Random Thoughts from a Restless Mind

I don’t feel so hot. No, that’s not quite right. I feel really lousy. That’s more accurate.

I’m really not much of a complainer. I go to work unless I simply can’t rise from bed and crawl to the shower. The entire staff, my family, and every patient who walks into my office, all feed off my mood. No matter how I feel, how up or down I might be, on the outside it’s always a good day and I’m always feeling great. That’s the way it is, and that’s probably the way it’s supposed to be whenever you set the pace, and it’s certainly what’s expected of a doctor in the office. I get that, and that’s what I’ve done all of my adult life.

Except now. I’m feeling really lousy, and it’s so bad that I’m having a really hard time hiding it.

It’s partly physical, and it might be medical. No one, patient and doc alike, ever really thinks of the doctor as susceptible to human frailty of any type. Sick day? Yer a doctor…you don’t need no stinkin’ sick day! Just the same, there are a couple of things which just aren’t right.

My hands hurt. Pretty scary, eh? I’m an eye surgeon; the quality of my kids’ diet depends on the health of my hands. Nothing too big dealish right now, but just enough to engage my consciousness, oh, all day. And my shoulder, the one I hurt 3 years ago doing push-ups, it’s been buggin’ me after a little kayak rescue adventure on the 4th of July. The gym hasn’t been the sanctuary it’s been for me over the last couple of years. I’m a Crossfitter–we measure everything in the gym. I’m not making any PR’s (Personal Records) on repeat WOD’s (Workout of the Day) to speak of. In fact, my times and loads on repeat WOD’s are actually off by about 10% or so. Greg Glassman, the founder of Crossfit (a real, live, certified genius) has postulated that measured fitness is a proxy for health. Indeed, he posits that fitness EQUALS health. I’m a huge Greg Glassman fan, but I really hope he’s not entirely right on this one.

Is that it? Is that all this is about? A few dings after 51 years of being a knucklehead athlete?

(Laughing) Sure! It would be cool if that’s all there is! But there’s this little bump in my neck (probably just left over from a virus), and a general decrease in energy, generally poor quality sleep. My tolerance for the little inconveniences in life is nil. My ability to let the myriad little discourtesies that are directed at a doctor or a boss is at an all time low. I’ve turned into every physician’s nightmare: the doctor as a patient.

Who watches the watchers? Who looks out for those who are tasked with looking out for others? Who is there to care for those who dispense care?

Medicine of all kinds is the ultimate looking glass. Patient or doctor, you spend pretty much all of your time on one side or the other. As much as we as docs try to empathize with a patient it’s simply impossible to do any better than sympathize, even if we have the exact same symptoms or diagnosis; our experience is NEVER the same. We speak the language so our conversation with our own doctors is different. They nearly always treat us as colleagues first, patients second. We either get a pep talk or end up with the “blue-plate special” work-up.

Me? It will likely turn out to be the result of the unrelenting grind of being a doctor who takes care of patients. The countless little cuts from non-medical folks who are involved in the “care” that make it more difficult to do your job. The incessant bleating in every media outlet about the “problem with doctors”. The patient, or family member of a patient, who has received state of the art, best in class care and the best possible outcome, yet finds it necessary to complain about something. It will likely be the endless weight of carrying the financial health of 15 families on my shoulders like so many other small business owners.

When the doc does go down he/she never goes alone. Private practice or huge institutional setting, we are each an integral part of a complex micro-economic and social ecosystem. Set apart, but never truly separate. We never go down alone.

I have an image in my mind, a slow video of waves washing over a rock which sits at the mid-tide mark. It’s a substantial rock. Sturdy. Large. Not unattractive. Steady. I imagine people walking by all day, every day, occasionally glancing at the rock, but mostly just peripherally aware that it’s there. A crab underfoot might prompt a jump to safety, a daydreaming beachcomber might stub a toe, but mostly folks just don’t really think about the rock. Nobody notices that after years and years of twice daily tides the rock has started to show some wear. A tiny crack here. A little chip there.

I don’t feel so hot, and high tide is nigh

I don’t feel so hot. No, that’s not quite right. I feel really lousy. Yah…that’s more accurate.

