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Medical Forum / General / Vision / May 2007

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How to Find the Right Doctor

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Ms.Brainy - 27 May 2007 22:25 GMT
How can I find out in advance that the doc I am going to visit may be
the right one for my situation and requirements?  Practically, I can't
check them all till I find the right one, so I need to have some
sorting tools before my visit, but I don't know how to find these
tools.

I need badly a cataract surgery and have already seen 3 potential
surgeons.

The first was at the UMC.  He was rude, didn't want to listen to my
concerns or answer my questions, but worse of all he wanted to operate
on both my bad eye (with a thick cataract) and my good eye (that might
have a beginning of a cataract that does not interfere with my vision
and I absolutely don't want to touch at this stage).  He didn't care
that I wanted implant for intermedate vision rather than distance.
Maybe he knows things that I don't know, but he provided no
explanation.  I was appalled by his attitude and dumped him.

The second doc was probably the best known and most competent in my
area.  He was recommended by my retinologist as the one that he would
take his mother to when she needs a cat surgery.  Until recently he
was the head of Ophtalmology in UMC, but a couple of years ago he left
that prestigious position and started his private practice, where he
probably can make more money.  His record is impressive, my first
visit was promising and he gave me very informative written material,
but...  he was highly impatient when I came back with some questions,
and he tried hard to convince me that Crystalens should be my choice
of implant.  When I refused, he dumped me with the excuse that I don't
trust him.

Then I went to the Eye Center nearby.  Again, the appointment was
hasty, she (the doc) said that she needed a written clearance from my
retinologist since she is not a retina specialist.  I couldn't discuss
anything else with her before she got the clearance, although I
assured her that I had already been cleared for the cat surgery.  My
feeling is that she is not competent to treat my delicate condition
(closed macular hole, re-attached retina with scleral buckle, and
probably a macular pucker or wrinkled retina).  She sent me to a
retina doc to get the "clearance", but I don't feel comfortable going
back to her.

What to do?  How and where can I find the right cat-doc?  My
requirements are as follows:

1.  Someone who will give me more than the famous 17-seconds
appointment, will listen and consider my concerns and wishes, inform
me about what s/he is planning for me and answer my questions.

2.  Someone who will care about me, the person attached to the eye, as
well as about the eye itself.

3.  Someone who can evaluate properly my potential corrected visual
acuity in the bad eye and will make a plan for a lens that will work
together with the good eye at this stage, as well as in the future if,
and when, I need a cataract surgery in the good eye.

3.  Someone who is competent and experienced in complex cases like
mine, with comprensive knowledge of cataracts and retinal conditions.

4.  Someone who will put my well being before his/her financial
interest.

At this point I have a pretty good idea of what I want:

1.  Monofocal for intermediate vision (probably aiming at -2D),
corrected with glasses (probably progressive) for reading and
distance.

2.  Small incision, no stitches, topical anastesia with sedation.

3.  The best correction at this time for the bad eye only, with a
future plan for the good eye (now with -4D) -- must work for vision in
both eyes now and in the future.

4.  Astigmatism will be corrected by glasses, not by limbal surgery.

5.  Procedure with as little risk of complications as possible.

Is it not reasonable?  Is it too much to ask?  How can I find someone
to fulfil my needs without going thru the entire yellow pages?  How
can I make them listen and discuss things with me when they are
rushing?  There must be somebody out there who is caring, competent,
considerate and polite, but how can I find out in advance?
otisbrown@pa.net - 28 May 2007 01:46 GMT
Dear Brainy,

You might contact this ophthamologist -- who used
to post on sci.med.vision.

I understand he is very concerned that you always
get the correct treatment.

http://eyesite.ucsd.edu/faculty/granet.htm

Perhaps you could ask Neil Brooks to contact
him, since I understand that Neil Brooks is
Dr. Granet's patient.

Good luck,

Otis

> How can I find out in advance that the doc I am going to visit may be
> the right one for my situation and requirements?  Practically, I can't
[quoted text clipped - 79 lines]
> rushing?  There must be somebody out there who is caring, competent,
> considerate and polite, but how can I find out in advance?
Ms.Brainy - 28 May 2007 04:56 GMT
On May 27, 5:46 pm, "otisbr...@pa.net" <otisbr...@pa.net> wrote:
> Dear Brainy,
>
[quoted text clipped - 11 lines]
>
> Good luck,

Thanks Otis.  Dr. Granet has not posted here since 1996, probably
because you and others upset and frustrated him.  He is a pediatric
ophthalmologist and I am no longer a child.  Indeed, in order to work
with young children one need much better attitude than what I have
encountered.  Dr. Granet is in San Diego and I am in Southern Arizona,
and I don't see how he can give me a direct advice, although I am
always open to hear words of wisdom.  I Neil thinks Dr. Granet can be
of any help, please Neil tell me how to contact him.

