we ever face that patient?” “Here’s an article by a pharmacist that says you could possible have contamination of an open bottle.” “Should we ignore this article that discusses the theoretic possibility of infection?” I also know from prior conversations with The Hospital Administrator that The One From Pharmacy cannot abide not knowing the destination of each drop, cannot abide not having the option of charging each individual patient (if only he could) for each medicine, and that a new bottle must be opened and assigned to each patient for this purpose. This I know.

Oh, I tried. I really did. I tried to point out that each of the articles the The One From Pharmacy shared with me were nothing more than opinion pieces, essays that were little more than editorials sharing one author’s thoughts. His or her feelings. “I think,” therefore it must be. But…but…but…there’s no DATA. No evidence. Nothing to refute decades of experience in the operating room. No results or reviews showing that the status quo is dangerous, only some somebody who managed to get what “they think” into some non-peer reviewed journal.

“Doctor, are you saying that we should just IGNORE these articles? You would have us simply continue with business as usual? The governing bodies ALL say this COULD happen. Are you saying that we should ignore what they THINK?” I confess, I had no answer. I was paralyzed, caught between my horror at the thought that decades of success, as well as common sense so obvious it made stomach hurt, were to be tossed aside because of some someone’s feelings, and my fascination at the sheer revulsion registering on the face of The One From Pharmacy. Funny, he wasn’t anything at all like what I thought the dragon would look like.

I stood there for a moment, bleeding, as the realization slowly came to me that I was defeated. Vanquished. It’s a shame, really, because doctors of my generation are the last, best hope for all of us. We bridge the divide between the ancients who lived through the Golden Age of Medicine–the Giants who cured polio, discovered antibiotics, replaced joints–and the moderns, the nextgen who will live through the silicon age of medicine–Dwarfs who will serve a system, cure the economics, replace care.

I felt small, diminished, inconsequential, a failure, a disappointment. It was hard, frankly, to haul my carcass to the operating room to begin my work day. Yet that’s exactly what I did. I mounted my steed and raised my lance; slowly, ever so slowly, we rode alone to the operating theater.

A white flag, attached to my lance, waving in the breeze.

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. 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. 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 first prospective, double–blind, randomized clinical study done on a cooperative basis across the entire country, and 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 this tale from Bellevue Hospital as part of our optics classes, is one of the men who trained me.

A message heard while calling to speak with a colleague at 5:01 on a Thursday afternoon: “Thank you for calling Waterworld Eye, a division of World-Class Hospital. Our office is closed. Our office hours are Monday through Friday 8:00 AM until 5:00 PM. If this is an emergency please hang up and dial 911, or go directly to the emergency room. This system does not take messages.” Something like that.

This is what has come to.This is how World-Class Hospital, held out as the beacon of hope, the shining example that all in medicine should follow, this is how they deal with emergency patients who are in need of specialty help. The same institution that took out a full-page newspaper ad touting  “same–day appointments” is not available to see emergency eye visits after 5:00 PM or on the weekends. This is the type of system that our federal government believes will bring better health care to all Americans.

Brings a tear to the eye, don’t it?

About a week ago my wife and I celebrated our 25th Wedding Anniversary. A part of our “gift” to ourselves was a four-day weekend, four days without any plans to visit the offices of Skyvision Centers, and four days where my partners would answer as many of the emergency calls that they were qualified to handle. My partners are optometrists, eye doctors who are trained in vision care, and at least in the state of Ohio eye doctors who are also trained and qualified to take care of medical diseases of the eye. I am an ophthalmologist, an M.D. I went to medical school, did a medical internship, and then did a residency in ophthalmology. I am trained in vision care, the care of medical diseases of the eye, and I am trained to perform eye surgery as well. As such even though my partners were the first line of “on-call”, and even though I was “off–duty” for my four-day Anniversary weekend, I still had to be available for any emergencies that might require my additional training, my special skills.

On Monday evening, day three of our four day anniversary gift, I sat next to Beth while finishing the last of the “Girl with the Dragon Tattoo” books. We enjoyed a magnificent dinner of lamb chops and all the fixings, accompanied by one of those rare finds at the wine store: a $20 Cabernet that tasted like 100 bucks! The bottle was still one third full; it sat just behind me next to my empty Reidel goblet. “You know what I miss,” I said. “When my face is already numb, I miss the freedom of being able to have another glass. Another glass of joy, another glass of goodness.”

