A Med Datum

From a reader who wishes to remain anonymous:

My work at an ophthalmologist’s office in an assistant capacity has provided anecdotal illustrations of many of the points Robin has made about medicine. One particular instance of the notion that medicine is more about showing you care than health follows:

Our practice has clear instructions about sterility. We are to use alcohol swabs to clean all pieces of equipment in the practice that come into contact with the patient’s person. Practically, this means forehead and chin rests on equipment used to test eye pressure, peripheral vision, etc. are scrubbed for every patient. Notably, we are told to perform this cleaning while the patient is being quizzed on his medical history, rather than in-between patients. It seems clear here that we want the patients to know we are being sterile, even if it takes time away from the actual exam.

Yet for all this production about sterility, after performing said tests, we do something that puts patients at significant risk for disease exposure. We apply dilation eye drops to patients—drops coming from bottles that have already been used on perhaps 50 patients prior! The probability that an eyelash or more has touched the tip of these eye drop bottles over the course of the multiple days they are used until empty is very high. Moreover, unlike the chin or forehead, the eye is a mucus membrane and is thus a more likely target for infection. This is particularly true considering the fact that our practice routinely sees patients for the express purpose of diagnosing and treating their eye infections!

Yes, we have clear instructions not to touch the patient’s eyes or eyelashes while applying said drops. But mistakes are definitely made. Many patients are not particularly compliant about keeping their eyes open while drops are being applied. The technicians that administer the drops are often sparingly trained (I myself have learned exclusively on the job) and have minimal oversight/feedback. Yet our doctors require that patients be dilated before they see them. Mistakes occur.

Meanwhile a foolproof fix exists: use individual droppers to administer the eye drops. My hypothesis as to why this has not taken place is that the practice feels little pressure from patients to make this change—perhaps the outward shows of sterility are assurance enough.

To reiterate, we seem to be biased toward making outwardly visible demonstrations of our ability to keep a sterile environment (scrubbing chin and head rests) but fail to do simple things that are less visible that would significantly cut into the potential for disease transmission. The result is, frankly, in the course of an eye health examination, our practice probably aids in the transmission of eye diseases. This is anecdotal evidence, but then again, data is just a collection of anecdotes.

Do you see how medicine could do more harm than good, even if almost all the time docs and their assistants feel in their hearts a sincere desire to help?  Only once in a rare while would someone raise an embarrassing question like the above, making folks momentarily doubt their effectiveness.

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  • Dave

    This point of view comes from the ever so popular school of thought that goes this way: All the day to day things we encounter that are conventional and claim to be authoritative, and good and are controlled by people who have power, are in reality corrupt and harmful ,and this is known to the authorities, who conspire to keep these evils in effect for their own selfish reasons.

    The problem with this theory is, other than in the news media, where are the bodies? In this instance, where are the patients streaming back to the doctor with eye infections?

    This is not to say that the procedure the doctor uses is great. If the procedure he is using, is out of date the he just didn’t learn it during his training. His professional association will eventually recommend some changes, which due to human laziness he may not follow. Perhaps government intervention ,or a lawsuit will occur. Or perhaps a drug rep will visit him and convince him to use a new improved,but expensive product. The problem is more cultural than any thing else.

  • Peter St. Onge

    I think this is miscategorized; it’s a story about misestimating probabilities for unfamiliar situations, rather than caring per se.

  • Marcus

    Humans having a tendency to miss glaring risks is universal, what is this supposed to be evidence of in this case again? I think people are pretty aware of the massively lengthened lifespans in the last century this hardly seems more than a wakeup notice, as we all experience frequently in our respective fields and endeavors.

    Besides, placebos and other psychological treatments can and do offer medical value, I don’t see evidence that a common error in application of eyedrops is more important a matter than reassuring patients who could be adversely affected by fear. (Making important tasks routine carries its own risks too, I’m not claiming that I have evidence the placebo value of demonstrated cleanliness is high, I’m just saying the counterclaim doesn’t seem complete either.)

  • http://entitledtoanopinion.wordpress.com TGGP

    Dave, I don’t know about eye-infections but large numbers of people do die on the operating table. The RAND health experiment showed no difference in mortality, which could indicate medical harms were about as common as medical healing. And Robin’s mention about the sincere desire to help does not sound like he’s arguing about corrupt people who know better conspiring for selfish reasons.

    Here’s a post at orgtheory on mortality that also involves the signalling model of education:
    http://orgtheory.wordpress.com/2010/09/15/education-and-mortality-it-doesnt-work-the-same-for-everyone/

    • Dave

      Yes,probably due to stupidity rather than selfishness. That can always be interchanged in these scenarios. Yet looking good compelled the doctor to clean the stuff that didn’t matter. Perhaps that is the point.

  • Hyena

    This is why I liked Kaiser so much. They spent a lot of effort showing me they care by speeding me through visits and telling me that “we could run a test, but we aren’t likely to find anything”.

    I don’t know about other people, but I feel better with a doctor who isn’t hyperventilating about my health.

  • http://kazart.blogspot.com mwengler

    This post would be a lot more interesting were it talking about actual eye infections rather than the untestable potential to cause eye infections by the untested exposure from touching eyelashes. If fact based medicine says (and it does) the doctor should wash his hands where I can see her do it, so be it. If fact based medicine is not implicating ophthalmologist’s eye droppers in eye infections, then hit me again.

  • Robert

    At my eye doctor, they wipe the top of the bottle with an alcohol swab
    Wouldn’t this make an infection from the bottle very unlikely ?

  • lemmy caution
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