Category Archives: Ramblings and Reflections of a Baby Boomer

Ask anyone and they probably know of a friend or a family member that has been diagnosed or is being treated for Age-Related Macular Degeneration (AMD). The macula is the central part of the retina measuring only 6mm in diameter and providing the central 20 degrees of our vision. Age-related changes of the macula occur in each and every one of us. What factors cause some of us to develop this pathological condition of an otherwise normally occurring aging process? The challenge as an eye doctor is to predict which of our patients are more at risk and to diagnose AMD before it progresses and causes vision loss.

The good news is that we have identified several factors that can reduce our risk as we age: not smoking, a diet rich in the leafy greens, use of nutritional supplements containing Omega 3, other lifestyle health changes, and using sun and UV protection. Current research is focusing on identifying certain genetic factors that put more of us at risk. New technology and retinal digital imaging systems to view retinal structure are constantly being updated and improved. On the treatment front, the use of injectable drugs to stabilize the “wet” form of AMD has proved beneficial to many patients. Newer drug formulations have been able to reduce and extend the number of injections required.

The bad and ugly news is that as the US population is aging the number of people with AMD is increasing. The sight-threatening “wet” form is projected to affect 3 million people this year. The grim statistics predict that up to 78% of AMD patients will have significant, irreversible vision loss in at least one eye before receiving treatment. (1) This presents a clinical challenge to us as eye care providers to identify subclinical findings that occur at a cellular level. Unfortunately, subclinical macular disease has no or minimally recognizable features. New dark adaptation studies identify that subclinical macular disease can occur 3 years before it can be seen with our current use of retinal photography or OCT imaging. We as doctors anxiously await new technology and are committed to combat this disease to improve the quality of life of our aging families, friends, and patients.

Rick L. Hartman OD, FAAO

1. Pizzimenti,JJ, Pinnacles of Awareness in AMD, Review of Optometry, 2019 Sept.,84-89.

I recently spent a beautiful North Carolina Saturday in front of my computer attending a Zoom Webinar. By now, most of us are familiar or have used the Zoom video conferencing platform. I was one of several hundred North Carolina Doctors of Optometry attending the North Carolina Optometric Society (NCOS) Virtual Spring Congress Webinar. This is usually one of the major statewide meetings of the NCOS to conduct business, elect new officers, and provide continuing education courses. The purpose for many including me is to attend the continuing education (CE) courses to receive the necessary hours required to stay current and for license renewal in North Carolina. So, conducting this very important meeting using virtual video conferencing was a new world.

The virtual webinar’s format required that I possess some knowledge of computer use, logging in and out of scheduled courses, use of webinar IDs, passwords, etc. For some of us Baby Boomers with no formal computer skills this can be stressful at times. Anyway, the webinar was well planned and except for some occasional audio glitches went well. The speakers were excellent and looked well-dressed, at least from the waist up since that is all we saw. The power point presentations were easy to follow and provided relevant and current clinical information. There was even an option to click on and raise your hand with a question. Just like being there in person… well, not really. In an actual meeting you can always jab the person seated at your side and joke about the stupid questions others ask.

The world and life are very different these days. Social distancing has certainly changed the things we have taken for granted in the past. I miss seeing and sitting next to my colleagues and friends at these meeting, asking questions of the speakers in person to put them on the spot, and coming away feeling reenergized and ready to return to my practice to put to use my newly gained knowledge. Doctors are always dedicated to continuing education and learning to provide the highest level of care to our patients. Virtual video webinars may be the reality of the present, but I miss the normalcy of the past.

Rick L. Hartman, OD, FAAO

      

     

Opium is harvested from the seed pod of the Poppy plant “Papaver Somniferum”. The opiates morphine, codeine, and others are naturally present and extracted from the poppy. Opioids for medical, recreational, spiritual, and cultural purposes date back centuries. In 1950, Chinese immigrants brought opium to the United States. The use of opium was introduced as a patented, unregulated medicine called Laudanum. This product could be ordered in the Sears Roebuck Catalogue. In the early 1900’s the original Coca-Cola formula contained alcohol and cocaine. It wasn’t until 1914 that the Harrison Act removed all opioid products from over-the-counter use, but did not make them illegal.

