On Becoming a Family Man and a Doctor

Having Someone Under Me

2012-01-28T10:41:00.000-06:00

You've probably heard of my intention of going into academic medicine. You may have hear me mention it. Sure there is a pay cut with it, sometimes quite a large one; although, the hours aren't near as strenuous for the most part.

But now that I've been something more than the most junior of residents for over six months now, I really think I have had a chance to confirm what I want to do. I rather enjoy the opportunity to teach. Since I've had more junior residents around, I have had plenty of opportunity to do this. Even if it's not always teaching a blurb about ophthalmology but rather imparting a gem of practicality in the management of a patient. Presenting a case at grand rounds is not such a bad thing, though sometimes the simple act of putting together the information in the form of a power point can be grueling and hard to begin. And I am supposed to have a lecture with the technician students coming up as well. Good stuff.

If only I could teach some people (no, not just any people; trained and practicing ophthalmologists in group practices) how to manage text book cases and navigate the health care system. I don't know a lot of things, but sometimes I just want to say, "C'mon!!" I've always thought a good reason to stay in academics was easy access to staying up to date on things, but one would think so-called "continuing education" would do the same thing.

Seeking a Travel Agent

2012-01-23T09:56:00.016-06:00

Job Description: Must be able to adequately and efficiently book multiple short-duration trips, sometimes at the drop of a hat. Must be flexible in terms of departure/arrival times and able to make changes to any previously arranged trip. Must be able to contact airport security prior to any departure so that they may understand why I have a one-way ticket somewhere so as to minimize suspicion and unwarranted overly friendly body searches. Must use my account with Southwest and my credit card so that I continue to accumulate points with both. Must be able to research and effectively utilize all methods of travel, including plane, car, public transport (rails, buses, carriages), taxis, horseback, and shuttles while minimizing use of rental vehicles. Must be effective and utilizing family, friends, and friends of family for reasonable lodging options. Must be able to select hotels, when appropriate, which combine in the best way possible shuttle service, proximity to target interview and dining locations, cleanliness, and cost while avoid the use of brothels. Must be able to ensure that my suits, shirts, ties, shoes, and underwear are clean before packing for each trip. Must be available via telephone, text message, or email throughout the entirety of the day. Must be willing to coordinate my absenteeism with my superiors and fellow residents in terms of clinic and call duties, respectively.

Oh, and one more thing. Compensation will not be monetary and may be in the form of a hug, small gift or gift card, or dinner where I may or may not cover your meal.

Please contact me if you are interested or need more information.

The Facebook Dilemma

2012-01-22T09:44:00.000-06:00

The whole process of applying to fellowship programs has been many things: expensive, stressful and tiring, exciting, humbling, just to name a few. But it is also far more intimate than the residency application process. A few hundred people apply each year to ophthalmology residency programs, and what program would have the time to thoroughly investigate each applicant?

Fellowship is different. In a given match cycle for an ASOPRS oculoplastics fellowship, there are typically between 20 and 25 positions available across the country. These will be applied for by between 40 to 60 or more people. If I haven't mentioned it before, those are the odds I am up against - pretty steep. At any rate, the point is, it's a much more intimate. There are few applicants that can be eliminated early and easily - those who try to "see what will happen" but aren't competitive on paper.

So suppose you've been able to knock your applicant pool down to around 30 to 40 candidates. That's still a lot of people to try to interview for only one position, and you simply don't have the time - your clinic and OR are still booked after all. So how do you further screen these people quickly, without making them pay a bunch of money to come out and talk with you only to find out they don't belong with you? A couple programs have chosen to do Skype interviews - two of which I have done. (I will discuss the pros and cons of a Skype interview later.)

The other option is Facebook. Let me first point out that I am vehemently against employers using Facebook as an additional source to screen potential employees or candidates. There remains, for most people, a sharp distinction between one's professional life and one's concurrent (or especially past) social life. Let's not forget that Facebook is a social network, not a professional network. There are separate networks for the professional side of things. But still, people do this.

While I used to have my Facebook profile open to viewing by people not listed as "friends," I recently restricted viewing to only my friends. Not that there is anything too incriminating on there - no pictures of me drunk and stupid, barely half dressed (except for some beach photos of my pale bod), or overly direct, opinionated statements. Nonetheless, some people would think to form opinions of how I would function in a fellowship based on all that stuff.

Well now they can't.

My Own Office Space

2012-01-11T17:57:00.000-06:00

You know what I think one of the best things about the VA is? My own office space. Or at least it's mostly mine. It gets used from time to time by other folks when I'm operating or not there, but overall it's my space. I can organize and run it however I want. At JEI and ACH, we are not afforded this liberty and the rooms are much more public which means searching for what I need every time I see patient. I'm not sure what the best solution for this is, but it can be a problem.

I never understood why people with their own rooms felt the need to put up signs that instructed borrowers of the room to be sure to leave it in its original condition. I always felt it was a little juvenile. But I can see where the point is - I hate it when I walk into my room on a Friday morning after someone else used it Thursday afternoon and there is trash on the desk, bottles of drops strewn all about, and materials not stocked. This is not an exaggeration at all - it's typical. I still don't think I'll put up a sign in colorful, bold letters, but then again, it should be universally understood.

I wonder if it needs new cabinets?

Hiatus

2012-01-09T18:35:00.000-06:00

Allow me to apologize for my recent hiatus. December proved to be busier than I planned. But alas, here is a quick update to be followed by more regular posting again in the present future.

The last time I wrote I had only two weeks before submitted the majority of my application materials to the available programs. Well, it's nearly two months later - what's going on?

I have had two interviews so far - at University of West Virginia and Massachusetts Eye and Ear Infirmary (Harvard) - but both via Skype. The up - I didn't have to travel all the way to these places only for them to decide they don't like me well enough to actually want me. This allows them to screen a lot more people, and then only invite out the ones they want. So I know if I ever get invited to actually visit, they are seriously interested in me and I should thus be very interested in them. The down - it is very hard to gauge a program and its personalities through a computer monitor and headphones.

I have also since then booked three more interviews - at Indianapolis, Seattle, and Milwaukee. The worst part about these is paying for lodging, followed by the flight, followed by transportation, and then the actual travelling. We shall see.

And I just found out today that the University of Iowa is only accepting internal applicants this year - sure seems they could have made that decision before I payed the money to send them my application. Their loss overall, I guess. Sounds like some internal shadiness anyway.

The Staff Who Steps Up

2011-11-18T07:02:00.000-06:00

Doing cataract surgery with a resident who is just starting out is surely a very stressful thing for the attending. The patient may not even belong to the attending - they're just here to oversee the care. But there comes a certain time when as an academician, as a teacher, you have to step up and be there for the resident.

I had a patient come to the pre-operative holding area one morning in preparation for his cataract surgery. Despite being told multiple times by multiple people to stop his aspirin a week before the surgery, he didn't to it. We always discuss with our patients, as residents, the use of blood thinners, primarily because in preparation for the surgery we give a retrobulbar block, the biggest risk to which is hemorrhage. But on aspirin, this risk is fairly low. And in the "real" world, a cataract surgeon may not even blink an eye about a patient being on aspirin.

OR, they change their game plan. Doing an anesthetic injection behind the eye (the retrobulbar block) is only one option for anesthesia. The other is simply using topical anesthetic with maybe a little bit injected into the eye. At my stage of training, many of my current attendings would have just cancelled the case - sent the patient all the way back home, only to have to reschedule and repeat the whole process, costing everyone more time and money.

But I was lucky enough to have an attending that day who stepped up. Everyone else would have cancelled the case. But he walked up to me, handed me the appropriate topical anesthetics and said, "We're doing this one topical. See you back there."

That about made him the best attending to do cataract surgery with. I think.

The Consultant's Magic Words

2011-11-09T17:55:00.001-06:00

As ophthalmologists, a surgical subspecialty, we are consulted a lot. As ophthalmologists in an academic center, we are consulted far more than is appropriate. And because we're residents, consults are frequently downright abused.

The fact is, people have learned the so-called magic words which buy a guaranteed-to-see consult. Even if it means the story is grossly exaggerated, if it gets the patient seen that day, that's all the consultee cares about. Of course it's not like this happens all the time, but there are a few key examples.

"It's a painful eye." I have been told this before only to find out from the patient that, in fact, there was no pain at all. "No, Doc, there's no pain. It's just that I have had this bump on my eye for a few months and decided to come to the ER at 5 PM on a Friday. Gee, I'm sorry you had to work me in for this." Yeah, right.

"The vision is worse than before." I have been told this before only to find out from the patient that, in fact, the blurriness is only when they first wake up and it goes away after a few blinks. "Oh, and let me guess, you're having eye pain too, right?" "No, Doc, just a little fuzzy after I intensely rub my eyes in the morning. Should I sleep in my contacts?"

Don't exaggerate just to get us to see the patient. It doesn't make you look any better to me. And I will be sure your attending doesn't think better of you for it.

Yes, I Worked Through Lunch

2011-11-08T19:38:00.000-06:00

It has not happened recently, seeing as I have been at JEI and ACH lately, but yes, sometimes I have to work through lunch.

What's funny is that some patients, should they come to find out this little piece of information, show a fake sense of sorrow about it. We all know that if they saw me walk by with lunch in my had, they would grumble about their "prolonged" wait.

"Oh, you haven't eaten yet?"
"Why no, I haven't."

For some reason, this is not a subject I like to discuss with patients. It's on par with discussing my age. I am not sure why this is, but it is. Maybe it is because lunch is that brief period of time during the day, even if only for five minutes, when my obligations to the patient population are nil. That is my time, whether I choose to spend it alone or with my coworkers. Or sitting on the phone with my wife. Or running a quick errand to the post office.

I don't ask you about your age or lunch break, so please feel free not to ask about mine.

The Apparent Stigma of Pink Eye

2011-11-07T18:24:00.000-06:00

I find it somewhat comical when a patient comes in to the clinic with a routine case of pink eye. Well, not funny that they have pink eye, but how it is often dealt with.

The first thing they do is put up a thick wall of defense. They come in knowing their eye is red and irritate. But there is no way in hell they have been doing anything that would give them pink eye. And so when I bring this up as a possibility from the get go, not long after entering the room, it's as if I have accused them of something dirty. It seems as though this disease is put on par with the clap or something. Then there is this wave of depression or let-down. I've told patients they had cancer and had them handle it better sometimes. Sometimes not.

Well, I don't know where it is you're putting your face, but pink eye not any different from any other infection. I suppose it has something to do with the fact that everyone can immediately tell you're "infected," whereas other infections may require special privilege to know about them.

Update

2011-11-02T18:40:00.000-05:00

So allow my to apologize for a little bit of a hiatus there. I have been quite busy with a number of things: writing a paper, trying to polish up an IRB proposal (over and over and over and over), and oh yeah, gathering everything needed to apply to fellowships. I have had a little stress to say the least, and although I enjoy writing here, other things just needed to take precedence.

That paper is more or less finally written. It has been rewritten more times than I can count. All that's really left is going through the arduous process of submitting the whole thing online. We'll see how it goes.

The IRB proposal has been a learning experience for more people than just myself. Starting a prospective study from square one is not something many people at JEI are familiar with. In fact, practically no one is. I have had to have multiple meetings with multiple people just to figure out what might fly. We shall see.

Then there has been the application process. The amount of redundancy has been sickening. Assimilating the information was probably ten times more work than it was for residency - even though the exact same centralized application service is used for both. Where's the trust?

Anyways, as I promised a mentor, here is a plug to his newly begun blog:
http://eyelidsurgeon.wordpress.com/ He has several posts about the do's and don't's that people in the real world care about. Check it out - he is looking for more hits.

Allow Me to Draw My Condition For You

2011-10-20T20:16:00.000-05:00

It is no secret that some of our patients border on crazy. Fact is, there are psychiatrists to manage the crazy people. When a crazy person walks into my clinic I am not always sure what to do.

So one day this, you got it, crazy guy comes into my clinic room. He brings in with him a large bag stuffed to the max with categorized folders documenting in detail his prior physician visits. This, off the bat, is never a good sign, if not always a bad one. Seeing as I was new to him and he to me, he began at the beginning, some years ago. But it wasn't with words. It was with pictures. He had drawn out in detail the visual distortions he noted in his vision. Each complete with color coded documentation.

Right off he clearly doesn't understand how unimportant all this stuff is. Of course, he then proceeds to tell me that no resident in the past was ever capable of seeing his problem, only the retina attendings. "Okay," I'm thinking at this point, "this guy is in for it." Even from his story it was obvious he had categorized residents and attendings on opposite sides of a tall cinder block wall. He was missing out on key elements of the resident-attending relationship that are quite obvious to others.

"Look, any new problems today?" I asked
"Well if you'll give me a piece of paper. . ."
"I'll just go get the 'Retina Specialist.' Draw while I'm gone."

Drawing is a true art. But then, so is knowing how to cut people short in their graphic rambling.

Moving From a Frustrating Case to a Satisfying One

2011-10-20T08:10:00.000-05:00

The best way to make use of operating room time, particularly in an specialty where operating days are limited to one or two (or three) a week, is to schedule all cases at that same time. Then you spend the morning going straight from one case into the next, hopefully getting yourself into a good routine. But as a learning surgeon, the inter-case variability may be significant.

One morning I was doing a cataract case during which it seemed like everything became ten times more complicated than they needed to be. Ultimately, the patient did just fine and in the end the surgery could easily be considered a success. But the path to that end was very rocky and difficult. This is never how you want to start the day; it seems to set everything else off pace and it can be very difficult to get back into a good rhythm.

Then my second case came rolled into the operating room. Somehow, things went just splendid - if not a bit longer than what an experienced cataract surgeon may take. Suddenly, it seemed as though the day was going to go okay.

Time to Take the Eye

2011-10-13T19:10:00.000-05:00

An enucleation spoon, believe it or not

As eye doctors we have this goal through training that ultimately results in saving vision and protecting the eye. But there are times when instead of keeping a bad eye, the best thing we can do for a patient is get rid of the eye. This is a process called enucleation, and while it's a generic procedure name many specialties use to refer to removal, it means only one thing to all eye doctors.

