Random Thoughts from a Restless Mind

The great Dick Lindstrom recently posted an editorial on the challenges faced by doctors in a world that is focused solely on the cost of medication, one in which pressure is brought to bear on both doctor and patient to use an inexpensive generic at all times. Dr. Lindstrom reaffirms his career-long position that only one factor matters in the complex decision making process that is medicine: what is best for my patient’s health is my sole concern. Indeed, it is important for each physician to fight for this outcome, to fight for the person who sits before us in the exam chair or beneath us on the operating table. When a clinical difference exists between the expensive branded medicine and the cheaper generic we are honor and duty bound to prescribe and support the better medicine.

Sigh. It’s just all so tiresome, this battle. We physicians certainly did not choose this fight, and frankly most of us have no dog in the fight other than the best interests of our patients. I wrote PREVIOUSLY that the notion that pens, penlights, and candlelight dinners prompt doctors to become shills for pharmaceutical companies is farcical and offensive. Come on…I’m gonna look for a reason to prescribe some new eyedrop because someone dropped off a couple of pens? That’s all silly enough, but the battle has escalated with the entry of insurance company and government programs that automatically switch to a less expensive “therapeutically equivalent” medication and then require doctors to personally run the gauntlet necessary to “justify” their clinical decisions.

We are on the receiving end of the same kind of stuff that big companies use to defeat smaller foes in court: we are bombed with paperwork. Not only that but it’s carpet bombing, indiscriminate deluges of time bombs meant to bludgeon doctors into submission. There’s collateral damage, just like in carpet bombing, only the casualties are more subtle. Forcing doctors to be a part of this irreparably damages the doctor-patient relationship, making it more of a commercial interaction as doctor becomes ombudsman for patient.

As Dr. Lindstrom exhorts, I’ve been fighting the good fight. Dr. Lindstrom doesn’t need this fight. He’s a living legend who has earned the right to stand aside from these types of petty issues and to choose to put his considerable gravitas to work on stuff that has to be more fun. Yet he willingly takes on this battle and I’ve followed his lead. Standing my ground and insisting on newer branded meds when they are superior to older, cheaper generics. It’s getting to me, though. I’m tired. My staff is tired.

I surrender. Up goes another white flag.

I’m going to surrender in the battlefield of Glaucoma. Why Glaucoma and not cataract surgery for instance? I’m tired and beaten up, but I’m neither a hero nor a coward, not a sentient nor an idiot;  I don’t need to be a seer, some kind of morbid Karnac the OK, to know the outcome for either cataract or Glaucoma. I’m declaring right up front what is going to happen, how it will affect my patients, my staff, and me, and what the ramifications will be for American healthcare. I’m surrendering in Glaucoma because I can, continuing to fight in cataract surgery because I must.

In my 27 years as a physician only one paperwork/government regulation/billing issue has ever resulted in better care of my patients: the requirement to do an extended Review of Systems for a particular kind of visit resulted in the identification of major side effects from glaucoma eyedrops. Indeed, this was a total surprise and led to a rapid change in the way we took care of Glaucoma patients. Older medications, effective or not, were replaced by newer medications or laser because the newer treatments were both more effective and freer of side effects. What will I find this time?

Timoptic (topical Timolol) was introduced in the early 1980’s. It was a Godsend. Nothing less than a miraculous savior of vision, keeping legions of patients out of the operating room and saving thousands and thousands of people from certain blindness. It’s been off patent for decades but is now no more than a third line treatment. Why? Tons of side effects, some subtle (decreased exercise capacity, erectile dysfunction) and others less so (my friend essentially killed his very first Gaucoma patient in year one of the Timoptic era by prescribing Timoptic and causing 1st degree heart block). It’s really cheap now, but who can write this Rx and look themselves in the mirror, white flag or not?

We know that the Lipid class of Glaucoma eye drops is the most effective group of pressure lowering medications. The original, Xalatan, dethroned Timoptic in less than 2 years. Lower eye pressure and no systemic side effects and a new treatment paradigm was nigh. The worst side effect was a permanent darkening of the iris in 9% of patients, the price to pay to save your vision. Xalatan is now available as a generic (latanaprost). There are 3 newer, stronger, more effective Lipid medications, all of which are branded and all of which are 2-4X the cost of latanaprost. They all reduce eye pressure on average 2-3 points more than latanaprost.