Fast forward to 1970 when President Nixon declared the War on Drugs and Congress passed the Controlled Substance Act. This Act created the Drug Enforcement Administration (DEA) and established the schedules for all controlled substances. Unfortunately, the war on drugs was not successful. In 1990, medical protocol adopted a 5th vital sign in the patient evaluation: pain level and untreated pain. The Epidemic was created in part by a Pharmaceutical Industry that marketed and promoted the use of opioids in pain management. These semi-synthetic and synthetic opioids were promoted initially as non-addictive.

National data collected from 2016 confirmed 47,000 opioid-related deaths. That was more deaths than reported in motor vehicle fatalities. As a result, many states (including North Carolina) are now adopting legislation to deal with opioid misuse and promote prevention.  The North Carolina Stop Act of 2017 made changes to physician prescribing of controlled substances and changes in reporting.

Opioid addiction and the altered chemistry of the brain is understood but complex. Genetic predisposition plays a role in making some individuals more prone to addiction than others. Males seem to have a higher addiction rate than females. Age-wise, the 25 to 55 age group seems more vulnerable. Also, addiction for some can occur in as little as 3 days of being prescribed an opioid-controlled drug. Current rehabilitation and treatment programs have not been as successful and have a high relapse rate. The problem with opioid use is increased patient tolerance. Tolerance for opioids increases with use, requiring higher doses to achieve the same level of pain relief. Increased dosage leads to increased risk of respiratory failure and death. Future research is attempting to unlock the secrets of addiction, cravings, and rewiring of the human brain. Hopefully, advances will be made in this war against the Opioid Epidemic.

Rick L. Hartman, OD, FAAO

Today’s healthcare system focuses too often on disease detection and medical treatment after the fact. The increasing numbers of people diagnosed with Type 2 Diabetes is a perfect example of this in our country. A far better approach is avoidance of the disease by lifestyle changes including nutrition, diet, weight control, and exercise. Physicians and patients are both guilty of facing the new health care challenges of the 21st century with 19th century thinking. For the patient, the easy answer many times is to blame the doctor or hospital and not assume some of the responsibility. For the doctor, his role is detection and treatment of the disease many times prescribing too many medications rather than taking time to educate about lifestyle changes.

In today’s environment, studies show we are dealing with many disease-causing toxins and pollutants that can weaken our natural immune system. In addition, the effects of over-prescribing systemic antibiotics, stomach acid blockers , and a host of prescription medicines has disrupted our bodies natural digestive, circulatory, immune, and regulatory systems. Despite a country that has more doctors and hospitals than any other, our life expectancy here in the USA has begun to decline.

For doctors, health care providers, and patients this is a wake-up call for changing our mindset about health and wellness. The human body can heal and recover if provided with the necessary nutrients, vitamins, and essential minerals to survive. We can avoid many disease processes by making lifestyle changes. This will require a commitment on all our parts to have the discussion about preventive care and research and educate ourselves on the benefits of nutrition.

In the eye care field, we can all do some basic things to take better care of the health of our eyes. Of course, how you manage your overall general health directly affects your eyes. Nutritional choices for eye health is much the same as is for general health: a diet rich in brightly colored vegetables and fruit, probiotic foods to aid in digestion, antioxidants such as Lutein and Zeaxanthin found in spinach and kale. Sunlight/UV protection is another must in reducing the aging changes and damage to the retina of the eye. Please don’t hesitate to ask if you have other preventive health questions to take better care of your eyes.

Rick L. Hartman OD, FAAO

The American Optometric Association has declared the month of March as Save Your Vision Month. The message is simple: the importance of the role of regular eye examinations in the maintaining of good vision and eye health. The message is worth repeating to those of us that are fortunate to have access to the care of our Doctors of Optometry.  The expression “An ounce of prevention is better than a pound of cure” certainly holds true for maintaining good vision.

I recently participated in a free vision screening sponsored by the Fuquay-Varina Lions Club. I commend the members who volunteer selflessly to support the Lion’s Club Mission in serving our community through free vision and hearing screening projects. The screening is a valuable service in identifying vision and possible eye health problems. Screening results are explained to every individual with the recommendation to follow through with a complete eye examination with their regular eye doctor if needed. I am not a Lion’s club member but welcomed the opportunity to provide my services. My take away was the number of people screened that never had a regular eye examination or were years overdue based on their age, or other risk factors such as diabetes, history of previous eye problems, or a family history of a vision condition or eye disease.