We recently had a patient who developed an infection in the eye. I happened to be the one to see him first on his visit to the emergency room with severe eye pain and redness. The infection was obvious and he as admitted for treatment. Several things, including surgeries and injections into the eye, were tried to save his eye. But ultimately, the pain and discomfort of a now blind eye became too great.

Only after removal of the eye did he completely turn around and become his old, easy going self.

Regenerating Hope

2011-10-11T17:52:00.000-05:00

You're Not in the Club!!

I may have mentioned before how there is a club to which certain oculoplastics fellowships belong. This is known as ASOPRS, or the American Society of Ophthalmic Plastic and Reconstructive Surgery. What does membership mean? Perhaps a bit more prestige in the long run and maybe a better academic appointment if that is desired.

So here is the plan. I will first apply to the ASOPRS programs simply because the application deadlines for those are first - the match occurs this coming April. If/when I don't match via this route, I will then seek out the non-ASOPRS fellowships and apply to those who are willing to take on a fellow in 2013. It's basically about putting myself out there and seeing what grabs. They typically interview only 8 months prior to the start date.

The fact is, of all the people who apply for ASOPRS fellowships during this match cycle, only 50% or less will get a spot. The remaining half who don't match will consist of a couple different types of people. One type is the one who isn't terribly serious in the long run about oculoplastics and will ultimately decide to apply for a different type of fellowship. I used to be this kind of person - I thought if the plastics thing didn't work out, I would go the cornea route. But after much reflection, I decided I just wouldn't be overly happy doing cornea. The other type is the one who will reapply and find these other non-ASOPRS people. That's how both of my current mentors did it and they're both great at what they do.

What's to lose? And if a few years lapse between finishing residency and landing in fellowship position, so what?

That Question Wasn't Directed at You

2011-10-10T22:14:00.000-05:00

So for those who visit regularly, you know I generally enjoy teaching - one of the big reasons my eventual plans are to enter as an academic surgeon. Having students around is usually enjoyable to me. But there are always those few students who are incredibly annoying. They come in several different types. And, hey, you can't expect everyone to like and enjoy everyone - it's just not reasonable.

We were all sitting in grand rounds one day. The third year medical students currently on the neurology/ophthalmology rotation came strolling in - late as usual, though not entirely their fault. Our grand rounds typically involve a lot of question asking of the residents - known affectionately in our field as "pimping." Although, the pimping at our program is pretty mild. At any rate, the questioner that day was not directing his questions openly; rather, they all started with, "Dr So-and-So, what is. . . ." This is all fine and dandy - it eliminates the type of silence where everyone is thinking: "Well, someone else will answer the question. I think. Do I even know the answer?? What if I'm wrong. Oh God, now I definitely won't answer. . ."

Well there was this medical student. Not even particularly interested in ophthalmology as far as I know. Any low-ball question that was asked to Dr. So-and-So, he was sure to blurt out the answer.

It didn't matter if he was correct in his answers. The temptation to slap him was overwhelming. I don't recall being like that as a student; I knew my boundaries. I think he will find himself having issues with this now and in the future.

A Dream About Failure

2011-10-09T12:23:00.000-05:00

Anything surrounded by a lot of thinking and worry can be expected to be accompanied with dreams from time to time. The quickly upcoming stress of applying to fellowships has led to such a thing.

The other night I had a dream I was interviewing for fellowship somewhere in the Pacific Northwest (there are a couple potentials in the area). Through an arduous process of elimination, the applicant pool had been narrowed down to just me and another female applicant - a completely made up person in my head. Someone once told me that the faces we see in dreams should always be from someone we know; this is complete bollocks.

Anyway, she interviewed first and I second. At the conclusion of the interview, the physician (also someone I have never seen) across the table from me looked up and said, "I just don't think you're who we're looking for here." I exited the room only to find everyone applauding for the other applicant who of course got the position. I can't figure out who all these people applauding were. They weren't there when I entered the room, and why would they be so damn happy? I have never placed a lot on the "hidden" messages of dreams, but I mean what the hell?

On the upside, one of my fellow junior residents was there and was given (by the stranger interviewing me) a card - a free pass if you will - stating he would be granted admission into whatever kind of fellowship he wanted when it was his time to apply. Or, at least I guess this is an upside. Either that or a fat slap to the face.

A Tick in the Eye

2011-10-03T18:13:00.000-05:00

In continuing with the tick theme as noted in a recent entry, I wanted to share this other tick story with you. Perhaps if I had gotten my sign up. . .

So this dude presented to the to emergency room (thank God it was during daylight hours) stating he has had something in his eye since the day before. He had been working outside and couldn't place anything as going into his eye. Naturally the emergency room immediately punted to us without an eye exam.

The eye looked pretty good at the surface. But further inspection with flipping of the lid revealed a moving target. Usually, a tick on the eye bites and latches on tight - much like skin. But this guy was moving, trying to avoid the giant approaching Q-tip. A single swipe and he was out of there.

Is there anything we can do that doesn't require the use of safety goggles?

Connecting On a Different Level with the Surgeon

2011-09-29T20:50:00.000-05:00

I have only recently truly appreciated the different depths of a given clinical teacher. People behave, and apparently teach, very differently in different environments.

So, yeah. Learning from someone in the operating room is totally different than learning from the same person in the clinic.

Pretty much lost the rest of my thoughts on this one. Don't know what happened.

Those Little Gray Spots

2011-09-27T17:51:00.000-05:00

You know what's scary to me? Children admitted to a psych ward. I have always felt uncomfortable in that situation. But do you what is even scarier? A KID IN THE PSYCH WARD WITH GRAY SPOTS ON HIS EYES!!!! AHHHH!!!!

Allow me to clarify a little bit while giving a lesson on time awareness. There was a child (yes, admitted to the psych ward) who fell while jumping on the bed. (Immediately I think of my daughter's feigned attempts at singing "No More Monkeys Jumping on the Bed.") Now, I am only being a little cynical by wondering why psychiatric physicians aren't able to assess someone after s/he fell to determine if head CT scanning is needed. After all, I have several friends in the department. But why they have to call a family medicine resident to do the assessment is confusing, if not concerning. At any rate, one did. And this one, we'll call him Dr. Thybeorver, noted gray spots on the kid's eyes. But even he knew this was not likely to be urgent and could wait until morning. Although, he still recommended an ophthalmology consult which was not needed.

Apparently, someone else (the psych resident) thought 5AM was a good time. "Non urgent you say? Well 5AM will do just fine, then."

Blah. So I saw the patient and of course agreed, there were a few perfectly normal looking gray spots on this kid's eye. Had probably been there since birth.

I got so scared I about shit a brick.

You Sound Like Tom Cruise

2011-09-26T18:33:00.000-05:00

The comments regarding my overly youthful appearance are always forthcoming. And I can't say they disappoint me - I would rather look ten years younger than ten years older than my current age.

Some have commented on a particularly soothing voice. I have had one attending say I sound like a radio announcer. Although, I will claim to have led a more straight and narrow path than the Ted Williams with the "golden voice."

What took me by surprise one day was a little black lady who told me I sounded like Tom Cruise. How she really knew what he sounded like is beyond me. Perhaps she saw in entirety his little freak out moment on Oprah one day. Never once did I get on my chair or desk and jump around though.

So that's it. I am an 18-year old radio announcer with Tom Cruise savoriness. With emerging gray hairs. It just doesn't all add up.

Look, a baby tick!!

2011-09-16T19:01:00.000-05:00

The VA clinic is a very busy place. There are distractions everywhere. The halls are lined with people and each of the rooms experience constant in and out traffic. But once you're in my room, you expect my full undivided attention. Likewise, I expect yours. There is already a sign on the inside of my door telling you of the importance of not talking on the cell phone while I'm in there.

But I didn't think I needed a sign for this. A lady, perhaps more accurately a less than well-kept female, was sitting in my exam chair. She asked me some question about her glasses prescription. I then proceeded to tell her why we couldn't give a new prescription at that time (certain conditions preclude giving a good, accurate prescription). I did not have her full attention; to this day, I'm not certain I had much of it at all.

She was too busy examining herself. I think she was doing everything possible short of stripping to find what was bothering her. Recall I described her as less than well-kept - stripping was not an option. Eye contact could not be maintained. Then she found it.

"Oohh - a baby tick!" she acclaimed. "I was wondering what that was. . ."
"That's great. Don't throw it on the floor, please."
"I'm sorry, Doc, what were you saying about my glasses?"

Okay. New sign. Here it is:

The Lady in the Scooter

2011-09-13T17:07:00.000-05:00

I know I have made an Austin Powers reference in the past, but I couldn't help but smile to myself and again think of that silly man when I saw exactly what this title implies.

You all know this scene. In an attempt to turn his little cart around, he wedges it between the hallway walls, switching from forward to reverse gears repeatedly to move mere inches.

Well, a lady at the VA did a very similar thing. Lots of those folks have found themselves in a powered scooter for one reason or another. Some have also become quite adept at maneuvering through the hallway; others not so much. This poor lady found her self similarly wedged in the hallway, except the effective walls were patients in chairs, each fiercely protecting what toes they had left (diabetes runs rampant in the eye clinic).

So what if I chuckled? There wasn't much I could do to help.

Look Mia - A Video Tape

2011-09-12T18:35:00.000-05:00

As residents, we make video documentation of most if not all of our cataract surgeries and anything else that may be done under the scope and worth recording. At the VA, the current recording systems use VHS tapes to record the material. I have heard a DVD system was once tried but worked miserably with poor quality. Hmm, I wonder. . .

While we could speculate all day about why that may be, that is not the point of this writing. The point is, look at those things. Finding them in the store means looking at the bottom shelf nested back in the corner somewhere. Finding a player means going into your back bedroom closet with a shovel and a trash bag. And while that just sounds like a murder scene, it's to rid yourself of other useless junk while you're at it.

She only knew that it was a tape and was probably best served by lying on the table. But that DVD? You bet she knows what to do with that.

The Chief Race

2011-09-07T18:31:00.000-05:00

At the VA, we are kind of in this position where we are between real chiefs. We have had acting chiefs, or people working in the chief position though not officially named. The way I have seen it, there seems to be two people currently in contention for the spot. The reality is, I didn't think either of these two people would have wanted such a thing; one has a few very little ones at home to help tend to, and the other seems to get way too stressed out over the little things.

Regardless, the VA now has a new surgery chief. Which means the decision process has only just begun - even if it already had several months before with the interim chief. Each of our two candidates serves as an ophthalmology chief for a period of time. Then it seems a winner will be chosen by the surgery chief. It almost seems like a season of Survivor.

I haven't been asked to be on a tribal council yet, but I'm sure it's coming. Look for us on the next VATV Morning Edition.

The Value of Patient Positioning

2011-09-05T21:07:00.000-05:00

I should first point out the fact that though I have rotated over the childrens hospital as of September first, I often have a backlog of blog entries to write. I have been averaging in the range of twenty at any given time. And since I have only been averaging about fifteen posts a month for the last three or so, well, you do the math.

One of my biggest mantras has always been about the importance of proper patient positioning during surgery or a procedure. Firstly, we do a lot of our surgeries on patients are still awake, perhaps just a little sedated. Of course, I do want to go into oculoplastics where there are more patients who are put under general anesthesia. At any rate, you want them to be comfortable so that they can lie there still for a good period of time.

Secondly, the person doing the surgery has to be comfortable. Imagine trying to do an entire surgical case straining your neck to see through the microscope or hunched over because the bed is too low to the ground. These situations make for a very unhappy surgeon at the end of the day and may even cause chronic back and neck problems.

So if there is one thing I always tell to people when I am teaching is to get everything set up so that everyone is comfortable FIRST, then you may proceed. And this goes for everything form an exam at the slit lamp to putting in a central line to doing an 18-hour muscle flap procedure.

The Post-Op Hug

2011-08-25T20:36:00.000-05:00

Who said hugs aren't nice. . .sometimes?

Cataract surgery has turned out to be a truly gratifying experience - and I think it's so for both the surgeon and the patient. In the academic and VA world, patients with cataracts have usually been walking around with them for quite some time. So by the time they present to us for the discussion about taking them out, they are usually fairly advanced. They have long lost their 20/20 vision, their sense of the color white is forgotten, and they can't remember the last time they were able to drive at night. It's different in the private world where patients have money and time and ability to keep regular eye appointments and cataracts are discovered and operated on early - though sometimes too early.

At any rate, for my patients, the difference between their preoperative vision and their postoperative vision is usually quite large. I've had some who couldn't even see the big "E" on the chart who now see 20/20 without any glasses. And even if we don't get to that perfect target, the vision is still far better, clearer, and brighter than before. Sometimes they are so thrilled, they can't help but hug me. I don't know that anyone ever hugs the surgeon who takes out an angry appendix; but cataract surgeons are frequent receivers of the post-op hug.

And that defines gratifying if nothing else does.

What I See in an Ambulance

2011-08-24T20:17:00.000-05:00

As a medical student and even as a medicine intern the things I thought when I saw an ambulance were quite different from the things I think of now. It used to be we just affectionately called the ambulance a "whaambulance" in reference to it's most common passenger: someone without a real medical emergency.

Now, and especially the days I am on call, I will be driving home on the highway and see an ambulance headed the opposite direction. All I can think is, I hope that's not a trauma with facial fractures and an open globe. This may not be the best way to think of them, but I do.

Adjusting My Volume

2011-08-23T18:31:00.000-05:00

Get the reference??

Something quite humorous happened to me in clinic the other day. I am currently seeing patients on a daily basis at the VA - the hospital for the veterans, for those who don't know. This is largely a population of patients 60 years old or older, usually with a list of medical problems with accompanying medications longer than the LOTR roll call.

At any rate, one day I seemed to get a particularly long stream of near-deaf patients in my chair. So over and over again I was doing nothing short of yelling at my patients, probably driving the patients and physicians in neighboring rooms to question my ability to establish good rapport. The patients in my room, however, knew no different. In fact, for some of them, I was doing little more than whispering.