I’ll start here. Starting next week every new glaucoma patient who opts for medical treatment will start on latanaprost. On top of that I will change every patient on a branded lipid to latanaprost if they risk losing insurance coverage for their drop. I will not respond to any insurance company challenge. If pressure reduction is inadequate I will follow my standard protocol and I will offer a second medication or glaucoma laser treatment, both of which are standard of care. If a second medication is chosen I will write for the generic second line Rx, an alpha-agonist. The generic and the brand alpha-agonist have equal efficacy; the generic has a 35-40% unacceptable side effect rate compared with the brand’s 10-12%. The generic cost is ~1/4 of the brand.

My staff and I will take the time necessary to inform my patients of these side effect issues, a time investment that will be a laughably small fraction of the time it takes us to fight the paperwork wars for Brand coverage. I will document this up the wazoo, noting every treatment failure and every last little side effect, jotting down every incidence of patient non-adherence. I will gear up for more glaucoma surgery, both laser and incisional, because I remember how much more of both I did in the days when Timoptic was king, in the days when version 1.0 of today’s medicines was so hard to take due to side effects. I will have this all on hand when we start to read of the new golden age of Glaucoma surgery.

I will be ready to answer the critics who accuse eye doctors of doing too much Glaucoma surgery.

I have been pretty generous in sharing my thoughts about some of the ills of our American Healthcare system, especially with regard to the barriers erected between physicians and patients. The attempt to “reform” medical care via a top-down, bureaucratic solution to what may or may not ail our system is ridiculous on its face. We are to believe that our Federal Government can handle something as complex as healthcare, a segment of the economy representing ~20% of GDP? A Federal government that has proven so adept at managing other major segments of our economy like, oh, energy policy?

The “baby with the bathwater” approach in the halls of our Capitol and the editorial offices of our leading media outlets (WSJ excepted) is about as wrong-headed as you can get.  What we need is an AMERICAN solution to the challenges that we presently face with the economics of healthcare in the U.S., using our present system as the foundation. We need a solution that emphasizes the strengths of our markets, with government providing oversight to establish a playing field that is as level as possible.

Not surprisingly, I have some thoughts!

1) Malpractice tort reform. See my thoughts in “Tort Reform = Healthcare Reform”. Effective reform will dramatically reduce the scourge of defensive medicine with its attendant costs and risks to patients. We all do it, and we do it when we don’t get paid to do it. Defensive medicine represents 15-25% of all medical costs in the U.S. That’s 15-25% of $2.5 Trillion. Do the math.

2) Tax Reform #1: Remove the tax deduction for employer-offered health insurance. Provide a 100% TAX CREDIT to the lowest 60% of wage earners for the purchase of health insurance. Provide a progressive TAX DEDUCTION for the upper 40% of wage earners. Level the playing field by removing the penalty for not working for a company that can deduct your insurance premiums.

Tax Reform #2: Remove the tax deduction for advertising as a business expense for Hospitals. If we are concerned about unnecessary increased utilization of medical resources why are we allowing advertising by hospitals? Seriously, why are we subsidizing the Ohio State Medical Center when it advertises for business in Cleveland. Ohio State is in Columbus, 2.5 hours away.

For that matter, remove the tax-exempt status of any hospital or  provider that advertises. How is it appropriate to allow a hospital system to advertise to increase revenue, deduct that advertising as an expense, and still be not-for-profit? If it looks like a business, acts like a business, and sounds like a business, tax it like a business.

3) Insurance Reform #1: Reverse all of the for-profit conversions of previously not-for-profit health insurance companies. Who was the genius who thought THIS was a good idea? I don’t remember insurance premium increases that were quite so massive when all of the Blue Cross/Blue Shield plans were not-for-profit, do you? And while there were $Million execs in the non-profits I don’t recall any $10, $20, or $100 Million execs. Removing the need to answer to the stock market will create companies that will compete quite nicely with the for-profit companies without the horror of a government run system. Let the equivalent of NGO’s compete with the United Healthcares of the world.

Insurance Reform #2: Remove state-level coverage mandates and create a minimum federal set of mandates for comprehensive insurance policies. A REAL minimum. REAL medically necessary items. This is the brilliance of Sweden’s system. No Viagra or artificial  insemination coverage. Allow cross-state competition for the business. Real competition always drives prices lower.

