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So yesterday some guy had put up a post asking about what was the typical day like for an ophthalmologist. I had been having a particularly bad day yesterday, and last night it was very cathartic for me to write out a reply. I spent a lot of time on it. I guess he didn't like my reply because the thread is now deleted. That upsets me a little bit because I spent like an hour and a half working on the reply, and I was honest in my reply. Whatever. So the thread has been deleted, but I want to repost my reply because I'm interested to see if other people sometimes feel about their jobs the same way I was feeling yesterday. Here it is:
I roll out of bed at 9:30 and go to the gym for an hour. Then I shower and dress and am ready to see my first patient starting at 11 AM. My first patient is generally an elderly female who comes in complaining of decreased vision. Her vision is 20/200 in both eyes. She has fairly dense nuclear sclerotic cataracts and no other ocular problems or health issues. I sign her up for cataract surgery. The next 3 patients I see before lunch are exactly the same.
After a 90 minute lunch at a gourmet restaurant I return to clinic. Mostly I am seeing post-op patients, similar to the patient described above on whom I did cataract surgery the day before. Each of them is beaming with delight at their 20/20 vision. They have each brought gifts of home-bottled fruits and delicacies. One of them has arranged the fruits inside the bottle to spell out my name, like a sand sculpture in a jar. They hug me on the way out, with promises that they will name their firstborn grandchildren after me.
At 3:30 my clinic day ends and I drive off in my BMW, headed wherever the hell I want to go, to do whatever the hell I want to do.
ALTERNATE SCENARIO
I wake up at 6:30 AM and stare at the mirror, dreading the thought of going to clinic. I shower and drive in to work. There is a pile of paperwork leftover from the night before and I work on dictating letters to various specialists and primary care doctors.
At 8:15 my first two patients are ready. As I walk out into the hall there is a bad small apparent. My technicians are scrubbing the floors. The first patient suffered fecal incontinence on the way into the exam room, and nobody noticed the nuggets that were falling out his pantlegs as he was taken into the room. The second patient, wheelchair-bound, rolled through said nuggets on the way to his exam room, leaving a nice linear trail of squished feces. I step over the trail and go in the first room.
The first patient is hard of hearing. I attempt a refraction, 1 or 2. After a 30 second pause he replies loudly "BOTH BLURRY!" "Yes but was one less blurry than the other?" I yell. "TRY IT AGAIN" he yells back. "1 or 2." Additional 30 second pause. He starts to read the 20/40 line, painstakingly slowly. I let him finish and then yell "Very good. Now I am going to show you 2 lens choices and I want you to tell me which of the two you prefer. 1 or 2." 30 second pause. "WELL WITH 1 I CAN SEE THE LINES ON THE E BETTER BUT WITH 2 I SEE THE SPACES IN THE B BETTER." "So which one do you prefer?" I ask. 30 second pause. "SHOW THEM AGAIN." The whole process goes on for 15 minutes, and I die a little inside.
While he is dilating I move on to the next patient, who is 40 years old but wheelchair-bound secondary to an MVA related to his drunk-driving habit. He is able to transfer but the technicians have not bothered to get him up into the exam chair, nor has his vision been checked nor has any meaningful workup been done. I do all this myself, and despite his general medical problems his eyes are in good shape and he refracts to 20/20. I explain this to him and write him a glasses prescription and hand it to him. "Does the state health plan cover my glasses?" "No, they only cover it for kids now." He promptly crumples up the prescription and throws it at me and wheels out. I die a little inside.
Later in the morning I see a 50 year old man who previously had a metallic foreign body/rust ring removed after it sat in his cornea for 4 days. He had recovered nicely but was left with a small central stromal scar and 20/40 vision in that eye. He has a pile of disability papers for me to fill out stating that he is now visually disabled and unable to work. I have long since grown weary of arguing with such patients about the details of their various BS claims. I tell him I'll fill it out but I doubt he will be given disability with his level of vision. He wants me to say his vision is worse then so that he can get disability. I tell him I'm sorry but I can't. He is very angry. He then gives me another form to fill out which will get him reimbursement for his travel to the appointment. I fill it out. When I'm done he asks me to indicate on the form that his appointment lasted 4 hours because "they will pay for my lunch along with the gas
money that way." I inform him that they would know that his 15 minute appointment could not possibly have lasted 4 hours and that I would get in trouble. I have no idea who "they" might be or who even receives this form. But I don't care and I'm angry at the leeches of the world and I don't give him his free lunch. The knowledge that this man will not receive a free lunch will be the only glimmer of happiness I have throughout the entire day. Despite this small glimmer I still die a little inside.