As I have discussed in a previous blog, early detection many times is the key to a better outcome in managing vision problems and preventing progression of many eye diseases. Unfortunately, in my 40 years of practicing I have witnessed cases of vision loss due to a patient neglecting their regular and scheduled eye examination. They ignored and failed to report eye symptoms until it was too late. Please don’t be one of these patients! Take time this month to reflect on the importance of the gift of sight and good vision. If you are overdue for an eye examination, contact your Doctor of Optometry and schedule an appointment.

Rick L. Hartman, OD, FAAO

Glaucoma is a disease that affects nearly 3 million people and the numbers are on the increase as our population ages. As a Baby Boomer this statistic concerns me both as an eye doctor and an aging patient. Presently, there is no cure for Glaucoma. However, with early detection progressive loss of vision can be prevented or slowed down. There lies the problem: early detection. Many patients have no visual symptoms and fail to schedule annual eye examinations. The key to preventing loss of vision is identifying risk factors, early detection, and treatment. Vision or glaucoma screenings are not a substitute for the comprehensive examination by your eye doctor.

Over my 40 plus years of practicing, the approach to diagnosing and treating glaucoma has changed. This has required yearly continuing education to remain up to date. Even the definition of the disease has changed. It is no longer just defined as increased eye pressure. Now, many types of glaucoma with different presentations have been diagnosed and classified. By definition, the one common feature is that glaucoma is an optic nerve disease that without treatment can cause blindness. The optic nerve (being the second cranial nerve) does not regenerate or recover once damaged. With the use of sophisticated optical imaging systems, the early loss of optic nerve and retinal nerve fiber tissue can now be measured. This is essential to the treatment and management of the disease.

I write this blog not to drum up business for optometrists or ophthalmologists, but to increase awareness about this serious and potentially visually threatening disease. I have been in the trenches and witnessed firsthand the consequences of patients failing to get early detection and then poor compliance following through with treatment. So, to my fellow patients and friends: Be proactive and answer the following questions. If the answer is YES to one or more of the following, it is time to do something preventative and see your eye doctor!

  1. Are you over 40 and has it been over 2 years since your last eye examination?
  2. Do you have a family member that has had or is presently being treated for glaucoma?
  3. Are you Diabetic? Have you been diagnosed with sleep apnea or atrial fibrillation?
  4. Have you experienced recent changes in your vision?

R.L. Hartman OD, FAAO

“I am so sorry, Mr. or Mrs. Patient, but nothing more can be done.”  These are words that doctors, including eye specialists, hate to utter. Unfortunately, patients that have lost significant vision may feel abandoned with little or no recourse. For me, this rings true for patients suffering from age-related macular degeneration (AMD). Age-related macular disease is on the rise in the United States. The sight threatening “wet” form is projected to affect 3 million people by 2020. (1) This will dramatically affect the rapidly aging Baby Boomer generation, of which I am one.  We can take steps to reduce our risk factors: not smoking, maintaining proper weight, using sun and UV protection, and maintaining a healthy diet rich in the leafy greens. But the reality at present is that there is no cure for the disease. Many treatment options at best may slow the progression and help stabilize vision loss.

The good news is that research is aggressively seeking a cure by focusing on genetic risk factors and use of stem cells to replace lost retinal cells. For now, the other encouraging news is the benefit provided by practitioners in the Optometric sub-specialty of Low Vision. Low Vision practice deals with the reality of vision loss in a positive way to help those affected by the visual impairments of AMD. The low vision practitioner never dwells on the vision that is lost. The examination evaluates the goals and visual needs of the patient and prescribes optical aides, devices, special filters and makes recommendations to maximize and benefit the remaining vision.

Low vision as a sub-specialty gets very little public attention. The efforts to help the visually impaired often get overlooked and are not offered or mentioned by our colleagues. The substantial time required during the examination and the commitment to the extra training often discourages eye practices and individuals from providing these services. I personally discovered this during my low vision externship many years ago in Philadelphia. Many days we worked long hours in examining only a handful of patients. But, this provided a teaching and learning experience that has stayed with me over my 40 years of practicing. As externs and resident doctors we were trained never to use the term “legally blind”. We treated our patient as a whole person who is partially sighted. Examining a partially sighted patient can present challenges but our mentor Dr. Randy Jose taught us to be positive, creative, and to think outside the box.

