Random Thoughts from a Restless Mind

We’ve lost the ability to be amazed. As a society, as a people, North Americans not only fail to be dazzled by things that are downright amazing, we have actually become quite blase about, well, pretty much everything. That sense of wonder at the new we celebrate in children is leached out of our kids at ever younger ages. Our ability to be awestruck has atrophied, and any sense of awe, wonder, or amazement that we DO experience is so fleeting that it’s almost as if it was never there.

How did this happen?

This idea, this observation has been stewing in my subconscious for a couple of months now. It popped its cork yesterday after a couple of experiences I had starting last week. The first, interestingly, actually involved seeing people who actually WERE amazed. I flew to and from Providence to visit my folks last weekend. On the way out I sat in the last seat in the plane (doorman to the restroom), on the way back in the very first seat (Walmart greeter). On both legs of my trip I was seated next to 45 year old men taking their very first trips on a plane. Imagine! 45, and never on a plane. These guys were simply awestruck at the notion that they were drinking a Coke inside an aluminum tube that was cruising at 35,000 feet. One of them took about a hundred pictures of the clouds out the window. Those guys were amazed! I let myself get swept up in their experience; it really IS cool, and not even just a little bit amazing, that I could get to my folks 750 miles away in less than 90 minutes!

Experience #2 occurred in my office on a one-day post-op day. Medicine in general, and certainly my field of ophthalmology in particular, is a victim of its overwhelming success. Indeed, this is not too different from the airline industry. We deliver the goods time after time, on time, without a hiccup. So frequently, in fact, that in those rare instances where things are rocky, or there is a complication, we view the outcome as only slightly less horrific than an airplane crash. Even a fantastic outcome, one that would have been so unlikely just a few years ago, is now viewed as some kind of a disappointment if it fails to meet the outlandish expectations of an audience that has been numbed by routine success.

Take, for example, cataract surgery. I had a patient with a very large cataract, a very small pupil, and a flaccid iris–a set-up for a very challenging surgery, one that a few years ago had a 10X increase in complication risk. Per our protocols the patient was offered several choices of lens implants, and the expected outcome (visual acuity, need for glasses, etc.) for each of these was discussed and explained multiple times by multiple staff members and doctors, all according to our protocols. Some of these implant choices were entirely covered by insurance, and others included fees for which the patient was responsible. These, too, were covered in detail several times by several staff members. In this particular case there was even a second, extra (no charge) visit to the office specifically to discuss these options and the associated expectations following surgery.

So how’d it turn out? The staff and doctors were turning cartwheels when we discovered that the one-day post-op distance vision was 20/20 without any glasses! Imagine our surprise and chagrin when patient and spouse sad glumly in their chairs at the news, not the least bit excited. In fact, the majority of the visit consisted of patient and spouse grilling doctors and staff about the fact that the patient could no longer see up close without glasses. This despite the many counseling sessions about implant choices and post-op expectations in a patient who could not pass a driver’s test with or without glasses prior to surgery. Not a word about how amazing it was that such a challenging surgery resulted in the ability to now pass a driver’s test without glasses!

You might fairly ask if I was amazed by this? Sadly, no, I was not. It’s not enough for the airline to bring you in on time and safely. Nope, now you had to be flown first class on a free ticket and arrive early to simply be satisfied. To be amazed one would need to have somehow been transported to and from the S.S. Enterprise by Sulu personally.

Manned flight, up and down with nary a hiccup each and every time. Cataract surgery that improves your vision 99.9% of the time with nary a hiccup. Joint replacements that allow you to play tennis. GPS in your car that directs you to within a foot of your destination. Neurosurgery while you are awake. Cell phones, for Heaven’s sake! Sometimes you fly first class or see 20/20 without wearing your glasses! Come on…that’s amazing! Right?

Amazing…

There are only two kinds of people in New York City: Targets, and people who hit Targets. At Bellevue we took care of the Targets.

It’s the first weekend in July. For most people in America that means the 4th of July and everything that goes along with that. Barbecues. Fireworks. Festivals and ballgames of all sorts. And beer. Lots and lots of beer. But in that curious sub-culture of medical education the first weekend in July means the first time on call for newly minted interns and newly promoted residents and fellows of all sorts. Everyone and everything is new, just in time for July 4th and its aftermath.

