The Fine View: Winter 2007
Estimates by the United States government indicate that there is to be anticipated a severe shortage in physicians by the year 2010, increasing in severity through the year 2020. At present, between 90 and 100 physicians graduate yearly from the Oregon Health & Science University (OHSU) in Portland. At the same time, over the next two years it is estimated that 1,200 practicing physicians in Oregon will be leaving the state or retiring, so clearly there is an enormous imbalance here and access to healthcare will become a real crisis.
OHSU has sought an innovative approach to address this crisis. The expense of expanding the classroom, clinic, and hospital facilities at their main campus in Portland would be exorbitant. However, there exists within Lane County excess capacity in classroom, clinic and hospital space. As a result, OHSU has joined Sacred Heart Medical Center and the University of Oregon (UO) for a joint venture which will involve teaching medical students and graduate physicians in clinical training here in Lane County. This will enable the number of physicians graduating from OHSU to double over a several year period.
|From Left: Dr. Packer, Christoph Thomas, medical student from Germany, Dr. Fine, Francisco Porfirio, MD, fellow from Brazil, and Dr. Hoffman.
The program will begin by having medical students come down for a portion of their first year medical school studies in classrooms at the UO and for their early clinical experience in the offices of physicians here in Lane County, and ultimately in the patient care facilities at Sacred Heart Medical Center. A number of local physicians will be involved.
Drs. Fine, Hoffman and Packer are all clinical professors at OHSU and instruct the senior ophthalmology residents in their last year of training in advanced techniques in cataract surgery. One of us travels up to the medical school and scrubs with the residents each month. The eye department at the medical school has been enormously gratified to have our expertise available to the residents in their program. The residents have expressed delight in our participation.
Almost all of our patients are aware that we very frequently have observers in our examining rooms, as well as in the operating room. As a matter of fact, Drs. Fine, Hoffman and Packer teach all levels of medical education from pre-medical preceptors at the UO, who spend a month in our offices, to medical students who come from all over the world for electives in our offices, coordinated through our faculty appointments at OHSU, to residents who spend time in our offices and who have us with them in the operating room, and most importantly, to fellows who come from all over the world to spend varying periods of time in our practice to learn our advanced surgical techniques. In addition to medical training, they also are grateful for the opportunity to learn all aspects of medical practice including how we deal with patients, other physician’s offices, nurses and technicians, industry, and how we teach other physicians. Of course, we most frequently teach practicing ophthalmologists through our participation on the podium and our demonstration of live surgery in meetings all over the world each year.
Starting next year, we will likely have some first-year medical students who will be rotating through our offices, not so much to learn about the art and science of ophthalmology, as much as to learn what it means to be a medical professional and to learn about medical ethics. Medicine is one of the few endeavors that involves making decisions based on what is best for the other person, rather than the decision maker, which requires special ethical consideration. Later, we will have students who will be taking electives in ophthalmology, who will want to learn about our particular specialty.
|From Left: Zainah Alsagoff, MD, fellow from
Singapore, with Dr. Fine, and Gero Krommes,
medical student from Germany.
Our patients have always been good-natured about allowing our fellows to examine them and to observe their surgery. They usually enjoy contact with our foreign fellows, especially because it is interesting to learn something of the countries from which these physicians come. We believe our patients will also enjoy the medical students.
It is important for us to reassure our patients that medical students and residents will not be providing any of their care. The care provided by our office will continue to be solely done by Drs. Fine, Hoffman and Packer, but there will be observation by medical students, and not infrequently an opportunity, if patients are willing, to have the students observe their eyes through the slit-lamp and other diagnostic equipment in our offices. This is a very important role for our office to play and an opportunity to address a healthcare crisis that is looming large in the near future. We anticipate our patients will enjoy their experience with the medical students, all the while knowing that they are still going to be receiving the most technologically advanced, economically cost-effective care, with highest quality of professionalism. [ top ]
|Mark Packer, M.D
Etymology means the study of how words and their uses change over time. Insight into the etymology of a word sometimes explains its connotations. For example, here’s an item from the Online Etymology Dictionary that describes some of the meanings attached to the word “doctor” (for more information, visit http://www.etymonline.com):
Doctor, c.1303, “Church father,” from O.Fr. doctour, from M.L. doctor “religious teacher, adviser, scholar,” from L. doctor “teacher,” from doct- stem of docere “to show, teach,” originally “make to appear right,” causative of decere “be seemly, fitting” (see decent). Familiar form doc first recorded c.1850. Meaning of “holder of highest degree in university” is first found c.1375; that of “medical professional” dates from 1377, though this was not common until late 16c. Verb sense of “alter, disguise, falsify” is first recorded 1774.