Insurance Reform #3: Do whatever it takes to encourage the purchase of  high-deductible catastrophic health insurance for all. Real insurance that covers real medical disasters like car accidents or cancers that strike young adults.

Insurance Reform #4: Allow insurance companies (Medicare and Medicaid included) to discriminate IN FAVOR OF people who make healthy lifestyle choices (eg. no nicotine, no DUI, etc.). We are all so afraid of the stick that we refuse to allow any use of the Carrot.

4) Freedom of Speech/Restraint of Trade Reform #1: Abolish, once again, direct-to-consumer pharmaceutical advertising. There was a quantum leap in the utilization of all sorts of medications immediately following the 1997 rulings that allowed DTC pharmaceutical marketing. If it is so obvious that our ever-increasing levels of spending on medical care is a threat to the very existence of our fair Union, then DTC drug marketing is a version of yelling “FIRE” in a crowded theater.

Freedom of Speech/Restraint of Trade Reform #2: Begin a return to the professionalism of yesterday by prohibiting all forms of advertising by, or for, physicians. The AMA gets a lot of criticism, most of it well-deserved in my opinion, but the court and FTC rulings that prohibited the AMA from censoring physicians who advertised was a seminal event in the de-professionalism of doctoring and medicine. Doctors and other medical advertising was, is, and always will be wrong. While we’re at it, do the same thing for lawyers and the practice of law.

5) Public Health. Finally, and most importantly, go to the true root of whatever “Crisis” we may have here in the United States, be it a “Healthcare Crisis” or a “Healthcare Finance Crisis” or what have you. We as a people are not healthy; certainly not as healthy as we ought to be. We are not healthy because of some wrong-headed previous Public Health decisions (simple-carbohydrate based diets, abolition of school phys-ed programs, tort-fearing closures of playgrounds, etc.). We are not healthy because our ability to treat the diseases that result  from poor lifestyle choices (cigarette smoking, alcohol abuse, preventable accidents, etc.) is SO GOOD that we are able to keep more and  more unhealthy people alive longer and longer, paying ever more to do so along the way.

This is where true leadership can make a difference. Remember JFK and the President’s Council on Fitness? I do. 8 pull-ups in the fifth grade for me. Sweden identified saturated fats from whole-milk products as a significant cause of heart diesease in the 70′s; a full court Public Health press for low-fat dairy brought about a dramatic decrease in cardiac deaths in the 80′s. Polio, measles, smallpox and whooping cough were once the leading killers of children in the U.S. but are now historical footnotes due to Public Health initiatives.

We lead the world in per capita alcohol related accidents and deaths, losing young lives by the thousands each year (is it just me or does it seem we have MORE alcohol-related problems in our youth since raising the drinking age?) We have ever more increasing numbers of truly obese citizens who go on to suffer the diseases caused by that obesity, and we pay ever more for their diabetes, hypertension, strokes and heart attacks. These lifestyle choices are root causes for our increased expenditures on Healthcare, much more so than all of the targets of Beltway demagoguery like insurance company expense ratios and pharmaceutical company profit margins. A solution to this issue, more than all of numbers 1 through 4 combined or any other proposal yet floated, is the true crux of the solution to any “Crisis” we may be facing. Everything else is only there to buy time. Time to get healthy.

It’s a Presidential Election year in the United States. There are no votes to be had in making Americans healthier. Nothing but hard work on every side of the equation. Who will stand up and do the hard work? Who will lead?

Who will have the guts to not only say that the Emperor is naked,  but also drunk and fat and puffing away our economy.

Been wondering where I’ve been on this one? Well, a couple of months of frustration, unable to log onto the CCF system either from my office (password issues) or the Surgery Center (no idea), followed by a brilliant phone call with one of the tech support folks downtown and a meeting with Andrew at the Surgery Center and I’m in!

Oooops…well, all is not ducky, but not too bad, really. 50 some odd op notes to sign, a couple dozen useless, unnecessary PAT lab sheets to ignore (we have patients sign a disclaimer punting all interactions re: PAT for cataract surgery to anesthesia who demanded it), and then the stab in the eye: 50+ med orders to sign that were ALREADY SIGNED  in the OR. Thankfully my guy Andrew promised to handle the duplication on the pharmacy side of the equation with a little “education”.