I’m really not much of a complainer, at least for a guy (women are much tougher than men in all ways). I go to work unless I simply can’t rise from bed and crawl to the shower. The entire staff, my family, and every patient who walks into my office feeds off my mood. No matter how I feel, how up or down I might be, on the outside it’s always a good day and I’m always feeling great. That’s the way it is, and that’s probably the way it’s supposed to be whenever you set the pace, and it’s certainly what’s expected of a doctor in the office. I get that, and that’s what I’ve done all of my adult life.

Except now. I’m feeling really lousy, and it’s so bad that I’m having a really hard time hiding it.

It’s partly physical, and it might be medical. No one, patient and doc alike, ever really thinks of the doctor as susceptible to human frailty of any type. Sick day? Yer a doctor…you don’t need any stinkin’ sick day! Just the same, there are a couple of things which just aren’t right. Sure, I’m 51 years old, and that might have something to do with this, but…

So what’s going on? Hmmm…my hands hurt. Pretty scary, eh? I’m an eye surgeon; the quality of my kids’ diet depends on the health of my hands. Nothing too big dealish right now, but just enough to engage my consciousness, oh, all day. And my shoulder, the one I hurt 3 years ago doing push-ups, it’s been buggin’ me after a little kayak rescue adventure on the 4th of July. It’s not really a new problem actually, and it still only keeps me from doing a couple of things I LIKE to do (play golf) and not anything I NEED to do (work), but it wasn’t getting any better, and for a few days it was a little worse.

The gym hasn’t been the sanctuary it’s been for me over the last couple of years. I’m a Crossfitter–we measure everything in the gym. I’m not making any PR (Personal Records) on repeat WOD’s (Workout of the Day) to speak of. In fact, if I’m really being honest here, my times and loads on repeat WOD’s are actually off by about 10% or so. Greg Glassman, the founder of Crossfit and a real, live, certified genius has postulated that measured fitness is a proxy for health. Indeed, he posits that Fitness EQUALS Health. I’m a huge Greg Glassman fan, but I really hope he’s not entirely right on this one.

Whaaaat! Is that it? Is that all this is about? A few physical dings after 51 years of being a knucklehead athlete? Not doing so hot in the gym? Ack, suck it up and quit yer whining!

(Laughing) Sure! It would be cool if that’s all there is! But there’s this little bump in my neck (probably just left over from a virus), and a general decrease in energy along with generally poor quality sleep. My tolerance for the little inconveniences in life is nil, and my ability to let the myriad little discourtesies that are directed at a doctor or a boss is at an all time low. A couple other vague and maddening symptoms that have turned me into every physician’s nightmare: the doctor as a patient.

Medicine of all kinds is the ultimate looking glass. Patient or doctor, you spend pretty much all of your time on one side or the other, and your perspective is irrevocably set by which side you started on. As much as we as docs try to empathize with a patient it’s simply impossible to do any better than sympathize, even if we have the exact same symptoms or diagnosis;  our experience is NEVER the same because we are doctors. We speak the language so our conversation with our own doctors is different, and our doctors nearly always treat us as colleagues first, patients second. We either receive a little lip service and a pat on the rump, or more likely end up with the “blue-plate special” work-up in which no stone is left un-turned, no opportunity to pet a Zebra missed.

Nope, it will likely turn out to be the result of the unrelenting grind of being a doctor who takes care of patients. The countless little cuts from folks who are involved in the “care” that make it more difficult to do your job. The incessant bleating in every media outlet about the “problem with healthcare” and the “problem with doctors”. The patient or family member of a patient who has received state of the art, best in class care and the best possible outcome, and yet finds it necessary to find something to complain about. It will likely be the endless weight of carrying the financial health of 15 families on my shoulders like so many other small business owners. It will likely come down to the blessing and the curse of having an out-sized work capacity and an under-developed ability to demand the same from others, to demand that they share the part of the load that is rightly theirs. Non-medical business owners have resources to call on in these situations, organizations like YPO, Tech, and EO. Docs? Meh, not so much.

Who watches the watchers? Who looks out for those who are tasked with looking out for others? Who is there to care for those who dispense care?

I know what you’re thinking. WAAAAA…what a crybaby! Send in the Whambulance and get this whiner outta here! Maybe. Perhaps. But you’d better have a bunch of those Whambulances on call, because when the doc does go down he/she never goes alone. Private practice or huge institutional setting, we are each an integral part of a complex micro-economic and social ecosystem. Set apart, but never truly separate. We never go down alone.