I recall that Dr. Judy wrote something about this subject (how to get
the right treatment from the right doctor, or something like that.  I
will welcome Judy's word of advice if she will.  Or anybody else.  I
am really desparate, my vision in the bad eye is dimishing rapidly.
Neil Brooks - 28 May 2007 05:59 GMT
> On May 27, 5:46 pm, "otisbr...@pa.net" <otisbr...@pa.net> wrote:
>
[quoted text clipped - 27 lines]
> will welcome Judy's word of advice if she will.  Or anybody else.  I
> am really desparate, my vision in the bad eye is dimishing rapidly.

Brainy-

As always, Otis has his head up his a$$.  Granet IS a pediatric
ophthalmologist, specializing in strabismus and ocular motility
disorders.

You need a cataract surgeon.  Otis is giving you the functional
equivalent of a proctologist referral for chronic ear infections.

If he'd even looked at the link he posted, he would have known that.
But ... Otis is more than a wee bit of an idiot, so ....

You're right: Granet left because of Otis and another roughly akin to
him, but without the clear pathological issues.
otisbrown@pa.net - 28 May 2007 17:25 GMT
I think Neil Brooks is referring to a long-running argument between
Alex Eulenberg -- who supports the concept of the preventive
second-opinion.

Alex went on to develop i-see, to further enhance knowledge
about this preventive second-opinion, and David Granet
left in a blue funk.

But that is the true nature of the second-opinion when people
can not agree on scientific concepts about the fundamental
eye's proven behavior.

Otis

> > On May 27, 5:46 pm, "otisbr...@pa.net" <otisbr...@pa.net> wrote:
>
[quoted text clipped - 44 lines]
>
> - Show quoted text -
Neil Brooks - 28 May 2007 17:36 GMT
On May 28, 9:25 am, "otisbr...@pa.net" <otisbr...@pa.net> wrote:

[snip]

None of that explains why you tried to refer a cataract patient to an
ocular motility specialist.

Do you know anything about optometry or ophthalmology?

Just curious.
FKS - 28 May 2007 06:03 GMT
So, you visited 3 surgeons and none of them satisfied you. Sometimes, it
pays to assess a situation from the other side. Imagine you're a surgeon....

> How can I find out in advance that the doc I am going to visit may be
> the right one for my situation and requirements?  Practically, I can't
[quoted text clipped - 79 lines]
> rushing?  There must be somebody out there who is caring, competent,
> considerate and polite, but how can I find out in advance?
Ms.Brainy - 28 May 2007 06:53 GMT
> So, you visited 3 surgeons and none of them satisfied you. Sometimes, it
> pays to assess a situation from the other side. Imagine you're a surgeon....

If I were the surgeon, and even if I didn't care, I would at least
pretend and treat my patients with courtesy and consideration.

FYI "FKS", cataract is the most common eye surgery in the U.S. and
it's a major money making tool for surgeons who do it in assembly line
method.  Many patients end up with the wrong implants.  I hear too
many people complaining about the rush attitude of cataract surgeons.
I have never encountered such rush from any physician in my entire
life.  Apparently it's characteristic to cat-docs.

My case is more complex because of the trauma that my flimsy retina
has suffered and my desire to spare the good eye from any tampering as
long as I can.  It's still not clear (at least to me) to what degree
my bad eye vision can be restored, and there are issues of disparity
between the eyes now and in the future.  All these require more
attention than the normal cataract surgery, and the assembly line way
is not suitable in my case.  I explained it in my original post, as
well as in previous posts on this forum.  If you didn't get it, too
bad.  I believe that my wishes and expectations are not unreasonable.
My question was how to find the right surgeon, since I am confident
that s/he exists.

At issue are MY eyes and MY vision.  I don't have a duty to please the
surgeon, but the surgeon has a duty to give ME the best medical
treatment possible.
Dr. Leukoma - 28 May 2007 12:58 GMT
> > So, you visited 3 surgeons and none of them satisfied you. Sometimes, it
> > pays to assess a situation from the other side. Imagine you're a surgeon....
[quoted text clipped - 24 lines]
> surgeon, but the surgeon has a duty to give ME the best medical
> treatment possible.

Try looking for the senior member of a group practice for whom
"production" is no longer a major issue.