So, I was feeling pretty good when Andrew asked about my standard op note which magically appears the week after surgery to be signed; I have one for right eyes and one for left, all teed up for any case that doesn’t deviate from the norm, representing upward of 80% of my cataract cases. Takes me ~2.5 seconds to sign each one. It turns out that the vaunted Cleveland Clinic is about to move to a digital signature only status for everything. That’s right boys and girls, come October I will have to log on, sign in, find each one, designate the eye or in some other way prove I was there, and “sign” the op note. Yup, ~2.5 seconds per chart will then turn into somewhere closer to 3 or 4 minutes. For the record my “cut-to-close” time for a standard case is roughly 6 minutes.

Sigh…

Let’s hear it for increased efficiency! Decreased errors! More accountability! Oh…right…we’re not having any problems with any of that now, are we? Well then, let’s hear it for progress!

I have been pretty generous in sharing my thoughts about some of the ills of our American Healthcare system, especially with regard to the barriers erected between physicians and patients. I find the various proposals now before our legislative bodies in Washington to be rather curious, even offensive. Since when does the United States of America adopt wholesale an economic solution from another country? Especially another country that is in some way otherwise riding the considerable coattails of the U.S. economy?

The “baby with the bathwater” approach in the halls of our Capitol and the editorial offices of our leading media outlets (WSJ excepted) is about as wrong-headed as you can get.  What we need is an AMERICAN solution to the challenges that we presently face with the economics of healthcare in the U.S., using our present system as the foundation.

Not surprisingly, I have some thoughts!

1) Malpractice tort reform. See my thoughts in “Tort Reform = Healthcare Reform”. Effective reform will dramatically reduce the scourge of defensive medicine with its attendant costs and risks to patients. Defensive medicine represents 15-25% of all medical costs in the U.S. That’s 15-25% of $2.5 Trillion. Do the math. While we’re at it, how is it good for the country to allow the tort bar to advertise for cases? Rake the muck in the hopes of unearthing errors or imagined?

2) Tax Reform #1: Remove the tax deduction for employer-offered health insurance. Provide a 100% TAX CREDIT to the lowest 60% of wage earners for the purchase of health insurance. Provide a progressive TAX DEDUCTION for the upper 40% of wage earners.

Tax Reform #2: Remove the tax deduction for advertising as a business expense for Hospitals. If we are concerned about unnecessary increased utilization of medical resources why are we allowing advertising by hospitals? For that matter, remove the tax-exempt status of any hospital or  provider that advertises. How is it appropriate to allow a hospital system to advertise to increase revenue, deduct that advertising as an expense, and still be not-for-profit? If it looks like a for-profit business, acts like a for-profit business, and sounds like a for-profit business, tax it like a for-profit business.

3) Insurance Reform #1: Reverse all of the for-profit conversions of previously not-for-profit health insurance companies. Who was the genius who thought THIS was a good idea? I don’t remember insurance premium increase that were quite so massive when all of the Blue Cross/Blue Shield plans were not-for-profit, do you? And while there were $Million execs in the non-profits I don’t recall any $10, $20, or $100 Million execs. Removing the need to answer to the stock market will create companies that will compete quite nicely with the for-profit companies without the horror of a government run system. Let the equivalent of NGO’s compete with the United Healthcares of the world.

Insurance Reform #2: Remove state-level coverage mandates and create a minimum federal set of mandates for comprehensive insurance policies. A REAL minimum. REAL medically necessary items. No Viagra or artificial  insemination coverage. Allow cross-state competition for the business. Real competition always drives prices lower.

Insurance Reform #3: Allow insurance companies (Medicare and Medicaid included) to discriminate IN FAVOR OF people who make healthy lifestyle choices (eg. no nicotine, no DUI, etc.). We are all so afraid of the stick that we refuse to allow any use of the Carrot.

4) Freedom of Speech/Restraint of Trade Reform #1: Abolish, once again, direct-to-consumer pharmaceutical advertising. There was a quantum leap in the utilization of all sorts of medications immediately following the 1997 rulings that allowed DTC pharmaceutical marketing. If it is so obvious that our ever-increasing levels of spending on medical care is a threat to the very existence of our fair Union, then DTC drug marketing is a version of yelling “FIRE” in a crowded theater.