I hope that the future brings a cure for eye diseases like age-related macular degeneration. In the meantime, especially for us Boomers, we must be mindful of the gift of vision.

Dr. Rick L. Hartman

References:

1.     National Eye Institute. Eye Disease Fact Sheet

Wikipedia defines retirement as “the withdrawal from one’s position or occupation or from one’s active working life.” For some, this withdrawal from active working can be a long awaited joy. Many times I hear, “now I have time to spend with the grandchildren.” For others, retirement can represent a time of uncertainty and concern over a need to feel fulfilled. This has been said about doctors; that they don’t retire because of the fear of no longer being useful. Umm… I think I’ll take my chances. Ernest Hemingway put it this way when he said, “Retirement is the ugliest word in the language.” Jonathan Clements had a different take and raised another issue as he wrote, “Retirement is like a long vacation in Vegas. The goal is to enjoy it to the fullest, but not so fully that you run out of money.”

These quotes raise questions and some uncertainty for all of us Baby Boomers approaching retirement. Is retirement right for me? When should I retire and can I afford to retire? How will I spend my time in retirement? It would be nice if each of us could gaze into a crystal ball that would reveal the answers to these questions. Unfortunately, the reality is that we don’t know what the future will hold. Our best laid plans and projections cannot fully predict our future health and wealth needs.

After many years of being in denial, I finally gave in and admitted to being a senior and joined AARP. As a member, I find that the AARP Magazine can be a source of interest for those of us entering retirement. I am certainly not in agreement with all the comments and articles. I do believe that today’s economic environment of deficit spending and ballooning national debt cannot be good. As many AARP members, I am also concerned that Social Security and Medicare benefits are in jeopardy in the future. Many of us may find the need to work longer and rethink our dependency on Social Security. Also, economic surveys show that many retiring Boomers have not saved enough to maintain their standard of living.

Well, on a personal level I have enjoyed my career as an Optometric Physician. I have received as much fulfillment from my loyal patients as I hope I have given back in their care. As you can tell, I have unanswered questions heading into retirement. But recently, with more free time on my hands and the encouragement of a loving wife to get me out of the house, I have become involved in new activities. I recently also became interested in meditation as a form of relaxation and stress management. Meditation takes practice but has taught me not to be stuck in the past and not to dwell on the future and enjoy the present moment. This is easier said than done. As all meditation ends, Namaste and Happy Retirement.

Dr. Rick Hartman

Fast forward to the year 2028 – The age of electronic medical records will be solidly entrenched. The sharing of your health information between you, your doctors, and all of your health care providers via the internet will seem common place. We will all have patient portals to communicate with everyone involved in our health care.  The creative advances that are well underway today will become standard of care. Technological advancements will all be available to individualize your care, including: the mapping out of our individual DNA, the use of cellular level digital imaging systems, the use of artificial intelligence to aid in diagnosis and treatment, and the use of implanted biochips to monitor vital signs.

So, I can try to predict what my area of expertise (optometry and eye care) will look like in 2028. Rumor has it that at that time, you may only have an encounter with a virtual eye doctor. Using telemedicine and data collected by a technician, the doctor may be in another office. I’m hoping the norm is that the patient-doctor encounter will still be face to face. Here at Johnson Optometric Associates, however, we will always pride ourselves on the personal patient-doctor relationship!

Since the human genome sequence (DNA) was completed in the year 2000, by 2028 our office might have a copy of your individual DNA. This can already be collected via buccal smear of your cheek to detect a gene variation associated with Age-Related Macular Degeneration.  Many other genetic eye disorders and systemic disorders that lead to eye disease will also be detected by an individual’s DNA.

Back to your visit at our office…  Technicians, using sophisticated automated refractors and topographers, will measure and collect your refractive data necessary for glasses or contact lenses. In addition, digital real-time images will be taken of your retina by the latest technology of imaging sensors by high quality retinal cameras. Abnormal retinal or optic nerve findings can be further imaged at almost the cellular level by laser scanners and optical coherence tomography. At present, this technology exists but is constantly improving. The use of artificial intelligence (AI) to recognize and interpret these images is being studied. The concept of artificial intelligence is to learn, interpret, and draw conclusions. As I see it, this is one of the biggest challenges of advancing technology, especially when the welfare of our patients’ vision is at risk. Is the artificial intelligence computer reliable and reaching the correct diagnosis?

