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Saturday, November 30, 2013
Current Affairs ... Health / Nutrition ...

I recently changed my eye doctor, despite officially being a “suspect” for a nasty little eye disease that eventually leads to blindness. I was going to the same doctor at a big multi-function eye clinic for over 15 years. I can’t say that he ever did anything that was technically wrong; I just got tired of his attitude that “I’m the miracle man and you are the poor victim, I’m always right and anything you believe outside of what I tell you is wrong; and hey, I’ve already been here too long and have to get on to the next patient, so if there are no further [futile and stupid] questions on your part, then have a great day”.

This fellow has been cited in various local magazines (including New Jersey Monthly — look under ophthalmology) as a “doctor of the year”, for many years running. At first this seemed impressive; but it finally dawned on me that these “super doctor” magazine nominations aren’t exactly made by the Nobel Prize committee. This is more of an old-boy network judgement than an assessment based on ultimate benefit to the patient.

I finally decided to change to the eye doctor that my mother used when she was alive. He is a few years older than my former “doctor of the year for every year”; actually, the new guy is roughly my own age. He is not featured in any magazines and has a very different kind of office. My former doctor was in a group practice with several other eye specialists, in a large facility that was fully equipped with all kinds of high-tech gadgetry, including the latest laser eye surgery stuff. They didn’t just treat eye disease or do annual eye exams, but marketed their services for vision correction and a variety of other “discretionary” procedures, such as an out-patient operation to increase the volume of flow from your tear ducts. No more dry eye!!! These guys could do it all. (And wanted to do it all on me; despite my “suspect” problems, they tried several times to sell me on vision correction and tear flow surgery, out of my own pocket. Obviously I always said no to my doctor — about the only refusal or disagreement that he would allow me to voice, however grudgingly.)

And do it all they did and still do to a wide swath of the public. The clinic was always packed with people, who were continually herded back and forth between various exam rooms and waiting areas by a staff of mostly young assistants and technicians. The whole operation was designed for maximum efficiency; the doctor only saw you at the end, after you finished all the question and answer sessions and eye drops and laser scans and eye chart readings. You would sit in a room alone for maybe 15 minutes, until the door would finally open and in would walk the great man with his assistant ready to jot down his every word. This is it, time to proclaim judgement upon me, right in front of a stranger to whom I am nothing more than the subject of the file she was keeping. But don’t worry, this judgement will be proclaimed quickly, as the next patient(s) are already in similar rooms, waiting alone in the creepy isolated solitude for their own judgements.

Hey look, I know that doctors have to sometimes give patients bad news, things that the patient just doesn’t want to hear. But a highly efficient and highly impersonal setting like the eye clinic I had been so loyal to is just not a good place to get such news. Not that there really is a “good” place for bad news, but a slower, more private and more humane setting where 2-way communication flows naturally certainly might minimize the angst.

My new eye doctor, incredibly enough, seems to maintain such a setting. His office is something out of the past, the way that doctors used to practice medicine. His receptionist is at an open desk, not behind a sliding glass door in a business-like office complex. You speak to her face-to-face when you walk in; you don’t see a poster saying “SIGN IN WITH TIME OF ARRIVAL, TAKE A SEAT, AND WAIT FOR CALL FROM STAFF”. You see the same faces working in the office over many visits, and not an ever changing blend of mostly young people fresh out of school. There is not a bank of TV screens on the walls with stupid shows or health infomercials playing non-stop. There usually are other patients waiting to go in, or coming out, but things are much less hectic and noisy than at the clinic. When it’s time to start the exam or procedure, the doctor himself comes out to get you from the reception area, not a 20 year old technician half-heartedly saying “follow me, how are you today”. The new doctor himself performs some of the procedures that are farmed out to technicians at the big clinic (although some other things are done by his assistant, reasonably enough). You have a fair amount of time to talk with the doctor, and he isn’t hurrying you out the door.

And what’s more, he takes your questions seriously, and even acknowledges that there might be something legitimate to whatever your idea or concern is regarding your eye conditions. He does not immediately and implicitly dismiss the thoughts behind your question, as my friend at the big clinic always did. He may well disagree with what I would be thinking and will make that clear, but he doesn’t just rattle off a rote explanation that anyone could get from a public health web site.

This is the health care of the past. I’m really surprised that I found this guy, that he’s still in business. I don’t see how he survives in the present medical economic environment (especially with the full implementation of Obamacare right around the corner). Perhaps in the future there will still be offices like this available to the very wealthy, those not dependent upon health insurance or government payment plans (mostly Medicare). But the rest of us will surely be herded into expense-minimizing high volume clinics so as to keep the costs to the government and the insurers under control. You will still have a few minutes face-to-face with your doctor; but use that time wisely, as it will be strictly limited. And don’t expect much in-depth discussion of your own fears and concerns. Just state the symptoms plainly and succinctly, listen to the doctors instructions, and off you go!!

Obviously, I do believe that a lot will be lost (and already IS being lost) as “old fashioned” medical practice goes the way of the vinyl record and postage stamp and typewriter. Medical practice will become more impersonal and more uncomfortable for most of us. Computerized records and text messages and even instant monitoring of health conditions from home are great, but will not make up for the deterioration in personal relationship and communication between doctor and patient.

