Random Thoughts from a Restless Mind

I am about to be forced to use the EMR abomination know as “Epic” in order to continue to perform surgery at a particular institution, one where I spend ~10% of my clinical time. My work there is very profitable for the institution; I am not paid by the institution. At present my administrative load is 2X what it was 5 years ago, but the majority is borne by my staff. Once I am required to use their EHR my administrative load will increase at least 20X and I will bear all of it.

Why? My forms are standardized and fulfilling my part of the administrative load presently requires approximately 8 signatures for each case. 8 swipes with a pen on 8 pages layed out before me and marked “sign here”. Time = 0:10/case. Soon I will have to sign into the system for each case and move through a series of ~5 steps to reach the point where I will perform the digital version of my sweeping pen. Time, I am told by colleagues using the system to achieve this, = ~4:00/case. Let’s be generous and assume that they can’t possibly be correct, that it can’t possibly take 4:00 to do digitally what I now do with a pen (Heaven help if I have to enter pre- and post-op orders w/out standard forms!), and that it’s only 2:00. A typical OR day includes 20+ patients. 40 minutes added minimum. Did I mention that I have to do it TWICE because you can’t sign an op note right after surgery?

Lest you think this 52 yo doc is a Luddite and has avoided any and all such technology let me assure you that quite the opposite is the case. We have had an extremely efficient EMR in our office for 7 years; our management and scheduling has been done by computer for 16. My home is littered with Apple products. I’m a buyer of tech WHEN IT MAKES SENSE.

Unfortunately, it appears that I’m about to be forced to be a buyer of this “meaningless use” very soon. I thought I’d share the experience with you here. I’ll keep a log under “The Epic Adventure” and I’ll record not only my experiences but also the time I will be forced to “invest” in learning how to use the system and the time it takes me to comply with its requirements.

It promises to be quite a ride, albeit a rather slow one

“Manic depression is touching my soul.”

You’re up;  you’re down. You’re happy; you’re sad. You have the best job in the world; thinking about going to work makes you sick to your stomach. You’re so good at what you do, everybody loves you; everyone is out to get you.

You are an American physician.

Recently I’ve been asked at least a dozen times why I became a doctor, or why I became an eye doctor. I’m not really sure why this has come up now, because most of the people who are asking have known me in some way for many years. Why I became an eye doctor is really rather simple, and I have written about it HERE. The question “why did you become a doctor” is much more complex, much more involved, and frankly I’m beginning to wonder about that myself.

“Why do you want to be a doctor” was at the same time the easiest and most difficult question for me to answer, especially during medical school interviews. I grew up in a small, dying mill town in Massachusetts. The happiest, most fulfilled, most IMPORTANT people in that town were the doctors, of which there were very few. The busiest surgeon in town, Dr. L., could possibly have been the happiest person in the entire town. Beautiful wife, attractive, intelligent, athletic children, really big house. He was even a decent golfer! I don’t think I ever saw him without a smile on his face.

It was Dr. Roy, though, my pediatrician, who really clinched it for me. There must have been another pediatrician in town–heck, there were 24,000 people there. For the life of me, though, I can’t ever recall any of my friends seeing any doctor other than Dr. Roy. He was confident. Secure. Always with a gentle smile whether in the office or on Main Street. My mom later told me that he was perhaps the most influential politician in town as well. Everybody looked up to Dr. Roy, no matter how young or old they might be. His was a happy, contented, full life, largely because he was a respected physician.

Can you name a single pediatrician now living and practicing in the United States whom you would describe like that?

Nevertheless, that’s mostly why I wanted to be a doctor. I want to be Dr. Roy. I wanted people to look up to me because I was good at doing something that was important, something that was meaningful to their lives. All of the doctors in town were like that.

Now? Well, I’m a 51-year-old eye surgeon and I am just like every other physician in the United States. I swing between the euphoria associated with a good outcome or a happy patient, and the bitter black hole that appears when a disease wins. My world is actually pretty good in this regard: for every defeat there are literally hundreds of victories. For every patient who is dissatisfied or unfulfilled there are hundreds who can’t wait to tell everyone in their lives how good their experience was. It’s just that there seems to be a couple more people who are less satisfied. A couple more each year.

Again, the success rate in my particular specialty is incredibly high, and these people who are less than satisfied have actually had an extraordinary good outcome if you look objectively. I think it all tracks back to the creeping consumerism in health care. It’s not good enough to have an outstanding outcome, it’s only truly even good enough if it meets the expectations of the consumer, the patient, no matter how outlandish or inappropriate those expectations might be.