Another aspect of health care in all doctors’ offices, including Johnson Optometric Associates, is the monitoring of your vital signs. Biosensors embedded anywhere in the body can monitor any vitals 24/7 from your doctor’s office or even on a patient’s iPhone. In addition to blood pressure, I see us in the future monitoring eye pressure possibly using microscopic biosensors implanted within a wearable contact lens or even embedded in the front chamber of the eye. The problem with monitoring any vital function is that these measurements fluctuate throughout the day. Twenty-four hour monitoring of eye pressure is important in diagnosing glaucoma. At times the eye pressure may be within the normal range when measured during daytime hours in the office. But studies confirm a diurnal fluctuation in intraocular pressure, sometimes much higher after midnight while the patient is sleeping. This increase would be detected using an implanted biosensor.

Our present healthcare system focuses on evidence-based guidelines and data collection that treats a population with the same disease pretty much the same. By transforming the future of health care, these creative advances allow doctors of all specialties to customize treatment to the individual patient. I encourage you to stay informed and empowered to deal with the future transformation of our health care system. I hope this change can be positive and continue to improve the quality of care while promoting more preventive care and improving efficiency to ultimately reduce costs.

-Dr. Rick L. Hartman

 

 

The Affordable Care Act (ACA) was passed in 2010 in an attempt to control runaway costs in our health care delivery system, improve efficiency, reduce errors in the present health model, and hopefully offer affordable health insurance to all Americans.  The ACA implemented a program of health information technology that utilized electronic health/medical records and mandated health care coverage for all.  From my perspective, as boomer-aged doctors (in the age range of 55 to 72) set in our own practice modes and, like most, reluctant to change our habits, participating in the ACA was a hard pill to swallow. This was an intrusion by Big Brother, our Federal Government, into how we practiced and delivered care, especially to our Medicare patients.  Of course, many boomer doctors opted out of participating, refusing to see Medicare and Medicaid patients, or planned an earlier than expected retirement. Let’s look at some of the changes initiated by the ACA.

The ACA was projected to be a future cost-savings benefit. For participating doctors, the initial costs were far from affordable. The converting of records kept in paper charts to electronic medical records (EMR) required computer servers, monitors in every location, software and software licensing fees and was not cheap.  This required down time from providing patient care for training of staff and doctors.  We were lead to believe that we could expect to reduce staff based on increased efficiency using electronic medical records. Wrong.  Our staff numbers from the additional techs needed in the exam lanes to our front desk personnel and business /insurance office increased.  And guess what?  Uncle Sam did not reimburse for all these added expenses.

I believe I can speak for most Baby Boomer Doctors: we love recording and at times scribbling in our own patient paper charts. We have our own descriptions, abbreviations for taking a medical history, and methods of recording our findings and impressions. Yes, sometime it is difficult for another professional to read our writing. But change is frustrating and slow, especially when our findings have to be recorded and typed into the patients Electronic Medical Record. Many Boomers (like me) are bad typists and have limited experience navigating through an electronic chart. There are security logins required, multiple screens, drop downs with descriptions that don’t fit our usual terminology, and added requirements that add nothing to improving the health of our patients.

Another interesting event that occurred during this initial period of transition under the Affordable Care Act that our patients and many non-medical personnel were not aware of: Doctors of all specialties had to adopt the 10th revision of the International Classification of Diseases, ICD-10 for short.  For doctors, this changed and expanded the number of codes for any disease or condition known to mankind from a total of 16,000 codes to over 70,000.  Although we were only responsible for those new codes in our specialty, updating our computer systems and ourselves and staff was a nightmare. The good news was that Medicare, and the insurance companies, gave us a 6 month grace period for filing incorrect codes and claims before they refused to pay. They were so generous… just kidding.  We were (of course) responsible for refiling claims at our expense.

One last point before closing, as a Boomer Doctor we not only practice our specialty and care for our patients, we have to run a business that must remain financially solvent. We need to pay rent, overhead expenses, meet our payroll, cover our own increased cost of health insurance for our staff and doctors, and afford the increased costs of new technology and equipment.  With increased government regulations and now under the Medicare Access &Chip Reauthorization Act of2015 (MACRA) the first step to replace the fee-for-service system with outcome-based reimbursement may put in jeopardy the ability to survive as a private practitioner or business.  More to come on this with my next blog on “The Future of Health Care”. Retirement is looking better and better.