Originally, the doctor was a teacher of decency, of moral and ethical behavior, and so the word became associated with religious leaders. The word’s relationship to providers of medical care came later, and its subtler uses (“who doctored the punch?”) grew from there. Many of the attributes we ascribe to doctors derive from the term’s earliest meaning as “teacher.” In fact, much of what doctors do entails teaching in one form or another.
The process known as Informed Consent represents a critical part of medical care and relies on the doctor’s ability to teach a patient about his or her disease, as well as about the risks, alternatives and benefits of treatment. Giving informed consent is much like making an educated decision. For example, in the field of cataract surgery, many options exist for the choice of lens implant that replaces the cloudy natural lens of the eye. We have available accommodative and multifocal implants that reduce or eliminate the need for glasses, toric implants that correct astigmatism, aspheric implants that provide higher quality images, and light-filtering implants that reduce the amount of high energy light striking the retina. It is the doctor’s job to educate and give advice in order to help patients make an informed choice.
|Dr. Packer teaching a fellow ophthalmologist the bimanual microincision cataract extraction technique at the Drs. Fine, Hoffman & Sims course on bimanual phacoemulsification in August of 2004.
Doctors also have a professional responsibility to educate government and society at large. Partly scientific and partly humanitarian, this duty encompasses both the development of new technology and the evaluation of current practice. As part of this responsibility, Drs. Fine, Hoffman & Sims continue to participate in multiple FDA-monitored clinical studies to prove the safety and effectiveness of new implants. The decisions of the Centers for Medicare and Medicaid Services (CMS) over the last two years to recognize the benefits of aspheric implants for improved functional vision, and to permit beneficiaries to enjoy the benefits of multifocal and accommodative implants for reduced dependence on glasses, represent two important areas in which we, as doctors, have made significant contributions.
Finally, doctors bear a trust, imparted to them by society, to educate and train the next generation of physicians. Reflecting the early meaning of the word doctor, the education of young physicians encompasses both moral and scientific goals. Drs. Fine, Hoffman and Packer serve as faculty in the Department of Ophthalmology at Oregon Health & Science University, where we have taught cataract surgery for many years. In addition, we author and edit articles, books and web pages read by thousands of surgeons in many countries. We also frequently travel to lecture and provide hands-on instruction at meetings around the world. It is perhaps in this role that the meaning of doctor as teacher becomes most clearly visible.
Teaching, advising, making it right – Drs. Fine, Hoffman and Packer take our responsibilities to heart. We recognize the trust our patients place in us. Their vision remains our greatest professional achievement. [ top ]
| Richard S. Hoffman,
DSAEK (Descemet’s Stripping Endothelial Keratoplasty) is a revolutionary technique that has allowed corneal transplant patients to see better faster, with less discomfort, and fewer complications. The technique differs from traditional corneal transplantation in that only the back surface of the cornea is transplanted rather than the entire corneal thickness. The thin posterior (back surface or posterior lamellar) graft is folded in half and inserted into the eye through a small 5 mm incision that is closed with just one or two sutures. After the graft is unfolded, it is positioned against the patient’s cornea with an air bubble for 1-2 days until it sticks in place.
|Folded posterior lamellar graft inserted
through 5 mm clear corneal incision
Preoperative swelling in a patient’s cornea will clear in 1-2 weeks resulting in much faster visual rehabilitation. Multiple stitches are not needed on the surface of the cornea and because most of the patient’s cornea is left untouched, the original shape or curvature is not violated resulting in less surgically induced astigmatism and a reduced need for thick glasses after surgery.
In the past, when a patient had borderline corneal disease and coexisting cataract, surgeons tended not to perform cataract surgery for fear of causing the cornea to decompensate thus forcing patients to undergo corneal transplantation with its subsequent year long visual recovery. With the advent of the DSAEK procedure, cataract surgery can now be performed sooner – knowing that if the cornea does deteriorate from the cataract surgery, DSAEK can be performed with a much shorter and simpler recovery period. The DSAEK procedure can also be performed at the same time as cataract surgery allowing patients to have the benefit of both techniques in one operation.