Freedom of Speech/Restraint of Trade Reform #2: Begin a return to the professionalism of yesterday by prohibiting all forms of advertising by, or for, physicians. The AMA gets a lot of criticism, most of it well-deserved in my opinion, but the court and FTC rulings that prohibited the AMA from censoring physicians who advertised was a seminal event in the de-professionalism of doctoring and medicine. Doctors and other medical advertising was, is, and always will be wrong. While we’re at it, do the same thing for the rest of the lawyers and the practice of law.

5) Public Health. Finally, and most importantly, go to the true root of whatever “Crisis” we may have here in the United States, be it a “Healthcare Crisis” or a “Healthcare Finance Crisis” or what have you. We as a people are not healthy; certainly not as healthy as we ought to be. We are not healthy because of some wrong-headed previous Public Health decisions (simple-carbohydrate based diets, abolition of school phys-ed programs, tort-fearing closures of playgrounds, etc.). We are not healthy because our ability to treat the diseases that result  from poor lifestyle choices (cigarette smoking, alcohol abuse, preventable accidents, etc.) is SO GOOD that we are able to keep more and  more unhealthy people alive longer and longer, paying ever more to do so along the way.

This is where true leadership can make a difference. Remember JFK and the President’s Council on Fitness? I do. 8 pull-ups in the fifth grade for me. Polio, measles, smallpox and whooping cough were once the leading killers of children in the U.S. but are now historical footnotes due to Public Health initiatives. (A pox on all the cretins advocating against childhood immunization).

We lead the world in per capita alcohol related accidents and deaths, losing young lives by the thousands each year. We have ever more increasing numbers of truly obese citizens who go on to suffer the diseases caused by that obesity, and we pay ever more for their diabetes, hypertension, strokes and heart attacks. These lifestyle choices are root causes for our increased expenditures on Healthcare, much more so than all of the targets of Beltway demagoguery like insurance company expense ratios and pharmaceutical company profit margins. A solution to this issue, more than all of numbers 1 through 4 combined or any other proposal yet floated, is the true crux of the solution to any “Crisis” we may be facing. Everything else is only there to buy time. Time to get healthy.

Pick a number; choose an age. 40. 50. 60. Anyone under that age gets “Well-care” or “Get Healthy Care” starting right now. Over that age they can have “sick care” only if they wish, but under that age if you try to be healthy you get rewarded.

There are no votes to be had in making Americans healthier. Nothing but hard work on every side of the equation. Who will stand up and do the hard work? Who will lead?

Who will have the guts to not only say that the Emperor is naked,  but also drunk and fat and puffing away our economy.

Skyvision centers is a hybrid organization that brings together multiple, disparate skill sets in a medical environment. If you ask any of the staff or doctors who we are and what we do you will hear something along the lines of “we’re a customer service business; our product just happens to be eye care.” The founding principle for Skyvision was the creation of a truly patient-centered experience achieved by borrowing liberally from such customer service stalwarts as Nordstroms and the Canyon Ranch Spa organization. These practices were then layered on top of a flow process that was adopted from the Toyota manufacturing system in order to allow the doctors and staff to provide medical care that exceeded all industry standards for outcomes, safety and efficiency.

It became clear very early in the development of Skyvision that a traditional management structure would be counter-productive. Most small businesses, and essentially all medical businesses, are run using a steep pyramid set-up: doctor at the top, office manager next, and all kinds of middle management on top of the folks doing the real work of caring for patients. Command and control was exactly the wrong strategy for us. We adopted the ultimate flat organizational structure, the POND.

The Pond Theory of Management is best viewed from overhead. Unlike the pyramid of the traditional management flow chart, the Pond Structure is nearly invisible when you look from the side. Staff members “float” on the pond like overlapping lily pads. Tasks are determined initially by job description. Responsibility for seeing that larger projects are accomplished is determined by “mutual affirmation” in the overlapping individuals, and those who affirm a leader take on the responsibility of helping that task leader succeed.

With the appropriate systems in place and so much of what we think of as traditional staff management happening on something that looks like “cruise control”, what is the role of the “Boss” in a flat organization? Rising just above the lily pad-covered surface of the pond are the very few “flowers”, the leaders of the organization. If the “Tribe of Adults” is managing its own intra-staff personal relationships and taking responsibility for outcomes, what does the Boss do?