I’m up. I’m down. The downs seem to hurt more because they are so much more, I don’t know, personal now.

I always got the idea that there was pretty much nothing to the business of being a doctor. All the docs seemed to have enough money, although none of them seemed wealthy. There was only one “girl” in the office and she made the appointments, gave you your bill, and took your payment. No back office or billing department. No special personnel responsible for charting, compliance, insurance communications. My “chart” was a couple of 5×7 cards stapled together.

Now? Oh man…the squeeze is coming from all directions. Private practice or big group practice, it doesn’t matter. You either deal with the external forces conspiring to make it more unpleasant to make a living as a doctor (insurance companies, the government, malpractice attorneys) or you deal with your boss (or more likely your boss’ secretary since you’re just another employee, after all). Your chart is now a legal document littered with land mines meant to ensnare even the most pious and dedicated among us.  Most docs do OK financially, maybe not 1%’ers but pretty well. It just seems like so many folks go so far out of their way to make us feel like we don’t deserve our pay. Any of us. Any of it.

I’m comfortable; you don’t deserve it.

Now, if you are not a doc you could sit back and rightly say “quit yer whinin”. I’d get it. I just can’t shake the feeling that Dr. Roy, and all of the Dr. Roy’s of the day, got and gave more out of what medicine could offer than any of us do now, despite the fact that those of us who practice now have so much more at our disposal on the medical side of the equation. It just doesn’t feel as good. There’s just too much that comes between doctors and that sense of service, of satisfaction in those bygone days. It just seems so much like work now. I don’t think Dr. Roy ever went to work. I believe he would have practiced pretty much the same way if he’d inherited a million dollars.

You’re up; you’re down. You have the best job in the world; you can barely make yourself open the office door. Everybody loves you;  you don’t deserve it.

“Manic depression is a frustrating mess.”

(With thanks to Ira Byock, M.D.).

I attended a talk yesterday on end of life care, the first in a lecture series honoring the friend I lost to cancer earlier this year. The talk was surprisingly moving, not only because it brought back memories of Ken but also because I will likely lose my Dad in the not too far future, and I thought of my folks throughout the talk. What the speaker discussed as end of life care and end of life preparations also offered a very important take-away that I will try to apply now, today, as if the end of life was nigh.

One should say 4 things often and with ease, not only in the course of completing a life’s work or concluding a life’s relationships, but in the course of living a life:

Please forgive me.
I forgive you.
Thank you.
I love you.

Sounds simple, huh? Maybe even a little trite. But each one of those little phrases is a bit of a minefield, each one laden with a hidden meaning and a back story, each one the mid-point in a little journey with a “before” you know, and an “after” you can’t possibly predict. There’s a little risk in that “after”, too, and that’s why those 4 little phrases aren’t really all that simple, and why considering this is not at all trivial. All 4 of those little phrases make you look outward, look at another, and in the stating they force you to put yourself at the mercy of that other. Each one of those phrases is a little opening in our guard, an invitation to accept or reject not only the sentiment but the sender.

I’ve spent the better part of 24 hours thinking about those 4 essential things and about how they fit in a life that is not necessarily concluding (at least I hope not!). We are, each of us, part of a tiny little ecosystem; thinking about using these phrases encourages us to look outward and see the others in our own worlds whether we are approaching the conclusion of a life or smack dab in the middle. How will my parents react if I approach this when I visit? Do they know it’s now the 5th act, that we are tying up all of the loose ends in the story?

How about my friends, my kids, my darling bride? Actually, without really knowing it I’ve been on this path for some years now, probably guided by Beth and her inherent goodness. Friends come and go; either way I’ll likely feel a sense of completeness in the relationship if I remember these 4 things. Patients and staff do, too. I think I’m a pretty good boss and pretty user-friendly for patients as far as specialists go. Bet I’ll be better at both if I’m thinking about these, even just a little bit, even now.

Please forgive me.
I forgive you.
Thank you.
I love you.

Don’t wait for the conclusion of your life to think about these.

It’s the jobs, Stupid. That’s what should be on the office wall of every legislator at every level of government across America. Say what you will about Bill Clinton, but did anyone ever get it more than that first Clinton presidential campaign? A simple sign in their campaign war room reminded everyone of the central message: “It’s the economy, Stupid!”

