Eye Clinic Follow Up

I went back in today for a one week follow up of laser surgery for a retinal tear.  An acute problem always brings some issues into focus so I thought I would continue on about some comparisons of psychiatry with modern medical technology as well as some of the differences that cast some advantage to psychiatrists.   As usual there are always political implications.  I have the added advantage of showing the retinal scans from today, courtesy of the clinic.  As most patients know, experience with getting results like this from clinics is highly variable.  Most of that confusion is a direct result of the Privacy Rule that started under the Clinton administration and ended under the Bush administration.  It is complicated by CFR42, a federal regulation that directly impacts the release of sensitive data and the way it can be released.  after the recent modification to make it clearer and easier to get date, one of the clinics I go to will no longer e-mail me graphical data.  That is the outcome I expected when special interest attorneys get involved in health care law.

The visit itself went very well.  The clinic demonstrated the same efficiency.  The retinal exam included scans of both eyes by physical examination of only the affected eye.  The scribe was in the room and she picked up an error in the original note and corrected it.  The conclusion was no change in retinal opacities  (blood in the vitreous) - but well sealed off laser site with resolving retinal edema.  In the manner of most proceduralists that I have encountered, it was time for questions.  No spontaneous advice.  I carefully outlined the physical activities that I am involved in and was advised that I could resume with nor restrictions.  I had stopped taking 81 mg of aspirin a day on my own initiative and was advised that I could resume that.  The only additional information was follow up in 6 weeks and call if problems.

That call if problems is always a tricky proposition.  With the retinal opacities from the original tear the large amoeba-like blob over about 1/3 of my visual field was still there, but over the course of the day it comes and goes.  At times there are about 20-30 very small black dots floating around in that eye.  Given what I know about brain adaptation to let's say prism viewing, I wondered if my brain was adapting to the retinal opacities and only showing me the clear visual field.  There were times when it seemed worse, but I concluded that unless it was consistently worse, I should probably not call the clinic.  I arrived at that conclusion on my own. but confirmed  it with the retinal specialist between now and the next appointment.

I also thought about the time it takes me to coach patients about how to self monitor and also warn them about rare side effects.  I can spend 10-20 minutes on serotonin syndrome,  neuroleptic malignant syndrome, prolonged QTc interval, drug induced liver disease, priapism, metabolic syndrome, and diabetes mellitus.  And that is after we have discussed progress and medication side effects.  When I thought about the complication rates quoted to me for retinal/vitreous detachments and tears and the success rate of laser surgery - I am telling people about many potential complications that are a thousand to ten thousand times less likely to occur.

That is the range I am living in.  I am not complaining about it.  I think it is much more reasonable to have informed patients who understand that taking a medication is not a walk in the park or a miracle cure.  I am concerned that despite my detailed explanations and accompanying literature many people do still not understand it or just ignore it.  On the other hand I have had people with known problems like cardiac problems come back and recite everything I told them about potential cardiac problems and what to watch for.  The side effect that bothers most people is the potential for weight gain, but most of them can be assured that there is a strategy to deal with that problem.  If a medication is effective, people will want to take it even if there are potential problems with it including weight gain and ECG abnormalities.

The measurement technology used in ophthalmology is interesting.  The human retina is unique enough to allow it to be used for biometric identification.  No two retinas are identical and technically even though retinal tears have similar characteristics they are all in a unique biological landscape.

Technology clearly differentiates ophthalmology from psychiatry.  We remain stuck in the 1960s with an obsessive narrative that classifies but probably does not diagnose.  Depending on who you read, phenomenology is there to some degree.  Ophthalmologists done't really need to depend on objective descriptions of symptoms - they can see what the problem it.  I just read an article on a consensus treatment guideline  for depression that adds absolutely nothing to the field beyond what a psychiatrist has learned in residency training in the past 15 years.   At the end of the day we have no retinal scan that we can hand a patient and say: "This is your problem and this is what we did to fix it in about 1 hour."

And that is what we need.



George Dawson, MD, DFAPA


Supplementary:

I could not fit this into the body of the post anywhere but age-related retinal and vitreous diseases seem like a major oversight in medical education to me.  I studied geriatric psychiatry and geriatric medicine and the major focus was on age related causes of blindness that were essentially chronic illnesses.  As far as I can tell age-related acute retinal and vitreous problems are a major epidemic and every physicians should know how to diagnose them and how fast they need to be triaged and referred (fast).


                    

  

Ophthalmology versus Psychiatry Part 2.

Spoiler Alert: Ophthalmology always wins!

I was driving home last Friday night and for several minutes it seemed like there was a bug in my right eye.  I did the upper lid over lower lid trick a couple of times and that didn't work so I pulled over and tried to rinse it out with artificial tears.  No change at all with that maneuver and then I started to see familiar floaters and small black dots in my visual field but only on the right.  I had the exact same symptoms a year ago that led to a diagnosis of a vitreous detachment with no retinal problems.  Later that night I started to see flashing halos in the upper right visual field.  I got in to see an optometrist through my health plan and was referred immediately to a vitreous and retinal specialist today.  At a about 2PM today, I had a laser surgery procedure to fix a small retinal tear in the periphery of my right retina.