Funny, but I ended up on call for every 4th of July in my four years of post-med school training. I’m not sure which, or how many, of the residency gods I offended, but whatever I did I apparently did in spades ’cause I hit the first weekend jackpot every year. I have no memory of my first on call as an intern, but the “Target Range” was open for business those first couple of years at Bellevue, for sure! In fact, if memory serves, the phrase “Target” was coined that very first weekend of that very first year as an ophthalmology resident.

“Hey Eye Guy! We got a John Q. Nobody who got shot in the temple just standing on the subway platform. Says he can’t see. Whaddaya want us to do with him? By the way…welcome to Bellevue.”

Crowds and beer and heat and stuff that explodes. Welcome to Bellevue, indeed. Some poor schlub survives the bar scene after the parade, makes it through pickpocket alley intact, gingerly stepping over detritus living and otherwise, only to get shot in the head as the A Train approached the station in a random act of anonymous violence. The bullet entered through the right temple, destroyed the right eye, and wreaked havoc in the left eye socket before coming to rest against the left temple. Right eye gone and malignant glaucoma in the only remaining left eye. And there I was, all of 3 days into my opthalmology residency, backed up by a chief resident of similar vintage. Whoa…

There’s no way to avoid it. After all, med students have to graduate and residencies have to start some time. There’s just this unholy confluence of weak links in the system all coming together in time for the second (after New Year’s Eve) most difficult ER day in our big, academic hospitals. Get sick or injured on June 4th? Everyone’s on top of their game and everyone’s in town. July 4th? The fix is in, and the game is as rigged against you as any carnival game attended by a dentally challenged carnie.

As I sit here, an Attending on call for the 4th of July weekend, covering the ER and cowering each time the phone rings, the Tweets and Facebook posts heralding the arrival of a new crop of interns and residents send me back to Bellevue. Year 2, cursed again, covering the spanking new 1st year ophthalmology resident (was it Dave?) as he got his welcome “gift” from the ER. “Hey Eye Guy. We got a Target down here for ya. 10 year old girl. Some dumbass tossed a lit M80 to her and she caught it. Went off before she could get rid of it;  blew off her right hand and looks like her right eye is gone. You from NY? No? Welcome to Bellevue, pal.” Yup…there’s something about the 4th of July in every teaching hospital in the U.S., and just like everything else, whatever it is, there was more of it at Bellevue.

Only two kinds of people in New York, Targets and people who hit Targets. At Bellevue we took care of the Targets.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The jury got it half right.

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

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

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

Little did I know how hard it was going to be to help my Bellevue target, Jean. He didn’t know he was being mugged when the gangbanger asked him for his jacket. How could he? He only spoke French. He couldn’t tell the police officer who came to the scene that it was HE who had been assaulted. How could he? He only spoke French! At Riker’s Island he had no idea that the gangbanger sharing his cell was demanding his fancy, leather sneakers. How could he? He, well, you know…

So what could I do? How could I help? What could I possibly do to help make the end of this very bad day a little bit better? Well, first off, I clearly needed to make sure that Jean did not go back to Riker’s Island any sooner than was absolutely necessary. The prison guards, who had now become quite a bit more interested in Jean knowing  his story, agreed that nothing but very bad things were likely to happen to this young, skinny, soft boy from France if he ended back at Riker’s. We decided to keep him at Bellevue as long as we could.

What else? Well, the theme that runs through John’s very bad first day in America was his total inability to tell HIS side of whatever story he was in because he spoke only French. I decided that what he really needed was to be able to tell his story, and to do so we needed someone to translate for him once he left Bellevue. No problem, right? I mean, we were in New York City, the biggest, most cosmopolitan city in all of America. Should be a snap.

It turns out that there’s actually quite a bit of France in New York. I called the French Consulate hoping to have someone from France take charge of my French target. It was pretty late at night, around midnight if I recall, and the consulate was closed. “Please leave a message…” No problem. Bellevue is on 1st Ave. at 27th St., and United Nations is only a couple dozen blocks north on the same Avenue. I rang up the French delegation to the UN. They, too were closed. “Please leave a message…”

I imagined out loud what it must be like to call France itself. You know, just ring up the country and talk with whoever answers the phone. This was back in the days of answering machines, not those ubiquitous “for thus and such press one” messages. At midnight midweek I told the guards it would certainly go something like this: “Thank you for calling France. Our business hours are Monday through Friday, nine o’clock in the morning until five o’clock in the afternoon. If you would like to negotiate a trade agreement, sign a peace treaty, or seek political asylum, please call back during normal business hours.”