The common misperception of management in a flat organization (and in groups practicing TQM/CGI) is that there is no longer a leader or “Boss” role at all. This, of course, could not be further from the truth. The primary role of leadership in a flat organization is to make broad policy decisions and set major goals for the organization as a whole. The first of these is to choose to have a flat organizational structure! It is the few leaders who are charged with setting the general course of the business, from choosing the products or services to be offered, to determining the variables that will be measured to keep the organization on track.

Once the organization is up and going it’s important to identify the metrics necessary to maintain a tight focus on the goals that have been chosen. Monitoring these metrics and reacting to them is the responsibility of the “Boss”. From just above the Pond an effective leader is able to offer broad guidance without being involved in the minutiae of the day-to-day machinations of the business by reacting to these metrics. This also frees up the Boss’ time for critical planning, meeting with significant customers, and other larger picture tasks that will help the business grow and prosper.

It seems as if the flat organizational structure is designed to inoculate the Boss from any real staff management, doesn’t it? In reality, the only thing that the Boss might miss out on is any of the fun aspects of day-to-day interaction with employees. For better or for worse while the Boss may not do the hiring it is the Boss, and only the Boss, who must do the firing. At the end of the day, a business that chooses a flat organizational structure is not immune to any of the factors that make an individual employee an unsuitable member of the team. Remember, there are no managers, only a Boss, and no one else available to perform this (hopefully rare) task.

The role of the Boss in a Flat Organization is at once bigger and smaller than in a traditional hierarchical structure. Smaller in that the number of management tasks he is asked to perform is radically reduced. Bigger since the remaining tasks are more global and reach into every aspect of the business. Certain types of individuals are more geared to fulfilling this role (it helps to be a little more laid back and patient), and certain abilities are more helpful (delegation, data analysis, “blue-sky” planning). Indeed, the more of these characteristics one has in a leader, the fewer leaders you need!

The better the Boss, the flatter the organization.

One of the strongest statements yet made in support of the private practice of medicine was made this morning at 8:00 AM, EST. I went to work.

What’s the big deal? Of course you went to work. You’ve got a job and today is a work day. Ah, Grasshopper, there’s the rub. I am a doctor in private practice. I don’t have a job, I own a job. I don’t report to any centralized HR department; there’s no single supervisor looking over my shoulder. Nope, I’m a practicing physician in a private practice specializing in eye care, and this morning there are some 60 patients who’ve scheduled appointments and a staff of 14 on their way in to the office, all of whom are depending on me going in. So even though I feel like a damp campfire long past its useful life, I came to work.

If all I had was a job I’d a stayed in bed.

The dirty little secret of private practice medicine is that market-based economics works on a micro basis. There’s payroll to meet and rent to pay. The mere perception that your patients will leave your practice if you don’t go to work drives the private practitioner to work even when she feels lousy. Even more than that, the absence of a corporate barrier between doctor and patient makes the private practice doc think twice before he takes that sick day, because each one of those patients belongs to him, and vice versa. The unfiltered connection is so personal that the private practice doc thinks about what Mrs. Pistolaclionne (bonus points if you name the movie) will say if he calls off sick.

The dirty little secret in large, corporate medical practices is that market-based economics work there, too. All that talk about how your “World Class Clinic” doctor isn’t paid by how much work he does? Nonsense. In fact, the amount of money generated by any individual doctor is even MORE closely monitored and includes stuff like how many tests and procedures get done on her patients even if she isn’t doing the work herself. That doc’s compensation is absolutely driven by how much revenue she is responsible for bringing into the institution.

It’s just that the corporate Doc doesn’t own a job, he simply has a job. He has no direct responsibility for the staff surrounding him or the bricks and mortar over his head. His compensation is driven by his corporate performance, and that compensation includes time off for vacation and for sickness. Leaving time on the table is the same as leaving money there. There’s no bonus for loyalty to the institution. Points aren’t accrued for attendance. Frankly there are no real points to be won for extraordinary customer satisfaction, only demerits for egregious behavior. Unused time off, like extending your hours or taking patient calls when it’s not your turn, is simply donating your services and talents to your primary constituent, your boss the institution.

We should all be very cautious about the trend toward fewer private practice doctors and more docs employed by ever-larger institutions. Continuity of care is more than simply an always available electronic chart, it’s also a relationship forged over time between two real, live people with skin in the game. The next time you see your private practice doc and she’s a little sniffly and hoarse, remember to give her a little pat on the back and a ‘thank you’. After all, she owns this job and could have stayed home today, but she knew you had an appointment.