So, where to turn? To whom do I bring this? My own doc will undoubtedly rule out any and all illness as expected (but I’ll still end up with that CT of the neck). I have an image in my mind, a slow video of waves washing over a rock on the beach which sits at the mid-tide mark. It’s a substantial rock. Sturdy. Large. Not unattractive. Steady. I imagine  people walking by all day, every day, occasionally glancing at the rock, but mostly just peripherally aware that it’s there. A jellyfish in the surf or a crab underfoot might prompt a jump to safety; a daydreaming beachcomber might stub a toe, but mostly folks just don’t really think about the rock. No body notices that after years and years of twice daily tides the rock has started to show some wear. A tiny crack here. A little chip there.

I don’t feel so hot. High tide is nigh.

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 and 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 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 the 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.

The most dangerous man in American health care is Greg Glassman. That’s right, the man who will make the biggest difference in making our country healthier, and thereby reducing the cost of providing health care, is a fitness trainer from Santa Cruz California. And you have no idea who he is.

That’s okay, though; you’re in good company. There are lots of really important, really influential people in American healthcare who have never heard of Greg Glassman. Donald Berwick, head of the Centers for Medicare and Medicaid Services? Not a clue. Toby Cosgrove, CEO of the vaunted Cleveland clinic foundation? Nope, never heard of him. So it goes, as well, for the presidents and executive vice presidents of all the various and sundry medical “letter” organizations like the AMA, the American Association of ophthalmology, and the like. The man who might hold the key to economic healthcare salvation is not even a blip on the margins of the healthcare establishment’s radar screens.

So what’s the big deal? Why is Greg Glassman the most dangerous man in American healthcare? There are two reasons, actually. First, he is right. Glassman has identified not only the most fundamental and foundational problem with the health of Americans, but he has also discovered, defined, and implemented the solution. Americans are not fit. There is an appalling lack of physical fitness in the populace. Fat and slow, or skinny–fat and weak, we are a nation of the unfit. What Science Daily calls “frailty” in an article linking a lack of fitness to poor health outcomes (ScienceDaily.com/releases/2011/04/110426122948.htm), Glassman calls decrepitude. Skinny or fat, how healthy can you be if you can’t get yourself out of a chair without assistance?

Somewhere around 2001 Greg Glassman co–founded a fitness system which he dubbed “Crossfit”(http://www.crossfit.com). He offered  the first actionable definition of fitness ever created: work capacity across broad time and modal domains. How much stuff can you move, how far, how quickly. It’s not enough to be strong, you must also be able to travel long distances. By the same token, it’s not enough to be able to travel long distances if you are not strong enough to lift your own body. This definition led to a measurement of fitness, power output or work.

To achieve this level of fitness Crossett offers the equivalent of a prescription. Exercise should consist of “constantly varied, high intensity, functional movements.” Intensity is the key. Fitness gains are not only magnified but are achieved in the most efficient manner when the exercise is performed at relatively high intensity. Functional movements include fitness standards like running, swimming and biking, but also weight training using major lifts like the deadlift, the clean, and the squat. Crossfit has returned those staples of gym classes in the 60’s, pull-ups, push-ups, and squats, to a prominence not seen since the days of Kennedy’s Presidential Council on Fitness.

Caloric intake matters; you can’t out train a bad diet or a bad lifestyle. Crossfit’s dietary prescription is quite simple: “eat meats and vegetables, nuts and seeds, some fruit, little starch and no sugar. Keep intake to levels that will support exercise but NOT BODY FAT.” Crossfit preaches the merits of both quantity and quality when if comes to food. Carbohydrates with a low glycemic index, protein containing all essential amino acids, AND FAT are all essential to producing physical fitness. Food should be seen as fuel and should be measured as such. Even the highest quality foods consumed in the most balanced proportions will produce increased body fat and decreased fitness if taken in too high volume

A funny thing happened on the way to revolutionizing the fitness industry. In addition to increased strength, increased endurance, and decreased body fat, which translated into a dramatically fewer inches and lower dress sizes, it seemed as if everyone who did Crossfit became healthier. Lower cholesterol. Lower resting heart rates. Decreased blood pressure. Elevated moods. It looked like a move away from decrepitude and frailty was actually a move TOWARD health. Toward WELLNESS.  A scientist at heart, Glassman digested this information and in 2008 made the following statement: fitness is a proxy for health. Indeed, Glassman declared that fitness EQUALS health. In this, Greg Glassman is right, or at least more right than not. At a minimum, fitness is the foundation upon which health is built. A healthy nation is one that need not expend countless $Billions on curing diseases that could be prevented by becoming fit. This is the first reason why he is the most dangerous man in American health care.