Then a patient with normal auditory function stepped in. But I didn't know this at first. I had found myself stuck in volume-to-eleven mode and began yelling to him.

"HOW ARE YOU TODAY, SIR?"
"Fine. By the way, I may be near blind, but I'm not deaf."

I couldn't help but look at the floor and silently laugh. It's not like he could see me anyway. (Actually, he was nowhere near blind).

Some Basic Anatomy, Doc

2011-08-22T19:53:00.000-05:00

Most of the people I come into contact with in a medical setting, at least on the doctor-to-doctor front, know their basic eye anatomy. Most nurses as well know at least the information on this here diagram. Now, I know the exposure to ophthalmology type stuff in most medical school curricula is limited. But this is basic anatomy - first and second year student material. Most learn this to a limited degree well before medical school even starts. Allow me to say that I would never expect the primary care doctor to know the eye and orbit anatomy as well as my mentors (I can't say "me" because I'm still learning). But something must happen when certain people graduate - any knowledge of the eye just leaves.

The example is when I was recently consulted to see a patient in the pediatric emergency room. I was told over the phone that the iris was lacerated from a stick injury.

"Okay, so you're telling me there's an open globe, then?"
"No, Bradley, the iris is just lacerated."
"That by definition, Dr. Wuposnockee, is an open globe."
"But. . ."
"What's the vision?"
"Well it's 20/20."
"You're telling me the patient had a stick go through the cornea, lacerate the iris, and yet the vision is perfect? The patient doesn't have an open globe, or an iris laceration."
"Well than what is it?"
"I'll tell you after I see the patient. . ."

The cornea had a scratch on it. Yep, he did just fine. I once had an open globe myself, and as minor as it was, I had nowhere near 20/20 vision. My iris was not even lacerated, by the way.

Call Before You Send it My Way

2011-08-21T20:36:00.000-05:00

There are a lot of things that get sent to us from other areas of the state to take care of. A good deal of it occurring on nights and weekends does so because some local eye doctor is not available (or more commonly doesn't want) to take care of it. But that is for another discussion entirely. There is another group of things that get sent to us because others just don't know what to do about them.

I am happy to help take care of anything that someone else may have a question about. But there are certain times when that help should more appropriately be provided over the phone. There are clearly times when the patient just needs to be sent to us - the trauma patient, the patient with the orbital abscess, etc. But here are a few that don't

The shingles patient. A patient shows up to your emergency room or your office with shingles involving the same dermatome as that involving the eye. Does this patient need an eye exam - yes. Does it need to be done three hours from home in the middle of the night - absolutely not. This has happened more than once. The patient got sent inappropriately for an eye exam in the middle of the night. Had someone taken the five minutes to call me and ask about this, the trip could have been avoided. Because, guess what? This is not an eye emergency - I could have told them to come the next day. Or better yet, see someone local after the sun came up.

The conjunctivitis patient. This can always wait until the next day. To top it off, never, EVER, send these patients by ambulance or helicopter (which has been done!!) for a viral illness we will treat with over the counter artificial tears.

Above all else, if you're sending a patient to me specifically for specialized eye care, it's common courtesy to let me know about it ahead of time.

Please Don't Shake Your Baby

2011-08-20T20:00:00.000-05:00

One of the less-than-satisfying tasks of being an ophthalmologist is getting that call from the pediatric intensive care unit after a child suspected of being abused is admitted. One of the routine exams performed in such a case is a dilated eye exam. Certain findings in the retina used to be a gold standard in making this diagnosis. But, thankfully, lately it has been more widely realized that such findings are only a single piece of the puzzle. They don't rule anything in or anything out; other than that the retina sustained a significant injury. It is not our job as eye doctors to make conjectures in these cases as to what happened.

But when we do see it, it's sad nonetheless. Any more, by the time we are getting called to do the exam, a pretty extensive history has already been undertaken and there is something there that made somebody suspect abuse. This, more than anything else, is probably most useful information that can be gathered. Interacting with parents or the accused during the process is extremely uncomfortable. We walk in the room and there is usually one of two responses.

The first is the catatonic response. The parent that doesn't want to interact much with me, or even the child. Are they guilty or simply in shock at the accusations? The second is the "Oh my God, what do you see, is he gonna be all right?" parent. These are hard to interact with simply because I don't know how much to divulge or to whom. That's when I become the catatonic one.

Just save it. Don't do it in the first place.

The Role of Teaching

2011-08-19T21:37:00.000-05:00

As we each progress through residency we learn a large amount of material. I remember as a fourth year student I was quite amazed at just how much stuff there was to learn about two little eye balls and their surrounding milieu of tissues. As I have slowly picked up some of these things, and some of them have actually stuck, I now find myself with a unique responsibility.

Now in my second year, there are three residents now affectionately called "the first years." Although, one of them is a prior trained ophthalmologist from another country. So the likelihood that I could possibly impart anything other than knowledge of how to navigate the local university system is low - I may go to her for ophthalmology questions. As for the other two, I was very recently in their shoes, and I remember well what it was like to know little. Now in my current shoes, and for any other no longer first year, the task of helping to teach the new people is upon me.

This has only reaffirmed, I think, that I want to be involved in an academic setting when I finally grow up. I rather enjoy teaching most days.

Everything Becomes Relatable to Cataract Surgery

2011-08-18T20:36:00.000-05:00

I briefly mentioned recently how cataract surgery serves as the bread and butter foundation for eye surgeons. We no longer do it like the guy in the red over there. The steps are much more humane now and the results much more satisfactory.

As I am learning to do cataract surgery, weekly refining different steps along the way, I have noticed something funny. Not uncommonly I will think of some very every day things in a new light - as how they compare to something done during routine cataract surgery. Brushing my teeth is like polishing the capsule - gentle but brisk. Routing the kitchen's trim is like grooving through a nucleus - shave it away until the desired shape is reached. Opening what should be an unopened envelope is like making a good capsulorhexis - don't let any tears go astray.

Making your wife mad is like having a case go poorly - you don't want to have to face up later.

ReReading

2011-08-17T20:52:00.000-05:00

A good residency program comes with at least a decent didactics program. I interviewed at several programs where there was no organized lecture time and it's hard to imagine how any accountability is given to the residents. At any rate, we have a very organized schedule. Of course, recent studies suggest it works only moderately well.

Our lecture series, and the board exam as it were, is based on a set of books published by the American Academy of Ophthalmology; all in all a few thousand pages of stuff. We read through the entire series each new year. So, all that said, this being the second year of residency, I am going through the entire set of books a second time. At first I thought this would make the reading easier to sit through. Easier to stay awake during.

It's not panning out so far.

The Maiden Cataract Extraction

2011-08-16T19:05:00.000-05:00

One of the rights of passage for an ophthalmology resident is cataract surgery, kind of like for otolaryngologists it's the ear tubes, for the general surgeons the appendectomies, and for the urologists the cystoscopes. One could argue it is much more technical that many of the other surgeries we do, but nonetheless, we start early with them.

The whole surgery is a conglomeration of small steps, none of which individually take very long, which together accomplish the removal of a cataract and placement of an artificial lens. Some of these steps are easy to learn and others take time and time again to get them halfway correct.

But the very first one, the one in which anything can go wrong, is one to sweat and clench through. A good cataract surgeon can enter the eye with the first step and be done in 10-15 minutes. A maiden case takes often an hour, or more. Thankfully, mine went well, and they have done so since then. And patients frequently don't care if it takes so long - they can almost all see better afterwards and are incredibly grateful. Kids are less so after ear tubes - they don't typically know the difference.

Oh That Propofol

2011-08-10T20:22:00.000-05:00

The first part of our routine cataract surgeries at the VA involves giving a retrobulbar injection of local anesthetic. As expected, not too many people are very fond of witnessing a long needle coming towards their eye. Really, they wouldn't even need to look at it, but I'm sure it doesn't feel good either.

At any rate, the way we deal with this is to put the patient to sleep for a few short minutes while we do it. One of the best IV medications for the job is propofol - a fast acting, though short-lived injectible. The effects on the patient are nothing short of often comical. You can imagine trying to talk to someone right as they're falling asleep - s/he won't fully comprehend the question, nor even the answery s/he is trying to give. Of course, this is how we know the near full effect is achieved - we ask them questions. When the answers become garbled, quite frequently coupled with big, fat yawns, it's time to inject.

To make the experience more humorous for us (okay, not really, it's for the patient to look at), there's a large paper butterfly taped to the ceiling above the patient's head. So not uncommonly, their final words may be:

"Gargle mmsnuff sshbipner. . .buttterrrfflyyyy. . . ." Nothing like starting eye surgery with a giggle.

The Ophthalmic Hazards of Dentistry

2011-08-09T19:21:00.000-05:00

I recently had a patient come into the clinic after what was apparently an eventful dentist appointment. While sitting in the grand chair of dentistry, he had his mouth wide open. The possible implications of this are many, but suffice it to say, we all generally have our mouths open while in the chair of dentistry. He was having some drill work done in his mouth when suddenly he felt as if there was something in his eye. Naturally it didn't want to come out and it is unlikely the dentist looked for it.

So he comes to the eye clinic with this complaint (BLOG!!, I thought). After a thorough exam of the redundant forniceal tissue, I found this little dark chunk. Was it enamel? Was it a chip off the old drill bit? Was a lasting memory of last week's polenta lasagna? Well, I didn't send it for further analysis.

At the end of the day, we all learned one more task during which to wear protective eye wear: being a dentist's patient.

Whether to Publish

2011-08-08T21:20:00.000-05:00

One way to beef up an application for fellowship big time is to have publications on board. But not just any - specialty-relevant publications would be nice. I have one online journal publication (ophthalmology based) and one peer reviewed article published on which I am a secondary author (not ophthalmology based). Where does this leave me? Fairly deep in the ground.

I have this research project on which I spent several hours gathering and manipulating data. Then several hours more building a presentation around it. The big question for me lately has been whether to take all of this to publication. The "information" I found was not ground breaking or likely to change the way in which anyone practices medicine. It mere takes something which has not been extensively studied in the past and fails to come up with a concrete answer to anything - just recommendations. And while they may be reasonable or even correct, they aren't deeply grounded. I just don't know that anyone would publish the rubbish.

Then there are a couple case reports I have sitting around I would work on. But even those are getting harder to publish it seems.

A Piece of History

2011-08-02T18:39:00.000-05:00

Recap from yesterday: I collect old medical stuff. So I guess in a way this is a continuation of yesterday.

This little (heavy-ass solid cast-freakin'-iron) thing is called an ophthalmometer. I can't say it's something I've ever seen used, nor had I ever seen one prior to acquiring this as a birthday present from my parents. I am somewhat familiar with its close relative, a keratometer. A keratometer is used to measure the curvature of the cornea. This does very much the same thing, though differently. And as a young eye doctor, I have no idea how.

One thing I've been trying to do is figure out when it was made. There are some models out there quite a bit older that this. And those that are much newer are all electronic. All of the mounted manual ones in clinic are also newer, but again, are known as keratometers.

I've got some research to do on this one. But I don't think it will be publishable.

What People Used to Think

2011-08-01T19:28:00.000-05:00

For those of you who may not be aware, I am a collector of old medical texts and equipment. This little gem you see here has brought me some real joy by looking at it from time to time. It was written circa 1900 (title pages didn't seem to be a requirement back then) by a very cocky, self-proclaimed expert.

I don't say this because of the statements made about treatments for ocular conditions - things were definitely very different then. He refers to cataract surgery as very barbaric, and back then, it certainly was. It was a big surgery full of complications only to leave you needing coke bottle glasses. But there are many other things stated in this book which are absolutely ridiculous. He has ascribed a "Mild Medicine Method" to all illnesses of the eye and ear. Phsssh. Taken from the text:

"There is barely a hint of agreement, among medical authorities, as to the cause of cataract, but it is pretty generally recognized that among the common causes are overworking and straining the eyes, reading or doing needle and fancy work with insufficient light, injuring the eyes by a blow or by a pressure or rubbing with the hands." Um, what???

On astigmatism, "For it is not a thing to be cured by the mere use of glasses. It may lead to a permanent injury of the sight, to cataract, or other dangerous afflictions of the eye." I think even most (real) eye doctors then didn't feel this way.

And the best part:
"If your eyes are tired, or if they ache and smart on account of their intemperate use, you should write to or personally consult me. I will give you advice and treatment that will undo the evil you have caused through your own carelessness and neglect. In the schools the sight of hundreds of children is impaired every year by the over-use of the eyes. Teachers should be very careful in this matter. Children had better devote a little less time to the books and preserve their eyes for use in the after life than to have them fail just enough to lead their parents to rush off to an ignorant oculist who may finish the work of destruction already begun." Where was this guy when I was in school?

Of course he finishes the book by telling you how to get to his office and why he was so damn brilliant in placing his office in Kansas City.

What's More Important - Your Kindle, or Your Eye?

2011-07-26T19:00:00.000-05:00

So we have had this wonderful patient at JEI who developed a corneal ulcer which ultimately bought her very frequent visits at the clinic. They always do. She was always very religious about making it to her appointments and always did what we asked. It's not an easy course if you've never done it - drops every 30 to 60 minutes in the beginning, sometimes even throughout the night the first few days. That's worse than having a hungry midnight infant.

She always had one thing to talk about which, to her, seemed far more interesting and important than her eye. It was her Kindle. Or her Cruz. Or whatever her most recent e-reader purchase was. She would buy one, take it for a spin (or a read), decide she didn't like it, and then turn around and sell it on Ebay for a profit. And they sold - every time. This lady made a profit turning over e-readers. What was even better was her ever longing desire to show me her latest one. I think it was only becuase I showed an interest.

It was only polite.

The Starving Artist

2011-07-25T20:12:00.000-05:00

It's comical to me (so I crack myself up, what of it?) that I often say my patients in the ER, as I'm sewing their face back up, that I compare myself to a starving artist. Okay - so the comparison is weak. But simply draw the thin line between an artist not making any money but trying with his artwork to an underpaid resident trying to delicately put a face together.