Okay then, plan B. Lots of other folks speak Parisian French in New York City. I thought the next logical place to look for Francophones would be at a French restaurant. Good thinking, right? At this time in the mid-1980s the most famous French restaurant in the United States was Le Cirque, so I gave them a call. A  little after midnight the restaurant was still open and still busy. I asked the woman who answered the phone if anyone there spoke French. Yes, indeed, there were lots of folks who spoke French. In fact, there were more than a dozen French citizens who worked at Le Cirque! Great, I said, I have this young man from France who has been assaulted and he needs someone to help him tell his story to the police and to the judge. (I was getting visibly psyched; the prison guards were smiling). Oh no, Monsieur, we are MUCH too busy to do any such thing. We could not POSSIBLY have anyone available to provide that type of service. Have a pleasant evening Monsieur.

Wow. Made me think of that Robin Williams routine where he describes a conversation with a Frenchman. “(Puffs on a Galoise) We are French (sneers)… we don’t care.”

Now I’m stuck. It’s almost 1 o’clock in the morning and I can’t think of any other way to get someone to translate for Jean. Think! Think… think… think. What would I do if it was ME? Who would I call if I was in a foreign country and needed a translator, needed help with the language and the authorities? And then it hit me: American Express Global Assist! Remember those commercials? Any help you could ever need any time anywhere, as long as you were a cardholder, American Express would be there. I reached into my pocket, pulled out my wallet, and took out my own American Express card (which I had never actually used). I dialed the number on the back of the card and the very helpful operator connected me to American Express Global Assist, and the equally helpful operator there put me on with the head of their French translation department, right there and then. I told her the sad story of Jean the target and then handed him the phone.

SCORE!

The only thing left to do now was to keep the Jean at Bellevue through the night so that he wouldn’t have to go back to Rikers; my friendly pair of prison guards pointed out that if we did, indeed, do this, Jean would miss the bus taking him to court, and would end up spending an extra day at Rikers. The guards were now fully into the project, however, and they agreed to ride the bus with Jean back to Rikers, and to sit with him in a duty room so that he did not have to go back into the prison population. Not only that, they personally escorted into court (off the clock, on their own time) and delivered him to a French speaking attorney whose assistance had been arranged  by American Express Global Assist. Upon hearing the story the judge threw out all charges, and the city of New York and American Express put Jean on a plane home to France that very afternoon.

There’s a very nice epilogue to this story as well. Many months later I received a letter in that same consultation room at Bellevue Hospital. There was a brief type written note from American Express. Dear Dr. White, we apologize for the delay in delivering this note. In the excitement of helping Jean we failed to obtain any of your contact information. Please accept our apologies. Please let us know if we can ever be of any assistance to you, or your patients, in the future. Sincerely. The note was wrapped around a postcard, the message written in French.

Thank you for saving my son’s life.

There are only two kinds of people in New York City, targets and people who hit targets. At Bellevue Hospital we took care of the targets.

There are only two kinds of people in New York City: targets, and people who hit targets. At Bellevue Hospital we took care of the targets.

I’m not sure if they still use these terms, but I take full credit for the original use of “target” to describe the victims of violence who came to the Bellevue Hospital emergency room. As an ophthalmology resident I was on call every fifth night, and because I lived outside of the city I actually have to spend each on-call night in the hospital. The bad news, of course, is that I didn’t get to sleep in my own bed. The good news was that I developed a more friendly relationship with the ER attendings, fellows, and residents, as well as the nursing and clerical staff. I also developed a very easy relationship with the prison guards from Riker’s Island. The term was coined, and the game was set when I sauntered into the ER in the wee hours of some morning and asked out loud to no one in particular: “okay, where’s the target?!”

Whether it was primary care or specialty care clinics like our ophthalmology division, Bellevue Hospital was where people who fell through the holes in the safety net went for their medical care. Pretty much everyone received care that they couldn’t receive anywhere else, so it was easy to feel good about the contribution that you were making, even as a resident. It would be difficult to pick out the person I helped the most over my three years in New York except for young Jean, the target from France who I saved one night while covering the ER.

It was around midnight and I was seeing an older woman who was complaining of flashes and floaters. A Latina, my patient spoke not a word of English, so I was delighted to make the acquaintance of her daughter, a lovely woman roughly my age who accompanied her mom and acted as translator. I excused myself when the phone rang. “We gotta target from Rikers for ya Darrell. Not a word of English.” Send ‘em right up was my response, pretty confident that my new friend the patient’s daughter would be able to translate for what I expected to be a Riker’s Island prisoner who spoke nothing but Spanish. Imagine my surprise when a rather thin, soft, artsy looking boy of 20 or so from France shuffled into our waiting room, his right eye black and blue and swollen tight.