The second reason is that he doesn’t care.

Greg Glassman is like the little boy standing at the side of the road watching the naked emperor parade by who declares “the Emperor has no clothes!” He is standing there watching a parade of the fat and the weak and he is saying “hey look…they can’t get their butt off the throne!” It’s uncomfortable to hear someone say that, but he doesn’t care; it needs to be said. The standard dietary dogma of high carbohydrate, low-fat diets with little or no meat? A straight ticket to decrepitude! He doesn’t care that statements like that make all of the Oz’s and Pritiken’s sputter and squirm. When asked once upon a time how to gain weight for a movie role Glassman famously responded: “ easy…non–fat frozen yogurt.” It’s no different with exercise. Walking and other low-intensity exercises? Better than nothing, but only almost. Cue the howls of the Jillians and the Jakes, and every glossy, muscly, fitnessy magazine editor in the English speaking world. Glassman is right, and he doesn’t care.

Greg Glassman has looked at what is wrong with the health of Americans and he is willing to say what that is and say it out loud. He is willing to say that we as a people are unfit, and that this is the primary cause underlying our lack of health, and our accelerating need to spend money to cure disease. He is willing to say that the vast majority of the advice that we have received to fix this is flat out wrong, whether it comes from the government or the cover of Fitness Magazine. He is willing to say the the road to economic salvation in American Healthcare leads through the gym, the grocery store, and the kitchen, not to or through something as meaningless as an “Accountable Healthcare Organization” (whatever that may be). Although he is convinced that he is right he is presently spending gobs of his own money studying the effects of the Crossfit prescription on the health of regular people.

Yup, Greg Glassman is right, and he doesn’t care that all of the so–called experts in healthcare don’t know who he is yet, or that they wouldn’t agree with him if they did. Judging by what’s going on in the physical fitness world right now as Crossfit grows 30% PER MONTH, I’d say that makes Greg Glassman the most dangerous man in American healthcare.

Better learn how to spell his name.

It’s still winter here in northeast Ohio, regardless of what the calendar may be saying. We don’t have weather right now, we just have shades of grey. My son, Randy: “I don’t know, Dad, seems like every day is either light grey or dark grey right now.”

I find it harder, and longer, and more of a conscious struggle to soldier on in the face of the obstacles and set-backs of daily life at this time of year. Tiny, insignificant inconveniences take on a wholly unreasonable level of importance (a series of dropped cell calls yesterday, for instance), making whatever shade of grey at least momentarily darker. The medical term for this is “Seasonal Affective Disorder”, and man, I’ve got it in spades. The effect is different on any affect I’m sure, but it makes me dark and edgy, on the verge of eruption, the trigger hair and phasers set on annihilate.

And yet, while my challenges and obstacles may or may not subside as grey FINALLY slides into Spring, I know that for me this is just a seasonal effect, born of geography, and borne as a consequence of geographical choice. With some 5 major moves behind me I have managed to land each time at the same latitude, plus or minus the same relative number of cloud-covered days, covered in mud and shivering.

There live among us souls for whom grey is not a seasonal phenomenon, who struggle each and every day to lighten the internal weather as they soldier on. For them even the lightest days are dark, and the best days are those that have the least pain. The darkest days are down right frightening, unknown and unknowable to the rest of us, where there may be only a speck of light somewhere on the far horizon, with consequences and choices that are more frightening, still. These individuals live in a world not of their choosing, shades of grey surrounding them always and everywhere.

Depression, real depression that descends upon a person and declines to leave of its own accord, is fundamentally different from sadness, from unhappiness. It is organic. It comes from within. While one may be able to pinpoint an event or time that might be a trigger, depression once it sets in is not reactive to any one aspect of a life. It is not present in response to something or someone bad. True depression, as well as its close cousin anxiety, gurgles and bubbles and flows from a toxic well within, a cold weather front that arrives and stays.

