American Academy of Ophthalmology Web Site: www.aao.org
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July/August 2006

 
Letters
 
 

• Risk Calculator, but Calculating What?
• Behçet’s Syndrome: Author’s Response
• Behçet’s Syndrome: A Clarification
• Physicians or Surgeons?
• Physicians and Surgeons?
• Pearls From and For a Young Ophthalmologist


Risk Calculator, but Calculating What?

The article entitled “Calculating the Risk” (Feature, February) starts by saying, “The medical management of glaucoma is haunted by the question, ‘Which patients can be expected to progress from ocular hypertension to manifest glaucoma?’” This comment seems to be an accurate representation of what most ophthalmologists currently believe.

This ghost is like most of the others that haunt people —a self-created fear that grows out of a subjective, inward reality that is out of touch with an objective, outward reality.

Unless inappropriately brainwashed by their physicians, patients could not care less about the development of asymptomatic changes that are unfortunately labeled by physicians as “glaucoma.” In contrast, for physicians, a development of an increase in the size of the optic cup or a unilateral nasal step assumes a consequentiality of such magnitude that preventing the change haunts the ophthalmologists.

Those changes, such as an increase in the cup/disc ratio of 0.2 to 0.3 or the development of an early nasal step, are worthy of note, but their significance is limited to whether or not they indicate a rate of change that is going to affect the patient’s well-being.

Findings that do not in any way affect a person’s functional ability are not measures of health or disease. They are, at best, risk factors for what his or her condition may be in the future. Put differently, most so-called risk factors are usually risk factors for other risk factors, not for health or disease.

But we physicians have not even reached a consensus regarding what constitutes wellness or illness or disease or disability. Taking a careful history has been and remains the best method of evaluating a person’s life and the appropriate aspects on which we should concentrate.

Yes, we do need a risk calculator that works, but not something that calculates the risks of other risks. It should calculate the risks of enhancing health or increasing disability.

George L. Spaeth, MD
Philadelphia

 

Behçet’s Syndrome: Author’s Response

In May’s Letters, a concern was expressed that the patient in the November/ December Morning Rounds (“Black Spots and Night Sweats: A Puzzling Case of Panuveitis”) was not placed on immunosuppressive therapy upon diagnosis of Behçet’s disease with posterior segment involvement.

This patient actually was initially treated with a variety of immunosuppressives, including cyclophosphamide, but refuses to continue any of them.

The article clearly states in the last sentence, “Corticosteroids, cytotoxic agents, cyclosporine and colchicine are mainstays of therapy for Behçet’s syndrome.” Further discussion of immunosuppressives was not possible due to space constraints.

It is also important to point out that the article mentions my patient was referred to and under the care of a university rheumatologist.

Andrea V. Gray, MD
Roseburg, Ore.

Ed: It is EyeNet’s policy to offer authors a chance to respond to comments about their articles in the same issue those comments are published. We regret that Dr. Gray was not contacted in this case.

 

Behçet’s Syndrome: A Clarification

When Russell W. Read, MD, was asked to comment on treatment of the Behçet’s case above (Letters, May), he noted that uveitis specialists “typically advocate early institution of systemic immunosuppressive therapy for posterior segment involvement in Behçet’s disease.”

An additional comment of Dr. Read’s was inadvertently modified. It should have stated: “If the treating ophthalmologist is not well-versed in the use of these agents, then either referral to a uveitis specialist or partnership with a rheumatologist should be strongly considered.”

We thank Dr. Read for clarifying that point.

 

Physicians or Surgeons?

I read with great interest Dominick Golio, MD’s letter in the March EyeNet regarding the need to “restore clarity” in having the public realize the difference between ophthalmology and optometry. Having been involved with scope of practice issues for the past 20 years, I sympathize with Dr. Golio’s sentiments and share his frustration. However, presenting ophthalmologists as “ophthalmic surgeons” sends the wrong message to legislators and the public.

