As I See It

‘X’ marks the eye and sometimes the lie

To those behind desks who come up with new ways to waste our precious time.

By Paul S. Koch, MD, Editor Emeritus

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

We talk a lot about improving efficiency, but perhaps we do not stand up often enough to those who want to waste our time. I speak, of course, of those sitting behind desks writing policies and procedures that sound good, seem to make sense and are not so easy to argue against.

Exhibit A: Marking the eye

How about marking the eye? Many facilities mandate the surgeon personally mark the surgery site. After all, he is doing the operation, he has to take responsibility. Apparently, marking an “X” is a task that requires a doctorate and years of training. In my office, marking an “X” means the patient does not know how to write his name.

What qualifies someone to mark an eye? This requires comparing the booking, the pre-op orders, the surgical consent and verbal confirmation with the patient. Let’s think about this a moment. Preschoolers know their left from their right. Granted, it might take a few years of education to be able to find the correct words on a page, and a few more to learn to read cursive. I estimate anyone over the age of 8 could do that job perfectly, time and time again, if he is paying attention.

Putting an “X” on the spot does not require a doctor’s intervention, nor should it pull the surgeon out of the OR. People in the tall offices think having the surgeon do it himself is good care, but in reality it is a nuisance and a distraction. Ditto confirming the lens power in the room. Anyone who can read numbers and pay attention can do this.

Why listen to the heart?

This brings us to my favorite, the heart and lungs. Forced into the very fabric of medicine is the need to listen to the heart and lungs in every encounter. Want to book a patient for surgery or check in a patient for a YAG? Be sure to check the heart and lungs. What on earth is that supposed to accomplish?

Are we to ask our eye patients to strip to the waist so we can put stethoscope to skin and listen intently? We do not, so we listen through the shirt, or the sweater or the vest. Can we hear rales, rhonchi or wheezes? No; at best we can hear air moving. But we know the patient is breathing because we’re looking at him. Can we hear murmurs, rubs and gallops? Never; at best we can make out a ta-thump, ta-thump. But we know the heart is beating because the patient is in front of us, alive.

Heart and lungs are required, and doctors all over the country perform it countless times every day — usually with no chance of a clinical finding. It is perhaps the biggest waste of time in medicine and does nothing for the patient. It should be done only when it will be helpful, and then done correctly.

Some just lie

Have time for one more? One facility near me requires the surgeons to document an H&P that requires comment on rectal exam and genitalia. Naturally they don’t do the exam, but they check if off anyway. They lie. How does that help a patient? OM