The big abdominal surgeon doesn't really care (nor should he) about the resultant belly wound after a big aneurysm repair. The patient could go about his life with only those very close to him knowing of the scar. The case is quiet different when someone has a big laceration on their face. There's this expectation, if not a defined duty, to fix the wound such that any scarring is minimized. It truly can be an art sometimes.

Fortunately, the face tends to heal quite well - especially when talking about around the eyes.

Projectile On Exam

2011-07-21T19:15:00.000-05:00

I mentioned once before the difficulty of trying to examine someone when they keep wanting to vomit. But every time in the past there was fair warning; a "Whoa, I really don't feel well." has generally sufficed. Things got just a little too close recently.

I went in to see a patient with orbital fractures who had just been brought up from the emergency room. I'm sure by that point he had been pumped full of IV morphine on an empty stomach. I had done the first part of the eye exam some time ago while he was still in the ER and had only to wait for him to dilate. The story at this point is not embellished in any way. He was lying in bed and seemed quiet and perfectly content; that is not to say there was a smile on his face or anything. I had my fancy light strapped to my head and my fancy lens in my hand. I was leaning in, though not for a kiss, when he suddenly sat bolt upright in bed and spewed across the room. My hand was inches away. Inches.

Fair warning is nice.

The Roast

2011-07-20T19:00:00.000-05:00

No - THAT'S a roast.

It has been tradition in our program to roast the outgoing residents on the infamous Resident's Day. It's funny - you spend all day "honoring" the chief residents only to end it by making fun of them.

There are all kinds of levels, bad to excellent, in which a particular roast may fall. I had see one of the bad types when I was a student - I basically spent the whole time wondering what exactly was going on. At first I thought it may have something to do with the fact I wasn't that close to the resident being roasted. But I later found out that, no, it was in fact just bad.

This past year, I can honestly say they were all pretty good (and not just because some of the roasters/roastees are occasional readers.) Things were tasteful yet still humorous. It can be easy to go overboard, beat a dead horse, or repeat things which have been overdone in the past.

I have since then been wondering how things will go when I do it. I think I have a fairly good idea who I will be roasting. I also think I have a fairly good sense of humor. Only problem is, it is a bit dry for a lot of people. I've been known to be pretty sarcastic yet overly blunt. Sadly, I have already been trying to keep a log of things potentially worthy of a roast.

We'll see.

No - I can't Accept That

2011-07-19T19:20:00.000-05:00

It is very common place, particularly at a tertiary referral center like UAMS, to get patients transferred to us who are in need of more specialized care than can be provided at their current location. In ophthalmology, for the most part, this occurs on an outpatient basis. But there a couple examples of people trying to send patients to the inpatient ophthalmology service (what??!?!?) in need of better eye care. (Hey, in our defense, we do occasionally have our own inpatients.)

One patient was one with sudden decrease in vision in one eye, not to mention multiple other systemic vascular issues going on. We don't even admit those people unless IV steroids are warranted.

Another was a surgical patient who complained of blurry vision. This patient had multiple surgical issues going on (as in not having healed from the surgery and now with infection). Would we please accept the patient? Um, no. Try the surgery service for a surgical patient and we would be glad to consult.

What are we, doctors?

It Can be Hard to Go Back to Routine

2011-07-16T21:19:00.000-05:00

Old picture, but she still pulls it off much better than I.

For about eleven months of the year, we have morning lectures on Monday, Wednesday, and Friday. Between the time of the OKAP exam and resident's day, the whole morning conference thing went to the wayside.

Naturally we've been back at if for about a month now. Probably one of the more difficult things to do was to get back in the routine of keeping up with a defined study schedule. I have always really enjoyed the fact that our didactic component of the program is rigidly organized - it forces our hand to keep up with reading regularly; whereas in other programs this may not be present and reading is just supposed to happen during magical free time. I was once told by a smart man that while surgeons may work at the hospital 80 hours a week and we maybe 50, we make up for that other 30 with extra reading. I'm not sure I get in 30 hours a week of reading, but you get the point.

Anyways, I suppose I should get back to reading about the biochemical oddities of the human lens.

Check a Blood Pressure Sometimes

2011-07-16T00:18:00.000-05:00

Even an eye doctor can use this.

I have mentioned before the feast or famine nature of the Children's emergency room - I'm either told way less than the actual truth, or the picture is painted way out of proportion. I'm used to it. But what is even worse is when I am consulted to see a patient with an "eye" problem when there is clearly something else going on. This has happened a couple times in the last couple months - and both times at the VA.

The first was a patient who had an episode of decreased vision in his only good eye, the other being nearly lost secondary to glaucoma. So surely I would want to see the patient right away, right? I walk in the patient's room in the ED to find him attached to a blood pressure cuff with fluids running into him. This was his second liter of fluids, with a systolic blood pressure still barely over one hundred. I already knew the problem - hadn't even stated my name yet or seen an eyeball. After further (proper) questioning of the patient, I come to find out he hadn't been eating or drinking, while on diuretics, and had this episode of decreased vision after he stood up and got dizzy and subsequently fell. Most non-physicians could diagnose this - LOW BLOOD PRESSURE. EYE = FINE.

The second was a patient sent from the vascular surgery clinic because he was having intermittent, brief episodes of dimming of his vision. Medications? Oh yeah, he was recently switched from one beta blocker to another because of excessively low blood pressure. What he was not counseled well on was to actually stop the first. So he went home from the hospital taking both. And his symptoms usually occurred while he was standing on a ladder painting the ceiling. Clearly another case of hypotension-induced vision change. Again, LOW BLOOD PRESSURE. EYE = FINE.

Moral? Check some vitals, ask some good questions, be a doctor, and then consult. Only then. These are two gleaming examples of textbook, board-worthy, EASY scenarios.

I Won't Miss the Consults

2011-07-14T18:48:00.000-05:00

Not really.

Tomorrow marks the end of the new first years' orientation stretch. This means a few things - all of which are generally good.

First, at least at JEI and the VA, I will never again be responsible for the consults. For the most part. There will always be vacations to cover, but those only come a week at a time. And of course at Children's the consults are done by both the junior and senior resident on a day-to-day basis, but oh well. I can't even begin to tell you how glad I am to be rid of the JEI/UAMS consults.

Second, their help will be present in the clinic. Lightened clinic or not, the extra hand is ALWAYS appreciated, no matter how many or few patients that one person can see in course of a clinic. I remember being in that position and feeling like I didn't contribute much by seeing a small handful of patients, but I later realized the luxury of (almost) anyone's presence.

Third, they are two weeks closer to taking call which only means less call for the rest of the junior residents. Yay.

"What? Candidemia? Call someone else! . . . .Please."

Ahh Yes, That Was a VA Monday

2011-07-11T20:03:00.000-05:00

Everybody likes to tell you about what makes their Monday worse than yours. Maybe it is. Maybe it isn't. Either way, most people have a Monday that sucks for them. For the last eight months, Monday was just another day of the week - busy but manageable.

But now that I'm back at the VA, Mondays are different. I can't really say that I almost forgot what they were like - nobody does. Mornings can be shaky - full AM clinics with a large uncertainty of what level of help will be available. Afternoons are always shaky. There is an overabundance of retinal patients scheduled, and again, uncertainty of what level of help will be available. The retina attending is excellent with his patients and has an excellent bed(chair)side manner. But this comes at a sacrifice for efficiency. Now some people are able to do both, but that can be difficult in a retina clinic. The unfortunate thing is, as a resident clinic, it should be residents doing the lasers and the injections - that's our time to learn them. But instead, to extend more good manner, the attending has a tendency to do them. This takes him away from staffing patients while everyone waits in the hall for him. I myself am not too worried about it since I plan on doing plastics and retinal lasers will be far out of my league.

But as I have said before, the chances are low. So I have to be prepared to do other things.

Awkward Moments

2011-07-10T10:22:00.000-05:00

This is another trip down memory lane type of post, but couldn't call it that for duplication of a prior title.

Every medical student goes though four years of school (or I suppose more in some less fortunate cases), and in probably every case, there is at least one encounter with an attending that makes you uncomfortable at least once. The biggest one for me was as a third year medical student.

I was rotating on the surgery service. As part of the deal, we had to spend a couple afternoons in the breast oncology clinic. This was a surgery rotation, and a surgery clinic, so naturally these patients had or were going to have surgery. For those of you who haven't figured it out yet, those shiny, white things in the corner are breast implants. At any rate, one of the attending surgeons who will remain nameless was very eccentric and somewhat odd overall. On a Stamp Out Smoking day she walked around with a fake cigarette in her mouth. Twisted, no?

Apparently at some point she saw an opportunity to make a medical student uncomfortable. Me. She came out of a patient room and practically demanded I come into this room with her. I went into the room and find sitting right there a bare chested woman. I think she even had a bit of a mock grin on her face, knowing what was about to happen. Behind her I swear there was a gathered crowd for the show: a fellow, maybe a resident, a family member or two, and there may have been a clown.

"What do you notice about these breasts?" the surgeon said.
"Well, uh, I. . ." I stammered. Usually there is a rapport established with a patient before you see her breasts. Usually.
"Well go ahead, touch 'em," the surgeon said.
So I did. What else would I do? Firm yet soft, well rounded. "Okay."
"Well, what do you notice about them?"
"I. . .I don't know. They feel different, but okay."
"They're fake!" I think at this point party streamers and confetti flew across the back of the room.
"Oh. Well good job, doctor." Then I turned and left.

Nothing like a wacky attending paired with a woman who is ready and willing.

I Would Be Catatonic Too

2011-07-09T19:50:00.000-05:00

As you well know, pretty much every hospital room comes with a TV, and most with a full range of basic cable channels. In fact, at the children's hospital, there is a full X-box set up in most of the rooms, making it difficult to convince them sometimes that it is time to go home.

At the VA, it seems as though the televisions are mostly controlled by a central output. I remember making medicine rounds (now over a year ago!!) at the VA and catching time lapsed segments of the same news broadcast (or Lawrence Welk rerun) as I went from room to room. By the way, as I'm writing this, beer and Starbursts don't go well together, but I keep it up anyway. At UAMS in any patient room that is intensive care or otherwise empty, there is some nature scene with serenading elevator music playing.

But one time, there was something else. I walked into this man's room in the ICU. He was getting frequent followup eye exams by us for something in his orbit. As I walked in, I found on the TV an invigorating episode of Curious George. He was, of course, just staring blankly at the screen.

I think I would also remain catatonic if someone left that on TV for me. I just hope it wasn't on a loop.

The Excitement of the New Guy

2011-07-07T20:38:00.000-05:00

You know I'm interested in doing a fellowship in oculoplastics. You know how much it would mean to me to gain a spot in such a fellowship. So naturally when I found out we were looking for a new oculoplastics physician, I was intrigued. Then, I found out we had actually hired one (tough to do on the tight JEI budget). Then I was truly excited.

After his arrival I found out what true excitement is. He is a young guy, fresh out of fellowship and after a stint in the military. He is far more published that most people this early in his career. His sheer enthusiasm for doing more research is nearly infectious.

We have a couple more new folks starting the coming months, but I somehow doubt they will match his excitement at being where he is.

You Know You're Ready to Rotate When. . .

2011-07-06T22:39:00.000-05:00

This may be a bit dated since it applies more to when I was nearing the end of my UAMS rotation, but I feel it will soon apply again since we are now on two-month rotations instead of four.

Because of the way things are, I spent eight straight months at Jones Eye Institute. I like most of the people there, enjoyed the relative ease over there, but was more than ready to leave. There are certain telltale signs to prove ones readiness.

One of these is counting down to the end of a rotation by the number of clinics. For example, at one point, I know I was saying, "Only three more Friday afternoon clinics until I leave this place," or, "Only two more neuro-op clinics left this block." It seems small to you, but these are milestones. Yeah, yeah, Mia sat up at six months, and that too is a milestone. But she never had to sit though contact lens clinic, she never had to sit through Friday afternoon optics lectures.

I know, I know. Big baby. Still, all countdowns come to an end. And I was happy.

An Update From the Fourth

2011-07-05T18:09:00.000-05:00

From Happy Bear Fireworks

The Fourth of July is an ophthalmologist's worst nightmare. That and New Year's Day. These are the two times a year when people can legally shoot fireworks, so naturally the do. Hey, we did too, but more on that later.

We at UAMS hate it even more because that is when the community ophthalmologists disappear (smart) for the weekend and their respective community hospitals are left with no coverage. As we start to roll into the weekend, so do the injuries.

As a general rule, injuries are secondary to things like bottle rockets and roman candles causing blunt trauma to the eye, resulting in a hyphema, or bleeding in the eye. But sometimes, the larger fireworks unexpectedly explode before people have a chance to get back. This has happened. And in one case, the eye injury was significant enough that the eye had to be taken out.

So we did fountains, sparklers, and smoke balls, but overall nothing projectile. I leave that for others, and watch from a distance.

Back At The VA

2011-07-01T18:14:00.000-05:00

I may have ended the first year yesterday, but with the beginning of the second today, I have returned to the VA. There isn't a busier rotation.

It will have its upsides, though. During this block I will start operating on a regular basis. I will be starting with cataract surgery, though at the children's hospital others will be starting with different things. Don't get me wrong, there are cataract surgeries done on children on a regular basis; but, the residents don't generally do much of them.

We'll see how things go. Currently my first cataract case is on Thursday next week. It would have been Tuesday, but that one already cancelled. Don't even get me started on what will be that huge headache. There are a lot of ways to cancel a cataract surgery, particularly at the VA it seems. And anesthesiology folks are often the driving force behind them (though not in this particular case). It's almost as though they just don't want to have to sit around during our cataract surgeries. Why not? They require minimal effort by anesthesia at the start of the case; the rest of their time is spent on an iPhone or with a magazine. Not being mean here, just simply stating a fact. The job doesn't get much easier than being in a cataract case.

