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?

What follows is the draft of an article that Kathy Weesner and I submitted to the Crossfit Journal in the Spring of 2010. Consider it a preview, a “sneak peak” of a series of articles that I plan to post on Health.

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Two Crossfitting MD’s Look at Health

We figured it out! Coach gave his Crossfit definition of health about a year and a half ago and it’s taken us this long to figure it out. We thought we had it after a dinner at the 2009 Crossfit Games,  but something still didn’t quite fit. There was something about “Fitness Over Time” that seemed incomplete. Health to a couple of doctors seemed as if it had to include something else, something other than just fitness as Crossfit defines it and a calendar.

Crossfit defines fitness as “Work Capacity Across Broad Time and Modal Domains”.  With precision and accuracy we can chart or graph our fitness by looking at our power output in multiple domains against time; we can then compute our work capacity, the area under the curve.

[Insert classic CF Graph work capacity age 20 CF training guide]

Coach has declared that his ultimate mission is nothing less than to revolutionize healthcare, to produce healthier individuals who can lead more productive lives and live longer while doing so. Consistent with that goal, and certainly consistent with his development of Crossfit, Coach first had to come up with a definition of “health’. The Crossfit 3-D definition of health is “fitness over time; fitness over a lifetime”.

A little background is probably in order. We are two practicing doctors who happen to be relatively experienced Crossfitters. Kathy is a pediatric anesthesiologist, so she’s the smart one of this pair! Darrell is an ophthalmologist or eye surgeon. We did a little experiment after Coach started to talk about health. What, exactly, do physicians think is the definition of health? What does it mean to be healthy?

When we started to ask our colleagues this question we were almost universally disappointed in their responses. We surveyed newly minted physicians right out of training as well as those who have been practicing for over thirty years.  Believe it or not, the most frequent answer we received when we asked doctors “what is your definition of health” was: “gee…I dunno…I never really thought about it.” Nuts, huh? Not so surprisingly, especially with an audience of American doctors, was the answer “health is simply the absence of disease.” All Crossfitters have heard Coach talk about the 95 year old man with absolutely no diseases on not one single medicine who can’t lift his ass off the toilet without help.  No disease, but healthy?

The flip side of that is where we as doctors struggle with simply defining health as “fitness over a lifetime.” How about the 36 year old man with a 500 Lb. deadlift, a 5:00 mile, 50 pull-ups and a 2:30 “Fran” who drops dead from pancreatic cancer 3 months after posting all of those numbers? Was he “healthy” then? He surely was fit, at least using our Crossfit definition of fitness, but it’s hard to say that he was “healthy” because the volume under his life curve abruptly stopped increasing.

The beginning of the solution to our quandary did come from one of our surveyed doctors.  Darrell was speaking in Florida and, as always, he asked the audience of physicians to define health. One of the docs at that meeting replied “unlimited potential, or life performance without any limits or potential limits.” BINGO! That’s the missing link–PROSPECITVE fitness, the potential to express fitness in the future.

The Crossfit 3-D definition of health is a LOOK-BACK, a retrospective evaluation of how healthy we have been. As such it is missing one of the key aspects of what health is more generally thought to include, the ability to make predictions about future life–in our case as Crossfitters about future levels of fitness. To truly invoke a three dimensional definition we need to include two more dimensions, two additional variables that affect our potential performance.

Interestingly, Crossfit already talks about one of these dimensions when Crossfit instructors discuss “wellness” at Level 1 Certifications. Wellness includes such widely discussed objective, observable, and measurable variables as blood pressure, cholesterol, %body weight fat, waist circumference and chest/weight ratios. Although we can agree that society as a whole is TOO focused on these variables, they do have some value in predicting future levels of fitness.  We are confident that we can identify a validated “wellness scale” that scores this category based on these established markers.

[Insert Illness-Wellness-Fitness Arc pg 16 CF training guide]

The last variable, the third dimension of a comprehensive Crossfit definition of health is “well-being”– emotional and mental health. Although it is virtually impossible to establish a universally agreed upon definition, let’s call this the “happiness” metric. It’s impossible to maximize your fitness if you have some mental or emotional problem that becomes a barrier. We can certainly understand how named problems like depression, bipolar disease or severe pathologic anxiety can affect our fitness. In the same way our ability, or relative inability to handle both the chronic stress of everyday life and the acute episodes of stress we face can affect our fitness.

How do we measure something as amorphous as “well-being” or happiness? We could certainly use something like the inverse of the VAS or Visual Analogue Scale that anesthesiologists use with all of their patients to evaluate pain control in the post-op period. A better option would be something along the lines of the Quality of Life Indicator (http://psychcorp.pearsonassessments.com/HAIWEB/Cultures/en-us/Productdetail.htm?Pid=PAg511 ). This independently validated proprietary test fulfills our measurable, observable and repeatable Crossfit mandate.

