This essay is intended primarily for those who practice the art of medicine. The first part is devoted largely to those who practice ophthalmology. The second part refers to all of the physicians who are currently in practice.
The title of this essay will inform you that it is my intention to offer some cogent thoughts to those who now practice the medical arts. It is clearly a case of gross pretentiousness in that I have no underlying academic background to serve as a springboard for my remarks. My observations are based upon a long association with the practice of medicine. The thoughts may be empiric but there certainly is no hearsay in what I have to say. My observations should be viewed as those of a friendly observer.
Dr. Leon who delivered all eight of the Carr children was held in high regard by our family. All things considered, my dealings with the medical community since I left Doctor Leon’s hands have been basically friendly. And so I would hope that what I have to say today will be regarded as basically helpful. It is not my intention to do any harm to the medical community in any fashion. On the other hand, there are times when the medical community can use a little help. Perhaps this is such a time.
At the outset, every physician would like to know the background of the patient that he is treating. I must observe, in good humor, that physicians use the word “presents” in a mysterious fashion. What I present is a case of blindness together with a string of other ailments and “procedures,” as the medics call it, performed on a white, Caucasian male who has now reached the age of 84 years. My health at the moment seems to be excellent, after a fashion, in view of the fact that I am able to exercise 80 minutes on four days of each week.
My academic background is nearly non-existent. I did not attend a school or university where ophthalmology or the study of cardiology were offered. I did not have a residency nor did I ever attend a medical school. In point of fact, I did not attend a university at all due largely to the Great American Depression which morphed into World War II. Therefore, my observations are empiric but they may be worth your while as you listen to or read them.
Let us turn first to blindness and the practice of ophthalmology. My total blindness has existed only since late summer of 2005. Glaucoma has been a doleful millstone around the necks of the Carr clan. While I have been only totally blind for a 13 or 14 months, my experience with glaucoma and blindness goes back much much further.
I come from St. Louis where baseball is considered as sort of a religious experience. In 1930 and again in 1931, the Philadelphia Athletics met the St. Louis Cardinals in the World Series. You may recall that the Philadelphia Athletics were owned and managed by a gentleman named Cornelius McGillicuddy. My mother would have referred to him as one of the boys from home. Sportswriters reduced his name to Connie Mack and he is remembered with reverence to this day. I would like to tell you more about the mainstays of the Athletics. They were George Earnshaw, a right-handed pitcher and Al Simmons, the left fielder who hit 390 in 1930 and 396 in 1931. Another mainstay was a tall left-handed pitcher named “Lefty” Grove. In those days almost everyone who threw from the southpaw side was called “Lefty.”
I wish that this essay could be more about baseball because I know more about it than I do about the art of medicine. But the World Series of 1930 and 1931 are significant to me. In those years my father approached his 50th birthday and was diagnosed with glaucoma. My father was cared for by two St. Louis ophthalmologists who were the Post brothers. Their operating room was at Barnes Hospital which is well-known throughout the Midwest and the South West. When the nature of my fathers diagnosis was explained to me, I began to understand that at the end of the line, blindness was a distinct possibility. So for more than 75 years I have been very much aware of glaucoma and its end result. Those 75 or 76 years count heavily when I refer to my empiric evidence having to do with blindness.
In my own case, in 1969 I was found to have “incipient glaucoma” which blossomed into a full case of glaucoma about a year or two later. Significantly, the case of glaucoma arrived at my 49th birthday, thus following the track laid down by my father. Because of my father’s diagnosis, all five of the surviving Carr children have visited ophthalmologists frequently. In my case, I began to visit those specialists more than 50 years ago.
My father became totally blind when he reached his 63rd or 64th birthday. My brother Earl became blind in his early 70s. I held off blindness until my 83rd birthday. In numerical terms, my father passed, by heredity, glaucoma to his five surviving children.
In terms of numbers, the five Carr children produced seven children of their own. Those grandchildren produced 16 children so you see by this time, the count is up to 28 as potential victims of glaucoma. It all came from one source. As you can see, the prospects for glaucoma cases in the future will be much greater, rather than fewer. Glaucoma will provide full time work for ophthalmologists for years to come, particularly as the coming generations tend to expand their life expectancy. And we haven’t even touched on other eye ailments.
