Archive for the 'Medical History' Category

Three Dutchmen Walked Into an Eye Clinic

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Three Dutchmen Walked Into an Eye Clinic and the Rest is History.

As a severe myopic, it is no wonder I have always had a certain interest in ophthalmology. And just the other day I had reason to ponder the peculiar Dutch dominance in the history of optics and ophthalmology.

When I was a nearsighted young school boy in Sweden, my mother brought me on the bus into town every fall to see the eye doctor. He must have been in his eighties, a tall man with a bow tie and a long white lab coat. His office was adjacent to his apartment in a white stucco building from the early 1900’s. It was a dimly lit space with dark, angular furniture. The doctor said very little as he made me read the letters on the Snellen eye chart while placing varying lenses in front of each of my eyes in an antique looking device, and while he peered into my eyes while holding a thick magnifying lens that focused a piercing light into my tearing eyes one by one. I could smell his skin and his hair as he leaned into me.

After each of my annual exams, he always sighed and wrote out a stronger eyeglass prescription with a old black fountain pen. He carefully blotted the prescription paper and always said to my mother “don’t let him read too much in bed”.

As my glasses got stronger, I became aware that if I looked at road signs or traffic lights out of the corner of my eye, the colors didn’t line up. The red outer circle of the Swedish no-parking signs would overlap one end of the inner blue circle and there would be a space between the two colors on the opposite side. In the same way, the red, yellow and green traffic lights wouldn’t be straight on top of each other, but at an angle. I learned in school that red light passes straighter than blue or green light through a prism, like the outer edges of my old-fashioned glass lenses.

As I approached my teens, working with an old viewfinder camera and black and white darkroom equipment, I understood why it was harder to read in dim light: a dilated pupil, just like a wide aperture, creates a shallower depth of field than a smaller one, and the ultimate small aperture, a pinhole, can replace the lens in a simple camera or even your high powered eyeglasses in a pinch.

In medical school I learned to do a neurologic exam, and the bedside test for visual fields – Donders’ confrontation, as we called it. I figured Donders was a Dutch name, but never gave it much thought.

The other night, wondering why my EMR incorrectly defines visual acuity by “Snelling” rather than Snellen, it struck me that Snellen was probably a Dutch name, just like Donders. A few minutes with my iPad and Dr. Google made me rediscover how much I enjoy medical history.

It turns out Donders built an eye clinic and hired Snellen to run it. They invited their friend Einthoven, who would later invent the EKG, to help in their research. Einthoven studied chromosteropsis, the phenomenon whereby red objects seem closer than blue objects. Donders, Snellen and their wives were the subjects, and Einthoven’s paper became his doctoral thesis. It seems that chromosteropsis has something to do with the fact that red light travels straighter and that our eyeballs are angled inward when we look at objects up close, which makes blue objects seem ever so slightly blurry.

So, anyway, my little exploration reaffirmed that if I ever cut back my clinic hours, I’ll read more about the history of medicine.

The Legend of the Avoidable Hospital Readmission

A long, long time ago, hospitals existed to admit patients when they were sick, treat them with medicines or surgery and good nursing care, and discharge them after they became well.

Hospital care was at one time a charity, which evolved into a nonprofit service, before it became a Very Big Business.

In olden days, nonprofit hospitals charged patients straightforward fees for their services. Then, when you were just a young whippersnapper or perhaps merely a gleam in your father’s eyes, Medicare and Big Insurance started collecting premiums from workers and dole it out to hospitals when the workers or retirees needed hospital care.

At that point, hospital fees became confusing. The people who received care didn’t see what the charges were, and the payers didn’t really know how much care was medically necessary or even actually delivered by the increasingly profit-driven hospitals, let alone how much it cost to provide those services.

Insurers demanded deep discounts, and hospitals raised charges. Billing became more and more convoluted and required more hospital documentation and more business staff at both the hospitals and the insurers.

When an aspirin became as expensive as a four course meal and an overnight hospital stay became more expensive than the monthly lease payment for a Bentley, Medicare thought they had figured out a way to outsmart the hospitals: They started paying a flat rate for each hospital stay, based on the diagnosis. Suddenly, the hospitals were penalized if patients stayed longer or required more procedures or more aspirins than the average case.

That’s when patients no longer got to stay until they were well. People were discharged home at five o’clock on Friday afternoons, only partway cleared of their symptoms, with promises of a visiting nurse the following week and instructions to call their family doctor first thing Monday morning for an appointment.

A few years went by, and Medicare realized patients often ended up back in the hospital shortly after their discharge. Hospitals, of course, got to bill twice for each such episode and Medicare was obligated to pay the hospitals twice – not what they had expected would happen.

Medicare’s next move came swiftly: They didn’t retreat and say “we were wrong, keep patients in the hospital until they are well enough to go home”. Instead, they announced they would penalize hospitals if patients with certain hot button diagnoses got readmitted within thirty days of discharge.

This was an ingenious move on Medicare’s part. They are now imposing this penalty not just for patients who were sent home before they were stable, but also for patients who have severe chronic or near-terminal illnesses. For these patients, even the best possible prognosis is multiple admissions or a lengthy stay until they die. Medicare is now forcing the hospitals to spend more money than they receive during each such hospitalization, and, through the penalties, Medicare is giving itself a rebate every time one of these chronically ill patients gets readmitted appropriately, weeks after any shortcomings in the initial care would have been compensated for by the follow-up care or the passage of time.

Today, Medicare is looking outside the hospital wards for a happy ending to this situation. They are starting to spend money (presumably the money they are taking away from the hospitals) paying primary care practices for reaching out to patients immediately after they come home from the hospital in order to identify gaps in care and plan for follow-up visits. We are now becoming more and more involved with the social and economic barriers to health.

So the legend continues to evolve. But, like all legends, it is only partly true: Hospital care doesn’t cure everyone or everything. Primary care practices and their new partners – Community Care Teams and all the other agencies they network with – can only do so much to help patients overcome the obstacles that our society as a whole cannot remedy. And as primary care practices shoulder more and more chronic disease management responsibilities, even with some extra money thrown in, will we be able to also provide the timely urgent medical care our patients need in order to stay out of the Emergency Department and the hospital?


Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.

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