Lessons for a lifetime
What I learned about ophthalmology in kindergarten
The ethic of reciprocity as applied to ophthalmology simply states that I will deliver the same high level of care that I would want for my own eyes. As simple as this seems, it can sometimes be a challenge to balance the scheduling, technology, insurance restrictions, and patient desires with sound surgical judgment. But I'm confident that it's a goal that every ophthalmologist can achieve, especially when we start teaching this concept to our medical students and resident physicians early in their careers.
What treatment would I want?
Patient desires are formed by many factors such as input from friends and family, bits of knowledge gleaned from television and media, and research done online. These desires can sometimes be unrealistic and beyond the realm of possibilities. It's the surgeon's job to know when to operate and when not to. For example, when a patient is simply itching for LASIK but something about the corneal topography and clinical work-up doesn't seem quite right, it's our job to defer surgery and take a more conservative approach. That's what I would want for my own eyes.
Clinical judgment is among the hardest aspects of surgery to learn, particularly when recognizing, evaluating, and responding to an intra-operative complication. Though initial instincts lead us toward denial and risky interventions, often the best course of action is acceptance of the complication and then a conservative approach. Every cataract surgeon will encounter a posterior capsule rupture and displacement of the lens nucleus during his or her career. If it's my eye, the best course of action is to let the nucleus drop because it's far safer to remove it with a proper pars plana approach than to fish for it using the phaco probe.
Technology has allowed us to image, evaluate, and treat ocular disease like never before. The retina can be imaged so precisely with optical coherence tomography that we can pick up subtle changes that are nearly impossible to see with our slit-lamp microscopes. But do all of these lesions require treatment, and just how many intravitreal injections are enough? These are seemingly difficult questions to answer until we apply the golden rule: if this were my eye, what treatment would I want?
Ophthalmologists tend to be very organized and efficient, and if there's a better or faster way of doing something, you can be sure that we will move in that direction. But is faster always better? When applied to surgery it's understandable that an efficient, but not rushed, procedure may induce less inflammation and heal more rapidly than a prolonged one. In the clinic, however, what level of care are we really giving when we spend just a few hurried minutes per patient? When it's time for my consultation, realizing that this eye surgery will affect my vision for the rest of my life, please spend the extra time to do a thorough job and answer all of my questions.
We are the experts when it comes to the eye, and patients seek us for our expertise in this area. They also believe that we ophthalmologists will act in good faith and give the best advice possible for their vision. By applying the golden rule to our practice and our surgeries, we can be sure that we will understand the patients' needs, be empathetic to their situation, and give the best possible treatment.
The only possible rebuttal to the golden rule is the argument that people have different preferences and tastes, and what you want may not be what others desire. That may apply to Matilda's fondness for paste over food, but not to the practice of ophthalmology. I want the best for my eyes and for your eyes, too.
By Uday Devgan, MD
Dr. Devgan is in private practice,Devgan Eye Surgery, Los Angeles and Beverly Hills, CA; chief of ophthalmology,Olive View UCLA Medical Center; and associate clinical professor, Jules Stein Eye Institute, UCLA School of Medicine, Los Angeles.
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