Not all patients requiring corneal transplantation can undergo DSAEK. When the central cornea in front of the pupil is scarred, a full-thickness corneal transplant or a variation of the full-thickness procedure is still required. However, patients with Fuchs’ Dystrophy, or corneal endothelial decompensation from previous surgery or aging, are excellent candidates for this wonderful technique. [ top ]
Understanding your insurance benefits can be very confusing. What provider can you see? Is there an annual deductible to meet before your insurance will pay? Will there be a co-pay or a percentage due at the time of service? Do you need a referral from your primary care physician in order for your insurance to pay?
In the world of ophthalmology, we add to that confusion by asking even more questions, with the first and most important being, “Are you using vision benefits or medical benefits?”
What are “vision benefits” versus “medical benefits” and why does it matter which one you use?
Vision benefits usually describe insurance benefits that are used for what would be considered “routine” eye exams, such as updating your glasses prescription. Medical benefits describe insurance benefits that are used for what would be considered medical or health-related issues with the eyes, such as for the treatment of glaucoma, age-related macular degeneration, or diabetic retinopathy. If you are having a medical problem with your eyes, you are most likely going to use your medical benefits, but if you are coming in for a routine “vision” examination, you would be more likely to use any “vision benefits” your insurance plan may have.
Why does it matter which benefits you use anyway – they are both related to your eyes, right? Payment for our doctors’ services is ultimately the patient’s responsibility, so it is to your advantage to know your own insurance benefits and how to use them. If we try to submit a claim for a routine examination using vision benefits for an examination that is actually a medically-related visit, the insurance company may not pay for the exam. Similarly, if we submit a claim for a routine vision exam to a medical benefits plan, it is likely that claim will be denied. In both of these scenarios, the patient is now responsible for the cost of the examination.
Some insurance plans do not have regular vision benefits and only cover medical-related claims and many medical insurance plans subcontract the vision benefit through a different company. Drs. Fine, Hoffman & Sims are physicians and surgeons. As medical doctors, if you have a medical complaint your claim will be considered medical unless you tell us to use your vision benefits. If you would prefer that we use your vision benefits, you MUST tell us prior to the time of service and provide the appropriate billing information for your vision benefits.
Why is it to your advantage to know your vision benefits vs. your medical benefits? For several reasons:
- Your claim will be filed with the right diagnosis and the correct insurance company from the start;
- Your vision benefits might have less out of pocket expense, perhaps no deductible, or just a co-pay at the time of service. On the other hand, your medical benefits might have less out of pocket expense, perhaps with only a co-pay at the time of service. By knowing your benefit package you can make an informed decision on what is best for you;
- Depending on your vision benefit package, you may be able to use it once every 12 months or 24 months WITHOUT a referral from your primary care physician.
There are many options to consider and these options change with individual benefit packages. We want to help make this process as easy as possible, but we may not know your particular benefit package. Help us to help you! Know your benefits package; let us know if you are using vision or medical benefits; and tell us what insurance company we will be billing at the time of service. We appreciate your help in making your visit with our practice a smooth and pleasant experience.
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Drs. Fine and Packer were honored again to be selected as two of the top 50 opinion leaders in ophthalmology by the readers of Cataract and Refractive Surgery Today. This is the second year in a row that they have received this distinction.
Dr. Packer was delighted to be promoted to Clinical Associate Professor of Ophthalmology by the Oregon Health & Science University in Portland.
Dr. Hoffman was inducted into the prestigious International Intraocular Implant Club (IIIC), during the annual meeting of the European Society of Cataract and Refractive Surgery. The IIIC was founded in 1966 with the purpose of promoting world-wide research and free exchange of ideas regarding intraocular implants and implantation surgery. According to their web site, membership is limited to 250 physicians world-wide and to be considered for membership, a physician must have “extensive personal, practical experience of intraocular lens implantation; shall be recognized as an outstanding surgeon and teacher in his/her country; shall attend and teach at recognized intraocular implant courses or meetings; and shall publish scientific research in recognized journals.” All three of our doctors are now members of the IIIC.
Dr. Fine was greatly honored to be awarded a Golden Orchid by The Eye Institute of the National Healthcare Group in Singapore, “for [his] outstanding contribution to ophthalmology in Singapore.” This is a particularly wonderful honor for Dr. Fine as he is especially close to and proud of his former students and colleagues in Singapore.
Drs. Hoffman and Packer received Achievement Awards from the American Academy of Ophthalmology. The Achievement Award program of the Academy recognizes those individuals who contribute to the scientific programs at the annual meetings.
Finally, we are proud of Amber Ambrozaitis, one of our ophthalmic technicians, who recently passed both the written and practical examination to become a Certified Ophthalmic Technician (COT).
Congratulations to all! [ top ]