With that background, let us now turn to the first major point of this essay. It is my contention that schools that teach ophthalmology do not go far enough in that they fail to prepare their students to deal adequately with patients who become blind while in their care. Generally speaking, ophthalmologists treat the patient until the blindness sets in, at which point the patient might be referred to an organization which handles social services. In effect, when blindness becomes a fact of life, the ophthalmologist often now believes that his work is done. In this instance, I am not interested in trying to determine where the newly blind person might look for a dog or might find a school that teaches Braille. It is my argument that the practitioners of ophthalmology must prepare the blind person for the role that he must now fill. Clearly, this world is made for sighted people. Those without sight are required to accommodate to the seeing world. My argument is that the ophthalmologists are in a unique position to help that patient as he encounters blindness in a sighted world.
But please do not consider this essay as an autobiographical one. I worked for 47 years including 17 years dealing with labor matters. In addition I did tours as a lobbyist in Washington, a General Sales Manager for the Bell System and finally, I represented AT&T in its International dealings on telecommunications matters with the rest of the world. I was well equipped to deal with the social side of blindness and to anticipate its happening long before it occurred.
Contrast that background with that of my father. He had a second grade education and worked with his hands all of his life. Blindness was a strange circumstance for him as he was unprepared for it. When blindness overtook him, he sat in a chair in the living room beside his Atwater-Kent radio and toward the end of his life, some 12 or 13 years later, began to listen to radio dramas about cowboys and Indians. My father certainly could have profited if the Post brothers had prepared him for his new life.
When blindness overtakes a person, he may well feel abandoned and hopeless. In that state, he might well conclude that life without sight is not worth living. In my essay, “A LETTER TO A FRIEND,” I told that friend that if blindness occurred, and he wished to end his life that I would respect that conclusion. I did not say that I would be enthusiastic about that decision; I said that he would have my understanding and support. On the other hand, I pointed out that there is much to live for including the spouse, the children, friends, music, etc. Blindness in and of itself is not fatal. It is a matter of adjusting and accommodating to it. It can be lived with even with all of its inconveniences.
When blindness takes over, the patient may feel a sense of complete uselessness. The old Irish lament “Johnny we hardly knew ye” comes to mind. When Johnny came home from service with the British Army minus two limbs, the song says “You haven’t an arm, you haven’t a leg; you’ll have to be put with a bowl to beg.” The ophthalmologist is in a position to tell the patient that life is worth living and that he will probably not have to take up begging.
In the American and British armies, there is a technical term having to do with when a soldier complains. The complaint might be against the food, the officers, the climate or whatever. That technical term, in plain English, is called “pissing and moaning.” To meet the high moral standards of the current administration in Washington, that earthy army name will be shorted to “P&M.” The patient should be told by the ophthalmologist that P&M’ing does no good. Quite to the contrary, it alienates the hearer. At the end of a day of P&M’ing, the patient will still be blind. If the patient persists in telling others of the disabilities of his blindness, he will cause them to regret their friendship with him.
In my view, blindness is a personal thing which I do not try to hide. On the other hand, I find it reprehensible that a blind person would transfer his grief to a sighted person. The ophthalmologist must remind the newly blind person that pissing and moaning is the best way to lose friends and to increase his sense of loneliness. And the ophthalmologist also should suggest that P&M’ing about other physical ailments is also a good way to turn off friends. If the ophthalmologist knows his patient as well as he should, he would have no problem in delivering this message.
Now let us turn to humor. The general public does not understand blindness in any respect. They know it exists, and they hope that it never occurs to them. But in fact, they do not spend any amount of time thinking about that subject. At the same time, you will notice that our conversations are filled with words having to do with seeing. “It’s nice to see you”, “I haven’t seen you for a long time”, or “I see you are wearing a new hat.” The word “seeing” or its derivations sneak into our conversations much more often than one might imagine.
If a blind person were to respond in a humorous way, saying you can see, but I cannot, his remark will probably be greeted with embarrassed silence. Please remember, there are no blind comedians. Just as there are very few blind ophthalmologists. Any attempt at word play on the subject of sightedness will result in embarrassment for the sighted person. The ophthalmologist should advise the newly blind person to please leave it alone. Again, remember there are no blind comedians.
Perhaps schools should teach ophthalmology students a maxim. The maxim goes like this: blindness will tend to teach the newly blind person a sense of logic. If the water faucet is here, logic will tell him that the left hand side turns on hot water, and the right hand side turns on cold water.