My last patient of the morning is a 70 y/o female who was added on to the schedule with a complaint of blurry vision. I open her chart and read her chief complaint: "Pt complains of blurry vision since 9 am this morning. Also notices she cannot move the left half of her body very well." I quickly go in the room. "I understand you are having blurry vision, but you are also having some weakness?" "Yes, on my left side" she replies, her speech obviously slurred. "Yeah," her adult son says, "we had to carry her out to the car." I perform a quick neuro check and indeed her left side is very weak. I also do a basic eye motility/pupil check and quickly look at her optic nerves with the indirect. They are normal. I explain that I am worried she has had a stroke and that we should call 911 and get her to the ER ASAP. I go out in the hall and instruct the tech to call 911, which she does. I go back in the room, wondering why in the world, with that
constellation of symptoms, would going to the eye doctor be the first logical step. I soon find out that most likely it was because the son thought it would be the cheapest route. Or he's just extremely stupid. Or both.
"Aren't you going to finish her eye exam?" he asks. Well, the ambulance will be here soon and really the first priority is to get her checked out for a stroke. We should do a full exam when she is stable and it is safe. "Ambulance?" he asks incredulously. "We can't pay for no ambulance. I'll drive her myself. Come on mom." He stands up to leave. "I cant get up" she slurs. "Yeah, I told you I was going to call 911. You should just wait and let the EMT's take care of her." "I thought you were just calling to let the hospital know she was coming" he says, as he is trying to hoist his mother up from the chair. He gets her up and starts walking with her trying to haul her out. Fortunately she is strong enough to stumble along and they don't fall. I argue with the son the whole way but he ignores me. In the waiting room he deposits her in a chair and heads out to get his car. He pulls it around front, but in the meantime the ambulance
arrives. The EMT's fortunately convince the son to let them take her, and they leave in the ambulance. I die a little inside.
I go back to my office for lunch. I have 10 minutes before my first patient arrives for the afternoon. There is a stack of charts on the desk with phone messages. On top is Mr. Smith's chart. "Mr. Smith called and can't see out of his left eye. He's coming in at 4:30" the note says. I sigh and die a little inside. The next 4 notes are from patients who had been seen during January and had called in upset because their eye exam had triggered their deductible for the new year and they were mad because "they had never been charged that much before," despite the fact that their charges had been essentially the same every year, but their eye exam happened to be the first medical visit of the year. I die a little more.
My first patient of the afternoon is a 60 year old who complains of a gritty sensation and intermittent blurriness, especially while reading, as well as tearing. He has a low tear film and fast tear break-up time and inferior SPK. I explain to him that his eyes are quite dry and that I recommend using frequent artificial tears. He stares at me angrily and says "Have you not heard a goddamn thing I've been saying? I said that my eyes are TEARING too much!! I have EXTRA tears streaming down my face! My problem is too much tears and your goddamn solution is to put MORE tears in my eyes???!!!" I die a little bit more and go through my dry eye spiel. He accepts the artificial tear sample, which he will take home and use exactly twice before throwing them away and declaring they do not help.
Later on in the afternoon I see a 45 year old female with horrible proliferative diabetic retinopathy. She was diagnosed with DM 7 years earlier and had been prescribed oral meds, but stopped using them because "they made me feel funny and they were expensive." She came in because her vision had "got real blurry." Her vision is 20/100 in both eyes and she has extensive neovascularization. I tell her this and recommend that she have pan retinal photocoagulation. "That eye laser?" she asks. "Yes" I answer. "Oh no no no." she says, shaking her head angrily as she wags her finger at me. "My uncle let them do that laser on him and he went BLIND! I don't want you blinding me with that laser!" I try to explain to her that most likely he went blind from whatever disease they were attempting to treat with the laser, and not from the laser itself. I explain to her the seriousness of her situation and the need for treatment ASAP. She does not believe me and will not be scheduled for treatment. She leaves. I will most likely see her back in another 2 or 3 months when her vision deteriorates to 20/400 in both eyes from tractional retinal detachments at which point she will cry and wail and ask me "Why didn't you tell me? How could you let this happen to me?!!" Imagining this I die a little more.