Anyway, I have bid farewell to eight straight months at JEI. And not that there was any one person to blame, but that was just too much.

Goodbye to First Year. . .Again

2011-06-30T19:04:00.000-05:00

I will take this opportunity today to stand for what I have gone through as a first-year resident. Again.

See, some specialty residencies have a unique start to them in that there is an initial transitional or intern year which may have little to no exposure to their specialty of choice. At UAMS, this is primarily the ophthalmology and dermatology residents. Many of the surgical subspecialists (though, dermatology is not a surgical specialty) have several months of general surgery scut or other "off-service" months, but they still get several months of their desired specialty. We got one month of ophthalmology, and it was one during which we just followed someone around and weren't allowed to do much. The other eleven were all internal medicine without even a once-monthly eye clinic to attend.

So then my actual first year of ophthalmology came around. I was finally really getting used to being a medicine resident when my feet were lifted off the ground and I was pushed over without a solid surface on which to stand. Even though I was a PGY-2, I knew nothing. I was like an intern all over again.

Alas, as a PGY-3, I have surpassed that point. I know a thing or two. And for once, I can spend the next year expanding on it. I can honestly say, "Okay, I've done this. I've seen this. Now what more do I need to learn about it?" Obviously, the answer will always be, "Plenty."

Sample Medications

2011-06-29T18:35:00.000-05:00

It's hard in this age of medicine to know what to do about free samples of medications.

There was once a day when wherever you went you were able to get free samples of the newest medications on the market, and nobody had a real problem with it. Ophthalmologists were certainly no exception to this with entire cabinets full of eye drop samples.

But things have changed. The great exposure of the pharmaceutical industry led many to become more aware of the problems with free samples. Free samples were equated with getting a patient on a branded, new medication for which they would in the future require a prescription and pay a lot of money. Most university health care settings have essentially banned the presence of pharmaceutical representatives from their campuses. Most would agree that this is generally a good thing. But have they really gained anything with the banning? If you figure that most of these patients are uninsured or have at best Medicaid/Medicare, which frequently won't cover the cost of the newer, higher priced medications, then the university wasn't a huge motivation for sales people.

Still, there is another side to it. Essentially all new drugs in their infancy are only available as the expensive brand name due to patents. And sometimes, just sometimes, the new medications is in fact the next best greatest thing. Unless an unbiased overwhelming amount of literature and data suggest otherwise, I typically don't prescribe these drugs until they've been on the market a few years when more safety data is available. But, again, sometimes the new drug is just too good to not use. And considering many of my patients would never be able to afford such a thing, is it so wrong to continuously give them free samples? You may argue that as long as the company is giving out free samples, the cost of the medication will remain high or even rise. This, I don't think, would hold water when you figure that the overwhelming majority of the company's income goes to profit and advertisement (which they often include in their supposed "R&D" costs), not manufacturing costs. There's good literature on this out there - I recommend you read it.

So I still believe that in moderation, the dispensing of free samples can be helpful to good patient care. So long as there aren't associated kickbacks, awards, and presribers' interests at hand. Now if you want to talk about equipment and instrument representatives, that's an entirely different story.

Our Company Stole My Pain Meds

2011-06-28T17:33:00.000-05:00

Working in a university setting we get a lot of patients who are uninsured and also frequently drug seekers. I'm not stereotyping here, but the two characteristics often occur together.

At any rate, the range of excuses used to explain how a 30-day supply of narcotics disappeared in seven days is quite broad. But this one certainly stood out the other day. In the post-operative period for eye surgery, we really don't even give out much pain medications. There are only a few surgeries which warrant good pain medications, and an open globe is one of them. One of these patients walked into the clinic, appearing to be perfectly well (aside from the obvious eye injury status post repair) and not in any pain at all. In the clinic room, it was a parent (not even then twenty-year-old patient) who first brought up the recent loss of pain medications.

It wasn't the typical "Oh, I've been in so much pain I've taken it already," or the, "No, doctor, I wasn't given the prescription when I left the recovery room." It was, "We had some company the other night who stole the pain medication."
"Well," I said to the patient, "you look to be doing well anyway."
"Oh, no, she's in a lot of pain," says Mom.
"I wasn't talking to you." I turn back to the patient.
"Oh, yes, I'm in too much pain," the patient said with the flattest face ever.

I couldn't help but give her two more days of pain medications and then refuse to see her on the return visit - she (her mom) would be someone else's problem.

Don't Play With Your Food

2011-06-23T20:58:00.000-05:00

Pear

Whenever someone gets hit hard enough in the eye, though not hard enough to rupture it, it is very common to suffer what is called a hyphema. This is when there is bleeding in the eye, though in front of the iris. This turns out to be something that is heavily dreaded during the fourth of July season.

Hyphema

But recently, I encountered a type of injury a little unusual to me. A couple of kids were playing around some pear trees. Turns out a couple of them were decent baseball players. They got to throwing the fruits around and, as anticipated by the direction we're going, one of them took one to the eye and got a hyphema from it. I hope it was at least a pitcher-type that threw the darn thing.

When this happened, I immediately thought of, "Honestly, who throws a shoe?

Austin Powers

Could I Have Done ENT?

2011-06-20T22:35:00.000-05:00

Sometimes I look back on my path and wonder what would have happened if I had decided to become something else. Something else physician wise, that is. I'm not known for my patience as a general practitioner. So internal medicine, family practice, general surgery, pediatrics, and even OB/Gyn were without a chance for my interest. Psychiatry just didn't excite me in the least.

But any of the surgical subspecialties have interested me at one time or another (orthopedics, urology, ophthalmology, ENT). I always say that if perhaps the ophthalmology thing hadn't interested me enough, I would likely have seriously considered the field of otolaryngology, or ear, nose, and throat. But could I really have done that?

Their program is clearly more difficult to get through than ours. First and foremost, it's a year longer. Then, there's the fact that their first year is riddled with lots of general surgery intern scut. Internal medicine scut is one thing, but general surgery scut is an entirely different beast since you spend about zero time in the operating room (at least at our medical center - perhaps elsewhere the training is better). Then, their call is overall worse than ours in terms of busyness. Anybody taking home call can have bad days. Although, let's face it, dermatology home call does not tend to equate to much work over the weekend. Any who think it does needs to take one of our weekend calls for perspective. The benefit for ENT folks is that there are more of them splitting the task of first call. We have six, they have a few more. Two or three more may not sound like much, but believe me, it is. We have been blessed in that the transition from the staggered start program to the traditional start program has given us a periodic surplus of residents.

Could I have done it? Sure, but I probably wouldn't have the time to do this.

I Was Admitted, But I Won't Admit You

2011-06-16T21:44:00.000-05:00

I have learned through time and personal experience how things change.

When I had my eye injury several years ago, I was under the umbrella of my dad's insurance. It was good coverage, and was even better if used at the hospital where he worked - which it was. With good coverage comes good payment to the hospital and the physicians. So, naturally, I was admitted to the hospital for about two and a half days after a fairly simple corneal laceration. And it's not like transportation would have been an issue for daily follow up - we lived maybe five miles away.

Since becoming an ophthalmology resident, things seem to have changed immensely. Whenever we see globe trauma, no matter what hour of the night, the patient is taken to the OR, repaired, and then sent right home. The patient sometimes earns an observation admission if the repair is going to be delayed several hours for some reason. The only other time a hospital admission occurs is if there are other injuries and the patient isn't even on our service. A rare exception might be if the patient lives far away and/or is not likely to follow up as asked.

First of all, most of our patients don't have insurance. They would never pay a hospital bill, and aren't likely to pay the emergency room and operating fees. So that would just be pure lost money. Secondly, perhaps in the growing realization of poor cost effectiveness practice in most of medicine today, we have realized that such hospital admissions are not necessary. If not downright fraudulent in the case of a well-insured patient.

Never Say Never

2011-06-14T17:33:00.000-05:00

I apologize for not having written anything in nearly a week. It was a busy weekend, and the motivation left me for a few days since since then.

At any rate, as doctors, we sometimes tote a certain complication or disease as being rare. And for those of us who are young doctors, the rare things may never have been seen. Yet.

In this amazing field of medicine, there are ever changing treatments available for different things. Age related macular degeneration (ARMD) is a common eye disease of elderly people. Treatment for it has been mostly lacking and disappointing. But when the disease becomes "leaky" or bleeds, we can at least give an injection into the eye. It's with a medication which binds and clears blood vessel growth factors, the root of the problem. We always tell the patients that in the process of doing this, there is a rare complication of getting an infection in the eye: endophthalmitis.

I have always told people that it is very rare, and I had never seen a case related to injections. That all changed recently. Sure enough, a patient came into the VA ED with a painful eye one week after an injection, and was found to have an infection.

Start counting. I can now say, "Well I've only seen it happen once."

Another Year Older

2011-06-09T21:15:00.000-05:00

Yep - 28 years old today. Don't really have much more to say about it. Get to celebrate by making final preparations for my presentation tomorrow.

Now That Really Could Have Waited Until Morning

2011-06-07T18:20:00.000-05:00

It is very common for people to present to the ED at odd hours of the night for problems that have been going on since they woke up, or for several days even. You know this. I've bitched about it before.

But this was even more ridiculous. I recently got a consult from the ED about a patient who had gotten mace sprayed in his eye. He complained of a lot of burning. Probably not a huge deal, I thought, but might warrant a visit by me nonetheless. I mean, isn't that the whole idea of mace? If it caused any damage to the eye, it would have long been pulled from the market. Still, if someone has a lot of continued burning of the eyes after getting something in them, it might be worth looking at.

"Have you checked the pH?" I asked.
"Well, uh. . ." the doc stammered.
"Could you?" I asked.
"Well, the patient's already gone," he said. "I just thought I could get him some follow up."
"And you felt you needed to call me at two in the morning for me to make a clinic appointment? What, you think I am going to call him now and set that right up?"
"Well, uh. . ."
"Fine. What's his name?"

Don't call me before the hour of seven about a patient and ask for advice and follow up if the patient is already gone. I really need my beauty sleep to balance out my ugliness. Thanks.

What is a Workin?

2011-06-06T20:39:00.000-05:00

There is this phenomenon commonly encountered in the resident clinic. It's called the workin. A workin is a patient who wasn't on the schedule at the start of the day and was later added for whatever reason. Much like everything else, workins typically get inappropriately dumped on the resident clinic.

You see, there is one huge advantage to academic medicine - office time. In all honesty, I can't wait for it. But at any rate, it is time dedicated for an attending to be able to work on administrative or research duties. And the reality is, it not uncommonly amounts to time spent away from work - a time when you are essentially unavailable. Again, I can't wait for this - I would likely do the same. The exception comes when you're talking about program directors and department heads.

But as residents we feel the brunt of it at times. Suppose a patient of Dr. Azulweebum comes with a complaint of some sort. In the private world, that patient would be put in Dr. Azulweebum's clinic. And if Dr. Azulweebum was absent, and as long as the patient's issue wasn't dire emergency, the patient would just be told to come back to her next scheduled clinic. Not at JEI. Patients get worked in left and right because that's the JEI policy - see all who come in. And there's a lot of office time to be had. But a line has to be drawn.

The other day, one of Dr. Azulweebum's patients needed an exam to renew her contacts. See, without a complete annual eye exam, most contact suppliers won't renew your contact prescription - as it well should be. So Dr. Azulweebum's primary tech, in her infinite wisdom, decided to work her in to my clinic which was already full, and I the only resident. Did anyone ask me if this was okay? No. Did anyone ask the attending if this was okay? No. And I can guarantee that if she had asked, the answer from either of us would have been the same: No.

This does not qualify as a work in. If you need your annual eye exam to renew your precious contact prescription, you can schedule an appointment with your regular Dr. Azulweebum just like everyone else. A workin should be limited to urgent issues, not to include patients who are four hours late or need their glasses fixed (which happens at JEI).

But no one ever asked me. Or Dr. Azulweebum.

I Actually Kind of Like Presenting

2011-06-05T16:53:00.000-05:00

I have had to do a lot of presentations in the last few weeks - with the biggest one yet to come. And you know what? Overall, I rather like giving presentations.

Now Dwight over there didn't think he would like presenting, but after some secretly helpful tips from a trusted coworker, he pulled through just fine, taking the stage away from his boss.

My methods were different. Sure I needed coworker tips at the beginning to understand what certain people expected out of a grand rounds presentation. But this knowledge mostly just came from having sat through them, week after week. There are fine details preferred by different attendings directing the show on a given day, but these can be discussed ahead of time. The biggest trick is mastering the presenting materials, and the presentation itself. You can't put a presentation together the night before and go through it in its entirety the first time in front of an audience and not stumble a time or two.

What I really need is one of these:

Oh, So That's A Chart Review

2011-06-04T10:40:00.000-05:00

The big "Resident's Day" is nearly upon us. We are all required to do some sort of research on an annual basis. This is the day we all get to talk about what we've done. There will be plenty of other people speaking as well - a few attendings with some topics to discuss, the PhD's who have done work, and of course a guest speaker who will give multiple talks.

My research consisted of a chart review. I gathered a list of patients with a common diagnosis and surgical procedure. For each patient, I performed an investigation into the chart to gather several pieces of information from the initial presentation of the problem to its immediate surgical management to long-term follow up of outcomes. The first step was getting the list of correctly identified patients - but that in itself was a challenge.

I spent a good amount of time on my vacation in San Antonio working on this since the list of patients was generated near my departure. Fortunately, I was easily able to do most of the work on a computer by remotely accessing the electronic medical records. But, I had to search out several different documents in the chart to gather the desired information. This was even more difficult when I came back to Little Rock and worked on the charts from ACH, which seemed to have much less usable information in a paper format. But I gathered what I could.

Once the data was all in my hands, it was sent off for analysis. What I got back was a bunch of percentages which failed to reach statistical significance. Yay - no publication from this.

It's OK You Didn't See it and I Did - I'm an Eye Doctor

2011-06-03T18:27:00.000-05:00

I like my ER buddies, but sometimes they make me giggle.

