Eye Care

On Friday I had a slightly, subtly dehumanizing experience at the eye doctor. It’s no big deal, really, almost not worth mentioning –

It was an entirely ordinary set of events that triggered this near-rant from this determinately positive blogger. But maybe the commonality of it – the blandness of what happened when I visited the doctor the other day – typifies what’s as a tragedy in modern health care: the loss of caring.

eyeglasses on a table (Wikimedia Commons)

How it went was like this:

That morning I raced (or, rather, walked quickly – but dangerously quickly for a woman with poor balance and limited gait) to catch the bus to take the train to reach the optometrist’s office on time. And I did.

The office was crowded but not full. A receptionist sat behind a partly glass-enclosed counter with desks, fax machines and filing cabinets and other workers.

“Name, please” she asked me.

I told the woman my name.

She nodded. “Take a seat, someone will be right with you.”

I waited just over half an hour, during which time I had the opportunity to look around and listen.  A man, who said he’d undergone Lasik surgery the day prior was “seeing great” as he chatted enthusiastically with a couple to my left, one half of which was contemplating the procedure.

“It’s a miracle,” he said. “I’m having each done separately, one at a time.”

After a while I returned to the receptionist’s window and noticed a sign having to do with Botox injections and information on a doctor who might provide those.

My mind wandered… I never knew that eye doctors do Botox. Then again, maybe they don’t…Perhaps this office maintains a reciprocal relationship with an office that provides those, where the staff posts notices about Lasik surgery. Either way, the sign is nothing more than a business strategy, which is fair enough if you believe that health care can or should be run as a money-making enterprise. (I don’t.)

Back to my optometrist, who was running late (OK, usually forgivable, human):

How I first met this capable woman was through the long-ago care of my semi-retired ophthalmologist, a medical doctor (MD) who provided start-to-finish eye examinations and might, if you ever needed it, perform eye surgery. I trusted him and always felt good about visiting his office.

Some time ago he expanded his practice, taking in some less-established doctors and optometrists. The idea, I imagine, was to have a doctor of optometry (DO) carefully perform the initial eye exams, patiently fit vision-impaired people with just the right prescriptions for their lenses and, finally, refer any questions or concerns to the ophthalmologist in the same office. In this sort of setting, he could spend more of his time helping, and doing procedures, for patients with serious eye problems like glaucoma.

I was happy with the system for most of 10 years. I genuinely liked the optometrist, and still do – she did a terrific job evaluating my vision and optimizing my lenses. Around the time I had breast cancer, bald and walking with a needed cane, she looked into my eyes with extra care. She was sympathetic and spent an unusual amount of time making sure that my glasses would be all right, if nothing else.

The problem – what I’d diagnose as a change in the practice’s character – manifest a few years ago after the group moved to a new office space where there seems to be a lot more traffic. The carpeting on the floors, once fresh-appearing, is no longer. The waiting area, formerly quiet, has a TV broadcasting CNN. But I don’t care much about the floors or media selection.

What bugs me is that the office has expanded and become so systematized that when I go there I don’t feel like I’m visiting a doctor, the kind of professional who sincerely cares about my health. Instead I feel like a commodity, which I suppose I am.

Back to the visit:

As has happened before, a technician called my name  and asked me to come with him, so I did. He was young and unfamiliar. He told me his first name and, without further explanation, indicated where I should sit while he used a machine to take pictures of each retina, the light-receiving membranous surface at the back of the eyes. Next, he asked me to follow him into a small room where he proceeded to open my chart and question me, sketchily, about my recent medical history.

I wasn’t thrilled about sharing, but went along up until a point. Then, when he began to perform my eye evaluation – the exact sort of work that the optometrist used to spend her time with me doing, I asked him what was going on. Where was she?

“She doesn’t do this part any more. It’s been like that for a while. Now please, can you read the letters in the first row…”

So now the optometrist, who had for years assisted the ophthalmologist, has an assistant who would evaluate my vision instead. This saddened me, first and selfishly because I’d spent the better part of my morning going to see her so that she could check my eyes and write another ideal prescription I could rely on, and now I couldn’t count on that small part of my health care going smoothly ever again.

What’s more – and the bigger picture – is that she no longer has time for me and my eye glasses. I see this simultaneously as good and bad:

Good – I suppose, because we don’t really need people with MDs, and probably not even with DOs, for routine examinations and procedures that could be handled by someone with less training and who is, therefore, less valuable in our limited health care system.