Secondly, blindness will teach the blind person an enormous amount of patience. The blind person cannot do for himself anymore so he must sit there patiently until something happens. If, for example, he orders a cheese sandwich at a diner and he wanders about the slowness of its delivery, he will not know whether the waitress is reading a movie magazine or whether the cook has put the sandwich up on the shelf where the waitress can grab it. He must just sit there.
In the third place, blindness teaches about logic and patience, but it does not offer tranquility at all. The lack of tranquility will, in all likelihood, transmit itself to the rest of the body and may very well have an effect on the blind person’s life span.
Finally, there are those who take comfort in religion. As delicately as the ophthalmologist can do it, he or she should point out that there is no recorded instance of blindness being reversed by appeals to Jesus, the Ayatollahs, the Grand Rabbi of Jerusalem or Pat Robertson who claims that he speaks regularly with God. Contrary to the assertion in John Newton’s hymn, “Amazing Grace”, “T’was blind but now I see”, is merely allegorical. In the history of mankind, restoration of eyesight through supernatural means simply has never occurred.
I am fully aware that the above suggestions plow new ground in the field of ophthalmology. I am also aware that ophthalmologists contend that this is going beyond their area of competence. If I may suggest, the ophthalmologist has reached his status, not because he is dumb, but precisely because he is bright. It seems to me that there is no real reason why an ophthalmologist who knows his patient well, cannot impart these pieces of advice to his patient. Schools that teach eye care ought to prepare ophthalmologists with this sort of information. I can think of perhaps another fifteen or twenty thoughts that ought to be included in the teaching school’s syllabus. But in the interest of time and space, they will be held for another day. In any case, I imagine my thoughts would add only a day to the teaching of ophthalmology. I believe it would be well worth the time.
To close on a lighter note, schools that teach ophthalmology should be told of certain characteristics of the sighted public. For example, in addressing a blind person, I find that the sighted person speaks louder and pronounces his words clearly, as though the trouble with my eyesight had spread to my ears. My hearing is in excellent condition. Then we have the matter of people addressing my escort instead of addressing me. For example, the clerk at the farmer’s market said to my wife, “Can he see anything?” I was fully prepared to handle that question, but the remark was not addressed to me. On another occasion, the medical group we patronize moved to a campus setting with several buildings. Guides were posted around the parking lot to direct people to the proper location. Upon seeing me, one of the guides said to my wife, “Does he need a wheelchair?” I had trouble dealing with that question because laughter convulsed me. And then on that same occasion, when I was seated in the physicians examining room, a nurse entered. She said to my wife, “What is the purpose of his visit today?” My wife replied, “Why don’t you ask him? He talks.” Again, I was so convulsed with laughter that I could not tell the nurse that I only spoke Swahili.
Two thoughts as I close this section of the essay. First, I would remind you that this is not an autobiographical series of thoughts on my part. My dealings with ophthalmologists have been reasonably excellent. My acquaintance with the way things work, particularly from the experience lobbying in Washington, has equipped me to deal with things as they are. So there is no autobiographical context in these remarks.
Secondly, because I had 75 years to think about the onset of blindness, I met it in a philosophical mood. I suspected that if I continued to have high intra-ocular pressure from glaucoma, and if I lived long enough, blindness would be my fortune. I did not welcome blindness, of course. But I knew it would happen if I lived long enough, and I did. I want to point out, that after the hemorrhage during the trabeculectomy that turned off the lights in my last remaining eye, I thanked Dr. L. Jay Katz who had performed the work. I told him that I was certain that he and the staff at Wills Eye Hospital had done their best and that I appreciated it immensely. No hard feelings, no acrimony, that is the way the ball bounces. The secret here is that if you have got glaucoma, don’t get old.
Well, so much for preparing the ophthalmologist to deal with a patient who has become blind. Now let us turn to the rest of the medical community with my Physician’s Payment Protection Plan.
I have been told by three physicians, that they would not advise their children to enter the medical profession. I suspect that much of their unhappiness has to do with increased paper work, less time for the patient, and a reduced level of income. My advice to the medical community is short and succinct. It is, on the first hand, to get yourself a federation of physicians. I know you don’t want to call it a union, so we will call it a federation or an association.
The point is that physicians must be organized to be heard in Washington. If I may say so, the American Medical Association, when I was in Washington, attracted no great attention. From my standpoint, the AMA is simply is not doing the job. It is a featherweight organization when it comes to lobbying. Without an effective association, or federation or union, or whatever, the government, the trial lawyers, the insurance industry can do whatever they wish and physicians will wind up with the short end of the stick. Until physicians bind together and present a united case to Washington, they will not be taken seriously.
