I’m the granddaughter of wheat farmers in northeastern Montana, the great-granddaughter of Swedish immigrants. In my favorite picture of my dad (now 89), the 7-year-old is wearing mud-spattered overalls with big holes at the knee and grinning with wild joy. The flat expanse of a 340-acre homestead is the backdrop, and though the photo is a monochrome one, I imagine the golden, mature wheat fields and the breath-stealing blue western sky.
Like many of us—including those born in large cities—I am a child of farm values. Grit, resilience, persistence, hard work, cheer, and gratefulness are typical qualities of ophthalmologists. And there are other parallels: Changes in the practice of ophthalmology can be compared to the evolution of the American farm. Like the wheat farms in my family, most ophthalmology practices once were small and, often, family-run. The ophthalmologist provided eye care for the local community and was part of a loosely knit network of independent physicians.
Like the family farm, solo and small ophthalmic practices still thrive in some settings, but they are slowly giving way to larger, more complex organizations. Many small groups are developing strategies that include adding partners or locations, joining groups together, or engaging private equity. Vantage EyeCare is one of the largest private ophthalmology groups. Julia Lee, the chief executive of the group, explains that “becoming a practice of more than 100 providers has allowed us access to important conversations in our community about more effective health care delivery, accessibility, and meaningful ways we can move the needle on cost without sacrificing quality.”
This makes me think of the writer and environmental activist Wendell Berry, who is also a farmer in Kentucky. He writes about consolidation and the mechanization of agriculture and suggests that large-scale farming can cause decay in local communities. In an interview, he said, “We must support what supports local life, which means community, family, household life—the moral capital our larger institutions have to come to rest upon. If the larger institutions undermine the local life, they destroy that moral capital just exactly as the industrial economy has destroyed the natural capital of localities—soil fertility and so on. Essential wisdom accumulates in the community much as fertility builds in the soil.”1
The practice of ophthalmology faces similar challenges. As our practices evolve, it’s easy to lose our ties to the community. How do we preserve our essence as we become part of and subject to a large system?
First, every ophthalmology group needs core values that guide decisions and transcend changes in leadership. In an interview at the Mid-Year Forum Advocacy Ambassador program, Keith Carter referred to “culture building,” noting that it involves a set of values that define an organization. Second, our professional organizations, including the Academy, set expectations for quality care, professionalism, ethics, and transparency (see “All About Trust,” Current Perspective, November). Third, and most importantly, ophthalmologists are leaders, and our opportunity to shape and lead ever-larger practices is unprecedented.
As Berry put it, “There can be no such thing as a ‘global village.’ No matter how much one may love the world as a whole, one can live fully in it only by living responsibly in some small part of it.”1 As ophthalmologists, our small part is the practice in which we provide eye care and the health systems, large or small, that we help shape. And—as Berry reminds us—going forward will require tenacity. In his poem “The Farm,” he advises:2
Stay years if you would know
The work and thought, the pleasure
And grief, the feat, by which
This vision lives.
1 Snell MB. New Perspectives Quarterly. 1992;9(2):29-34.
2 Berry WE. A Timbered Choir: The Sabbath Poems 1979-1997. Washington, D.C.: Counterpoint; 1998.