Bad – It happens that the particular technician who started to check my eyesight did a poor job until I stopped him at that. The machine he used to project letters into a mirror shook so much that the small blurry letters in the lowest row wobbled clearly.

More generally – it’s bad because the time I once valued with my optometrist, as previously with the ophthalmologist, is gone. I guess it wasn’t sufficiently worthwhile for them to keep the relationship going as it was. No more annual, while they’re flipping the glass circles, questions like “how are your kids?” or “how’s your summer going” or a generous, once-credible “how are you feeling?”

My visit was almost reduced to a series of standard interactions with a technician of unknown credentials who I don’t expect to ever see again. I intercepted that, this time, but this scenario will surely recur, overwhelmingly, as health care delivery becomes more checklist-based and efficiency-minded.


Some definitions – for those of you who aren’t completely confident in your knowledge of the distinctions among eye care specialists:

An ophthalmologist is a medical doctor (MD) who specializes in eye diseases and might perform eye surgery.

An optometrist is a professional who’s earned a doctor of optometry (DO). Usually this requires four years of post-graduate education that covers eye diseases, pharmacology, anatomy and more. Optometrists are trained, extensively, to examine the eyes, give prescriptions and perform certain procedures.

An optician is someone, typically a licensed professional, who helps people get the eye care they need and may prescribe eye glasses or contact lenses.

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The Physical Exam’s Value is Not Just Emotional

Lately there’s been some talk about the value of the physical examination. It’s my sense that this discussion was sparked by a lovely piece by Danielle Ofri published two weeks ago in the New York Times. In that, Dr. Ofri describes a patient’s visit in which, toward the end and almost as an afterthought, she pulled out her stethoscope and performed a physical exam in a perhaps cursory but essential, thoughtful manner.

Or is it so cursory? There’s little scientific evidence to support the physical exam in practicing medicine but, as she writes:

…Touch is inherently humanizing, and for a doctor-patient relationship to have meaning beyond that of a business interaction, there needs to be trust — on both ends. As has been proved in newborn nurseries, and intuited by most doctors, nurses and patients, one of the most basic ways to establish trust is to touch…

KevinMD picked up on the story, essentially echoing the idea in a post called “Touch Humanizes the Doctor-Patient Relationship.” In that, he considers that some doctors (including him, previously) dismiss the physical exam obsolete – “like staying with a horse and buggy when cars are rapidly becoming available.”

It happens I know something about physical exams. Early in my years as a junior faculty member at Cornell’s medical school, around 1994, I was assigned to teach physical examination to second-year students during each of two consecutive spring semesters. To prepare for teaching, I carefully reread my copy of Bates’ Guide to Physical Examination.

my old copy of Bates’ Guide to Physical Examination, on my desk now

Together, my students and I listened to normal and abnormal heart sounds. We looked in each others eyes with ophthalmoscopes. We visited some of my patients with lymphadenopathy (swollen glands), big livers and palpable spleens who were willing to let us learn from their pathological physical findings. We listened and described course and fine rales on some pneumatics’ lung exams, and checked arthritic joints for swan-like deformities characteristic of rheumatoid arthritis. We examined patients’ petechiae, purpura, ecchymoses and more, and discussed the differences among those findings and what they might signify. All of this we did without CT scans or echos.

I know also, as a patient, that physical examination can be life-saving. Once, when I was in the hospital as a child and had unexplained fevers after surgery, it seemed for a while that no one could figure out what was wrong. I was terrified. The surgical team consulted with an infectious disease specialist, who as I recall ordered a whole bunch of unpleasant tests, and then my dad – a physician – noticed that one of my legs was more swollen than the other. He realized, based on my physical exam, that I might have a blood clot. It turned out that he was right.

So I agree that the physical exam is humanizing. So much so that, later in my career when I routinely donned space suit-like gowns and masks on rounds for the leukemia and bone marrow transplant services, I became frustrated by those barriers, and by the very lack of touch which, I think, can help patients heal.

But what’s also true, in a practical and bottom-line sort of way, is that a good physical exam can help doctors figure out what’s wrong with patients. If physicians were more confident – better trained, and practiced – in their capacity to make diagnoses by physical exam, we could skip the costs and toxicity of countless x-rays, CT scans and other tests.

Recently I wrote a piece on medical education and going back to basics. The physical exam should be included, for sure.

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