The target part was pretty much standard fare, punched in the eye, but everything else was totally out of place. The visual was just wrong on more levels than I could describe. My new best friend said she knew little bit of French so I sent her out to chat with Jean while I examined her mother’s retina. Our French lad was clearly not much of a threat; the unwritten communication between the doctors and the writers Island guards told us as much, the guards chatting between themselves at the other end of the room. These two particular guards, a man and a woman who were not part of the normal Bellevue Hospital crew, would actually become a pretty important part of saving this target.

I finished up with my older woman, reassuring both her and her daughter that the flashes and floaters were nothing to be alarmed by, and that they would eventually go away. I asked her daughter what she had discovered, and with a sad, slow shake of the head she started to tell the story.

Jean, our target, had been in the United States for less than 24 hours. He was to visit friends, and had arrived a day earlier than a bilingual friend, another young Frenchman who would be the tour guide and connector for a group of kids in New York City. Rather naïve and not the least bit street–savvy, Jean decided that he would go on a walking tour of the city around Penn Station. This was back in the mid-1980s, and Jean came from a very fashion conscious family. It was cold in the city and he was wearing a fancy, team logo jacket, the kind the gangbangers in the city were wearing at the time. Sure enough, he happened upon a group of gangbangers very early in his travels.

The leader of this street corner group told Jean that he admired his jacket. He admired it so much, in fact, that he thought Jean should give him the jacket. Jean, of course, had absolutely no idea what the gangbanger was saying;  he only spoke French. The gangbanger pulled a knife and threatened Jean. Amazingly, Jeann took away the knife and stabbed the gang banger! When the police arrived and asked what had happened Jeann stood mute while the gangbanger screamed that John had tried to kill him. Unable to tell his side of the story–the street cops didn’t speak French– he was arrested for attempted murder and sent to Riker’s Island.

Now jacketless but still otherwise fully clothed, our target found himself in a holding cell at Rikers. It turns out that he was also rather fashionably shod, wearing brand-new leather sneakers that were all the rage at the time. You know, the kind of sneakers the gangbangers wore. Not too surprisingly his cell mates, at least some of them, were gangbangers. One of them approached Jean and proclaimed his admiration for these brand-new sneakers. Jean, of course, had no idea what he was talking about, seeing as he still didn’t speak a word of English. When it became clear that the gang banger was demanding his shoes Jean refused. The gangbanger cold-cocked him in the right eye and another target was off to the Bellevue Hospital emergency room.

With the exception of this fascinating story taking care of Jean was otherwise standard target fare. After prying open his swollen eyelids I was able to determine that his eye was intact and that no damage to his vision would ensue. But now what? What do I do with this thin, soft, French speaking 21-year-old all alone in New York City. I decided that I would help this one. If I ever made a difference, I would make a difference for this one.  This target, the recipient of violence he neither deserved nor sought, this was the one target, that one patient I would help outside of the professional help I gave everyone else.

How? What could I do? What did this young man need? There it was! What this young man needed was help telling his story. I was in the middle of the biggest hospital in the biggest city in America. Surely I could do this. Little did I know…

We’ve had lots of new people around Skyvision Centers recently. Two sets of consultants have come through at our invitation, our hope being that they would help us improve our patient education process. While they certainly had lots of really good ideas, systems and protocols that have been tested and found to be quite helpful in typical eye care practices, we found that they didn’t really translate terribly well “off-the-shelf” at Skyvision.

Why? It turns out that we have a very different culture at Skyvision, and that the management structure we use to foster that culture is so foreign to traditional medical care that we had to eat up some of our consulting time teaching the consultants who we are and how we work. Oddly enough, the question that set this process off was one that probably seems to be ridiculously basic to these two groups of consultants, but one that turned out to be nearly impossible for us to answer. “Who is your office manager?” Um… well… Gee., we don’t really HAVE an office manager. “Well, who should we talk to , then?” The answer to this question turned out to be just as difficult for them to understand: “everybody.”

