Random Thoughts from a Restless Mind

I stand by the side of the road, wide-eyed in amazement, alone despite the fact that I am surrounded by other spectators. We are watching a parade, a great spectacle to celebrate the apparent dawning of a new age in cataract surgery. One after the other they pass me, the great and famous experts, the Emperors of ophthalmology. Each one sits upon a throne surrounded by bags filled with the coin of the land, the thrones built upon the newest fashion, a femtosecond cataract laser. The rest of the crowd is dazzled; they stand in silent awe as these men with such magnificent reputations usher into the kingdom the latest fashion.

I blink once. Twice. I cannot believe what I am seeing.

Over the millennia there have been thus far three truly revolutionary advances in cataract surgery (a cataract is a clouding of the natural lens in our eye). The ancient Egyptians, and for all we know Ancients of many other sorts, “cured” cataracts through a procedure known as COUCHING. Using a thin bamboo reed the “surgeon” punctured the eye and simply pushed the opaque lens into the gel–filled open cavity in the middle of the eye. Not terribly elegant, but if the eye did not become infected it actually dramatically improved vision in the days of the Pharaohs. This was the original cataract surgery.

The advent of very fine suture material and magnifying glasses brought with it the development of intracapsular cataract surgery. The eye was entered through a large sterile surgical incision and the cataract was removed as a whole. After the incision was closed with these rudimentary sutures it was necessary for a patient to remain stationary, her head held still by sandbags for a week. As barbaric as this sounds today, this procedure, along with cataract glasses, dramatically improved both the safety and the visual results of cataract surgery. Revolutionary change number 1.

Intracapsular cataract surgery was followed by extracapsular cataract surgery, the procedure made necessary by the creation of intraocular lenses. These tiny implants, less than half the size of a dime, are implanted in the capsular bag left behind after the inner workings of the cataractous lens had been removed; think of it as filling an empty grape skin. Better vision, greater safety, and with the addition of mechanical assistance extracapsular cataract surgery also brought efficiency and speed to cataract surgery. Clearly superior, the extracap supplanted the intracap, and during a time of transition both procedures received identical financial coverage from all forms of health insurance. Revolution number 2.

What followed next in ophthalmology was probably the predecessor of all that we have come to know about the intersection between commerce and care in American medicine. A certified genius who was so sure that he was right that he simply did not care what any of his colleagues– indeed what any ophthalmologist at all–thought about him or his invention, introduced  phacoemulsification. Charles Kelman discovered that you could remove a cataract of any size through an extremely small incision by first dissolving it inside the eye with high–frequency ultrasound. Kelman was initially viewed as a heretic, and early adopters of phaco technology were scorned by the ophthalmic orthodoxy. In response they marketed phacoemulsification as the superior procedure that it was, further enraging the establishment by becoming wealthy and famous through the efficiency and efficacy of this surgical revolution.

Once again, during the time of transition from extracapsular cataract surgery to phacoemulsification, both procedures were treated equally in the eyes of health insurance, and every patient’s surgery was paid equally with either technique. Revolution number 3.

As phacoemulsification gradually ushered extracapsular surgery into extinction in the 1980’s there began an era of relative tranquility in the world of cataract surgeons. There was very little to distinguish one surgeon from another save for gross incompetence, a complication rate so far outside the norm that it could not be ignored. How could this be, you ask? Well, all of the intraocular lens implants during the initial part of this era were essentially the same. Each lens development, each evolutionary step however big or small, was quickly adopted by the overwhelming majority of surgeons, and pretty much every cataract surgery patient received a state–of–of the–art implant for her surgery. The SURGEONS surely knew who among them was better. They knew who was faster, slicker, more elegant, and dramatically less likely to have any complications whatsoever. But even the most astute patient was incapable of knowing the difference between a 20-minute cataract surgery and a five-minute cataract surgery, one plodding and clumsy, the other elegant and quick, so powerful was this new technology. Every cataract surgeon in America could, and did, look their patients in the eye and say their outcomes were essentially the same as every other surgeon; they, themselves, were just as good as every other cataract surgeon.

This happy time of peace, love, and tranquility came to a screeching halt in 2003 with the introduction of an implant called the Crystalens. Here, for the first time, the cataract surgeon was able to give his patient excellent vision at any and all distances WITHOUT WEARING GLASSES. The problem, though, was that the Crystalens was actually rather tricky to insert. You really DID need to be more equal then your surgeon peers in order to get this extraordinary outcome. Not only that, but the implant was almost 10 times as expensive as what now became known as standard implants, it required roughly 3 times as much work preoperatively and postoperatively to achieve this outcome, and all of a sudden there was a very clear division between cataract surgeons. There were those who did what became known as premium surgery because they could, and there were those who didn’t.

Surgeon Emperor’s rode on their thrones through the throngs of what once were their peers, adorned with wondrous capes and crowns they so deservedly wore for they were truly better surgeons, and they were paid more to do this premium surgery. For you see, a great change had occurred:  the health insurance companies did NOT view these new implants as equal to those in present use, and in their wisdom they allowed patients to pay with their own money for these more expensive lenses. This they did, though not in great numbers, just enough that it started to become clear that some surgeons were more equal than others. This was not a true revolution in cataract surgery itself, only the economics of cataract surgery.

So here I find myself, one of these Lesser Surgeon Emperors of the premium implant era. I stand among the crowd as this very small group of self–proclaimed Greater Emperors glide by, pulled along on their grand femtosecond chariots. They are declaring, loudly and to anyone who’ll listen, that laser cataract surgery is the fourth great revolution in the long history of cataract surgery. “It’s more accurate,” they declare. “It will make cataract surgery safer!” They cry. “It’s the next, mandatory step in premium cataract surgery. It’s well–worth every penny of the additional $1000 the premium cataract patient will pay,” they state as they preen on their perches.