We live, or fancy that we live, in a country with “up by your bootstrap” values. “Come ON…get OVER it” is a mantra ingrained in our national psyche. Frankly, that actually works very well, eventually, for the sadness or unhappiness one feels in reaction to unpleasantness. Depression, however, is as unresponsive to platitude as this Cleveland season of Grey, and depression has no calendar to eventually force away the Grey.

People who inhabit this world in which shades of grey are all that exist have a problem which is as serious and life-threatening as any other “invisible” problem. Think diabetes: there is no outward manifestation of diabetes, no stigmata to alert the observer to its presence, and yet without insulin the diabetic will die. So, too, the soul afflicted with depression must be treated for what is organic and internal. Voluminous research has shown that a combination of “Talk Therapy” and medicine is necessary, and that for most it is necessary for the better part of a lifetime. Without this lives are lost. We’d not deprive the diabetic of insulin, would we? And yet…

Various medicines for “depression” are rampantly prescribed for varying degrees of sadness, unhappiness, even ennui. I confess to being conflicted about this. Who am I to deprive anyone of additional happiness, or less sadness, or even less time in the middle of life’s  great Bell Curve of emotion. But these medicines are expensive, and the “market” effects of their broader use affects the conversation about treating organic depression as the medical entity that it is. This is a hard conversation; where is the line?

Smarter people than I have failed to find a bright dividing line, to be sure, but there IS a difference. We lose people we love who live only in a world with shades of grey. At some point, for some, only the grey remains. No light is visible, and only one question exists in that world of grey. Do I live with the pain, or is today the day the pain ends? Grey descends into dark. The weather becomes deadly.

Every now and then, through any number or routes, a light begins to glow in one of these people. Nurtured, caressed, husbanded and encouraged, it grows steadily and slowly. To be sure, it waxes and it wanes; there are setbacks wherein the light may be rendered not more than a tiny ember. But in these fortunate ones it never goes out; it continues to grow, bringing light as surely as Spring lights the grey.

To witness this can be as thrilling and monumental as a sunrise in the mountains, or as subtle and delicate as the opening of an orchid. But oh ho, to be there to SEE this, to be a spectator to this, to see light where there was only dark, brilliant color where there was only grey. One night, in a darkened car on a grey, starless night, I drove home bathed in this light emanating from the back seat, so long in coming but now so bright and so strong. The obstacles and the challenges remain, as they always will, but they will seem so much smaller and more manageable in this light. It was hard to drive, so brilliant was that light as it shone through my tears.

So brilliant is that light as it awakens me each morning, still the father of not two, but three children.

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.

Consider this an official “Request For Proposals” from Arnold Kling to design a health care plan. And just so Dr. Kling doesn’t think I’m picking on him, what the heck, let’s hear from Tyler Cowan and René Herszinger, to0. While I’m at it, I have a certain health care policy rock star brother-in-law, Jim, and I’d love to hear what he has to say about it. Let’s toss in that blogger Maggie Whatever-Her-Name-Is, and why not invite one of the smartest guys I’ve ever actually chatted with, guy named Barry Cooper in Louisville. I’m ready to appoint each and every one of you, and anyone else who’d like to take a shot, as uncontested Health Czar for a large group of people. This is a Request For Proposals to design a health care plan from scratch.

Let’s see who’s got game.

This isn’t something I just made up; this is actually a real group and a real possibility, although it’s highly unlikely that the real players have either the imagination or the balls to really do something new. Nonetheless, it’s very cool to apply imagination and balls to this question. The group consists of 250,000 individuals, 95% men, between the ages of 20 and 60. The average age is 45. Once they become part of this group they essentially remain so for their entire working career. They have a single labor representation, and while they work for a number of different companies there are four major employers. Health insurance has been part of their negotiated contracts for decades.

You have carte blanche to design a health care program for this group. You are not bound by any ERISA regulations, and you will “participate” in any financial savings you might create. Let’s say that it will be a 10 year trial, and in year one you have the average amount of money actually spent on healthcare over the past three years for this group. Each year the funds available to you will increase by only the CPI, inflation in the general economy and no more.  In years one through five any money that you do not spend is yours to keep. Remember, the members of this group do not come in and out, and any investments you make in the early years that reap savings in latter years will come to you and not another provider or payer. In years five through 10 you will share any savings with the employers, the payers.