I should start, I guess, with a word about our culture. I described the Skyvision culture to a new employee yesterday as a group of adults behaving like adults and treating each other like… adults. I told her to think of us as a Tribe of Adults! This is all I really wanted from my staff five years ago when I founded Skyvision. My most enjoyable part of management has been “blue-sky thinking”, setting priorities, charting a course, and allowing my people to work to the absolute limits of their capacity and ability in order to bring us home. Employee relationship monitoring and management is beyond boring and only barely tolerable. Hence, a Tribe of Adults.

Unfortunately, the typical management structure in small businesses in general and medical businesses in particular is not really conducive to fostering this kind of culture. Pretty much every other medical practice that I’ve ever been involved with, either as a physician, a patient, or a consultant has been set up as a steep management pyramid. Very strict top–down management in a command and control environment. Lots and lots of rules and regulations with an equally dense layer of middle management whose prime objective appears to be applying discipline to everyone who falls below it on the pyramid. Individual initiative is totally suppressed, and even the task of managing your relationship with a coworker is given over to a manager. Yuck.

But a Tribe of Adults clearly needs to be managed in a totally different way. A group of people who are willing to take responsibility, not only for the outcomes of their work product but also for their own personal behavior and relationships within the organization is best managed with as flat a management structure as possible. The ultimate flat organizational chart would be one in which literally no management existed. This is impossible, of course, because at some point someone has to chart the course, lay out priorities, and designate goals. After that  a Tribe of Adults shouldn’t need much management!

Enter the “Pond Theory of Management.”  Unlike the top–down management of a pyramid, if you look at an organizational chart set up according to Pond Theory from the side, what you will see he is a very thin layer on the surface of the pond and a few tiny flowers sticking up a bit above the surface. The magic, though, is looking at this organizational chart from above. If you look down on the pond what you see are a number of lily pads which flow on the surface of the pond, one for each employee in the business. The flowers above the lily pads represent a small number of individuals responsible for big picture issues and those very few instances where the Tribe of Adults cannot work through an issue on its own.

How does this Pond Theory of Management really work? The key, critical difference between a business run based on Pond Theory and one that is run on traditional command-and-control principles is in the allocation of tasks. In command-and-control theory some manager assigns a worker to a task, and might even assign that worker responsibility to direct other fellow workers in the accomplishment of that task. In the Pond there are areas where lily pads overlap, tasks that could be performed and responsibilities that can be shared among two or several workers with similar skills or job descriptions. Where these lily pads overlap the responsibility and the accountability for completing this task or achieving this goal is determined by mutual affirmation of all the workers whose lily pads overlap.

The individual who now has accountability and responsibility for this task retains them as long as he or she is able to deliver the desired outcome; all of the other workers whose lily pads overlap accept this individual as their leader for this particular task. In a similar and related manner, those workers who have affirmed this individual give up any “right” to criticize how this outcome is achieved. There are certain rules and regulations that might apply, of course. In our medical world HIPPA and other government regulations are unavoidable. National, state, and local laws apply, too! Beyond this what we achieve in “The Pond” is outcomes with minimal managerial oversight,  interference, or necessity.

After two full days with us I’m still not sure the consultants really got what I was talking about, and if they did I’m pretty sure they didn’t really believe me. How about my new hire? She came from an extremely rigid practice with rules and regulations to account for pretty much every minute of her day, and a manager who monitored each one of those minutes to make sure that there was 100% compliance with all of those rules and regs. What was her reaction when I explained to her the culture of a Tribe of Adults working in an extremely flat organization, working on the Pond?

“Wow! We’re all BIG girls here!”

Man, what a place Bellevue Hospital must’ve been back in the day. It was crazy enough in MY day in the mid-1980′s. Bellevue is arguably the most famous hospital in the world, famous mostly for the treatment of psychiatric patients, and made all the more famous by the Christmas movie “The Miracle on 49th St.” in which Santa Claus was institutionalized in one of Bellevue’s top floors. For those of you who don’t know Bellevue Hospital, the top six floors of a 30 floor tower were (are?) reserved for psychiatric patients, at least one of them for psychiatric patients who hail from Rikers Island.

I’m not really sure why, but I’ve been thinking a lot about Bellevue recently. My experiences as an ophthalmologist in private practice in the suburbs of Cleveland, Ohio really have exactly nothing in common with my experiences as an ophthalmology resident on the lower East Side of New York City. Nonetheless Bellevue has been on my mind. I thought I’d share some stories about Bellevue and about my time as a resident at all of the NYU hospitals. This will also give me an opportunity to introduce you to some very special, very interesting characters whose lives crossed paths with mine.

