The Eyes Have It by Pat Conrad MD

How many of you have had, or plan to have, cataracts?  (pssst – raise your hands, everyone).  And as we know, it takes a specialist to remove the little buggers.  Apparently they can be nuclear, cortical, or posterior capsular, or other variants that I’ve never heard of because I didn’t do that weekend CME where they train primary care docs to take them out.  But ophthalmologists spend years studying these and the various ways of dealing with them, thank goodness, which can be a sight-saving proposition.

Cataracts are indeed ubiquitous with age, which I guess ends up costing a lot of money to treat, because Big Insurance player Anthem has found a nifty new way to make their removal more affordable   Now ophthalmologists won’t need to elbow their way around the anesthesiologist in the OR – they can just handle it all themselves.

When I’m not sure about the topic, I like to consult an expert, so I called an ophthalmologist who’s been taking out cataracts for about half a century.  I asked what he thought about Anthem’s latest cost-saving move.  “It’s bullshit”, was his reply.  It seems that ophthalmologists would rather not place sharp edges against moving targets, at least not the squishy little marbles we use to see with.  So anesthesiologists used to place patients under general anesthesia for the extractions.  As medicines and techniques evolved, the gas-passers developed conscious sedation routines now administered by nurse-anesthetists called Modified Anesthetic Care (MAC) which is much shorter in duration, with (I presume) less chance of systemic toxicity complications.  The patient is “out” for only minutes, while the surgeon is able to inject select spots to paralyze and numb the eyeball, before cutting and sewing on it under a microscope (again, I missed that weekend CME, but how hard could it be?).  The ophthalmologist I spoke with said that some of his number are now just performing a local block and more geometrically direct approach which has a higher post-operative infection rate, which he also described as “bullshit.”  I threw a softball devil’s advocate query:  “But once the conscious sedation is over and the blocks injected, why do you need the anesthetist in the room?”  You guessed the answer, didn’t you?  Because this surgery is generally done in an elderly population that has more that its share of co-morbidities, respiratory depression and arrhythmias, and it’s best for someone appropriately trained to keep an eye on the O2 sat, vitals, and rhythm monitor while the surgeon is staring through a microscope and his fingers manipulate sutures finer than a human hair.  And because a vagal response and serious bradycardia might occur, but jamming in some IV atropine might not be the best immediate response during eye surgery.  My consultant agreed that Anthem’s latest gimmick is simply sub-standard care and a danger to patients, just to pad the bottom line next FY.  It is just wrong.

 I’m guessing the Anthem actuaries have probably already forecast a complication/adverse outcome rate, including the likely number of lawsuits and average settlement payouts over the next decade.  I’ll bet someone with no medical training beyond watching “Greys Anatomy” has figured out cost curves and acceptable loss rates, and decided Anthem will lose less profit by skimping on anesthetists and taking an occasional hit.  So what if a few ophthalmologists get put on the NPDB, or a few patients lose some eyesight or spend a night in the ICU?  As the old saying goes, you can’t make an omelet…

 I hear some of you in the back row starting to clamor for a Bernie Sanders Medicare-for-All plan as a solution to this corporate corruption.  But before we go there, consider that wait-times for this elective surgery are lengthening in Britain, and increasing numbers of patients are simply going blind waiting for the fix.

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Douglas Farrago MD

Douglas Farrago MD is a full-time practicing family doc in Forest, Va. He started Forest Direct Primary Care where he takes no insurance and bills patients a monthly fee. He is board certified in the specialty of Family Practice. He is the inventor of a product called the Knee Saver which is currently in the Baseball Hall of Fame. The Knee Saver and its knock-offs are worn by many major league baseball catchers. He is also the inventor of the CryoHelmet used by athletes for head injuries as well as migraine sufferers. Dr. Farrago is the author of four books, two of which are the top two most popular DPC books. From 2001 – 2011, Dr. Farrago was the editor and creator of the Placebo Journal which ran for 10 full years. Described as the Mad Magazine for doctors, he and the Placebo Journal were featured in the Washington Post, US News and World Report, the AP, and the NY Times. Dr. Farrago is also the editor of the blog Authentic Medicine which was born out of concern about where the direction of healthcare is heading and the belief that the wrong people are in charge. This blog has been going daily for more than 15 years Article about Dr. Farrago in Doximity Email Dr. Farrago – [email protected] 

  7 comments for “The Eyes Have It by Pat Conrad MD

  1. Igor Immerman
    February 28, 2018 at 11:26 am

    I am not an ophtalmologist but a hand surgeon. In my field, the technique of wide awake surgery (local only, no anesthesiologist) is gaining steam and has been shown to be very safe, and safer than even mild sedation, especially in the elderly. Yes, its cheaper, but also safer and patients love it. So maybe there is something to this.

  2. sm
    February 27, 2018 at 1:05 pm

    As a physician married to an Ophthalmologist, I would like to observe that most ophthalmologists I know are a lot less articulate than the one you quoted….

    • Pat
      February 27, 2018 at 7:26 pm

      I’ll pass it on !

  3. Max
    February 27, 2018 at 10:34 am

    This is complete bullshit. If you are sticking things in my eye you better damn well be focused on my eye. I hope all a
    Opthamologists refuse to work without an anesthesiologist.

  4. Dr Bonz
    February 27, 2018 at 7:26 am

    From Anthem. The same folks who have a policy stating that they MIGHT or they MIGHT NOT pay for your ER visit. The real kicker is, that they won’t tell you until AFTER you’ve been there and been treated! Then, THEIR bean counters will tell you if it was an emergency or not. So Anthem wants it’s patients to essentially practice medicine without a license and expects them to know before they go whether or not their chest pain is cardiac or musculoskeletal.

    • Perry
      February 27, 2018 at 10:37 am

      Make no mistake. It’s the damned insurance companies that continue to practice without a license.

  5. Steve O'
    February 27, 2018 at 7:08 am

    My friend Dr. A. the ophthalmologist did my cataracts.
    “He’s a little light,” he said during the surgery.
    “I’m a little light.” I agreed.
    Dr. A offered helpfully, “Everything’s pretty blurry, because I have your cornea out of the way.”
    “Wow.” I said. Fentanyl / Versed makes a man rather unflappable. “Do tell.”
    Earlier during prep, his resident stated helpfully, “I’m going to get a needle in around your extraocular muscles to paralyze them for surgery. You might feel a twinge behind your eye.” He slid what appeared to be a one-gauge needle into position over my tear duct.
    “Wow.” I said. I found this fascinating.
    In another, more stressful encounter, I discussed the presence of anaesthesia for sedation with a colonoscopy.
    “How often does the anaesthesiologist have to intervene?” asked a Member of the Audience.
    ” I suppose ten, twenty percent of the time.”
    He started at me. “You know, you’re a criminal, and everyone who supports that sort of corruption. For 10% of the time, that’s outrageous! Medicine is a criminal enterprise!”
    The new Standard of Care is – What Would Oprah’s Audience say? Forget medical indications and impressions – those doctors are all in cahoots! Everyone knows what you need for a cataract replacement – my gosh, it’s just a cataract replacement!
    The word is HUBRIS. It’s a killer when it gets loose in a civilization. Arrogance and ignorance breed. Americans pretend we hate it. If we did, why are we all so eager to inflict petty power on others?

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