DrG
Ms.Brainy - 28 May 2007 21:30 GMT
> Try looking for the senior member of a group practice for whom
> "production" is no longer a major issue.
>
> DrG-

Sounds like a good thing, except that I don't understand what it
means.  Can you please explain?
FKS - 31 May 2007 05:33 GMT
> At issue are MY eyes and MY vision.  I don't have a duty to please the
> surgeon, but the surgeon has a duty to give ME the best medical
> treatment possible.

Life isn't so simple. You don't have to please a surgeon, but if you do,
you'll be treated better.

The surgeon does not have a duty to give you the best medical treatment
possible. S/he doesn't owe anything to you.
Ms.Brainy - 31 May 2007 06:52 GMT
> > At issue are MY eyes and MY vision.  I don't have a duty to please the
> > surgeon, but the surgeon has a duty to give ME the best medical
[quoted text clipped - 5 lines]
> The surgeon does not have a duty to give you the best medical treatment
> possible. S/he doesn't owe anything to you.

FKS:  I am sure you are familiar with the Hypocritic (or Hippocratic)
Oath.  How about this:  "I swear ... to practice and prescribe to the
best of my ability for the good of my patients, and to try to avoid
harming them."
Kay Lancaster - 28 May 2007 16:42 GMT
I'm going to suggest a new book, "How Doctors Think" by Jerome Groopman,
as potentially useful reading.  
http://www.npr.org/templates/story/story.php?storyId=8946558

It's a general book about medicine in the US today, not specifically
about any one category of doctors, and it helps to understand how the
delivery system affects care, and some ways around doctor/patient problems.

Quite readable, too.

Kay
Rich - 28 May 2007 18:39 GMT
> I'm going to suggest a new book, "How Doctors Think" by Jerome Groopman,
> as potentially useful reading.  
[quoted text clipped - 7 lines]
>
> Kay

MARVELLOUS!

Wonderful description of what happens (unfortunately) in the real world.

In response to Ms. Brainy's question/concerns:

I would also suggest people remain aware of the constraints on Doctor's
time placed (primarily) by insurance companies.  (I'm speaking in the
U.S.) In order to offer affordable insurance (whether paid for by the
patient, his/her employer, or the government), insurance companies
require Doctors to diagnose, treat, and record for every patient in a
VERY short period of time. America's legal system has shaped a Doctor's
treatment obligation quite differently than years ago. A doctor's day is
packed with patients, plus many other administrative and professional
duties.

If you have the wealth to afford it (and choose to use it this way), you
could probably book 3 or 4 appointments consecutively (paid for out of
your own pocket) and get a relaxed, personalized, in-depth
appointment... but I have never heard of someone doing so.

Rich
Kay Lancaster - 29 May 2007 03:42 GMT
> If you have the wealth to afford it (and choose to use it this way), you
> could probably book 3 or 4 appointments consecutively (paid for out of
> your own pocket) and get a relaxed, personalized, in-depth
> appointment... but I have never heard of someone doing so.

I've done it and it's worth it when dealing with complex issues.

Kay
Dr. Leukoma - 29 May 2007 04:13 GMT
> I've done it and it's worth it when dealing with complex issues.

I'm so glad to see this topic being discussed.

DrG
Neil Brooks - 29 May 2007 04:34 GMT
> > I've done it and it's worth it when dealing with complex issues.
>
> I'm so glad to see this topic being discussed.

Brainy,

I've always scheduled my eye doctor appointments so that I am the last
appointment of the day.  I have an established rapport with my doc,
which helps, but ... even if it's somebody new ... there may be less
pressure on their schedule to rush you out.

When scheduling the appointment, it also may be beneficial to mention
that you are "a complex case" and ask them to simply allow a little
extra time.  Often, they will simply do this without asking any
additional questions.

Can't hurt.

Where's the nearest teaching hospital??  Who does corneal and
refractive surgery that AND teaches students there?  They tend to be a
little better in terms of people skills, and are usually up on the
latest and greatest.

I do know a refractive surgeon or two in San Diego that I wouldn't
hesitate to recommend ... if you are willing to travel.

Neil
Ms.Brainy - 29 May 2007 04:55 GMT
> > > I've done it and it's worth it when dealing with complex issues.
>
[quoted text clipped - 23 lines]
>
> Neil

Thanks Neil.  My retina-doc used to schedule me at the end of the day
since he knew that I require information and always have
questions...:-)  But he is gone now.

Unfortunately, I can't set appointments anymore late in the day, since
I can no longer drive after dark.  My cataract is just too bad and the
glare at night is unbearable and dangerous...

