As I See It

The Happy Airline Approach to Practice

Questioning mandates, like assigned seats and pre-op EKGs.

By Paul Koch, MD

I just flew home from a bit of sea exploration in another part of the world. It was a most wonderful trip and you must remind me to tell you about it someday. But, lest I get distracted from the matter at hand I must move on or I shall remain dreaming and distracted.

This tale begins when we reached the airport to begin our trip home. The authorities had what appeared to be a little karaoke machine, and whenever it was time for a group to board they would move the machine to the gate and make the announcements. No overhead noise to pollute our calm. No wondering if we missed an announcement. If there was an amplifier it was for us; if not, what was said did not matter.

Two Lessons To Learn

Lesson Number One: If you don’t know what the big airports are doing, you can make a perfectly simple, accurate and helpful system of your own.

We boarded the plane. The flight attendants watched as family and groups came aboard and on the spot they rearranged everyone’s seats so friends could sit together. Once the cabin door closed but before leaving the gate, people roamed up and down the aisles, gabbing with friends old and new. There was none of those announcements to “Sit down, dammit!” even though the plane wasn’t moving and wasn’t planning to for a while.

Lesson Number Two: If you didn’t have the nuns telling you to sit up straight and not move, a flight can be fun and not a boot camp.

The point of all this is, we have become accustomed to following strict commands, some proven to work, such as pre-surgical time outs; others never proven, like pre- and post-intravitreal antibiotics.

Our Academy Gives It a Shot

Recently, our Academy took a stab at separating out a few things that arguably defy convention, and while one may quibble with the details of their selections, at least they gave it a shot.

First on the list was not performing EKGs prior to cataract surgery. “Huzzah!” screams the crowd. We don’t want them in the first place. They’re mandated (like not moving from your assigned seat) by some hospital or ASC committee. Good for all if they can be eliminated as a routine, maintained as indicated.

Another was the aforementioned antibiotics for intravitreal injections. With a few million injections performed each year, and no proven benefit, this is one to look at.

Next I hope they look at using antibiotics for cataract surgery. They’re also not proven to prevent infections and are not approved for that indication — and yet we prescribe millions of bottles each year to comply with a tradition. The cost is justified by the legal consequences of an infection in the face of not following a “standard of care” that remains unproven. This is a battle best fought from the top, not from the trenches.

Where Our Dues Lend a Hand

The airline I flew home already figured some of this out. Why separate family and friends for the purpose of forcing everyone into assigned seats? If the plane is not moving, why not let people stand? The same critical thinking can be brought into our field. Why do EKGs? Why make using unproven medications be a standard of care? The answer perhaps is fear of legal action.

That makes it hard for one or two of us to buck the system, and so this is one place where our dues can give us a hand. If our national organizations take the lead in questioning unproven mandates, we can find a lot of opportunities to reduce cost, to improve care, and, when the stars are aligned, do both at the same time. OM

Paul S. Koch, MD is editor emeritus of Ophthalmology Management and medical director of Koch Eye Associates in Warwick, RI. His e-mail is paulkoch@kocheye.com.