The afternoon grinds on and at the end of the day I see Mr. Smith. Mr Smith is 55 years old and had LASIK 10 years previously with several retreatments needed because Mr. Smith is an engineer and comes with all the fun personality traits that accompanies that. I had the unfortunate circumstance to do cataract surgery on Mr Smith's Left eye. He had a horrible outcome with his vision only being corrected to 20/20. It was a horrible outcome because he had a diopter of astigmatism after surgery and needed glasses to see the 20/20. He had the diopter of astigmatism before I operated on him. We had a long discussion before his surgery in which I clearly explained that IOL calculations after LASIK are inexact and most likely he would need glasses to achieve his best corrected acuity. He indicated that he understood this. I repeated it several times. He either did not understand this or forgot about it because he has been extremely upset about his 20/20 corrected vision ever since.
I go into the room with Mr. Smith. The technician has worked him up and once again refracted his vision to 20/20 with the same prescription as always. "I cant see out of this Left Eye" he says. "You were able to read the 20/20 line with a little help" I said. "But its blurry." he says, and sits back in his chair angrily and folds his arms, staring at me. I pull the phoropter around and go through the motions of refracting him. And once again he is able to read 20/20 crisply. I point this out to him. He repeats that he does not want to wear glasses. He repeats the fact that when he looks through the glasses at an oblique angle it is blurry. I suggest he does not look through them at an oblique angle. He looks at me as if this is an absurd suggestion. We go round and round and round, the same conversation we have had multiple times. And as we talk I don't just die a little, I see my soul literally being sucked out of my body. I am not
exaggerating or taking literary license. My soul is sucked out of my body and floats out the window. As it goes out it pauses briefly to turn around and flip me the bird. It is the last time I will ever see it.
After I finish with Mr. Smith I return to my office where a pile of paperwork awaits me including several piles of new disability papers patients have brought in for me to fill out. I spend an hour filling it out. I dictate a few letters to PCP's from the diabetic exams from the day. My head is ready to explode so I leave a few of the letters to be done the following morning. Then I stumble home at 7 pm, excited about the prospect of repeating it all tomorrow.
----------------------------------------------------------
So there you go, two different types of days in medicine. The truth of course lies somewhere in between. The first day is I guess more like what I imagined life to be like before I went to medical school, and the second day is a bit closer to reality.
I roll out of bed at 9:30 and go to the gym for an hour. Then I shower and dress and am ready to see my first patient starting at 11 AM. My first patient is generally an elderly female who comes in complaining of decreased vision. Her vision is 20/200 in both eyes. She has fairly dense nuclear sclerotic cataracts and no other ocular problems or health issues. I sign her up for cataract surgery. The next 3 patients I see before lunch are exactly the same.
After a 90 minute lunch at a gourmet restaurant I return to clinic. Mostly I am seeing post-op patients, similar to the patient described above on whom I did cataract surgery the day before. Each of them is beaming with delight at their 20/20 vision. They have each brought gifts of home-bottled fruits and delicacies. One of them has arranged the fruits inside the bottle to spell out my name, like a sand sculpture in a jar. They hug me on the way out, with promises that they will name their firstborn grandchildren after me.
At 3:30 my clinic day ends and I drive off in my BMW, headed wherever the hell I want to go, to do whatever the hell I want to do.
ALTERNATE SCENARIO
I wake up at 6:30 AM and stare at the mirror, dreading the thought of going to clinic. I shower and drive in to work. There is a pile of paperwork leftover from the night before and I work on dictating letters to various specialists and primary care doctors.
At 8:15 my first two patients are ready. As I walk out into the hall there is a bad small apparent. My technicians are scrubbing the floors. The first patient suffered fecal incontinence on the way into the exam room, and nobody noticed the nuggets that were falling out his pantlegs as he was taken into the room. The second patient, wheelchair-bound, rolled through said nuggets on the way to his exam room, leaving a nice linear trail of squished feces. I step over the trail and go in the first room.