Now, I’ve always taken ER call. Every practice I have ever been part of has always had doctors available to see emergency patients, pretty much 24–7, 365. No “nurse on call”, no call 911 or go to the emergency room. Nope, I have always worked in a place where an eye doctor was available to see you if it was truly an emergency. Makes sense, don’t you think? The eye is a pretty specialized area, so specialized that we actually have super–specialists who concentrate either on the front or the back half of the eye! Think about that… and organ roughly the size of a large marble that is so complex and whose care is so complicated that it has to be divided in half! Call 911 for this?!

I left my original Cleveland practice some 5 1/2 years ago to start Skyvision. Suffice it to say that it was not an easy or clean break. No, it was all kinds of messy and ugly, with very hard and uncompromising business and legal stuff before, during, and after. And yet, with all of the inconvenience, and all of the bad blood, and all of the hardships that we and I endured as Skyvision Center started from scratch, the only thing that really affected me, the only thing that really hurt, was when I was ousted from my emergency call coverage group because I left the other practice. That one hurt, and continues to hurt. (If anyone involved in my prior practice or in that call group decision reads my blog, and I certainly would if I were them, the score on this one is definitely you 1–Darrell 0).

Why is that, exactly? Why should such a seemingly minor part of an otherwise very hard experience be the only thing that hurt? Well, it’s rather simple and rather complex. You see, everything about the way we handled emergency calls in my previous practice, and everything about the way the other practices involved in our call coverage group handled emergency calls was exactly correct. Everyone, and I mean EVERYONE involved, routinely and regularly took the high road. Everyone answered patienT calls. Everyone went in to see a patient who had a true emergency, seven days a week, at all hours of the day or night. Emergencies, true emergencies, do not respect either the calendar or the clock.

Now some folks certainly abused our collective goodwill, calling after hours or on the weekend and manufacturing an emergency simply because it was more convenient for them as patients to come in during non–office hours. But this was really more the exception than the rule; all of our patients respected our personal time and personal space, and demonstrated their respect and gratitude for our collective availability by calling only when they had a real problem. (As far as I know, all of the doctors in all of the practices in that call group continue to do just this.)

So who’s right? Are we, the private ophthalmologists and optometrists who take the phone calls from our emergency patients and see them when it is necessary, are we right? Or is it Waterworld Eyecare and World-Class Hospital, and by extension our federal government and “health care reform”, dial 911 or go to the ER? Are they right.  Let me tell you a story and I’ll let you decide.

Just before my four day weekend I got a call at 10:40 at night, 20 minutes after I had retired for the evening. The father of my patient, a 10-year-old girl with a extremely high glasses prescription, had torn her contact lens when she was trying to remove it for the evening. Half of the contact lens ended up in the sink, and half of the contact lens was still in her eye, stuck way up underneath her eyelid and unreachable by either  young Maria and her parents. My phone was right next to my bed, 2 feet from my pillow as it is every night. I answered the phone, spoke with the father, got dressed and went to the office to remove the other half of the offending contact lens. Didn’t even really give any thought to any other options, to tell you the truth. What if they had been patients at Waterworld I? “Hang up and call 911, or go to the emergency room.” Your call.

So on that Monday night, day three of my four day weekend, wine in the bottle, glass empty, face not yet numb… I sighed, turned the page, and continued to read.

…well, you know.

It finally happened; I have finally made decisions that were based primarily on covering my own  ass.  One of these decisions was strategic, and the other one was directly related to the care of one particular patient. Let me explain.

The first decision, the strategic decision, had to do with performing consultations in the hospital setting. These have never been a whole lot of fun, and they have never been a terribly profitable venture from a business standpoint. But for many years I, and most other off ophthalmologists in my community, have performed hospital consultations at the request of both community primary care physicians and hospitalists, pretty much whenever we were asked. Almost none of these consultations was mandatory, an examination that absolutely had to occur during the time of hospitalization. Oddly enough, or perhaps not so oddly, a significant percentage of the patients for whom these consultations were performed were uninsured, way more than the likelihood of this occurring due to chance.