San Diego is only 6-8 hours drive from Tucson, but I still believe I
can find somebody here.  I wouldn't mind visiting beautiful SD after I
recover from my surgery, when you enjoy the mild summer and we here
bake in the heat...  But we have A/C!
Neil Brooks - 29 May 2007 05:50 GMT
> > > > I've done it and it's worth it when dealing with complex issues.
> >
[quoted text clipped - 31 lines]
> I can no longer drive after dark.  My cataract is just too bad and the
> glare at night is unbearable and dangerous...

Can you get a ride/use mass transit/taxi it?  I've had to do any of
those /or/ even ride my bike to and from appointments.

> San Diego is only 6-8 hours drive from Tucson, but I still believe I
> can find somebody here.

What /about/ the U of A Medical School:

 http://www.eyes.arizona.edu/ForPatients/PatientHome.html

??

If it were me, I would likely call/e-mail the head--Joseph Miller, MD,
MPH, and ask him for direction.  Another avenue might be to contact
one of the /manufacturers/ of the IOL that you like (or even an IOL
that you don't like) and ask them what refractive surgeon, in Tucson
(or Phoenix) THEY seek out when they're looking for somebody to trial
their products.

The two in San Diego that I would refer you to are widely sought after
by IOL makers AND manufacturers of new laser refractive surgery gear/
techniques.

Good luck!

> I wouldn't mind visiting beautiful SD after I
> recover from my surgery, when you enjoy the mild summer and we here
> bake in he heat...  But we have A/C!

I've seen smoke coming from the bare skin off people while standing at
an intersection on a hot August day, in Phoenix.  It's not for
me ... ;-)
Ms.Brainy - 29 May 2007 06:12 GMT
> > > > > I've done it and it's worth it when dealing with complex issues.
>
[quoted text clipped - 66 lines]
>
> - Show quoted text -

Yeah, we usually fry eggs on the sidewalk in June-July-August...
I know Dr. Miller and love him.  He was present at my detached retina
surgery and visited me the following day.  He took care of minor
issues for me with devotion and dedication.  But he is a pediatric
ophthalmologist with specialty like Dr. Granet.  No wonder he is nice,
he works with children!  I have had long chats with him...  and I did
call him last week, and he recommended (first) Dr. S. (the former head
of the department, the one who wanted to stick me with crystalens, who
is considered the best cataract surgeon in Tucson).   After I told him
that Dr.S. dumped me he recommended somebody else, whom I am going to
see later this week.  I have hopes and will prepare to tell him all my
issues within the first minute, expecting that he would listen...
Neil Brooks - 29 May 2007 16:13 GMT
> > > > > > I've done it and it's worth it when dealing with complex issues.
>
[quoted text clipped - 79 lines]
> see later this week.  I have hopes and will prepare to tell him all my
> issues within the first minute, expecting that he would listen...

So it sounds as though you're onto good people.

Let me be a bit brash here ... with apologies in advance:

For YOUR needs (managing your own health care), you seem to represent
a near-ideal patient: you have educated yourself, understand your
particular needs, and have developed a position on the options that
you prefer.

>From the perspective of MANY doctors (not only the bad ones), you
represent something between a challenge and a threat (to their
security).  Wayyyy too many doctors still view themselves as deities
and feel that it's something like impudence for a patient to challenge
their wisdom.

So ... ya' gotta play the game.  There's a big bit of "more flies with
honey than with vinegar" at play here.  Your wisdom has to be soft-
peddled, your opinions have to be couched with "what do you think
about the new X lens?"  Your resentment when you feel hurried has to
be phrased as, "You must be horribly busy today, and I understand, but
I just have a few more quick questions."

At the end of the day, though, if you've "presented yourself" in the
most effective manner and /still/ don't have a good feeling about the
doc, then that--in my opinion--is puh-lenty reason to move on.

I think somebody else (FKS?) made a comment about "the surgeon's
perspective," but ... I think their remark was too glib and not
particularly instructive.  Maybe this is what they were getting at.

Look, I have absolutely no evidence to suggest that frame of mind
going in has any quantitative bearing on surgical outcomes for
cataract, but .... who cares?  It can only help, right?  You have to
have some rapport with a surgeon that goes beyond "recognition of
their hard skills."  Those hard skills are usually easier to find than
the softer skills that give you comfort, preoperatively.