It’s more than that, of course. Now, you could say, “It’s the jobs, Stupid!” What can you do to stimulate the creation of jobs now? Sure, you can take a page out of Rahm “Never Waste a Crisis” Emmanuel’s book and combat our crushing unemployment by pumping money into grand public works. Who doesn’t agree that our bridges, roads, sewers and subways are in dire need of repair? But everyone was enticed by President Obama’s promise of “shovel ready” public projects into which stimulus funds could be pumped, followed instantaneously by the hiring of willing hands to man those shovels. Stimulus I didn’t really turn out that way, so why would we embark on Stimulus II? Or III? Return on this investment was pretty much zero.

Nothing will get our economy moving faster and restore our national spirit than employing more people, and at a higher wage. Let’s take a quick look at the kind of job sector that would be most desirable.

Any industry into which we might pump money should have the ability to ramp up employment at the first dollar of public investment, or the first loosening of a needless regulation. OR BOTH.

Any sector targeted should be able to create and fill jobs across a broad range of salary, experience, and skill levels, and it should be relatively gender-neutral. It should reward achievement and educational advancement. Any jobs created should be domestic, although any hard products created must be attractive for export. It should be an American business sector that is expanding now, and poised for additional growth.

Pretty ambitious list of criteria, huh? Where will we ever find an industry or economic sector that could fulfill all of these criteria without some new genius discovery or mega-bureaucratic mischief?

Easy. Healthcare.

Think about it. Right now our country is fixated on cutting the money flowing into healthcare businesses such as hospitals, nursing homes, and doctors’ practices. Government regulations make it more and more difficult to make a profit while providing healthcare. Perhaps more frightening is the fact that similar regulatory agencies make it nearly impossible to bring new medical products to the market or build the sales of existing products.

Despite that, healthcare and related industries (pharmaceutical manufacturing, medical device manufacturing, health insurance administration and sales) continue to grow in all ways that we can measure, except the most important one: jobs.

I know your reaction. “We’re gonna go broke paying for healthcare as it is; how could we possibly pump MORE money into that?”

Hear me out before you dismiss my theory out of hand.

Every new regulation, every new requirement, every cut in payment for an office visit or a medicine or a hospital stay results in a net LOSS of jobs. And worse, pretty much no one in the entire healthcare and medical sector is hiring now, partly because of declining pay for services and products, and partly by the gloom caused by an assumption that the future holds nothing but more of the same.

We should try to identify regulations to remove. Start with removing the prohibition on drug companies marketing so-called “off-label” use of prescription drugs when it is clear they are beneficial. More sales of existing drugs means more jobs. More sales of existing drugs — along with fewer barriers to approving new drugs — means even more jobs.

People in healthcare and related businesses make a good wage, and there are jobs available across a broad wage scale. These folks buy houses, employ skilled trades, go out to eat and the like. As they advance, they earn higher salaries, and then they do the American thing: they spend it!

Pump more money into healthcare rather than less. Stop all of this talk of cutting payments to hospitals and doctors and instead index fee increases to inflation. Stop reducing Medicaid rolls and give doctors and hospitals an incentive to care for these people by increasing Medicaid payment to the levels of Medicare. That would create more jobs.

Education matters in all things medical, whether you are a doctor or someone working in a pharmaceutical factory. Generally, the more education you have, the better you fare economically. There is no systemic gender or race discrimination in healthcare. With doctors, nurses, hospital administrators, academicians, the only requirement is to be good at what you do. Same thing in related industries like medical device manufacturing; ambitious people of all types, men and women, young and old, can advance in their careers. Advancement means more job openings.

And guess what? More jobs means generating more income that can be taxed! More jobs create more spending and more sales that can be taxed! You could even encourage more of this by decreasing income taxes on those people most likely to spend that money, which would then create…wait for it…more jobs!

Oops. Sorry. Politicians are involved. Decrease taxes? That’s just crazy talk.

The next thing you know someone will propose some really crazy thing, like increasing the money we spend on healthcare.

*Credit for the idea to William J. Petraiuolo, M.D.

“I’m sorry, Doctor, but we can’t have you give that talk; you have a conflict of interest since you’ve been paid to do research on that medicine.”

“Well, Senator, it’s a conflict of interest for a doctor to sell those crutches in his office.”

“It is the opinion of this newspaper that physicians should declare to each patient any ownership interest they might have in a surgery center so that the patient is aware of any conflict of interest.”

And on and on the drums beat, droning incessantly and insistently about the dreaded “conflict of interest”.

