How I know I'm Awesome

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

The Access to Care Issue

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

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



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

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

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

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

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

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

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

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

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. 

Post Test Era

The OKAP is over.

This test yesterday was about four hours. Some of the questions I knew without a doubt the correct answer; some I flat out did not. Some I know I made good guesses, and some I did not.

We grilled out with some burgers and beers at a fellow resident's house yesterday evening. Nothing exciting, but a good excuse for everyone to get together. No one (except one) can come up with the excuse of being out of town.

I wish I could say with that test behind me I could relax for a bit. But the very public Resident's Day is coming up in June and everyone has a lot to do to prepare for it. It's when we all present our research project for the year, or a case report for those who want a cop out.

I will relax some today, but it's back to it tomorrow for sure.

The Calm Before the Storm

This OKAP thing is finally here. Tomorrow morning I will have to sit through four hours of answering rapid fire questions about things I am supposed to know. I am really not very nervous about the test, hence the calm. I just hope all the effort doesn't end up being a waste of time.

The Upside: There's nothing riding on this test like there was with the MCAT and the USMLE Step I. This is supposed to just be a self assessment test. Also, the questions are generally one-line questions instead of the gruelling clinical scenarios to weed through like on the USMLE exams. There will be a reason to celebrate tomorrow evening - every year we do so at one of the resident's house. It's an excuse to get together and booze and schmooze.

The Downside: First and foremost it's taking up my Saturday morning/afternoon this weekend. It's a written multiple choice test on a Scantron - it's been a while since I've done that and computerized tests have grown on me. One could argue shorter questions are more difficult since if given several lines of vignette, the diagnosis may become more narrowed down. Also the department is literally threatening to stamp a label on our backs if remediation is necessary. Okay, not literally, but this has never been the case in previous years.

Do They Feel Remorse?

I may have mentioned it before, but I will say it again: The majority of the things we eye doctors see on call (particularly at the local level one trauma/tertiary referral center) are the result of traumatic injury. Motor vehicle accidents and fist fights are the big players.

Obviously, a car accident is not always avoidable and there may not ever be one person to blame. But what about the fighting? We get called about several orbital fractures every single week, and a significant portion of them are related to fights.

These fights are frequently amongst acquaintances, though not always. More than once I have seen a patient who got out of hand at the bar/club and was (supposedly) punched by a bouncer. Clearly the validity of the stories is often in question, but I can't claim to be a witness to any of these events.

You already know the biggest question I have - it's in the title. Does the assailant care that they've very possibly sent someone (innocent or not) to the operating room? What about when the eye itself is severely injured and possibly blinded? They may not ever know.

You Know That Feeling You Get With Procrastination



Outside my front door this morning.

You've got something you need to do, or continue doing.

You're tired of doing it. But you know it's more important than your current activity.

There's that feeling in the back of your mind. Not a thought, but a feeling.

You can even concentrate fully on your act of distraction any more.

Best get back to it.

Healthcare is an Inudstry

Not a free-for-all. Not a guarantee. Not a promise. And certainly not perfect.

I saw a bumper sticker on the way home the other day which stated: "Health care for people. Not for profit."  Sorry doofus, there is a lot of potential for profit in health care, and plenty of people to take it.

Allow me to say, though, that I am all for providing the most basic health care needs to every U.S. citizen. But only citizens. And only basic necessities. And whoever decided immigrants could come here and have a baby, making that child a citizen, has obviously never had to care for such families. You want to talk expense? How about the expense of having to provide interpreters all the time? Unnecessary, uncalled for. The real expense comes in overpriced pharmaceuticals and material costs, and having to pay personnel for CYA duties; after all, physician compensation has and continues to drop significantly. The paychecks of pharmacists and ancillary staff will likely follow suit.