Neil
Who still thinks Otis Brown is mentally ill ;-)
Ms.Brainy - 29 May 2007 17:26 GMT
> > > > > > > I've done it and it's worth it when dealing with complex issues.
>
[quoted text clipped - 122 lines]
>
> - Show quoted text -

Thanks for your words of wisdom, Neil.  There is not a word there that
I disagree with.
FKS - 29 May 2007 22:18 GMT
> Thanks for your words of wisdom, Neil.  There is not a word there that
> I disagree with.

In marketing, customers are divided into two groups: right vs wrong
customers. It's been shown that trying to satisfy wrong customers is not
just worthless but highly costly. So, companies dump and ignore wrong
customers.

In your case, you need to approach surgeons methodologically. They don't
want to be bluntly told what to do by patients. They'll categorize such
patients as wrong patients. So, you need to develop skills to make surgeons
listen to you without sounding like you're challenging their expertises or
egos. Good luck.
Kay Lancaster - 29 May 2007 22:42 GMT
>> I've done it and it's worth it when dealing with complex issues.
>
> I'm so glad to see this topic being discussed.

Actually, the insurances I've dealt with have covered at least partially
an "extended visit" that was primarily for the purposes of figuring out
"so where do we go from here?".  But I've also paid out of my own pocket
when I was uninsured.  I've found it good value for the money.

I've found that I accomplish most on these visits when I've given the
doctor a clue ahead of time about what I want to talk about -- I would
feel a little more organized and less "ambushed" if I were the
doctor.  I've also sent or brought a couple of PubMed (NLM) abstracts
during regular visits, and handed them to the doctor with a "Been
doing some reading, and I'd like to talk to you about whether or not
this might be worthwhile.  Not today, but another visit."  I find it
takes time for me to shift mental gears from routine, "get your head down
and plow through today's work" to a thoughtful consideration of
an issue that is more complex.  My assumption is that other people
work similarly, and giving them the chance to switch gears helps
to open a space for discussion.  Seems to work well for me.

Kay
Ms.Brainy - 28 May 2007 22:00 GMT
> I'm going to suggest a new book, "How Doctors Think" by Jerome Groopman,
> as potentially useful reading.  http://www.npr.org/templates/story/story.php?storyId=8946558
[quoted text clipped - 6 lines]
>
> Kay

Excellent link, Kay.  I am still in the midst of reading...

Let me just say that this came from a DOCTOR who became a patient.  He
probably has not experienced what most of us do.  He and his family
members would probably get more respect and attention, as well as
better treatment, from his fellow doctors.

In great part it's the healthcare delivery system (including
insurance, HMOs, medicare etc.) in the U.S. which forces doctors to
shortcuts due to sharp time restrictions.  It's not necessarily the
same in other countries.
Kay Lancaster - 29 May 2007 03:42 GMT
> Let me just say that this came from a DOCTOR who became a patient.  He
> probably has not experienced what most of us do.  He and his family
> members would probably get more respect and attention, as well as
> better treatment, from his fellow doctors.

Actually, I'd say he got pretty much run-of-the-mill treatment from fellow
doctors; in fact, I'd say I've found better doctors than most he'd seen
for his hand problem -- and I did have to hunt.  He does have a better
than average organic fertilizer detector for his hand issues than most
laypeople would, but it really didn't help him a whole lot in getting
treated properly.

Do read the entire book, not just the interview -- it's not long, and
it's easy reading, a long evening for me.  He's got some very
valuable points, and includes the whole insurance* "cost containment"
and discount stuff that tends to clog up medical care in this country.
I don't recall anything specifically about ophthamology in the book, but
the general principles for working with doctors for your health care
were right on, in my experience.   And some good techniques for getting
your care out of a rut.

*do not get me going about this... grrrr...

Kay
Ms.Brainy - 29 May 2007 03:54 GMT
Kay,

Where did you get the book?

> > Let me just say that this came from a DOCTOR who became a patient.  He
> > probably has not experienced what most of us do.  He and his family
[quoted text clipped - 20 lines]
>
> Kay
Kay Lancaster - 29 May 2007 16:42 GMT
> Kay,
>
> Where did you get the book?

From my local public library.  But it's probably in bookstores now,
as it's only been out a couple of months, and it was on they NY Times
bestseller list for nonfiction.  It's not normally a list I pay attention
to, but it indicates that it's probably quite widely distributed.

Kay
Jane - 30 May 2007 04:29 GMT
Ms. Brainy, I've had very good experiences with Castle Connolly
doctors.  You can check the website www.castleconnolly.com for their
inclusion criteria; essentially their doctors have been nominated by
their peers.  In case you need another referral, Dr. William Fishkind
of Tuscon, who specializes in cataract surgery and glaucoma, is listed
as a regional Top Doctor.
 
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