We would like to propose a slight variation on the Crossfit 3-D definition of health by specifically naming two additional dimensions: traditional Wellness, and let’s call it “Well-Being”. We would further like to expand on Coach’s contention that increased fitness will drive all of our wellness measurements in a positive direction by saying that fitness, wellness, and happiness form a bi-directional “virtuous circle” that leads to health; any increase in each of the three elements will drive the others in a positive fashion leading to greater health.

In the end we think Coach has it more right than anyone else when he says that health is work capacity over time. By explicitly adding the pre-existing Crossfit definition and concept of Wellness to this definition, and then by going further and adding the concept of Well-Being we complete the full 3-D Crossfit Definition of Health. Health at any one point can be depicted by a sphere whose volume is determined by the interaction between Fitness, Wellness, and Well-Being.

Our conjecture (hypothesis?) is that the volume of the “Health Sphere”, perhaps combined with the volume trends over time, is a more accurate predictor of prospective fitness or work capacity in the future.

If this is indeed the case we will have further cemented the primacy of Crossfit’s definition of physical fitness. By combining our measurement for fitness with similar metrics for medical wellness and happiness Crossfit will have created the first truly measurable, observable, repeatable, and ACTIONABLE comprehensive definition of health.

So, time to begin our Crossfit conquest of healthcare!

(NB: Graphs and figures to be added)

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I will address all three categories and then expand on the unified definition of health in upcoming posts.

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…

Former Budget Director Peter Orszag wrote an Op-Ed piece in the New York Times titled “Health Care’s Lost Weekend” in which he offers several reasons why healthcare in general, and doctors in particular, should be open for business 7 days a week. “Doctors, like most people, don’t love to work on the weekends…” is his first shot across the bow. He cites a study in the New England Journal of Medicine (the only medical journal to which God subscribes) which is actually a pretty darned good study, one that shows an increase in cardiac mortality of 0.9% (decimal point is correct) for people admitted to the hospital with a heart attack on the weekend in comparison with those admitted during the week.

I’m willing to buy this conjecture, even willing to say that Mr. Orszag’s conclusion, that medical services should be available 7 days a week with expanded hours of business to boot, is a desirable and necessary goal for American Healthcare. The difference between the two of us is that I will openly state what it will take to make such a thing happen, whereas Mr. Orszag has taken the cowardly politician’s route but simply saying “this isn’t right…this isn’t fair…this must be changed,” without offering anything about how.

Someone, or some someones, will pay something somewhere to make this happen. There, I said it.

There are actually a couple of really good examples of this phenomenon right now in my community,  Cleveland. The vaunted Cleveland Clinic is downgrading the trauma service at one of its hospitals, ostensibly because the city of Cleveland is “oversupplied” with trauma centers,  and because it is becoming increasingly difficult to find trauma surgeons to staff these emergency rooms. All true, but in reality it’s because the Cleveland Clinic has decided that the operating loss associated with keeping this trauma center open is more charity than the institution wishes to give to the city, especially in light of a palpable lack of civic gratitude. Similarly, all of the emergency rooms in town are finding it difficult to provide specialty coverage as specialists are declining to make themselves available. Insufficient compensation for the inconvenience associated with that availability, as well as the significant exposure to a litigious patient population are the culprits.

The funny thing is, once upon a time we actually had the equivalent of a 24/7 medical service economy. Back in the day, when Mr. Orszag and I were children, physicians were held in high esteem because they put their patients and their medical practice first, in front of every other aspect of their lives, 24/7.  They were incentivized to do this in two very specific ways: they were paid, and paid very well to perform their services, and they were afforded out–sized doses of respect, occupying a place of honor in every community. In return for this combination of handsome concrete and social compensation medical care was provided when medical care was needed, 7 days a week.

My first real job was caddying for wealthy golfers at the local country club. Not surprisingly, a significant percentage of the country club members were local physicians. Mind you, this was back in the day when only doctors carried beepers. I can’t begin to count the number of times I had a fantastic loop toting the bag for a doctor in the middle of a career round only to see some easy shot go careening into the woods when his beeper went off at the top of his backswing. I vividly remember seeing the assistant pro speeding down the fairway coming directly toward us in a golf cart to retrieve a doctor who was needed at the hospital. Saturday afternoon, Sunday morning, Wednesday evening… no matter.

What was the cost? Well, certainly the doctors didn’t do this for free. They asked for, and received, handsome compensation for this 24/7 availability. Society readily made this investment, in part because the best technology available was actually the technology available only between the ears of the physician. This is somewhat different today given all of our fantastic technological innovations and advancements, but not so different, really, because the stuff between the doctors ears is still what drives all that new technology.