She knows who she works for!

Fly an airplane. Take Dad’s car on a date. Finish your residency and perform your core surgery without a professor over your shoulder. The first solo is a milestone event, and many such events become life’s touchstones to which we return time and again. My first solo attempt to log on and clear out my “Basket” on EPIC, the EMR that I am mandated to use in order to continue to operate at a surgery center where I’ve been the primary ophthalmologist for >15 years? Meh, not so much.

At 0 Dark 30 I was doing glaucoma lasers, and I finished well before I was due in the office. Perfect time to log onto a dedicated terminal, take a look at the items demanding my attention, and get on with the real work of eyecare. Full disclosure: I called the IT guy with whom I’d bonded a  couple of weeks ago to see what I should do with the pharmacy boondoggle and received permission to blow off all of those entries. Whew! Home free. I sat down and went through the log-in process, just like my new best friend had shown me. No love. 0 for 15. Unable to log in.

BZZZZTTT. Sorry. Johnny, tell Dr. White about our lovely parting gifts for losing contestants.

Might turn out to be more like expected after all.

As I posted a few weeks ago, in order to continue to use an outpatient surgery center where I have performed surgeries for 15 years or so, I am now required to use the electronic medical record EPIC. My hope had been that I would be able to continue to run “under the radar” by utilizing my pre-–dictated notes and standard orders, signing the papers as I have done lo these many years. Tragically, this was not to be. Having come to this realization about a month ago I reached out to the IT department and asked for training on the system. Being the somewhat self–involved surgeon that I am, I naturally assumed that a single phone call or e-mail would see multiple individuals leaping into action in order to help me so that I might continue to use that surgery center and generate revenue for the hospital. Silly me.

Four weeks, a dozen conversations, several e-mails, and I am assured more than several telephone calls later, I finally received a call from IT and one of the physician–advocates/trainers. I explained that I had a back log of signatures (little did I know!), and that I would be taking ER call soon, and did he perhaps have some time available to show me how to use the EMR? In the first of several remarkably positive little things in this process, Andrew did, indeed, have some time available the very next morning when I, too, could sit with him for a little bit.

Andrew himself was one of those little surprises. And ex–cop who had put himself through nursing school with the intention of using his nursing degree as a springboard to management, he informed me that he was one semester away from an MBA. It was clear he was anticipating a hostile interaction; this had been his typical experience when teaching physicians the system, especially private practice physicians. I liked him instantly, we connected, which probably contributed to the speed with which we flew through phase 1 of my indoctrination.

This can’t be all good, of course, otherwise there would be no reason to do this series! After learning how to get into the system (no, you cannot change your username), we looked at my chart deficiencies, specifically op notes that needed to be signed tracing back to November. I cleaned up all the old stuff, and then we got stuck with all of the charts that were sitting there from last week. Apparently part of the efficiency of the system allows the medical records department to put you on the “bad boy” list as soon as the case is done! We agreed to ignore these deficiencies since these would still be paper charts needing to be signed and moved on to pharmacy orders.

This was rich. I looked at about 200 orders with a “signature required” tag. Things like IV orders, and medicine injected to into the IV. Some were anesthesia orders which have no business on my list, and essentially all of the rest had already been signed. Andrew told me he’d taken a look at my in basket before we met and deleted three or four months of the pharmacy orders. I think the number he used was 800,000 orders! Whoa, maybe this isn’t going to go as well as it looks like it might. There is no connection between the electronically entered pharmacy orders and the signatures on the order sheets! 30 some odd orders per patient, each one individually entered and requiring a signature. I did 22 cases yesterday! Are you kidding me? This is what my colleagues were talking about when they mentioned the four minute per chart rule.

Like I said, though, this was a surprisingly positive interaction. Andrew took a couple of screenshots and said that he was going to sit with the IT magicians and see if we might be able to figure this particular one out. Man, that’s gotta work. I mean, the whole exercise took me about 45 minutes, and I didn’t even learn how to ENTER an order.

I can sign one, though. I’ve got some ER call coming up, and I’ll have to do some–patient consultations as part of my responsibilities. I’d better polish up my “helpless look” and rehearse my supplications. Getting someone to take verbal orders is gonna be the key to salvation.

More to come…

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

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

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

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

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

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

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

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