As part of this proposal you must not only try to save money, to provide health care in a more cost–and efficient manner, but you must also achieve superior health. In years one and two the health outcomes of your 250,000 members must be no worse then the aggregate outcomes across the United States for individuals in a similar demographic. However, in years three through 10 you must demonstrate superior health outcomes for your group, each year better than the last. In other words, you must design a program that will not only save money but will also produce superior health.

That’s it. No other rules. You may use economic incentives with the members, both positive and negative. You may put together what ever type of provider group, physicians and physician extenders, hospitals and clinics that you wish. Pay the healthcare providers any way you’d like (probably ought to be sharing the lion’s share of any savings with this group, if you wish to be successful). You only have to do two, simple things: make these 250,000 men healthier, and spend less money doing so.

Wadda ya think, Dr. Kling? You in?

I don’t want to sound like I’m picking on Dr. Kling because it was actually his short manuscript, “A Crisis of Abuncance” that really got me to thinking about the barriers we have erected in our healthcare system to actually providing healthcare, providing for the creation of health. The best example of what you CAN do, as well as what happens now when you DO do, is the Mayo Clinic program designed to take care of patients with kidney failure. Given free reign to design a program that would accomplish exactly what I am asking for with my 250,000 member group, the Mayo Clinic did just that. By creating a team that was given free reign to utilize best practices, the Mayo Clinic designed a program for kidney care that resulted in fewer mortalities, fewer complications, and greater health, all with a lower price tag.

So why, you might ask, do we not know more about this program? Why is this not the gold standard for ALL medical care, let alone chronic kidney disease care in the United States? The sorry fact is that the Mayo Clinic actually LOST money on this program despite the fact that their patients had BETTER health by doing less and doing it better, thereby resulting in the need for LESS work still, The Mayo Clinic essentially cut off its nose to spite its face. Not willing (and reasonably so) to lose money, and unwilling to practice medicine any way less than what they have shown to be best practices, the Mayo Clinic has now declined to care for Medicare patients in some of its satellite locations.

But you guys don’t have to worry about that. I’ll let you keep the cash! So, what do you say, folks? Ask your friends. Everyone can play. We might even catch the attention of the real, live people who are presently negotiating new labor contracts for this very group. Here’s a chance to start saving the American healthcare system. This is a formal Request For Proposals.

The lines are now open…

Uh oh. Now they’ve gone and done it. Someone has gone and rained the facts down on what is generally considered a feel–good story in American medicine, the dramatic increase in female doctors in America. In response to Dr. Herbert Parde’s “The Coming Doctor Shortage” article in the Wall Street Journal, Dr. Curtis Markel pointed out that there is a difference between the raw, gross number of physicians in America, and the EFFECTIVE number of practicing physicians.  Not only that, but he had the audacity to point out that roughly 50% of newly–minted American trained physicians are women, and that many of them do not practice full-time.

The NERVE of that guy. I mean, how dare he bring facts into a discussion of physician manpower? Wait a minute… maby that’s it right there… MANPOWER. This must be just another incidence of the male–dominated world of medicine cracking down on those female party-crashers. Except for the fact that…no… this really isn’t a case of that at all. Just an illumination of a significant part of a more general trend. When we look at the economics of physician resources the more important statistic is NOT the number of physicians working, but the number of physician–HOURS that are worked. Physicians newly minted in the United States in the last 20 years work fewer hours per week and annually than their predecessors, and “mommy–track” docs work even less.

That, my friends, is a fact–based reality of healthcare economics in the United States. The fact remains that Heinlein was right: there ain’t no such thing as a free lunch. The facts do not care what you think. They do not they do not care how you feel about them. They do not go away and they do not change if you try to change the topic or bury them with obfuscation. Torn between self–righteousness (I’m staying home for my children) and righteous indignation (I work HARD), the mommy-track docs have fired back.