That was okay, though, for the longest of times. Everybody was doing it, performing these consultations, and those of us who did so received a kind of “good Samaritan” benefit of the doubt. You see, we do such extraordinarily good work as a specialty, and that work is so terribly dependent on very advanced technology including large, expensive, and mobile equipment, that every consultation that we performed in the hospital setting was a pale, inferior product in comparison to a consultation performed in our offices. As time has gone on my sense that I would continue to receive this “good Samaritan” dispensation has disappeared. I have  come to feel more and more vulnerable, more and more concerned that the inherent deficiencies of the hospital consultation in  ophthalmology make it more likely that I will miss something important despite my best efforts.

And so I am now declining to  accept hospital consultations except when I am obligated to do so as part of my turn covering the emergency room.

Now, you could accuse me of being selfish, of using everything above as a simple rationalization to stop doing something that is inconvenient and unprofitable. It’s ALWAYS been inconvenient and unprofitable! What has changed is that it now feels more dangerous to ME.

I’ve struggled with this decision, frankly. In the end, though, the decision to stop doing consultations in the hospital was actually rather easy because the quality of care that I was able to provide in that setting was so dramatically inferior to the quality of care that I have been able to provide in my offices. It was a different event, a different decision made in the context of caring for one, individual patient that has brought home just how pervasive this climate of fear in which all physicians live has become. Faced with the decision that hinged on my safety versus the convenience and care experience of one of my patients, THIS time I chose my own safety, and I made the decision in a nanosecond.

My patient was scheduled for cataract surgery on her left eye. During her prep in the pre-op holding area it became clear right away that she had prepared at home for surgery on her right eye, putting her preoperative eyedrops in the wrong eye despite our verbal and written instructions to the contrary. What  should we do, the nurses asked? Easy answer: cancel the case. But her son had to take off work, and another family member took off work to stay home with her this afternoon. Easy answer: cancel the case.

It wasn’t always this way. Years ago, in the early 90s, a patient prepped the wrong eye for glaucoma surgery. Knowing that I was planning on doing both eyes eventually I simply changed course, changed all the paperwork, and went ahead and did the eye that she had prepped. Things are different now, though. There is a paper thin line between “other eye” surgery and “wrong eye surgery”. Wrong eye surgery is a “never event”, one of those things that is simply inexcusable, and one of those things that various and sundry watchdogs are looking to find. Take a chance on some overzealous, faceless, nameless functionary, perhaps someone who has never been involved in the surgical process confusing “other eye” surgery with “wrong eye. surgery? Not a chance…cancel the case.

And that was that. For the first time in my career I had put my own ass ahead of the convenience and experience of my patient. I willingly and knowingly inconvenienced by patient and her family, even though the eventual plan was to remove both of her cataracts, because I was afraid to change the surgical plan at the last minute. Afraid that some red flag would be raised because I had changed the surgical site. Afraid to expose myself to those overzealous, nameless, faceless functionaries.

I covered my own ass!

Again, one could accuse me of being self-serving, self-righteous even. This was the first time that I had ever knowingly made this kind of decision, and frankly I can’t even remember a time when I made a similar decision for a similar reason. What was so extraordinary was how instantly I came to this conclusion, how quickly the words “cancel the case” came out of my mouth, and how completely comfortable I am with the decision. Me, the champion of patient-centered medicine, borderline obsessed with the crusade to bring the best customer – centered practices from the best consumer service industries to medical care. I instantly and knowingly put my own self protection ahead of the convenience and experience of my patient and her family.

To be honest, both the patient and her son were very understanding, and she has gone on to have very successful cataract surgery on the correct eye. No harm no foul, as the basketball great Bill Russell would put it. But that’s not really true, is it? An entire system is set up in such a way that my decision has become the  ONLY viable decision. Only the foolhardy, the reckless, or the naïve would do anything else. It’s a non-choice anymore. We physicians, descendents of those who willingly and knowingly walked among lepers and ENTERED plague-infested cities, fearless in our professional service, we have finally met our match. Terrified by those nameless, faceless, functionaries, cowed by those most definitely named, whose pictures grace the covers of our phone books, we are now left with but one  course of action.

Physician, cover thine own ass.