Recently I got called to the emergency room to see a patient who presented after a full day of excruciating one-sided eye pain. After a very thorough exam by not only the ER resident but an attending as well, I was called and they said, "We just don't see anything wrong. Please help us and come see this patient."

"No problem," I said. I was sure something simply got missed. I talked to the patient who told me about how he had been working in his fields the prior day - working around a lot of soy seeds. At the time, I didn't know what soy seeds looked like, but now I can say they look like this:

At any rate, the exam was superficially unrevealing except for an angry red eye.

But after flipping the lids and peeking underneath, I found what appeared to be a small shell of a seed, not but a couple millimeters in size.

The ER docs were nearly embarrassed for not having found it. I told them it was quite alright. The fact is, I flip someone's lids inside out nearly daily, and have become damn good at getting a good look at everything there is to see under there.

It's okay - I'm an eye doctor. We are better at examining eyes - I hope - than you. Just like you are better at placing chest tubes than us.

Is that enough pictures, Jess?

The Difference Between an Adult and Pediatric ER

2011-06-01T17:58:00.000-05:00

The consults that come from the pediatric versus adult emergency rooms are amazingly different - and it's actually somewhat of an enigma to me.

When I get called from a physician in the adult emergency room, as a general rule, the problem is accurately stated. The severity of the situation is usually conveyed well. In fact, with some, I can expect an accurate diagnosis from the initial phone call.

For some reason, things are very different from the pediatric emergency room. (The exception being when one of the adult emergency medicine residents happens to be rotating at the children's hospital). One of two situations is commonly the case. The first is when I get painted a picture of doom and gloom with a probable open globe and a bad marginal laceration; but on my arrival, there is little more than a small conjunctival laceration and a nick on the eyelid - neither of which will need anything done to them, although would require my visitation. The second is of course the exact opposite. I have been told about a "normal" eye exam (which doesn't even warrant a call to me) and come to find something much more - something very much not normal and needing ophthalmology care.

This is to be expected from residents - we are all learning and no one knows everything. I would never fault a resident early in their training for this kind of stuff. But this has not always been the case. I kind of feel an attending should be involved at least peripherally before the decision is made to consult someone. But no matter, because even the attendings at the pediatric emergency room do the same things. I don't know why this is. Is the training in eye probelms inadequate? Is there just a tendency to pawn stuff off onto consultants when the going gets rough? I know the latter is true since the consulting becomes more poorly done as the waiting room fills up.

I am always more than happy to help - when it's appropriate. But you don't call a cardiologist before you've listened to the heart, right? So why would you call me before you've actually taken a second to look at the eye and have some of your own thoughts as to what's going on? A well-informed consultant is always better than a blind one.

Oh How I Love Erasing That Board

2011-05-31T18:34:00.000-05:00

The easiest way to keep track of all the patients we are seeing who remain inpatient is to write them all on the resident room white board. It's very easy sometimes for this board to become completely filled with names, locations, and diagnoses.

But every once in a while there is opportunity to start erasing names. People who no longer need our expertise, people who have been discharged, or, more sadly, people who have died become little more than a black smudge at the extreme edges of the board.

I know this is short, but damn it's a good feeling.

Vacationing Sucks - When It's Not You

2011-05-30T19:39:00.000-05:00

When I went on vacation, it was awesome. For me. And those with me. But it didn't take long for me to realize that it wasn't so awesome for some others.

The other first year resident with me at JEI spent the week by herself manning, or womaning, all the consults; not to mention there was overall one less resident to do all the work. It would have helped if certain people did a better job blocking the appropriate clinics when people are gone, but that seems to be too difficult a task to be done correctly.

At any rate, upon my return, she was gone the very next week and it was me manning all the consults. My first day back the board was full of inpatients who would need followup at some point in time - her week had obviously been very difficult. Even though I was able to eventually clear some of those off, more just kept getting added on. And when we're down a resident, you can't leave the afternoon clinic to go see floor consults; they just have to wait until the end of the day, thereby pushing the "end of the day" further back.

We will be back to full numbers this week. This should make everyone happy. Too bad tomorrow morning's clinic has more people in it than ever have been; at least more than I've ever seen.

A Little Background

2011-05-29T01:22:00.000-05:00

This is a blog about me becoming a doctor, among other things. So it's only appropriate that there is something on here somewhere about why I chose to become an eye MD.

Some time ago, like at age eleven, I thought I wanted to be a geneticist (thank God that didn't work out). But then something happened. Two of my brothers, one older and one younger, were one day firing broken paper clips hooked over rubber bands at each other. I maintain to this day that I wasn't partaking in the games. In fact, I distinctly remember going into the kitchen to grab my sixth-grade English book off the counter when I turned to the doorway. In it was standing my younger brother, locked and loaded. Before I knew it, I was pulling a paper clip out of my eye. Who knows if that was really a good idea or not?

We immediately went to the emergency room and I recall waiting a good long time for the ophthalmologist on call to show up. I had gotten a chance to see what my eye looked like and found it with a teardrop shaped pupil. My vision was slowly improving (from just a yellowish light) but was still pretty crappy.

Dr. M. finally arrived and after only a brief look decided I had what we affectionately call an open globe, or more specifically a corneal laceration. I went to the operating room that night where he put five stitches on my cornea. I spent two nights in the hospital (odd, I will have to expand on this later) without much excitement and then went home. I just remember the awesomeness of having a Nintendo at my disposal at all hours.

I visited Dr. M several times over the next several months, finally getting the final stitch out about six months later. I was very fortunate. To this day, with glasses, my vision is 20/20 in that eye.

At that time, I had decided I wanted to be an ophthalmologist. Sure I was young, what did I know? But I stuck with it and knew when I started freaking high school (way, way, way, before medical school) what I wanted to do. Sure other things caught my eye, but for various reasons, they didn't lead me astray.

Healthcare and Social Assistance

2011-05-25T20:33:00.000-05:00

Now this guy needs social assistance.

I am currently signed up with a survey service that sends me online surveys about various topics on at least a weekly basis. Each survey earns me points, and the cumulative points can be exchanged for some sort of cheaply made merchandise or gift card. Each point is worth about one-half cent, and at least 5000 points are needed to get any thing worth while. It takes a while to get there.

Any way, there are always classification questions asking about my age, my race, where I live, what kind of work I do, etc. Sadly, it's the same group of questions with every survey which becomes redundant. And when comes down to my line of work, social assistance and health care are lumped into the same category. Totally irrespective of the truth of it.

I did not go to four years of college, followed by four years of medical school, followed by four years of residency to be a social servant, or a social worker. I am a doctor. Please note the difference.

Writer's Block

2011-05-24T21:23:00.000-05:00

This isn't the kind you get when you want to write about anything, but just aren't able to do so. This is a very specific kind - a research kind. Trust me, I have plenty of potential blog topics about which to write - all one would have to do is look at my dashboard to find many titled but unwritten entries.

I have spent a fair amount of time looking through many patient charts, copying several bits of information, and all in hopes of finding some sort of statistically significant information. The data was all analyzed by the bioinformatics people, but I don't think they came up with anything I couldn't have on my own. That is not to say they suck at their job - just that my pile of data sucks. It's not bad data, just data that doesn't really show anything.

I started this research project in hopes of finding some sort of publishable information; something that could potentially get practitioners thinking about the way they do things and how they might change. I know that in order to be a competitive fellowship candidate, a few good publications related to oculoplastics under my belt would be super helpful.

I have none. And all the writing in the world can't save me.

That Tuft of Grey Hair

2011-05-23T20:36:00.000-05:00

Who says grey can't be sexy?

I have mentioned in the past peoples' incessant commenting on my young looks. But as proof that I'm not as young as my boyish features suggest, there are more and more grey hairs popping up over time.

There are a number of possibilities for this. One is that I'm a dad of a two year old. Let's face it, Mia is a hand full. A lovable, non-stop handful.

Another possibility is residency. Again, let's face it, the work is not easy. When not at work, we're at home studying. (Or writing a blog.) The only reason it hasn't given me wrinkles is because I don't often smile, laugh, or even frown about it. It is what it is.

Or it could be that every time someone accuses me of being nineteen, another one pops up. Thankfully I have otherwise beautifully thick hair. Anyways, my twentieth birthday is coming up soon, so slow down, Life.

Isn't this a blog about being an eye doctor?

Gas Station Contacts

2011-05-22T23:25:00.000-05:00

I recently found out something that was downright frightening to me.

There are places, gas stations for example, where a random Schmo-jo can walk in and just buy an over-the-counter contact lens. Of course these are usually wacky colored and patterned ones for what some odd ones call "style" or "making a statement." But the point remains, no prescription, no proof that one knows how the hell to take care of a contact, and no guidance on how to do so is required.

What's worse is someone can walk in, stick their grubby little fingers in the contact container to try one, not like it, and put it back. It's true!! Or so our contact specialist has told me, and I see no reason why she would fabricate this.

There a few idiots here:
1) The idiot who makes and distributes them: I have low suspicion that reputable contact manufacturers allow this. But who does, I do not know. This is a law suit waiting to happen.
2) The idiot who sells them: As if they have any idea what to tell buyers.
3) The idiot who buys them: Really? I mean, really? At least go buy real ones - even reputable makers of contacts have these special ones available, but at a higher cost. A cost you should be willing to pay.

Naturally we have seen these people show up in our clinic with problems related to improper contact use. Who knew?

I have no financial relationships or obligations to makers of contact lenses. Or any other ophthalmic devices or medications for that matter.

One Way to Get Burned

2011-05-20T20:55:00.000-05:00

Rachel's former employer

As people who take home call, i.e. we don't sit overnight at the hospital waiting for people to page us, we have to develop good working relationships with the people who frequently consult us in the middle of the night. This is primarily limited to the ED physicians and trauma team - with whom, overall, I have developed good relationships. When one I really trust calls me and relays to me what is going on, I can pretty much take it as truth and make immediate clinical decisions. I will discuss in a later post those instances in which what I'm told can be taken as nothing more than pure fiction.

I give in specific the case of orbital fractures. In a given week, we see these more times than I have ever cared to count. And for the most part, barring any catastrophic globe injury, there is nothing emergent about the fractures for us to address. So when a trusted ED physician calls with a routine orbital fracture and tells me the vision and pressure and eye exam are essentially normal, I feel comfortable having the patient follow up in the clinic the next day without an immediate visitation by me. In the private world, this is how it routinely happens. Of course in academics, it's rare that one would try to do this, but I was going to give it a shot. It had been done successfully in the past by others.

The clinic visit comes and goes, and the patient doesn't show up. You may note if you're a frequent reader, I have talked about this before. My heart pounds up into my throat and I wonder if I have made a mistake by not seeing the patient in the emergency room when I had the chance. I call the patient, but of course the available phone numbers are not connected. Ass.

This is how you can get burned. Thankfully, he showed up two days later, thinking that was his scheduled appointment, and everything regarding his eyes truly was okay. But talk about a moment of clench. I am sure clench moments will be much more warranted as I become more experienced in my training, but the simple thought of a program director yelling at me if a patient was lost and had a complication is frightening.

That Dreaded First Page

2011-05-19T21:16:00.000-05:00

There are a lot of trends noted on call. This one is a trend much discussed among colleagues.

You can never know how a night of call will turn out - at least not before it starts. But it doesn't take very long to figure it all out. Typically, within the first few pages of the night, the pattern is set.

Suppose the first pages are soft balls - easy consults or things that don't even require my presence at the hospital. Generally the rest of the night will be similar, quiet or at the very least with just a few simple things. On the other hand, suppose the first page is a complicated lid laceration or an open globe injury - the two things which commonly make us go to the operating room in the middle of the night. You can then expect the rest of the night to go poorly. Now it may just be because going to the operating room in the middle of the night requires a lot of leg work and eats up a ton of time. But it's no exaggeration that one bad case generally means another will follow too soon.

Though I have never literally gotten the "Your call will suck balls," page, that is certainly what I see sometimes.

The "I'm Not A Diabetic" Argument

2011-05-17T19:57:00.000-05:00

Some people have a very difficult time admitting or understanding the fact that they have diabetes, and how it's not something to take lightly.

I would venture to say that no one sees more diabetics than ophthalmologists, except endocrinologists and primary care physicians. Mostly because every diagnosed diabetic needs at least an annual eye exam. And there are plenty of cases where a diabetic is seen in our clinic far more than their own primary care doctor, sometimes as often as every few weeks.

But then there's the population of people who don't recognize their own diabetes who present to an eye doctor first when things start going down hill. On more than one occasion, I have seen a patient come into the clinic with some acute vision change. I ask them about any history of diabetes and they claim they had it at one time, but oh it has been controlled with diet ever since their second year of disease, fifteen years ago. And then I ask them who manages their diabetes. Well, no one, they might say. In some cases this is because they have failed to present to any primary care doctor on a routine basis. But in others, there is a failure of the primary care physician to keep a check on things.

Plain scary. If I had diabetes that was "diet controlled," I would sure as hell still want to know on a fairly routine basis if anything had changed.

I Think It's Time to Go to the ER

2011-05-16T21:23:00.000-05:00

What is it about the middle of the night that makes people think they should go to the emergency room for their problems?

Here is a not so uncommon patient. Mr. Schlofferboot presents to the ED complaining of "eye pain." On further questioning, he reports the pain to have been present for somewhere between 3 and 4 weeks, although he isn't quite certain. At this point there are two available paths, or follow up questions if you will. The first: "Why the hell did you come now, then?' The second: "So what changed about your condition which made you decide to come to the ED now?" The first question may get me in trouble, if nothing else make me mad at myself later when Mr. Schlofferboot details some sob story about how his mom was ill and he had to be out of town where there wasn't a nearby doctor. The second at least allows him to explain himself; whether or not I choose to believe him is another story.