I am fully aware that a strike by physicians would probably be out of the question. On the other hand, a reasonably decent labor lawyer can advise your federation or association of tactics that the federal government must be forced to recognize. The point here is that alone, physicians can be picked off by the bureaucrats in the federal government and no one can do much about it. My advice in the first respect is to get yourself a forceful federation that will present a robust front to the government.
Certainly, after you form a federation or whatever you wish to call it, it would be important to hire a lobbyist, much as the pharmaceutical industry retains. In point of fact, the pharmaceutical industry literally and totally, wrote the bill that became the Medicare Prescription Drug Plan. You may have been amazed to know, as I was amazed, that the bill prohibits the federal government from bargaining with the pharmaceutical industry for lower prices. It is completely forbidden. How do you like that? I think it is completely outrageous. But these things happen, and the United States Congress can be rolled over by lobbyists. By the way, Tom DeLay was the main mover and shaker of this ill conceived piece of legislation. My advice is to get a high level lobbyist to work on your behalf.
As you may have suspected by this time, I hold liberal views, support such causes as Social Security and Medicare. There are those who do not hold those views in any case. One of them is Grover Norquist, a super lobbyist. His philosophy is to deny funds to all of the so called “entitlement” programs. Those include Social Security and Medicare. Norquist’s belief is to “starve the beast”. This means he will deny funding to the entitlement programs. This, of course, leaves the government free to waste money on its tax cuts and on Haliburton contracts in Iraq.
George W. Bush is an advocate of Grover Norquist. During his term in office, Bush has toured the country commenting dolefully that “Docs” are leaving the practice. He invariably sights legal fees coming from lawsuits against physicians. Well, physicians, I am here to tell you that Bush is totally dead wrong.
Physicians are losing their practice because of insurance rates. Can any of you reading this essay or hearing it, tell me the last time your insurance rates were reduced? I suspect that no hands would be raised.
At the same time, the insurance industry is a major, major contributor to the Republican Party and the likes of George Bush. The trial lawyers contribute to Democrats by and large. Their numbers are miniscule in comparison to the insurance industry. So Bush is doing the insurance companies a favor. He does nothing to reduce their rates but instead blames trial lawyers for the physicians difficulties.
In addition to the increased insurance costs, we find a continuing effort to reduce the payouts under the Medicare program. So physicians are hurting both ways. They have the higher insurance costs, and they must deal with the threat of reduced income from the Medicare program. I fully understand the physicians dilemma.
This is a cynical ploy by the Bush administration. It comes from the fertile mind of Carl Rove. On one hand Bush complains about the lack of medical care, and on the other hand, he is ripping the community of deserved income. If physicians do not stand up and fight back, there will be no one to help them. The situation has not yet reached crucial proportions, but it is well on its way. I want to see the physicians well treated, but it is not happening under this administration. In any debate where the merits of the physicians case is considered, the physicians are bound to win. It might even be what George Tenet called “a slam dunk.”
Well there you have my thoughts about blindness and what physicians might do to help themselves. I hope you understand that they come from a person who spent seventeen years in the labor field and who spent another four years as a lobbyist for AT&T. The world does not work, at least in Washington, in logical and decent terms. Politics is a brutal business. Politics can destroy physicians unless they protect themselves. It is for this reason that the title of this essay is, “Doctor, May I Help You with Your Work?” That title is offered in good faith and trust. I like physicians. They are critical to my well being and extended life. I would hate to see anything harm them. So men, women, children, stand up on your hind legs and fight back. And while you are fighting back, the ophthalmologists among you may want to offer comfort and useful help to the newly blind among us.
If I weren’t so old, I would offer my assistance to the physician’s association or federation just to see that decency and fair treatment prevails. I might also take a good deal of pleasure (schadenfreude) from seeing government officials grilled and brought to account. I am sorry that the physicians association did not know me when I was in, shall we say, full flower.
E. E. CARR
September 28, 2006
Essay 208
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Kevin’s commentary: I forget, sometimes, that one can lobby for good causes as well as bad ones. The word has a decisively negative connotation these days. Certainly the medical associations could be doing a little bit more. Also the amount that hospitals and the government (incl. VA hospitals) have to pay for medical supplies is almost comically high. I hate hate hate that they can’t negotiate for prices or even buy supplies in regular markets, so they wind up having to charge like $80 for a bag of saline solution, for which the materials cost $2.