The specialist explained pathophysiology, the rationale and the expected success rate.  There is age-dependent liquefaction of the vitreous humor and in that process it can pull away from the retina.  That process can be benign like it was for me a year ago or it can lead to a "traction-event" on the retina and cause a tear.  The main reason for the laser surgery is to spot weld the tear by forming a photcoagulation scar where the laser hits and prevent a more extensive tear that could require open surgery of the eye and the risk of infection and further vision loss.  The decision for the laser surgery was an easy one, especially because I have known many people who required variations of the open surgery.  I sat in an ophthalmology exam chair with my head in a fixed position.  This video illustrates the exact procedure that I underwent today.  The laser light was green and at the end of the procedure I was completely blind in the eye for about 10 minutes and then transitioned to a violet vision and then back to normal.  This phenomenon is cause by saturation of the photoreceptors by laser light.  The procedure I underwent was much faster with repeated pulses of the laser.  If I had to estimate, I would say about 150-200 pulses of light were used.  The specialist kept me posted: "30% done.... 50% done, etc)" and also coached me on how I was doing focused on the extreme limits of my visual field.    

I had some observations about ophthalmology and orthopedic surgery last year and this year is no different.  First, I am amazed at how many of these vitreous retina specialists exist across the country.  Given my previous estimate of the total number of ophthalmologists and the numbers of people that they treat,  the distribution must be very good across the country.  Their services are certainly in demand.  Retinal and vitreous disease is clearly an age related problem.  There were 15 people in the waiting area and there was one person younger than me.  Most were considerably older and many were there to get injections to slow the progression of macular degeneration.

I am no stranger to ophthalmologists.  When I was in the 8th grade I shot myself in the eye with a BB gun and have had appointments every year to follow up on that injury.  That has also allowed me to follow the way that ophthalmologists practice.  Back in the 1960 to 1980s they did everything.  They started out with visual acuity tests, then visual fields, the intracranial pressure by tonometry and eventually the slit lamp approach.  They did the entire refraction and tried to get the visual acuity as good as possible. They proceeded to the slit lamp exam and at some point started doing retinal exams using hand held lenses and lens in conjunction with the slit lamp.  If an ophthalmologist was really flying and had a patient who was able to  cooperate - it might be possible to get all of this done in 20-25 minutes.

Things have changed drastically since that time.  I was roomed by a medical assistant who recorded the history and  took my vital signs.  In Room 2, I saw another medical assistant who took additional history, cursory social and family history (only eye diseases and diabetes in parents and siblings) and a cursory review of systems (have you had a heart attack or stroke? do you have chest pain today?).  She did visual acuity, visual fields by confrontation, and ocular motility and recorded it in the chart.  She did a slit lamp exam.  She measured intraocular pressure by some kind of digital hand held tonometer that I had never seen before.  She got my eyeglass prescription off the new lenses and did not need to do a refraction.  In Room 3, I was introduced to a scribe who told me that she would be taking notes for the specialist.  She set up twin displays with the EHR spread across.  The specialist walked in and performed indirect ophthalmoscopy by both slit lamp and standing hand held lenses.  He told me that I had a retinal tear and we discussed the surgery.  The scribe reminded him how it needed to be worded in the chart and how she was going to record it.  I electronically signed the consent form.  In Room 4, I saw a person who only did retinal scans with a blue light.  Finally in Room 5, the laser procedure was done.

This was a significant display of efficiency in terms of division of labor with a sole focus on problems related to the eye.  The social history is not that important in this case - they were only interested in marital status, offspring, and occupation.  They were not really interested in a review of systems other than a more detailed review of ocular symptoms - including my history of the BB gun injury.  They efficiently proceeded to laser my torn retina (at about the 45 minutes mark) and if the quoted statistics were correct - greatly reduce the likelihood or a major retinal tear and the need to open surgery or in the very worst case partial or complete blindness.      

Unfortunately in psychiatry we have nothing like this.  I am still doing what I have done for the past 30 years - an obsessive 240 plus point interview that included a detailed history.  My medical history, review of systems, social and family histories are all comprehensive and customized for the situation.  If I want vital signs or some examination - I have to do it myself.  In some clinics I can get checklists - but despite all of the hype about collaborative care or measurement based psychiatry those rating scales are a poor excuse for detailed questions about the problem.  The people who believe they are actually using quantitative metrics to measure care with these scales are fooling themselves.  In order to make up for the stunning lack of efficiency in psychiatric practice we have the workarounds of more and more prescribers - all asking their own questions and making their own diagnoses or we have the collaborative care psychiatrist advising primary care physicians on how to treat their patients based on rating scale scores or the questions of those physicians.

The other limiting factor is the lack of value assigned to the psychiatric evaluation.  I have not seen the bill for laser eye surgery - but I can speculate that it will be many times what I am paid for a comprehensive evaluation in roughly the same period of time that it took to diagnose and repair my retinal tear.  With the division of labor, the ophthalmologist was seeing 7-8 times as many patients in an hour than I can see.

To me that is both the most positive aspect of clinical psychiatry, but also its downfall.  Psychiatry is too complicated to commoditize.  Don't get me wrong - it happens all of the time.  Very few psychiatrists who are not in private practice have the luxury of talking with people for an hour.  That makes patient experiences highly variable.  We have to find a model that takes us out of the 1970s but also provides more clear cut results.  Ophthalmology has clearly been able to do that.  Science and treatment in medicine is better with precise measurement.  There is nothing about rating scales that I would call precise.

With my retina and vitreous problems I have come to another conclusion.  Training in Geriatric Psychiatry is designed to increase sensitivity to ageism and and biases against the elderly.  I have had plenty of that training.  Now that I am technically a geriatric person myself, I can speak with authority -  aging is an inescapable disease.  I hope someday there is a better solution.

But that is a topic for another post.



George Dawson, MD, DFAPA