Chairs Missing by Joe, resident at the New England College of Optometry

10Jul/12Off

New Health Rock: Part 1

Summer’s Here, Kids

Summer’s here, but I can’t help but think about other things.  Originally, I was going to write a post about this being a transitional summer: the end of college student style summers off, the first summer of life as the rest of the 9 to 5 world lives, where the fun times are reserved for the weekends, just like that song by that band Foreigner… or maybe it was Loverboy.  To be sure, the weekends thus far have been almost as busy as the weekdays, with hikes in the Great Blue Hills, bike rides around the Esplanade, and road trips to Cape Cod.  There’s been a ton of cool bands and hip hop to check out at local venues.  I've been able to see a few summer blockbusters, Moonrise Kingdom (it's good, but it's no Rushmore) and Prometheus (a muddled, disappointing mess). And for the first time in probably 15 years, my favorite team, the Pirates, have a better record than the Red Sox at the All-Star break.   But despite all this, I feel other issues creeping to the forefront of my consciousness, both throughout the week and the weekend.  So indulge me, if you will, as I wander.

Forever Changes

Optometry’s scope has rapidly changed and expanded over the last 25+ years.  This has led to the coining of an adage which goes a little like this: “The number of things that the general public doesn’t realize is within the OD’s scope can fill the Grand Canyon.” Or something like that.  And it’s probably true. The historical and political reasons for this are multifaceted and subject to debate.  Whether it boils down simply to the rate of change outpacing our ability to inform the public  (due to inadequate marketing on our part), or something else like creeping corporatization, powerful lobbying by organized medicine, or maybe something even larger and further beyond our control, I don’t know for sure.

If I had to guess, I’d say it’s the latter:  it’s a side effect of the dysfunctional maze that is health care in America, ripe with inefficiencies and redundancies and its focus on specialization, rather than on primary and preventive care.  What are the solutions that are actually possible to fix it?  Probably no one person has the answer.  Maybe no one ever will solve it.

Supreme Clientele

One thing that’s for certain is that the politics and future of all areas of health care weigh heavy on people’s minds, especially in light of the recent Supreme Court decision preserving (most of) the Affordable Health Care Act, aka Obamacare.

It seems this week everyone at clinic has an opinion on whether it’s good or bad, and they try to strike up conversations to see what we think.  My patients’ opinions seem to be correlated with whatever era of war they served in.  The Korean War vets are far more trusting and optimistic, versus Vietnam vets who seem to inherently distrust anything to do with the government.  I, of course, choose to politely abstain from comment, as politics and patient care simply do not mix.  I merely like to point out that the program is, in fact, not socialized medicine, and also that the court case confirms it while taking away its teeth by allowing states to ignore the mandate without any possible penalty.

On lunch break, I get to hear the perspective of our staff and again I take a Socratic approach, asking questions without fully tipping off my personal opinion.  Some believe it’s going to be Armageddon and bring down all health care as we know it, via significantly reducing future incentives to become doctors in the first place (aka their reimbursement rates will decrease).  Others seem to somewhat agree, but with less contempt. The younger staff seem to be more measured in their thoughts, reasoning that the same law has been in effect in Massachusetts without the world ending, and therefore see more positive in it than negative.  I continue to abstain from comment one way or the other and I will keep it that way in this space, except to say that it seems likely that all sides could be right, all at the same time.  But no matter what, it’s all very interesting and makes me want to consider studying public health somewhere later on in my career.

Do You Realize?

So back to my previous train of thought, which is: what exactly is optometry’s role in today’s world?  I’m closer to knowing now than I was 3 years ago.   As a freshly minted optometry student on Day 1 of classes, you don’t fully realize the scope of what you are responsible for when a patient sits in that exam chair. There is an ongoing process of micro-epiphanies that occur as you learn more material and get more experience in clinic.  Generally, we are so busy at school that we take little time to reflect and connect this process back to our everyday lives.  But now that I’ve began to think and write about these last three years, I can see where the abstract met the clinical in ways I did not initially realize or expect.

Sometime in March of my first year, sitting in Neuroanatomy class, I came to the realization that we could be the first to discover signs on an eye exam that lead to the diagnosis of cancer in a patient, maybe in an otherwise asymptomatic patient.  And not just cancer of the eye itself, but also the brain, or maybe even the lung or colon. And beyond this, that the cancer could be incurable.  Fifteen years ago, if I you told me that I would have a job where this could be possible, I would have called you crazy (at that time I feared anything resembling science). But here I am, where day to day such a thing would be rare, but not out of the realm of possibility. After a month and a half of seeing patients full time, I can see how easy it would be to miss clinical signs if I failed to take stuff seriously and not carefully examine patients. And yet there’s more.

From here, the clinical meets the personal; from just sitting and talking to patients, you see why the human side of cases should not be neglected.  We need to make sure that we are still seeing the patient as a person.  And we also can’t ignore the psychological and physical toll a grim diagnosis could have, not only for the patient, but also for his or her caregivers and extended family.  For all the debates about health care, about its scope or role in society, and about the politics of how it’s rationed (and make no illusions about it: no matter the system of delivery, care is rationed in one way or other), this all remains secondary to the personal experience of facing life and death.

In the second part of this post, I hope to discuss a little about my own personal experiences facing diagnoses of cancer with friends and family.  There are two people in my life, one past and one present, which unfortunately give me more perspective than perhaps is needed or is fair. One is a close friend with a child who has an inoperable optic glioma, who faces the challenges of treatment decisions and day to day living.  The other, a cousin (more like an older brother, actually), who faced the sudden diagnosis of inoperable brain tumor, and sadly lost his fight.

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