Unfortunately, their return fire has been little but emotion-loaded pellets, rather than fact–filled ordinance. An ER physician talks about choosing to work fewer shifts in order to tend to her family, or an ailing parent, or even to avoid “burnout”, and conflates the effects of these personal choices with her feelings about the effects of inequities between the compensation for so–called cognitive versus procedural specialties. Another talks about wanting to work part time with the thought that this will make her a more effective doctor. Still others try to shift the conversation from the “mommy–track” to general lifestyle considerations: I wish to “paint, or cycle, or just read.” All well and good, of course, but all also well beside the point. The fact remains that women physicians tend to work fewer hours than their male colleagues, those who have children take long stretches of time away from practicing medicine to do so, and both men and women recently trained tend to work measurably fewer hours than their predecessors did and do.

Sorry. You CAN’T have it all. Thinking that you can is a fantasy; it’s just not consistent with a fact–based reality. There ain’t no such thing as a free lunch. In medicine or anywhere else.

Please don’t get me wrong. I personally find absolutely nothing inherently wrong with working fewer hours or taking time out to have children. Back in the day there was often a terrible price to be paid because of the traditional work ethic of the American (mostly male) physician. The landscape is littered with the carcasses of medical marriages that didn’t survive this “profession first” rule. Substance abuse was rampant among these physicians, and the physician suicide rate was (and is) a multiple of the general population’s. Younger physicians, mommy–track and otherwise, are certainly onto something. The life balance that is so important to them is healthier in almost all respects, at least as far as the physicians themselves go. But in terms of our health care system as a whole? Nope. The facts say we either need more doctors, or doctors need to work more hours. To say that you, the physician, are making these choices for anything other than lifestyle reasons, to blame some reimbursement inequity or other external factor is disingenuous at best.  My mother used to call it “the consequences of your decisions”, but I prefer Heinlein. TAANSTAFL.

While there are some medical specialties that are very lucrative (neurosurgery, gastroenterology), the income that physicians take-home is generally reflective of how hard they work. How many hours per week they to spend doing clinical work. How much they actually do in each of those hours. General surgeons tend to make more money then family practitioners,  not so much because they get paid all that very much for any individual thing they do, but because they tend to work lots of hours, and they tend to do lots of work in each one of those hours. Nights, weekends, dinnertime, and long after Conan has called it a night, general surgeons are at work because the work needs to be done. The vast majority of primary care physicians work 40 hour weeks, hours that look more like the proverbial banker’s day than the surgeon’s. Nothing wrong with that, and neither is this always the case. I have a friend who is a very successful, family practitioner who is blessed and cursed with both ADD and insomnia. I think he works more than anyone I know, doctor or otherwise, and his income is consequently more like that of a general surgeon.

Perhaps an illuminating example would be the decision I made approximately five years ago to totally change the way I practice my specialty. Suffering from a severe case of professional and business dissatisfaction, I left an extremely successful practice (a practice that remains extremely successful in my absence) and started Skyvision, a very different type of eye care practice. (As an aside, when they finally got around to replacing me, it took TWO 30–something year-old physicians to do so.) At Skyvision I see many fewer patients each day, and consequently have a dramatically lower income. When presented with the Zen–like question “do you wish to be wealthy or happy” I chose happy. The decision has made me quite “UN–wealthy”, but I really am quite happy.

That is the fact–based reality of physician economics, my  little micro–economic example to explain the macro–economic effects of physician–hours versus physician numbers. There’s no one to blame. No government conspiracy. No specialty vs. primary care inequity. I am the sole bread–winner in a home with a “mommy–track” Mom. There are more eye doctors where I live because some of the eye doctors who are already here, mommy–track or otherwise, are now working less.

Are mommy–track docs the sole problem why we face a pending physician shortage in the United States? Of course not. We have a decades–long history of new physicians working fewer hours than their predecessors, a relatively static number of new physicians being trained, and an ever–expanding population of patients who need the care of these physicians. No matter how they might FEEL about it, and no matter how they might feel about having it pointed out, the fact remains that, on average, newly–minted doctors work fewer hours than their predecessors, and mommy–track docs, on average, work fewer hours than their peers. Wanna stay home with your kids? Cool. 12 weeks to bond with the new baby? Sure, who WOULDN’T want that. Just “man up” and face the facts–you can’t have it all. Nobody can. Be a grown up and accept the consequences of the choices that you have made, and accept this gracefully when someone else points that out in the Wall Street Journal or elsewhere.

There ain’t no such thing as a free lunch. Somebody, somewhere, always pays.

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…