The Most Efficient Office in the World: The Most Efficient Doctor’s Office in the World

Medical and surgical technology is constantly pushing the boundaries of health care around the globe and redefining how we diagnose disease and improve health outcomes.

Keeping pace with this vigorous progress, physicians, surgeons, academic centers, hospitals, and private offices across the world are continually updating their equipment and services in order to offer the latest in high-tech surgical and medical care. From specialty surgical and medical centers with state-of-the-art digital imaging scanners, to multi-disciplinary mega-hospitals featuring cutting-edge medical robots, all surgeons and physicians are trying to provide the best possible care with the best efficiency… since every one of us, especially a sick patient, hates waiting and waiting to see the doctor or doctor’s staff.

Everyone I know is working hard on this issue. Still we have emergencies that interrupt a perfectly orchestrated schedule to minimize our waiting times.

In ophthalmology we are blessed and cursed. The eye is so intricate that we now have practically a machine for each of it’s important layers and functions. At Harvard, each of the key machines was on a different floor. The Retina floor had the OCT. The Glaucoma department had the HRT, HVF. The Cornea department had the only MARCO in the whole institution and there were many fights as to who could use it.

In private practice, we are blessed to have all the key machines in one location. Still because imaging the many areas of the eye are crucial in many patients to being sure one does not have a potentially blinding or debilitating chronic pain condition, it can take hours to get through an eye doctor’s basic visit.

This is frustrating for everyone.

Also, no one wants to be made to feel they are on a conveyor belt of testing. But this is what it seems we have to deal with.

Currently patients check in and then sit down. They they are called to have basic testing. They have to get up and sit down at each of the following machines at times. If the doctor needs another test, they have to go back and get the other machine check. Each machine is crucial for particular issues and sometimes the patient will not complain about an issue unless asked point blank by the MD and then the machine can help determine if further testing or surgery is needed.

Our biggest obstacle is how to evaluate all the layers of the eye as efficiently as possible without making the patient feel they are literally on a conveyor belt.

I love these machines! They make me the best physician and surgeon I can be. I have saved countless lives and patients’ eyesights with these machines! When I walked into Visionary Eye Doctors for the first time after having been at Harvard for 9 years, my jaw dropped! “You have all these machines in one floor? Are you kidding me!” I was so thrilled! I still am.

A few months ago, a 48 year old patient came in to the front desk and announced, “I think I am having a stroke.” But he could move his hands and arms and walk and talk normally. His vision was normal 20/20. He was so sure of it, we did an immediate Visual Field (below machine) and sure enough he was right! He was having the beginnings of a stroke. The ambulance came and he had immediate care at the hospital nearby and came in with tears to thank me recently for saving his life. If he had had to wait to get the visual field, the story might have ended differently.


This is the autorefractor that allows us to more precisely determine what glasses Rx a patient might need. It is sometimes repeated after dilation to determine if headaches or eye strain are due to latent hyperopia (needing a stronger glasses Rx.

This is a Pentacam that determines the curvature of the cornea, the extent of astigmatism, checks to be sure you do not have early Keratoconus or other corneal disease, checks your angles (inner eye drain) to be sure you do not have narrow angles which can cause headaches and is a risk for glaucoma, a potentially blinding condition). 

This is a LipiScan which scans the Meibomian Glands to see if they are healthy or atrophied. Meibomian gland disease is the leading cause of eye redness, pain, burning, tearing, dryness and can lead to a chronic pain syndrome, loss of vision, depression. 

This is an Optos which allows us to see the inside of the eye and the retina with a wider view, even through an undilated pupil. It wills how most inner retinal and vitreous pathology very well to the MD and patient. It can save the patient a great deal of time and avoid the 4hrs of blurry vision after dilation. 

This is the MARCO Refraction System. This is one of the most expensive machines out there. It can do an autorefraction and check your need for glasses Rx fast. The machine in the back measures your current glasses Rx.

This is an HRT or Heidelberg Retinal Tomography which is an amazing machine. It literally takes slices of images of the central retina and macula. We can determine if someone’s loss of vision is due to fluid under the macula from macular degeneration, diabetes, surgery, trauma, tumor, local stroke. 

This is a Humphrey Visual Field (HVF): this determines if there is a defect in the optical pathway of the brain, from the occipital cortex to the optic nerve. It helps us determine if one had glaucoma (localized nerve damage) or a brain tumor.

These are the ERG and VEP machines that allow us to determine the functional health of the retina and optic nerve. If the MD cannot see anything abnormal on the microscope, these machines can pick up sub-clinical diseases. These are used for retina and optic nerve diseases.

This is the IOL Master and Manual Keratometer: this determines the curvature of the cornea and axial length of the eye in preparation for cataract or corneal transplant surgery or IOL exchange, LASIK, PRK. 
This is an Endothelial Cell Counter: it takes a photo an counts the number of endothelial cells on the inner surface of the cornea and determine if their shape are normal or abnormal. If these cells start to die or malfunction, your clear cornea will no longer be able to pump out the water that makes it clear like a piece of glass. Loss of endothelial cells make the cells turn from looking like a clear piece of glass to being thick and opaque like the white wall of your eyeball called the sclera. We check this in every patient over a certain age to be assess his or her risk of Fuch’s Dystrophy (a loss of these priceless cells). 
So does anyone out there have any suggestions on best line these machines up so patients do not have to get up sit down over and over again without being made to feel they are on a conveyor belt. We laugh that in Russia, this is how cataract surgery is sometimes done…literally on a conveyor belt. But Americans can’t stand the idea. But they’s can’t stand inefficiency either.
My vote is to line them up and put the patient lovingly in a rolling chair and roll them to each machine. Could it be done in a way where patients do not feel pushed through a conveyor belt? That is the key question.
But our key goal is to cut down our waiting times so the surgeon and doctor can spend more time with the patient. 
Sandra Lora Cremers, MD, FACS

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