Irwin Siegel was an optometrist with multiple roles at Bellevue Hospital. His most important role for me and my fellow residents was to teach us about optics and refraction, the science and technique of prescribing glasses and contact lenses. Dr. Siegel was also a noted researcher in the diagnosis and treatment of retinal diseases, specifically diseases of the macula or center of the retina; there is actually a syndrome named after Dr. Siegel and two of his partners.

Dr. Siegel was a fascinating man, especially fascinating to a child of suburbia like me. The prototypical New Yorker, Dr. Siegel lived his entire life in Brooklyn and Manhattan. He did not own a car, and used some form of public transportation for more than 95% of his travels. You got the sense that any forays outside the island of Manhattan were viewed as akin to a ride on the “Heart of Darkness” express. The guy simply reeked of New York, and he spent his entire professional career at Bellevue Hospital.

Recall that my life’s memories are wrapped up in eyecare, optics, and the optical industry. My father’s first job was at American Optical in Southbridge Massachusetts, at the time the largest ophthalmic manufacturing company on the planet. The very first lasers were actually developed in the laboratories of AO. In the early 1960s Dr. Siegel and his partners were doing research on lasers at Bellevue. Now, as you can imagine, something as powerful as the energy of the laser light had also come to the attention of the U.S. Military. So comes the story of the Bellevue Death Ray!

Dr. Siegel and Dr. Carr were doing laser work somewhere in the bowels of Bellevue. This would have been in the early 1960s, and the laser they were working on was an enormous mechanical monstrosity, a piece of equipment that took up more space than most upper East Side kitchens. Not only was it physically enormous, but the generation of a single pulse of laser took well over a minute, a minute filled with a crescendo of sound not unlike what one would experience when a jet engine is engaged . Imagine a room, half filled with this exotic piece of near–science fiction equipment, surrounded by white–coated scientists all wearing goggles that look as if they had been spirited away from a Mount Everest expedition. Add in a few very senior military officers in full dress regalia and the scene is set.

The officers visiting from the Pentagon really had no idea what to expect. They were intrigued by this new technology, interested to see if there might be some military application. Dr. Siegel noted that he and Dr. Carr were mostly bemused by the presence of the officers, although he did admit being a little bit impressed by the two-star general in their midst. The  experiment/demonstration was set up, on one end of the room the monstrous laser, on the other end of the room a rabbit in a box, his head poking through a hole, the laser aimed at his left eye. Goggles were donned and the switch was flipped.

The laser came to life, slowly building energy in the rudimentary laser tube, the whine and the clang and the clatter growing in intensity with each passing second. Dr. Siegel and Dr. Carr stood calmly to the side, ignoring the laser and concentrating on the rabbit. The officers, on the other hand, slowly crept back away from the laser, trying to melt through the wall, and failing that trying to become as small as possible. Two-dimensional, if possible. The wail of the laser grew… the sound filled the room… the wail, the clatter, a crescendo… BAM!

And then, silence. The doctors and the officers took off their goggles. They walked over to the  box and discovered that the rabbit was dead. Immediately one of the colonels started doing a jig. “We have a death ray! We have a death ray!” He began to run for the door, headed for the telephone (no cell phones or sat phones in those days). “Well, hold on a minute,” said Dr. Siegel. “Let’s just take a closer look.” It turns out that rabbits are not terribly bright creatures, and that when they are frightened they tend to forget how to move backwards. This poor bunny, the only creature in the room without Ed Hillary’s goggles, had been so frightened by the noise of the laser that he literally suffocated himself, pushing against the rim of the hole in the rabbit box in an effort to escape.

When Dr. Siegel looked inside the rabbit’s eye there was a single perfectly round burn, approximately 2 mm in size in the middle of the rabbits retina. There,  in the space of approximately 5 minutes, was born and died the Bellevue Death Ray.

The epilogue of this story is rather interesting, though. About 10 years later, after numerous refinements of both the production of laser energy and the focusing of that energy, one of the most important trials in the history of medicine took place using focused laser light to prevent vision loss from diabetic retinopathy. The Diabetic Retinopathy Study was the first prospective, double–blind, randomized clinical study done on a cooperative basis across the entire country, and the results of that study have saved countless individuals from a life of blindness due to diabetes.

This is where I trained, and men like Dr. Siegel who told this tale from Bellevue Hospital as part of our optics classes, is one of the men who trained me.