Ophthalmologists are a great deal more than surgeons and, in fact, spend most of their time taking care of patients with nonsurgical problems. Optometry has long argued that we care only about cutting and as a result they need diagnostic and therapeutic privileges, oral and injectible drugs, and even lasers to fill the “vacuum” in eye care that we have left. We must avoid, not reinforce, this characterization.

We are not only surgeons —we are physicians who have gone to medical school and completed residencies and fellowships. The depth of knowledge, experience and understanding that we bring to each encounter is what clearly distinguishes us. The Eye M.D. branding concept was an excellent attempt to point out the distinction of our training and the range of services that we provide. I genuinely believe that the problem is in marketing, not terminology.

In the end, it will be the ongoing involvement of all ophthalmologists, regardless of how they are described, that will save our patients and our profession from optometric scope of practice expansion. Once we “clarify the blur,” (per Mel Rubin, MD), the answer to the question “which is better, number one or number two” will be obvious.

Paul N. Orloff, MD
New York

 

Physicians and Surgeons

We were pleased that you published Dr. Golio’s letter regarding the need for clarity with respect to the public’s confusion about eye care providers. The Michigan Ophthalmological Society has been concerned about this confusion not only among patients but also among our medical colleagues.

Like Dr. Golio, we felt that our society was in need of a more definitive and authoritative name. We felt that it should make us more clearly identifiable as physicians with traditional medical training, and because of the potential for scope of practice legislation in Michigan, we wanted to be readily identifiable as the authorities on surgical eye care.

We proudly announce that in recognition of these issues, and taking a cue from a dozen other state societies, our membership voted on March 15 to change the name of our society to the Michigan Society of Eye Physicians and Surgeons. It is our hope that this simple and straightforward designation will help us to accomplish our mission of advocacy, education and service.

Robert J. Granadier, MD
President, Michigan Society of Eye Physicians and Surgeons
Royal Oak, Mich.

 

Pearls From and For a Young Ophthalmologist

After finishing my first year of practice, I reflected on ways in which I could improve as an ophthalmologist. Below are observations that I have acquired from mentors. I hope this will inspire all of us to be better physicians.

Interactions with patients. When meeting a patient for the first time, introduce yourself as “Doctor” and address them as “Mr.” or “Ms.” Call them by their first name only with permission. Remember the small details—a child going to college, getting married, etc. Patients requiring more time to discuss their issues should be scheduled at the end of the day—let them know that you want to provide enough time to answer all of their questions. It’s all right to say, “I don’t know, but I’ll find out.”

Interactions with staff. Greet staff in the morning. Ask often, “What can I do to make your job easier?” Speak evil of no one, and listen attentively. Write clearly in your charts. Maintain a high level of respect for your staff and vice versa by having them address you as “Doctor” in front of patients.

Interactions with colleagues. Never be afraid to ask for a consult or admit you are wrong. Strive to learn from the patients you refer in order to improve your own skills. Ask for a follow-up on the status of a patient that you referred. Provide new information to your colleagues with gentleness and respect.

Interactions with consulting physicians. Introduce yourself to all physicians in your area—this will help build your practice. Dictate letters not only for consults, but also carbon copy the letter to all doctors involved in the patient’s care. Provide information in your consult letter that is educational. Thank the individual for the consult and call them personally. Attend community functions to meet the public. Coordinate a lecture series involving a broad spectrum of physicians discussing various topics.

On-call issues. Be respectful of everybody, even when it is 2 a.m. Remember, we have a specific skill that a person needs. Be grateful for the opportunity to serve the public. Create a special on-call bag with all the instruments and drops you may need. Be prepared for any ophthalmic emergency. Obtain CPR certification and know the basics of emergency care. Remember, we are physicians first.

Personal time. Spend time and get reacquainted with your family and friends now that you are done with formal training. Begin financial planning. Remain enthusiastic; after all you are practicing ophthalmology.

Rob Melendez, MD
Rio Ranch, N.M.

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Dr. Melendez will be moderating “Pearls and Pitfalls in Your First Year of Practice” at a Breakfast With the Experts discussion at the Joint Meeting in Las Vegas (Course B246).

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To refer to articles mentioned here or past letters, visit www.eyenetmagazine.org/archives.

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