In a world now run by the terminally attention deficited, with multi-tasking and synergy-seeking all the rage, we apparently have one domain in which nothing but the purest, most antiseptic, monastic and single-minded devotion to a single task and goal is acceptable: the provision of health care in America. Think about it…the simple existence of OTHER interests is de facto evidence of some nefarious CONFLICT of interest. The underlying assumption appears to be that it is impossible to have any additional interest–ownership of a business, a consulting agreement, stock or stock options–without the ability to devote your primary attention to the best interests of your patient. Any other interest is automatically bad, and every physician is guilty and can’t be proven innocent. How did we come to this?

There are issues and examples both substantial and trivial, and yet each of them is addressed as if they are one and the same. I bought pens last month for the first time in my professional career (I graduated from med school in 1986). It was weird. Who knew that there was a place called Office Max and that this huge store had not one but TWO aisles of pens to peruse?! I think it was Bics in a KMart the last time I bought a pen. Somehow this fact means that I have been making decisions for my patients based on all those pens I DIDN’T buy all these years. There’s only one problem with that: I don’t remember a single thing about even one of those pens.

And yet somehow accepting those pens is a “conflict of interest”. Seriously.

Why is it that if I somehow get something from someone, big or small, even if I perform some service or even buy something from them, that it’s a “conflict of interest” if some company or other might make money from what I do for my patient? Why is every peripheral interest that exists around the little silo in which I practice medicine–a space occupied by me, my staff, and my patient–why is that automatically a “conflict of interest” with some sort of negative connotation? That I must be doing something bad? Why not just “another interest”? Why can’t these things be a “convergence of interests” between what is best for my patient and any of the other stuff that might be going on around us?

Listen, I get it. There have been instances where docs have pushed inferior products on their patients because they had a significant financial incentive to do so. I’m reviewing a med-mal case right now where the plaintiff had an eye problem which resulted in cataract surgery. The cataract surgeons are not being sued, but I looked over the surgical record and saw that they put an inferior POS lens implant in this guy’s eye, and I KNOW they did that because they own the surgery center and that lens is dirt cheap. THAT’S a conflict of interest. But for every surgery center owner like this putz I know 50 who put in state-of-the-art implants because that’s what’s best for their patients. Those docs still make a profit, but it’s smaller because they are putting the patient first. Why is THAT a conflict of interest?

It’s not.

Three different companies make 3 versions of the same kind of medicine, all of which have identical efficacy and safety, and all of which sell within pennies of each other. How does one choose among them if one needs to be prescribed? Is it such a heinous insult to humanity to choose to prescribe the product from the company that pays the doc to consult on some other project? Or the company that brought in lunch? Or (GASP!) the one that left a couple pen lights in the office? Tell me, how and why is this a “conflict of interest”?

This trivialization of the concept of “conflict of interest” is actually weakening the protections that we should have against REAL conflicts that cause real harm. Pushing unproven technology (artificial spinal discs, anyone?) on unsuspecting patients prior to definitive proof in return for obscene “consulting” agreements, for example. Applying the same degree of moral outrage to a ham sandwich as we do to conflicts which truly pit the best interests of our patients against some profound interest on the part of the physician that prevents him/her from centralizing the patient is farcical moral equivalence. I think it is actually harming our patients.

Our most renowned medical editors, innovators, inventors, and teachers are withdrawing from public positions that require a monk-like aversion to these “conflicts of interest”. Who will replace them? Will the ascete cocooned in the conflict-free zone and unaware of what developments are on the way contribute? How about the teachers? Will we be taught by “specialists” who put together the purest power-points from the latest scrubbed articles, priests who are not stained by the sins of the those who are touched by the commerce of medicine by actually touching, you know, patients?

Here’s my bid: a true “conflict of interest” is one in which there is an essential tension between what is best for a patient, and some other ancillary benefit that might accrue to the physician. Something that makes the doc think about that other benefit first, before the patient. Everything else is an “additional” benefit. We should stop this silliness; stop trivializing the concept of “conflict of interest” through the dumping together of all other interests in the same gutter. We should all be allowed to ignore all but the truest of conflicts as we continue to put our patients’ interests first.

We should be allowed to seek a “convergence of interests.”

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

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

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

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

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

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

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

The second reason is that he doesn’t care.

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

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

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

Better learn how to spell his name.

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

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

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

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

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

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

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

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

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

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

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

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

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…

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

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

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

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

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

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

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

The jury got it half right.

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

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

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