There were hidden costs back then, too. Hidden costs are the ones that are actually the most expensive when we really drill down to see what the ramifications would be if Mr. Orszag had his way. Countless physician families were roadkill, collateral damage to the single-minded emphasis doctors placed on practicing medicine. Troubled children, troubled marriages, broken marriages, broken people all littered the landscape of the medical community, silent testimony to the cost of 24/7 availability. So, too, the nurses and technicians and orderlies who worked the swing shift and the graveyard shift. The social and physical pathologies of shift work are now quite well known. How does Mr. Orszag intend to handle THIS cost? Surely he’s not willing to ignore the well–documented evidence of the social and psychological harm that befalls workers and their families when they are forced to to work weekends and nights?

Behavioral economics is based on the simple concept that people will act in a manner consistent with rational self–interest. Most of the time this is EXACTLY how people behave. Over the course of the last several decades, as physician incomes have declined and as the doctors’ societal esteem has plummeted, physicians have been notably less willing to put their families in jeopardy by putting their profession first and foremost. By the same token, the vast majority of non-–physician workers in healthcare are loath to do the same, hence the difficulty filling nighttime and weekend shifts in hospitals, clinics, and the like. No one likes to work on the weekend when their family is home, when their friends are not working.

So, a  24 seven medical service economy? Sure. Who wouldn’t want THAT? Even without the data from that NEJM study it would be very convenient to have that colonoscopy I’ve been putting off on a Saturday instead of a workday, maybe even a Sunday with Saturday for the prep (prep…yuck). Heck, I found it pretty inconvenient that I couldn’t get a sandwich at one o’clock in the morning at a big convention hotel in Chicago last weekend. I was even willing to pay a premium, not only for my sandwich, but also to the person who made that sandwich appear. I would have given effusive thanks as well.

Therein lies the beginning of the solution. If you wish to have high technology medical care available seven days a week you must provide a significant incentive to those people who provide the care. Simple. I will offer as well that it probably doesn’t make a whole lot of sense to bash those very same people you are trying to convince to put aside some part of their self-interest (or the interest of their families) to work weekends; who is going to do something nice for someone when their reward is to have that same someone turn around and show nothing but disdain for not only the service provided, but also for the provider of the service?

So Mr. Herzog if you want me and my colleagues to be available on Sunday afternoon to take care of people exactly the same way we might on a Tuesday morning you  have to be willing to do two things which thus far you and others of your ilk have demonstrated no inclination to do: you must pay us what those services are worth, and you must be thankful that we are willing to provide them. It’s not enough to declare the “what”, you also have to declare the “how”. Isn’t that what REAL economist do, Mr. Orszag?

Heinlein was right. It doesn’t matter what time you serve it, There Ain’t No Such Thing As A Free Lunch.

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.

Bob Ryan, the great Boston Globe sportswriter, is famous for a writing style in which he simply jots down short little “thoughlets”. He basically just throws out whatever’s on his mind, expanding on some thoughts, and just letting others dangle, tiny little flags sent up the flagpole. If you’ve ever read him, and if you pay attention, you notice that he occasionally revisits these “thoughtlets” with a much deeper examination.  This technique or style has been ripped off by countless other sportswriters, usually without attribution.

Over the course of my day-to-day life I find myself interested in countless little ideas, tiny thoughts, or random observations. Not all of them are worthy of the full attention of the “Restless Mind”, but I think a lot of them really  ARE interesting, and I really hate to lose  them. So I thought on occasion I, too, would steal this technique from Mr. Ryan, only I am going to openly acknowledge that it’s his, and openly thank him for giving me the idea. So, without further ado, here are some  random thoughts banging around between my ears…

1.)  Lacrosse.  I am absolutely up to my eyeballs in lacrosse this weekend, and loving every minute of it. My son Randy had a  game yesterday, and looking back I realized that I spent at least six hours in front of ESPNU watching NCAA lacrosse as well. It’s really a fantastic sport. I’m a little guy, and lacrosse would’ve been a great sport for me when I was younger. Unfortunately, I didn’t come upon lacroses until I was a high school junior, and I didn’t get a chance to actually play lacrosse until I was in college. I was a pretty typical football player turned lacrosse player — great wheels, no stick. I was a defensive midfielder before the position actually  existed. “Hey, Darrell, see that kid over there? Yeah, that one. The one who knows how to play lacrosse. Go beat the crap out of him and don’t let him score!” Yup, I was THAT guy.