I will admit that there is one down-side to my decision to leave the big clinic for an old-fashioned solo practice. My possible eye condition today is often diagnosed and monitored by high-tech laser scanning equipment that allegedly has the ability to detect even the slightest changes in the eye that would indicate the start of a real problem. The proponents of these machines say that they are a big advance over the kinds of tools that my new doctor still seems to rely on to monitor my eyes; that they would allow responses to a problem months earlier and thus could allow medications or other therapies to be implemented earlier, thus decreasing the chances of eventual blindness or significant sight loss.

So perhaps I have given up some safety margin in protecting my future eye sight. This is a real concern. On the other hand . . . there is also a real concern that all of these high-tech machines are “dumbing down” the technicians and even the doctors who participate in the examination and diagnosis process. A recent article in The Atlantic discussed the dangers that automation is already having on professional judgement; e.g., there have already been airplane crashes where pilots became too used to letting the computer fly the plane, and when that computer had a glitch or couldn’t handle what was happening, the pilot who took over failed to apply a basic skill that all trained pilots should reasonably have, causing loss of plane and loss of life.

(I’m not a medical expert, not at all, but I can’t help but suspect that all of this high-tech equipment might be TOO sensitive . . . given the fears of high-stakes malpractice lawsuits against lavishly capitalized and lavishly profitable practices like my former eye doctor has, this machinery could well be designed with a bias towards “false positives”. I can’t help but wonder if all of these expensive machines increase the odds of a permanent diagnosis for a chronic condition, when the actual triggering causation in the body might have been transient, even if it could also be the starting point for the disease in question.)

My new doctor is a seasoned veteran with around 30 years of professional experience (and no malpractice lawsuits or disciplinary actions that I could find on the State web site). Even if he doesn’t have all of the latest super-duper laser scanners, he certainly does seem to take longer than my former clinic doctor did in directly examining my eyes. In the clinic, the old doctor reviewed a computer screen for several minutes, then almost as an after-thought got out a pin-point light and had me look up, down, left, right . . . I’d like to think there is a best-of-both-worlds mix, and I’m not entirely at ease with betting my future eyesight on human judgement. But for now, I’m sticking with the old school (so long as the old school is allowed to stay open). We shall see . . . I hope literally to “see” . . . how this turns out.

◊   posted by Jim G @ 4:12 pm      

  1. Jim, Your description is about right for so many doctors it isn’t even funny. It’s almost a “what else is knew” kind of thing when it comes to doctors.

    But I also remember back when I was a young girl and our mother took us to the doctor (who was much admired and considered a wonderful doctor, to say nothing of being a good friend of the family). Then the doctors were GP’s (general practitioners) and did literally *everything* – including every kind of surgery. While that doctor had his own very personal approach to each patient, it was a real chore going to see him; waiting to even get into his office took literally hours. He’d begin by starting a conversation about say politics and/or anything else that he might find interesting to talk with the adults; this conversation might last half an hour. Then he’d get around to seeing about who was visiting him as a patient in the family.

    So, while today hospitals and doctors’ offices are run like factories (everything on an assembly line it seems to me) there is the other side (when I was a kid) and waiting literally for hours to see the doctor while he took his time visiting with his patients and making them feel at home.

    I don’t know what is best. Perhaps the old fashioned guy was; he’d even come to your home if you were so sick that getting yourself out of bed would not be healthy for you. A while back a doctor told me I should not be driving taking the medication I was taking. I simply could not resist saying: Would you have come to my home to see me? The doctor had no answer as it was very clear what the answer would be.

    As to the “dumbing down” of doctors: I’ve tho’t that in my heart several times with all the computerized stuff that gets printed out and put into your hand as you leave a doc’s office. I find myself wondering: Did the doc just look that up on some computer and figure, “got to be that”? Makes me wonder too.

    I sometimes wonder which is/was better: The old time GP who knew how to do “everything”, yet whose office waiting room had patients waiting for almost 3 hours to see the GP? Or is the “factory system” (as I call it) the way to go? Somewhere in between seems to me should be the solution.

    One thing I seem to note is that doctors’ practices are becoming filled with who knows how many (is this the right word?) partners and/or associates. (Somewhat like big lawyers offices have been for a while.) You generally are assigned to one doctor; but should you be in the hospital, you might see any one of the doctors. It’s not too bad a system; I’ve experienced that last one under some serious circumstances. The docs were all very good at what they did. Yet, any consideration of establishing a personal relationship with one individual did not seem likely, unless one was in the hospital a very long time. Back in the office, the doc one saw initially was the one seem by the patient – accompanied by 4 or 5 “doctors in training” and all “business” was conducted with all these other “learners” present. I’m not sure I liked that too much; but then, I guess they have to learn “on the job”, so to say.

    I doubt that the medical system is really going to improve much in the near future. I think it’s too early to see how it’s actually going to turn out. Time will tell is the “factory system” works well; or if a better system will have to be found.

    Glad you seem to like your newly found eye doctor – and glad that so far you have good results from your tests. I hope both that the tests will stay “good” and that you will find your new doc such that you will stay with him/her for some time and be well satisfied. MCS

    Comment by Mary — December 1, 2013 @ 12:09 am

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