Fact is, it is usually not the Schlofferboot family drama keeping people from seeking care during daylight. People go to the ED seeking free, or at least cheap, health care. Emergency doctors being just like most others (and no offense), the eyes present somewhat of a mystery. And then in academics, every patient is just expected to be seen at the drop of a hat. While this is largely inappropriate (again no disrespect to our ED physicians) it just happens to be the culture of academic medicine - no consult gets turned down. Mostly.

So, Mr. Schlofferboot, if something is bothering you for more than a couple days, but not so much you seek emergency care emergently, the emergency room is not your best choice. Call your doctor, or the nearest eye doctor. Because unlike many other specialties, you don't usually need a referral to see an eye doctor.

Mr. Schlofferboot is a made up person. Any (un)likeness of this person to a real person, named Mr. Schlofferboot or otherwise, is purely coincidental and should be ignored. Except for the decision to delay seeking care part.

Back Home

2011-05-15T19:26:00.000-05:00

No, I can't pencil you in.

Let me just say it's good to be back home.

We had a lot of fun in San Antonio. Did some shopping, some site seeing, some theme parks (well, really just Sea World), etc. We got to spend some quality time together, and quality time apart - that's needed too you know, especially on vacation. Rachel and I even got a fair amount of time to ourselves with free babysitting, courtesy of doting grandmothers.

But now, after a nearly nine-hour drive back home today, it is time to get back to the real world. (Man, I hate that phrase.) I was able to get a fair amount of data entry for my research done while on vacation, but still have a long way to go, with the first of two practice talks scheduled for this week. In fact, the only reason I have this copy of a calender for myself is because it was the only to plan out and keep track of everything up and coming. Six calls and four presentations over the next two weeks.

Welcome home, Doctor.

San Antonio

2011-05-11T16:53:00.000-05:00

Fresh duck, eating my fresh chips.

Greetings from our vacation spot in San Antonio, Texas. Well, technically, we are merely nearby - about 20 minutes from the town proper. We have rented a house in Converse, Texas. No matter; it's quiet here aside from the frequent taking off of aircraft from the nearby air force base.

Thus far we have done more relaxing than anything. We got in late afternoon on Sunday after a nine-hour trip. Mia actually did quite well on the way - just a few short bouts of fussiness and constant asking of questions. On Monday we visited the historic Alamo and took a quick overview gander at the Riverwalk. We shall revisit later this week. Yesterday we visited the zoo and to our surprise, Mia was not as thrilled as we hoped. Oh well. Today we have done essentially nothing. I have worked on some research and reading a novel. Perhaps we will visit the movie theatre later this evening.

Up next, Sea World and a more thorough look at the Riverwalk. TTFN.

Vacation

2011-05-07T13:18:00.000-05:00

Starting tomorrow, and for the next week, we will be on vacation. We will make the nine hour drive to San Antonio to get away for some fun. No, San Antonio is not particularly well known for any beaches, but you get the point.

In the meantime, for all those who read regularly, I don't anticipate much in the way of blogging during the next week. I may have a few posts, but these will likely be more related to our trip, not the usual droning on about the fallacies and wonders of what I do.

So go enjoy yourself. I know I will, I hope.

The Difference Between DNR and Comfort Care

2011-05-06T18:00:00.000-05:00

Recently while on call a nurse called me from ACH. She stated that a Dr. So-and-so called in a particular dilating drop for a certain baby. She was only questioning the order because the baby had been made DNR (do not resuscitate) earlier that day. Firstly I told her that Dr. So-and-so was an outside eye doctor, so if he was calling in orders for a particular patient, they needed to call him, not me. Secondly I asked her what difference it made if the baby is DNR.

I don't think she really understood what DNR means and how it is VERY different from comfort care or hospice care. DNR is what is done when it isn't felt a person is well enough to survive resuscitative efforts, should they become required. DNR means simply this: if a patient enters cardiac or respiratory arrest, efforts are not to be made to restore those functions. Outside of one of these two occurrences, all possible care is to be provided. This includes any antibiotics, any minor procedures (major ones requiring intubation in the operating room require a temporary lift of the DNR order but are otherwise allowable), and basically any other medical treatment necessary for the patient's well being, even pressor support if need be. So if Dr. So-and-so wanted her to have dilating drops so that he may perform a good dilated exam the next day, this is perfectly acceptable.

Comfort care is very different. Comfort care should occur when there is absolutely no hope that a patient will get better, and will with 99% certainty die, typically very soon. I would say 100%, but you never can be 100% sure. At any rate, all medical treatment is stopped. The only treatments provided are those meant to keep the patient comfortable until the time of death, as implied by the name. Patients going into hospice care are generally in this category, though I once took care of a patient in the ICU who came from a hospice care facility with the family thinking she was there in substitute for a nursing home. Very different, but there was no convincing the family of that.

Oh, and don't ever tattoo "Do Not Resuscitate" on your body. If you have a witnessed cardiac arrest, and are otherwise kinda healthy, not even necessarily totally healthy, your chances of survival are high, and you've instead just bought yourself a death wish. Very, very stupid.

Why I Will Never Do Research at the VA

2011-05-05T20:52:00.000-05:00

All of the residents have three sources from which to gather data for their research projects - UAMS, ACH, and the VA. Most of us choose to limit our data pool to patients/charts from UAMS and the VA. But one of my bolder colleagues has decided to also gather data from the VA. She is working on the type of project the VA population can provide a large number of data points, so it's reasonable for her to involve them. Question is, is it worth it?

Not uncommonly she presents with yet another frustration related to her project. And pretty much every time it goes back to her involving the VA patients. I have seen the list of forms she has had to fill out just to look at the same charts she looks at every day at work. The amount of redundancy between them is amazing. Taken out, there would really only be a couple forms remaining. She has made more phone calls for a simple retrospective review than one would ever think necessary. To top it off, she has literally had to gain special security clearance to go talk with certain people (who work in the very same building our clinic is in) behind locked doors about doing this. There is more red tape than I thought 3M capable of making.

What makes the veterans any more privy to privacy protection than the next person? Nothing.

The Undecided Third Year

2011-05-03T21:36:00.000-05:00

As we are nearing the end of yet another academic year, the third year medical students are beginning (or already have) to submit schedules for their fourth and final year of medical school. Most of them by this time have a pretty good idea what their primary interest is. This is not the case for everyone.

I suppose this is somewhat of a foreign concept to me. I knew what I wanted to do before I even hit the doors of my high school years. After being cared for when I had my eye injury, I was forever inspired and chose ophthalmology as a career path. Which is a damn good thing since at the time my aspiration was to become a geneticist, and thank God I didn't. At any rate, I tried my best to maintain an open mind during medical school should some other practice grab a stronger hold of my attention, but none did so. Those that came close offered a relatively shittier resident life with higher divorce and suicide rates. No thanks.

But still, it would seem at this point that the decision ought to be near made. I am full aware that one of my close colleagues didn't decide until June of her third year to enter ophthalmology. She is very fortunate it worked out for her - it's an overall pretty competitive field which meant she already had good credentials. She is probably the exception - especially for blooming ophthalmologists since their match is earlier than others.

Well, I wish you well, third years. Give yourself time to decide, because you'll want to test the waters some more before you commit.

The Patient's Responsibility

2011-05-02T19:03:00.000-05:00

There is only so much we can do to ensure a patient gets the proper care.

Suppose a patient comes to you in your clinic with a problem that is going to require regular and frequent follow up. They came to you in the first place because no one else could or would take care of it. It's obviously a bad enough problem for them to seek help, so expecting them to maintain good follow up should be natural, right? I think so - it's certainly not an outrageous expectation. So you tell the patient, "Mrs. Flaggerbatham, I will need to see you again in two days." "All right," she says. You make the appointment, you give her a specified time, and even a phone number to call if she can't make the appointment.

Two days go by. You are nearing the end of clinic and you have realized, perhaps an hour or two before, that Mrs. Flaggerbatham didn't arrive. You call the phone number she gave reception at her initial check in. This may or may not be a real phone number. You call it anyway, but no one answers. You leave a polite, though blunt and grounded message. "Mrs. Flaggerbatham, I noticed you didn't keep your appointment today. It is very important we see you again. Your condition is very serious and without proper care you could loose your vision or your eye. I expect to see you in clinic tomorrow, and if not, please call us." This message is also documented in chart, for you lawyers.

Another day goes by. No Mrs. Flaggerbatham. Another phone call, another no answer, another message. You do this two or three days in a row, and then send a certified letter, to what is possibly a rogue address. Ultimately, Mrs. Flaggerbatham doesn't show and is never heard from again.

Sadly, this happens. As doctors, we kind of feel that this circus should end after the first phone call, perhaps even at the end of that first visit. If a patient is given all the proper warning, all the proper information, the ball is in their court from the time they leave the clinic, the hospital, or the emergency room. It should be, and quite frankly is, their responsibility to get proper medical care.

Unfortunately, malpractice attorneys don't see it this way. Bastards.

All characters above are fictional, except for me. Anyone found to be named Mrs. Flaggerbatham, on Google or otherwise, is purely coincidental and has no bearing on my saying so.

A Trip Down Memory Lane

2011-05-01T09:34:00.000-05:00

Throughout most of my college years, I worked as a pharmacy technician. It helped pay the bills, gave me experience working in the hospital and ultimately likely helped pave the way for my entry into medical school. I met a lot of very cool people, and made some great friends, some of whom I still talk to on occasion.

One of these was a quite goofy guy, but a good one. For whatever reason his brain decided to do so, he coined the name "Dr. Bear" relatively early on. Most of the people there knew I had plans to go to medical school, and I wasn't shy about saying so. Not cocky, just clear on my goals. At any rate, the name stuck and many people referred to me as such. Some still do.

Sometime later, in my infinite wisdom, I mentioned this name to another good friend of mine, who we now call "Dr. G." He got quite a kick out of this and picked up its use instantly. He wasn't content keeping it to himself though. He felt the need to tell mutual friends/acquaintances. One of these was also mutual through a few people at my college, Drury University. Even though, he somehow didn't get the memo that Bear wasn't actually my surname. We will call him "Guy."

On a return to campus one day, this guy stopped in on one of my former professors. I had sent a very simple message with him.

Guy: "Oh, hey Dr. X. So I was supposed to tell you Brad Bear said 'Hi.'"
Dr. X: "Who?"
Guy: "Brad Bear, you know."
Dr. X: "No, I don't. I have no idea who the hell that is."
Guy: "Well he said 'Hi' anyway."

When Guy later found out what he had done, he went straight into ROTFLOL. I hope Dr. X still hasn't figured it out.

How I know I'm Awesome

2011-04-30T15:23:00.000-05:00

Pretty much sums it up, and there's no better source.

The Access to Care Issue

2011-04-29T19:13:00.000-05:00

There are many angles by which to approach the question of access to care. When most people think of this subject they immediately jump to the insurance issue. And we all know the two sides there, and if you're a regular reader, you know which side I stand on. True emergency care is one thing. Routine medical care is entirely different.

But when I think about access to care, I think about it literally. The real issue is whether someone is able to obtain health care, regardless of how it gets paid for. I really don't wish to ever hear anyone say they don't have access to health care - mostly because they, in fact, do. Most states have at least one, some multiple, academic medical centers, and those are largely fueled by non insured beings.

But here's the kicker. They offer hospital discounts, sometimes up to 100%, for people of low income status. They, and even most privately funded/insured institutions, allow patients to be set up on a no interest payment plan. In my experience, with multiple institutions, they don't really care how much a patient pays down their bill every month, as long as they pay something.

It is not an exaggeration for me to say that most of the patients coming through our resident clinic are self pay - no medicaid, no Blue Cross, nothing. And yet we see them, we take care of them like any other. For those who care about their eyes, they will make the three hour drive to our clinic knowing that we don't care if they don't have insurance, so long as they pay around $25 at check in and pay their bill eventually. I know it can be difficult for people in very rural areas to have access to every physician they need. But you can't expect a physician to be in every nook and cranny in every state, can you? No.

One Reason Not to be in Solo Private Practice

2011-04-28T21:39:00.000-05:00

We had a nice little coding seminar recently by some firm, telling us what the correct and incorrect ways to bill are. Sure all people need a little training in this. Not uncommonly, physicians enter the world after residency not having had any exposure to billing and all of its dirty workings. In the fields of ophthalmology and optometry in particular, we have our very own set of codes, the eye codes. No other specialty, except dentistry, has their own codes.

At any rate, it was three or four hours of lecture basically covering the required minimums for different billing codes. As if I'm going to remember every little detail. As if I'm going to recall later which modifier applied to which type of procedure within a predefined time period after a minor versus major procedure. That's too many variables to manage. That is why we have a billing department, and a darn good one. The reality is, I don't want to perform a small exercise in economics after every patient I've doctored. I'm not a business man - I'm a doctor. And while some are excellent at both, I for one don't wish to be superb at business. I want to make the job for our coders easier by doing the right thing on the front end, but I will be far from perfect at it.

At least in academics you have a good billing support team. In private practice, you may have a few good billers if you're in a large group practice. If you're solo, you may have a business manager, but you still have to manage that person. This is perhaps one of the big reasons academics appeals to me - good support. If I'm to make any money, I need help doing it.

Finding a Legitamate Research Project

2011-04-27T18:50:00.000-05:00

Of course making it bigger doesn't help

While this was an endeavor I undertook several months ago, I wasn't blogging so much back then. So in light of the upcoming Resident's Day, I will on occasion recount the frustrations revolving around research, and discuss new ones as they arise.

It all starts with a question, an interest in a particular subject. This is pretty difficult as a first or even second year resident. Suppose I run across a particular clinical or surgical situation, usually more than once in order to inspire questioning for possible research. You can immediately design a research project to maybe answer the question and get right to work. Or, you can do the smarter (and often more frustrating) route and do a literature search for any prior addressing of the subject.

I ask a question. I go to PubMed to do a literature search. What do I find? The issue was addressed, maybe as far back as 1961. So then I tweak the question to perhaps explore a different aspect of things. More searching reveals this too was thought of, but maybe only as far back as 1995. I try to tweak the question some more, but then find myself really only splitting hairs and ultimately addressing the same things. So ultimately a new question has to be found and the process starts over. I go through all these questions I have, only to find I really just don't know the things everyone else already does.