The first patient is hard of hearing. I attempt a refraction, 1 or 2. After a 30 second pause he replies loudly "BOTH BLURRY!" "Yes but was one less blurry than the other?" I yell. "TRY IT AGAIN" he yells back. "1 or 2." Additional 30 second pause. He starts to read the 20/40 line, painstakingly slowly. I let him finish and then yell "Very good. Now I am going to show you 2 lens choices and I want you to tell me which of the two you prefer. 1 or 2." 30 second pause. "WELL WITH 1 I CAN SEE THE LINES ON THE E BETTER BUT WITH 2 I SEE THE SPACES IN THE B BETTER." "So which one do you prefer?" I ask. 30 second pause. "SHOW THEM AGAIN." The whole process goes on for 15 minutes, and I die a little inside.
While he is dilating I move on to the next patient, who is 40 years old but wheelchair-bound secondary to an MVA related to his drunk-driving habit. He is able to transfer but the technicians have not bothered to get him up into the exam chair, nor has his vision been checked nor has any meaningful workup been done. I do all this myself, and despite his general medical problems his eyes are in good shape and he refracts to 20/20. I explain this to him and write him a glasses prescription and hand it to him. "Does the state health plan cover my glasses?" "No, they only cover it for kids now." He promptly crumples up the prescription and throws it at me and wheels out. I die a little inside.
Later in the morning I see a 50 year old man who previously had a metallic foreign body/rust ring removed after it sat in his cornea for 4 days. He had recovered nicely but was left with a small central stromal scar and 20/40 vision in that eye. He has a pile of disability papers for me to fill out stating that he is now visually disabled and unable to work. I have long since grown weary of arguing with such patients about the details of their various BS claims. I tell him I'll fill it out but I doubt he will be given disability with his level of vision. He wants me to say his vision is worse then so that he can get disability. I tell him I'm sorry but I can't. He is very angry. He then gives me another form to fill out which will get him reimbursement for his travel to the appointment. I fill it out. When I'm done he asks me to indicate on the form that his appointment lasted 4 hours because "they will pay for my lunch along with the gas
money that way." I inform him that they would know that his 15 minute appointment could not possibly have lasted 4 hours and that I would get in trouble. I have no idea who "they" might be or who even receives this form. But I don't care and I'm angry at the leeches of the world and I don't give him his free lunch. The knowledge that this man will not receive a free lunch will be the only glimmer of happiness I have throughout the entire day. Despite this small glimmer I still die a little inside.
My last patient of the morning is a 70 y/o female who was added on to the schedule with a complaint of blurry vision. I open her chart and read her chief complaint: "Pt complains of blurry vision since 9 am this morning. Also notices she cannot move the left half of her body very well." I quickly go in the room. "I understand you are having blurry vision, but you are also having some weakness?" "Yes, on my left side" she replies, her speech obviously slurred. "Yeah," her adult son says, "we had to carry her out to the car." I perform a quick neuro check and indeed her left side is very weak. I also do a basic eye motility/pupil check and quickly look at her optic nerves with the indirect. They are normal. I explain that I am worried she has had a stroke and that we should call 911 and get her to the ER ASAP. I go out in the hall and instruct the tech to call 911, which she does. I go back in the room, wondering why in the world, with that
constellation of symptoms, would going to the eye doctor be the first logical step. I soon find out that most likely it was because the son thought it would be the cheapest route. Or he's just extremely stupid. Or both.
"Aren't you going to finish her eye exam?" he asks. Well, the ambulance will be here soon and really the first priority is to get her checked out for a stroke. We should do a full exam when she is stable and it is safe. "Ambulance?" he asks incredulously. "We can't pay for no ambulance. I'll drive her myself. Come on mom." He stands up to leave. "I cant get up" she slurs. "Yeah, I told you I was going to call 911. You should just wait and let the EMT's take care of her." "I thought you were just calling to let the hospital know she was coming" he says, as he is trying to hoist his mother up from the chair. He gets her up and starts walking with her trying to haul her out. Fortunately she is strong enough to stumble along and they don't fall. I argue with the son the whole way but he ignores me. In the waiting room he deposits her in a chair and heads out to get his car. He pulls it around front, but in the meantime the ambulance
arrives. The EMT's fortunately convince the son to let them take her, and they leave in the ambulance. I die a little inside.
I go back to my office for lunch. I have 10 minutes before my first patient arrives for the afternoon. There is a stack of charts on the desk with phone messages. On top is Mr. Smith's chart. "Mr. Smith called and can't see out of his left eye. He's coming in at 4:30" the note says. I sigh and die a little inside. The next 4 notes are from patients who had been seen during January and had called in upset because their eye exam had triggered their deductible for the new year and they were mad because "they had never been charged that much before," despite the fact that their charges had been essentially the same every year, but their eye exam happened to be the first medical visit of the year. I die a little more.