As for health care workers, everyone is in it to make a living - no different than any other career choice. Sure I became an eye doctor to help people when they have eye problems. But I also did it to have a sense of job security - I will always be needed. I can also depend on making a reasonable living on which to support my family. Sure it's a better living than, say, a plumber; but I worked a hell of a lot harder to get here. And, let's face it, my work is much more specialized and substantial.

If you want your guaranteed access to health care, and I don't care who you are, you better damn well be willing to pay for it. Otherwise you can go get your colonoscopy by the local plumber, or your appendectomy by the head butcher (you after all don't want the novice). See where that gets you - but it still won't be free.

You want to lower costs? I told you who to attack. But there will NEVER be free health care. You better pray there never is.

How to End the Day on a High Note

Well, there are lots of ways.

This certainly isn't one of them

I had gotten through most of the day without realizing I was on call today. Sometime around 3:30, the question of who was on call came about.

"Not me," I stated with a smug look on my face.

Everyone started to look at each other as if to ask one another, "Well then who is?" I just shrugged my shoulders and continued to drill my beaten brain with more questions from a book. (Yes, that OKAP thing coming up.)

Someone looked at the schedule posted on the wall. "I though it was you," he said, looking right at me.

I had to double check the most recent schedule, mostly out of disbelief, as posted in my email inbox. Sure enough, I was listed on call.

"Shit," was all I could say.

I am only posting this now as I wait for anesthesia to sedate a little kid so I can sew up an eyelid laceration. Fun times - at least it's 6:30 and not 12:30 at night. Then on to see a severed optic nerve. Hmm, that sounds kinda bad. . .

How the Field of Genetics Has Taken Over Our Lives

The explosion of knowledge regarding genetics changed medicine probably more than anything ever has or ever will. Some may argue that the uprising of hygiene may have been a bigger change, and they would be legitimate in their argument.

Now, people are trying to relate everything back to genetics. For most it's a true search for a genetic relationship and what that might mean for treatment or prognosis. But I think others use genetics as a crutch. I personally don't think genetics explain everything. Some people suffer from obesity, heart disease, cancer, and diabetes simply because they haven't lived as healthy as they should have.

Genetics has also caused quite a change in the curriculum of medical students and residents everywhere. Our knowledge base is far more expanded now, simply because of genetic influence, than it was just ten years ago.

Trying to memorize all of these genetic associations has only thrown another wrench into this OKAP thing.

Who Has Two Thumbs and Makes a Grumpy Daddy Happy?

This Girl!



It doesn't seem to matter how ticked off something at work makes me, or how frustrated I am after one of those "review" sessions, I can always come home to this. For me, a bad night on call has nothing to do about staying up all night; it's about not getting an hour to spend at home with my family.

What is it About Seven o' Clock?

Or later?

Most people have a pretty good understanding of what normal business hours are. Eight to five, right? What are the inherent implications?

If you need to call the clinic, be it with a concern about your chronic problem or for a medication refill, perhaps you should do it during regular business hours. Calling the person on call at seven o' clock in the evening because you've been out of your glaucoma drops for three days (which you've been on for three years) is not appropriate. Calling because you have a little irritation in your eye which was operated on a month ago can be addressed during the day.

Because here's what happens when you call me while I'm on call. I don't know you from Adam (or Eve).  So I have to stop whatever I'm doing and get on the computer to look at your chart. Then I have to make recommendations on often limited information. Now it doesn't matter what I'm doing, eating dinner or seeing another patient in the ER; regardless, I am doing something. I am never staring at a wall just waiting for your call.

So next time one of these non-urgent issues arises, and it's after hours, just wait until the next day. And no, I don't make house calls, you cannot have my pager number, and you most certainly won't get my cell phone number.

What's That Smell?

For those who may not know, I have continued residency at the same place where I went to medical school, UAMS. In case you don't know, the only real thing UAMS is well known for is the myeloma institute. All moral issues aside, it is by far the most prominent myeloma center in the world - and that is not an exaggeration. Patients come from all over the world to see the specialists there.