But it's supposed to be a learning process, right?

Losing the Better of the Two

2011-04-26T20:55:00.000-05:00

Taking a break from the tornadoes

People in health care tend to get comfortable in a routine working with one another. Physicians tend to have their nurses with whom they get along best. They understand each other. They know what the other one wants in certain situations. This all ultimately leads to better efficiency. Granted, in academic medicine, this largely falls apart, but anyway.

In ophthalmology, rather than nurses, we tend to have technicians with whom we become acquainted. Of course as residents, we would never be in a situation to have our own tech. But in the resident clinics, we for the most part have the same two technicians. They understand our clinics, our scheduling needs, and the flow of things. Because, let's face it, private retina clinics aside, more patients go through the resident clinic than any other at JEI.

One of these technicians has been uprooted from our possession to work as the primary technician for two new staff we are soon to have. Key word: soon. They're not even here yet. One is an oculoplastics specialist (hell yeah!!) who starts sometime in the next two months, and the other is a pediatric/strabismus specialist who starts in September or later (and of course she will primarily be at ACH, not JEI). And instead of having the leaving one train his replacement, the tech who is staying with us (the far slower of the two) has the job.

A consulting firm is telling JEI to either increase patient visits or trim the number of technicians for financial sustainability. And yet we've hired two new technicians/RN's long before new staff shows up, and we're about to lose a different staff member - that's only a net gain of one physician sometime in the fall. Not sure this was an economical decision. Increasing patient load is not feasible - for residents because we see more than anyone else already, and for several staff because they could never handle it, either because they are efficient but overbooked, or just plain slow.

What Happens When You Fail at Killing Yourself With a Gun

2011-04-25T18:53:00.000-05:00

I guess scissors DO work better.

Sadly, it is not uncommon for us to be consulted to assist in the care of a patient who attempted suicide. It's never the people who use drugs - they generally don't involve ocular injury. It's never the people who use a knife (or scissors) - they generally go for the chest which is sixteen or more inches from our comfort zone. It's always the people who use a gun who give us work to do.

But this too has variety. Pistols tend to be aimed at the temporal region or face front (or chest). The frontal approach I think tends to work well. The temporal ones fail (surprisingly) from time to time. But then there's the shot gun type - either in the mouth or under the chin. In the mouth is plus or minus. Under the chin frequently fails. The kick back with a long-barrel shot gun causes a gun once pointed towards the occiput to now point straight up through the face. The result is a failed attempt at suicide with a disfigured face.

Not having been there myself, I can only imagine one has to be at a pretty low point in their life to get to suicide. But regardless the reason, I don't think failure with a shotgun is a positive result in any way. You may call me cynical but hear me out. You're already so depressed you decide to shoot yourself and then don't do it right. What happens? 1) You failed - I think this falls pretty far short of being a wake up call. While suicide is never the answer, failure to do so correctly doesn't exactly boost morale. 2) You are now very disfigured. How does that work for your self esteem?

I would never say there is a right way to commit suicide, but in terms of doing it wrong, failing with a gun is about as wrong as you could go. You become a burden to the medical system and ultimately yourself and your family.

Yes, I Am Old Enough to be Your Doctor

2011-04-24T20:29:00.000-05:00

Smart-Ass MD

Remember this guy? Of course you do. People ask me on a daily basis (literally) how old I am, and whether I am really old enough to be a doctor. I am plenty old enough, young of course, but old enough to be a doctor. The most popular guess I get is age 19. Believe me, I enjoy a youthful look and hope to for many years to come. But you don't need to guess out loud. The guessers become even more surprised when I tell them I am married with a two-year old kid.

Besides, I like this version of Dr. Harris better:

Evil-Ass PhD

Where Homeopathy Works

2011-04-23T10:21:00.000-05:00

Chuckle, chuckle, chuckle, chuckle.

Not here. I'm not sure I can point out with experience any place where it does, but I will give it the credit for working for something. But there is a reason it's not mainstream. I can discuss this in more detail at another time; so, for now, just the Cataract Care. Don't waste your money.

A single patient walked into my room yesterday who opened up a big can of worms. I knew before going into the room she was using these, thanks to the technician who prepped me. I go into the room to find she has had this "cataract" for about a year, diagnosed by a Wal-Mart optometrist (no exaggeration here). The most s/he said was that there was no view past the lens, so clearly she had a cataract. Her vision is currently in the hand motion range, or worse than 20/1000. According to her, the drop has helped. What??

Things are already sounding suspicious. A hand motion cataract doesn't just pop up over several months to a year, particularly in a woman in the chair who is unusually inert about the whole thing. How could you just let yourself loose so much vision? On further questioning, the patient is found to be a diabetic and hypertensive. She's been diabetic for 20 years and is on no medication. What??? She checks her blood sugar most mornings (and the values she quotes are too high as is), but has no primary care doctor. What????

On exam, sure there are cataracts, but they are NOT hand motion ones, and they are more or less equal on both sides with her other eye being 20/40. RED FLAG - something else is going on. The retina is not at all visible in the hand motion eye. The other eye shows diabetic retinal disease everywhere, though certainly not the worst I've seen. Nice work diagnosing a cataract, Mr. Wal-Mart Optom. I refuse to use the title "doctor" for this individual. She clearly had hemorrhage in the right eye, with 90% certainty it's related to her diabetes. And the fact is, it was probably even easier to see the hemorrhage 9 months ago.

This all brings up several issues addressed in recent blogs:
1. Ophthalmologists are true physicians - I suspected diabetic disease before even looking at her eyes because I TALKED to the patient about her MEDICAL problems. We've done our part trying to get this lady to someone who can help us with the diabetes.
2. Are these optoms the ones you want pointing lasers in your eyes? Although it's possible the patient only heard what she wanted to, she was obviously not given the reality of what was happening to her. I'm also suspicious the optom didn't even dilate her and look at the other eye. Even without dilation, one could easily see her bad eye did not have a hand motion cataract.

A few new issues, at least to this blog:
1. Homeopathy is not good for cataracts. The most those drops would have helped is dry eyes, and even that is questionable at best. Surgery is currently the only help, sorry optoms.
2. Homeopathy is not good for 20 years of diabetes. I asked her if she had been offered treatment for her diabetes in the past, and she said no.
3. So, as Dr. House always says, patients always lie.
4. A passive/alternative approach to chronic disease will kill you, eventually. And it kills me to witness it.

Free From Clinic = Free Clinic

2011-04-21T19:54:00.000-05:00

There are primarily two situations which cause this equation to be true.

The first is more applicable to the first year resident mostly responsible for the consultation services we provide. Should a morning, or more rarely an afternoon, come about when there isn't an immediate obligation to be in clinic, the consulting resident will likely have consults to field. Many of these may come from the ED, but several come from the floor as well. Either way, since most payers don't recognize consultation as a payable service, these people are getting a complete eye exam for free.

The second possible situation is when a clinic has been cancelled, and all responsible residents have that time opened up. Invariably, there will be patients to be worked in and be seen. Not a big deal, since we are after all there to learn and see patients. But here's the problem. There is this policy at JEI stating that all patients seen by residents in the clinic need to be staffed with an attending. While this is probably best for the patient and starting residents, it is certainly not always necessary. Either way, the only way to be paid for the visit is if an attending sees the patient. That all being said, then why the hell would you work patients into a clinic where there is no attending? If you do, so as not get anyone in trouble, I have to go through the often painful process of trying to find a staff. The solution is simple: work the dang patient into a staff's clinic instead of mine. They really just need to step up to the task, regardless of the patient's insurance status. And don't preach to me about how it's not like I'm busy then. Because let's face it, the patient load in almost any attending's private clinic is no where near the load in a private clinic outside the university setting.

Why I'm Not an Optometrist: Part II

2011-04-20T21:38:00.000-05:00

Pretty Much Sums it Up

Yesterday I embarked on a two-part post about why I chose to become an ophthalmologist instead of an optometrist, or at least to discuss two hot topics in my mind. Yesterday was about ophthalmologists being well-rounded physicians, not just eye specialists.

The other hot topic as of late? Practicing privileges. Some people have them; some people don't. And it always seems those who don't have them, want them. Generally, specific practice privileges are given to those who have undergone the complete and appropriate training path to obtain them. And then there are times when those without, push hard to obtain the privileges they don't deserve.

For most physicians, this is best illustrated by advanced practitioners (basically a nurse with a masters, sometimes doctoral, degree) wanting to perform procedures on patients. One specific example is them wanting to perform colonoscopies. How many of them have done a three-year fellowship to become proficient at this procedure, and ultimately know what to do when things go terribly wrong? None. If that is your dream in life, go to medical school, do an internal medicine residency, and follow it with a GI fellowship.

For ophthalmologists, the competition obviously comes with optometrists (from here on referred to as optoms for short). Optoms are not trained in school to do laser surgery, or any kind of surgery for that matter. And yet, there is a huge push by them to gain practice privileges doing so. They recently gained such privileges in the state of Kentucky, along with few other simple office procedures which involve cutting skin. And while one may argue that it's not like they are doing cataract surgery, all they need is s stepping stone. The reality is, they have a much bigger, stronger, and richer lobby on Capitol Hill than ophthalmologists.

Sadly, they have to learn how to do these procedures from someone. And that someone is probably an ophthalmologist. Probably well-paid by the optom lobby. They have shot themselves and their kind in the foot, and shall be banned from any circle of ophthalmologists I am in.

Clearly not all optoms will want to join the surgical ban wagon and will just keep doing what they always have. They understand that doing such procedures is an added liability; and them being what they are, if something were to go wrong, the level of potential malpractice suit is likely to be significant. I just hope insurance companies covering both the patient and the doctor see it the same way.

Why I'm Not an Optometrist: Part I

2011-04-19T21:13:00.000-05:00

The reasons are several, but there a couple things in particular which have been on my mind as of late. This is the first.

As part of our training (after college, after medical school), we as ophthalmologists do a year of internal medicine. At least at my current program. There are some which do a year of surgery to start, but frankly I find this useless since what a general surgeon does has basically no relation to what we do other than good sterile technique. As a medicine doc, though, there are many things important to us.

During my cardiology rotation, the attending once told me that as an eye doctor, I must never forget to treat the eye in the patient as a whole. We met again just a few months ago and revisited one of his favorite topics - plaques in the eye. It is felt amongst the eye community that certain of these plaques, calcium or platelet ones in particular, originate more likely from the heart than the carotid arteries, the source of cholesterol plaques. So, if seen by us, we order an echo evaluation of the heart. And yet, he complains bitterly, stating that all plaques come from the carotids and some super specialized retina doctor isn't thinking properly about the patient by ordering "unnecessary" tests. In his mind, only carotid dopplers should be done for any plaque.

Hold on a minute. The whole reason we order the echo is to make sure the heart is okay and screen for stroke risk. We ask them to have their lipid and CBC profiles checked. We always get carotid dopplers to rule out coinciding carotid disease AND address stroke risk. How is this not treating the patient as a whole, and thinking outside the eye? It's not about the academic argument of where such plaques come from; it's about protecting the patient from future, potentially life-threatening events.

We screen patients ALL the time with diabetes and hypertension. And you know what I always ask them first? Hint: It's not, "How's your vision?" It's, "How's your blood sugar doing? How is your diabetes? Are you checking your blood pressure regularly?" Again I ask, how is this not treating the patient as a whole?

This, I think, is the biggest separation between an ophthalmologist and an optometrist. An optometrist attends college, followed by optometry school where they become master refractionists (most better than most ophthalmologists in this particular area) and gain a solid understanding for most eye diseases. They don't attend the four years of medical school every MD or DO does. They don't undergo the extensive licensing exams every MD or DO does. They are not governed by the medical board as every MD or DO is. I have or am all of the above.

If you want to see a doctor who treats the eye and can give you good glasses, go to an optometrist. If you want to see a doctor who treats the eyes of a human body and understands physiology and surgery, go to an ophthalmologist. They each have their place and neither is fit for everything.

I will expand more on this in part II.

An Old Dog is a Dumb Dog

2011-04-18T19:45:00.000-05:00

It is genuine truth that you can't teach and old dog new tricks. A human I think you can, but not a dog.

I love my beagle, but she is incredibly stupid. If you didn't already know, we had to put her outside when we figured out Mia's alleriges to her were what made her throw up all the time. Yes, yes - so sad how we had to kick the dog out. But I couldn't very well put Mia out, could I?

Bailey was outside for quite a long time before she figured out she could dig under the fence and escape. I know - beagles are known for their longing to escape and explore, maybe even become lost in the process. So the first, most affordable option was to put her on a 30-foot line to keep her away from the fence. But then the moron would just go around and around the bush, or tree, or porch railing slats, and become grossly entagled. I thought putting a gate up to keep her off the porch would help - it didn't.

After being at a friend's house, I noted his two beagles did just find staying within the confines of an electric fence - there wasn't even a privacy fence like I have. So I thought I would go out and buy one so I could at least get her off the line. Well, she learned to stay away from the fence quickly enough.

But there's this corner of my yard which I intend to landscape this year, maybe hang a hammack, put up a swing set for Mia, etc. I want to lay mulch in the whole area with few if any plants. I don't want the dog over there. So I decided to lay the electric fence to border this area to let her learn early. What does she do? She crosses it routinely. And what's worse, the system has a built in feature that continues to shock her for ten seconds if she crosses the line, stops for ten, the shocks for ten more. It does this a maximum of three times over a minute so as not to fry her brain (you know, from pudding to corn syrup). Yet she does it anyway. Is she a masochist?

To top it off, when I retrieve her from the forbidden area, she wants to run onto the deck, where the wire is actually quite concentrated. As the system starts to shock her, instead of turning around into the safe zone where she should know she won't be shocked, she runs into the corner - right on top of the wire. Even worse, the damn thing beeps as she approaches the boundary to let her know to back off, and she doesn't get it.

Maybe in a few days she will learn. I have my doubts.