When my oldest son, Danny, started playing in junior high school I rekindled my love for the game. I’ve been telling people for years that lacrosse is the perfect game for boys. You get to do everything your mother ever told you NOT to do: you get to run with a stick, and you get to HIT people with! Seriously, how good is THAT?! It’s funny, though, because it’s exactly this part of the sport that is putting this wonderful, lovely game at risk in our local public high school.

You see, our athletic director is concerned that lacrosse is inherently a dangerous sport. He’s concerned that the injury rate is, or will be, much higher than all other sports simply because it’s lacrosse. I don’t think that’s the case. As a matter of fact, after watching very high level lacrosse on television this weekend, I’m convinced it’s not the case. I say this after having watched my youngest son, Randy, get the snot beaten out of him in his last three games (Randy is an attackman who plays the “X.” position; he has the ball an awful lot making him an inviting target).

What the athletic director is actually seeing it is a rather unskilled version of the game. As such it’s really not any different from unskilled versions of any other contact sport. Who among us hasn’t seen an unskilled basketball team rough up the team made of five extremely skilled but rather slight hoopsters? Or the soccer team that consists of brutes, muscling their opponents off the ball? Or the classic example, the hockey team whose tactics consist largely of muggings on skates? No, it’s not the game. Lacrosse is no more or nor no less injury-prone than any other contact sport.

It’s really quite beautiful, and I have to make sure our athletic director realizes this.

2.)  Women’s lacrosse. If you love men’s lacrosse you’ve probably watched a game or two of women’s lacrosse. While I write this I’m watching the Virginia women beat Towson State in a playoff game. They have lacrosse sticks, they shoot at 6′ x 6′ goals, and the ball spends an awful lot of time in the air being passed from player to player. The similarities seem to end there, though. It’s a totally different game!

I’m I’m reminded of watching my sister play field hockey in high school. Man, talk about a game with lots and lots of rules, totally impenetrable to all but the chosen few who have been initiated in some secret athletic rite. I could never figure out why any whistle was blown in field hockey, and I have to confess that I’m just as bewildered watching women’s lacrosse. The women are very fast, clearly elite athletes, and they’re certainly holding lacrosse sticks and shooting at lacrosse goals.

I hope I figure out women’s lacrosse in less time than it took me to figure out field hockey!

3.) There was a  very insightful article, an interview of the great economist Gary Becker in the Wall Street Journal couple of weeks ago. Becker touched on all kinds of topics, and spent a little bit of time on one that’s very close to my world, namely healthcare economics. He’s a little frustrated, heck were ALL a little frustrated by the willful obfuscation foisted upon the great unwashed mass of humanity that doesn’t work inside the Washington DC beltway when it comes to health care economics.

A case in point is the effect of out-of-pocket expenses on the overall amount of money that is spent on healthcare in any given country. In the United States we presently spend about 17% of our GDP on healthcare. Out-of-pocket expenses make up only about 12% of total health-care spending. In Switzerland, however, a country widely acclaimed for a very effective health care system, and equally acclaimed for spending only 11% of GDP on healthcare, the Swiss have out-of-pocket expenses equal to about 31% of total spending.

Swiss consumers of medical care are assumed to  have the ability to make complex medical decisions on their own behalf. Do you think maybe, just MAYBE there is a correlation here? Do you think that perhaps the fact that Swiss patients individually own 31% of the skin in the game has anything to do with driving overall healthcare costs lower? That perhaps the fact that every healthcare transaction is roughly 1/3 the responsibility of a patient, thereby involving every single patient in the financial aspects of every single health care decision, might be in part responsible for a lower percentage of the GDP being spent on healthcare?

Nah. Couldn’t be that.

4.)  Aches and pains. My partner Greg Kaye turned 41 years old this week. Greg actually handled the “turning 41” part much better than I did 50, only finding it difficult over the last month or so. Greg is also a former athlete, just a little less  “former” then yours truly. But Greg has struggled over the last month or so because of a couple of nagging injuries which have limited his athletic exploits, and consequently reminded him that he is no longer 21.

I’ve got pretty much the same chronic infirmities that I’ve had for several years. I’ve made my peace with them, at least I think I have. The difference for me now is that every time something new crops up I’m having a hard time putting aside the thought that it’s not just a little niggling effect of being 50 years old, but that it might actually be something serious. I’m starting to see friends, and friends of friends die. Some of them are dying from common things, and some of them are dying from relatively uncommon, weird things. I have a little bruise on my trachea right now. In all likelihood that’s all it is. The good news: I probably won’t put a tie on for a week or so. The bad news: until I put a tie back on I’m going to be wondering.

We used to call this “medical students disease”, the phenomenon where every medical student came down with whatever disease we happen to be studying at the time. I apparently was never cured of “medical students disease”!