What is myeloma? It is a malignancy of a particular subgroup of cells in the hematopoietic system. I won't go into any further detail other than to say the typical treatment involves a bone marrow transplant. This ultimately leads to prolonged periods of immune system suppression, which is how they often end up in our clinic or on our consult list - to rule out infection or bleeding within the eye.

Here's the problem. These patients, for reasons I don't know much about, have a very peculiar *bad* smell about them. I'm sure it's related to the cocktail of chemotherapy they have received, but I have no confirmation of that. Some people have likened it to the smell of sweet corn. I will never eat sweet corn smelling like that. And when they leave the clinic room, the smell lingers for quite some time. Whatever it is making the unique scent must be emanating from every pore on their bodies.

How do they do it?

Rules are Made to be Broken - Unfortunately

We in the world of academic medicine have a just a few simple rules that we hope to be followed.

1. When the weather is crap, so is clinic show-rate.  BROKEN today.

2. When a clinic is cancelled, I wish to be left alone to do whatever else I need to do, which may or may not be work related. BROKEN today.

3. If I am called while on call to come see you in the emergency room, I expect you to show up for your follow up appointment. BROKEN today.

4. Consults should be legitimate. Asking me to see your patient to evaluate for a condition which we already know the patient has does not count. BROKEN today.

I'm sure there are others, but these are the ones which stand out for the day.

What Ophthalmologists Hate About Lawyers

Had to sift through all the Jude Law pictures to find this.

Certainly not all lawyers are bad. There will be the day when I want to join a practice or contract with an academic program, and I will most certainly want my own lawer to help me iron out the finer details. But, as a physician, there is a certain breed of lawyers which annoys us more than any other.

We all know about the lawyers who dive deep into malpractice suits. We also know they don't do what they do to increase awareness about suboptimal healthcare, or to be advocates for an unfortunate patient population. After all, I firmly believe medical negligence is no more common now than one hundred years ago, except for the fact there is much more we can do for the human state nowadays and thus much more that can go wrong. True accidents, however, probably are more common only because of all the road blocks put in place from prior law suits and our so-called government.

They're in it for the money, and are there to further and to capitalize on the litigenous tendency of our society.

A particular type of malpractice lawyer is unique to ophthalmologists - ROP (retinopathy of prematurity) lawyers. There are actually folks who specialize in this. Now, tell me. Do you really think there are eye doctors out there being deliberately negligent when screening babies for ROP? Not likely. What happens is a baby is screened, the decision is made to observe rather than do laser therapy(and legitimately so based on pretty well-defined guidelines), and the poor child's disease progresses causing visual deficit. Did anyone do anything wrong here? No. It was a proper decision paired with a bad result.

And yet, we are still sued, and the bastard lawyers win on occasion. Do you really have to ask why healthcare is so expensive in our country?

Practicing Oral

 After the completion of residency, the final steps in becoming board certified include an expensive written test, followed by an even more expensive oral exam. It's obvious what the written test consists of, but let me tell you about the bazaar nature of the oral exam.

It's hosted in a hotel somewhere. A bunch of examining ophthalmologists are there, each in individual hotel rooms. As the examinee, you go into a room (past the bathrooms and beds to the little window-side work table) and sit down. The examiner begins asking questions, covering several cases over about 30 minutes. Then it's on to the next room.

Did you catch the bazaar part? How about the fact this is done in hotel rooms, the very ones the examiner stayed in the night before? This is supposed to be a very formal exam, but I think this is somewhat hampered by being in a hotel room. I hope at least the beds are made and there isn't a hooker scurrying out of the room on my way in. Do think anyone is still in pajamas?

So anyway, we (the junior residents) had a very brief practice session yesterday - one case in one room (not a hotel) that lasted 3-5 minutes at most. We were each video taped and we then conglomerated in the conference room to watch each other when the examining was done. I think we all did fairly well, but I didn't realize how soft spoken I was in this type of testing situation. Maybe next year I'll bring a megaphone.