I blink as I stand there. Something’s not quite right. The rest of the crowd cheers these magnificent creatures but still something seems wrong. A better, more accurate and uniform capsulorhexis (the initial opening into the cataract)? That doesn’t seem to be a problem with premium cataract implant surgery today, at least in the hands of the best surgeons. Better sealing wounds to decrease the number of post–operative infections? Again, the busiest, highest volume, best cataract surgeons already have the lowest infection rates in America. A simpler, more reproducible and accurate limbal relaxing incision (a technique to treat astigmatism)? Well, I HAVE heard that an inability or unwillingness to handle astigmatism IS a barrier to implanting premium cataract implants, but that doesn’t really seem to be much of a problem for those surgeons who are successfully using them now.

I blink once again and then it hits me: the Emperor Surgeons have no clothes! They are parading right in front of us, declaring the femtosecond laser the proverbial silk purse to be utilized as part of a premium service, carried only by those cloaked in the finery of the court as they have been told by the industry courtesans.  Femptosecond laser cataract surgery is a revolutionary step, but it is a premium service like the Crystalens, and is properly utilized only by Emperors.

They are right but they are also so very wrong.

Blinded by the hype, blinded by the glow of their reputations, by the industry courtesans as they wave their empty clothes hangars, the naked Surgeon Emperors are trying to MISS the fourth great revolution in cataract surgery, because femtosecond cataract surgery is not a silk purse, it’s actually just a better backpack! Femtosecond laser cataract surgery is the technology that reestablishes real equality among cataract surgeons. It is not the scepter of the Greater Surgeon Emperor, it is rather the butter knife of the common surgeon.

Think about it. The best cataract surgeons in America are not having any difficulty making a proper capsulorhexis, and they are obtaining over–the–top outstanding outcomes with literally every single type of intraocular lens available. These are not the men and women who are having outbreaks of endophthalmitis (a total eye infection) because of poor technique creating their incisions. We are not seeing an epidemic of untreated astigmatism in the population served by these extraordinarily talented surgeons, especially in those eyes that have received a Crystalens or other premium lens implant. The femtosecond laser as a necessary, mandatory tool to improve the outcomes in THIS group of surgeons performing premium service cataract surgery? Please. The incremental improvement in outcomes will be infinitesimally small in this group, and I will go out on a limb and say that any of the Emperor Surgeons in the parade who are truly among this group of noted surgeons would tell you just this.

No, femtosecond laser cataract surgery is the next great revolution in regular, garden-variety, standard implant cataract surgery performed by the middle–of–the–Bell Curve cataract surgeon. Here is a quick story to illustrate my point. An 80-year-old man had cataract surgery performed in his right eye by one of the most deservedly famous cataract surgeons in the United States. Perfect incision. Perfect capsulorhexis. Limbal relaxing incisions that reduced astigmatism to 0. Every single aspect of the operation that would have been impacted by the femtosecond laser was performed flawlessly. The outcome? Not so great, actually. The patient had a poorly positioned implant causing blurred vision, which was not discovered for approximately 9 months due to postoperative inattention. This caused him to be greatly unhappy with his result and ultimately causing him to seek another surgeon for his left eye even after the blur was fixed.

This new surgeon simply could not be more different from the world famous surgeon. A very kind and gentle soul with a lovely and caring bedside manner, he was at best deeply buried in the middle of the surgical Bell Curve. The outcome? Not so great, actually. A poorly done capsulorhexis prompted him to default to a much older lens implant, a clear technological backward step, and a surgical problem that would clearly be prevented with the use of the femtosecond laser.

So my friends, the femtosecond laser actually IS the fourth great revolution in cataract surgery, but the Greater Surgeon Emperors are failing to see that, like intracapsular to extracapsular, and extracapsular to phacoemulsification, phaco to femtosecond is a revolution for the masses. The femtosecond laser will make an average cataract surgeon a good one, a good cataract surgeon a very good one, and a very good cataract surgeon potentially a great one. It will do very little for the outcomes of the already great cataract surgeon. Oh, there may certainly come some new type of implant where the outstanding surgeon will require a femtosecond laser in order to properly use it, but as of this moment that particular widget doesn’t exist. The femtosecond laser is a technology looking for a use, an investment looking for a market. Will it find its place only with the Emperors, those who should be leading, now instead just riding behind?

The greatest of Emperors lead.  If I am right, if this is actually a technology which will make regular cataract surgery safer and more predictable, Surgeon Emperors and their industry minions should be pounding the streets of Washington to make this fourth revolution just like its predecessor: available to all. They should call it as it is, the average surgeon’s pathway to greatness. They should lead on behalf of every 80-year-old man who deserves a perfect capsulorhexis and a perfectly created wound to go along with his most modern standard implant. They should lead their surgeon brethren on behalf of their people. The greatest among these Emperor Surgeons will see nothing that is negative happen to them if they fight to make femtosecond laser cataract surgery just the next revolution in every day cataract surgery.

I blink. I wait for one of these Emperors to put on some clothes, get out in front, and lead.

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

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

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

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

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

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

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

The second reason is that he doesn’t care.

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

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

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

Better learn how to spell his name.

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

We’ll see more, of that I am sure.

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

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

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

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

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

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

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

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

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

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

Let’s see who’s got game.

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

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

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

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

Wadda ya think, Dr. Kling? You in?

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

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

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

The lines are now open…

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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.

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.