My first patient of the afternoon is a 60 year old who complains of a gritty sensation and intermittent blurriness, especially while reading, as well as tearing. He has a low tear film and fast tear break-up time and inferior SPK. I explain to him that his eyes are quite dry and that I recommend using frequent artificial tears. He stares at me angrily and says "Have you not heard a goddamn thing I've been saying? I said that my eyes are TEARING too much!! I have EXTRA tears streaming down my face! My problem is too much tears and your goddamn solution is to put MORE tears in my eyes???!!!" I die a little bit more and go through my dry eye spiel. He accepts the artificial tear sample, which he will take home and use exactly twice before throwing them away and declaring they do not help.
Later on in the afternoon I see a 45 year old female with horrible proliferative diabetic retinopathy. She was diagnosed with DM 7 years earlier and had been prescribed oral meds, but stopped using them because "they made me feel funny and they were expensive." She came in because her vision had "got real blurry." Her vision is 20/100 in both eyes and she has extensive neovascularization. I tell her this and recommend that she have pan retinal photocoagulation. "That eye laser?" she asks. "Yes" I answer. "Oh no no no." she says, shaking her head angrily as she wags her finger at me. "My uncle let them do that laser on him and he went BLIND! I don't want you blinding me with that laser!" I try to explain to her that most likely he went blind from whatever disease they were attempting to treat with the laser, and not from the laser itself. I explain to her the seriousness of her situation and the need for treatment ASAP. She does not believe me and will not be scheduled for treatment. She leaves. I will most likely see her back in another 2 or 3 months when her vision deteriorates to 20/400 in both eyes from tractional retinal detachments at which point she will cry and wail and ask me "Why didn't you tell me? How could you let this happen to me?!!" Imagining this I die a little more.
The afternoon grinds on and at the end of the day I see Mr. Smith. Mr Smith is 55 years old and had LASIK 10 years previously with several retreatments needed because Mr. Smith is an engineer and comes with all the fun personality traits that accompanies that. I had the unfortunate circumstance to do cataract surgery on Mr Smith's Left eye. He had a horrible outcome with his vision only being corrected to 20/20. It was a horrible outcome because he had a diopter of astigmatism after surgery and needed glasses to see the 20/20. He had the diopter of astigmatism before I operated on him. We had a long discussion before his surgery in which I clearly explained that IOL calculations after LASIK are inexact and most likely he would need glasses to achieve his best corrected acuity. He indicated that he understood this. I repeated it several times. He either did not understand this or forgot about it because he has been extremely upset about his 20/20 corrected vision ever since.
I go into the room with Mr. Smith. The technician has worked him up and once again refracted his vision to 20/20 with the same prescription as always. "I cant see out of this Left Eye" he says. "You were able to read the 20/20 line with a little help" I said. "But its blurry." he says, and sits back in his chair angrily and folds his arms, staring at me. I pull the phoropter around and go through the motions of refracting him. And once again he is able to read 20/20 crisply. I point this out to him. He repeats that he does not want to wear glasses. He repeats the fact that when he looks through the glasses at an oblique angle it is blurry. I suggest he does not look through them at an oblique angle. He looks at me as if this is an absurd suggestion. We go round and round and round, the same conversation we have had multiple times. And as we talk I don't just die a little, I see my soul literally being sucked out of my body. I am not
exaggerating or taking literary license. My soul is sucked out of my body and floats out the window. As it goes out it pauses briefly to turn around and flip me the bird. It is the last time I will ever see it.
After I finish with Mr. Smith I return to my office where a pile of paperwork awaits me including several piles of new disability papers patients have brought in for me to fill out. I spend an hour filling it out. I dictate a few letters to PCP's from the diabetic exams from the day. My head is ready to explode so I leave a few of the letters to be done the following morning. Then I stumble home at 7 pm, excited about the prospect of repeating it all tomorrow.
----------------------------------------------------------
So there you go, two different types of days in medicine. The truth of course lies somewhere in between. The first day is I guess more like what I imagined life to be like before I went to medical school, and the second day is a bit closer to reality.
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