Knock Knock Eye: I Had a Surgical Complication—Here’s How I Dealt With It
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The U.S. healthcare system, it needs some improvement. Yeah, there's room for improvement. Yeah, it's a confusing, scary place for everybody involved. Absolutely. Physicians, families, patients, everybody. Everybody. And I've experienced it from both sides, right? I'm a physician. I've also been a patient. So I wanted to use my platform to give people practical education, really the only way that I know how.

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Knock, knock, hi! Welcome everybody to Knock, Knock, I! With me, your host, Dr. Glockenflecken, your one-stop shop for all things eyeball-related. I'm coming to you in my studio slash parents' guest room while they're here. So if you're watching on YouTube, there is a bed behind me. I kicked out my parents so I could record this episode. And I gotta say, today...

A rough day at the office. You know, you just have those days where it's just like, it's just a tough day. I'll tell you why. I was in surgery this morning and had myself a tough case. A bit of a complication. Not something I could really avoid, but it still doesn't feel good when things don't go exactly the way you want it to be. Surgeons, we are...

We're perfectionists, like most people in medicine, like we're type A in a lot of ways. And we were perfectionists. That's like a fault to a fault often. And I am no exception. And so I want everything to go perfect. Sometimes that doesn't happen. And today it was my old nemesis.

pseudo-exfoliation. It struck again. And so I'll just tell you what happened. And I think I've talked about this maybe a little bit before, but it's worth discussing again. I think it's helpful to hear people talk about things that don't go right because it happens with all of us, right? And so anyway, this is a patient, lovely patient. They're all lovely. All my patients are wonderful.

And doing, you know, I'm not going to call it routine cataract surgery because it wasn't routine. It was a fairly severe lens. And this is another reason why I always tell people, like, don't wait until like your 90s. This patient wasn't 90, but you don't want to wait a long time before you have cataract surgery because the cataract surgery, there's lots of things that can go wrong. And the surgeries become more difficult the longer you wait.

I'll keep saying that till the end of time. That wasn't so much the case here, but it was a fairly dense lens. So this is a cataract in a patient. I just started seeing this patient recently. It actually was referred to me for a cataract evaluation. But this is a cataract that could have been removed probably 10, 15 years ago.

And so I know it's going to be a dense lens. It's going to be a little bit more difficult of a surgery. When I say dense, that just means that over time, the cataract, which is your natural lens, it gets darker and it cloudier and just thicker and harder. It's dense. So it takes a lot of the little...

Well, we call it a FACO needle, which is basically like the thing that cuts through the cataract to break it up into a bunch of different pieces so we can suck it out through a two millimeter, two and a half millimeter incision. And so whenever the cataracts really dense, it's just harder to break it up. And it's just like breaking up a rock.

So that's kind of what I was dealing with, but it wasn't just that. If that was the case, okay, fine. I've done tons of cataracts like that. That's just part of the gig, right? That's what they pay me the big bucks for is to take out the tough cataracts. But the other thing was that this patient had one of the arch nemeses of ophthalmologists

the disease pseudoexfoliation. I'm going to talk a little bit about pseudoexfoliation, and then I'll tell you what happened with the patient because I think that's the order that this makes sense. We may take a break here in the middle of it. So pseudoexfoliation, we're getting into our eyeball knowledge early, folks. So pseudoexfoliation is an age-related disease. It's actually a systemic disorder

That targets mostly the eye tissue. And so this is a disease that is characterized by this fibrillar material, these little white-ish clumps of...

we don't really know exactly what it is, but we think it's like extracellular matrix and like degeneration of basement membranes that basically just causes this whitish grayish, um, fibrous material, almost like cotton. Like if you pull apart cotton and you see these little flecks of tissue that build up really throughout the body, but it,

Only seems to really affect the eye. There may be an association with heart disease, but that's really not established. So we're not going to talk about that. This is an eyeball podcast episode after all. And so but you get this accumulation of this material in patients over the age of 50.

And it goes everywhere inside the eye. So you see this on the lens. That's the easiest place to find it. You see it on the lens capsule, like the front of the lens, the ciliary body it's on, the zonules, which again, those are the strings. This is going to be really important in the context of my patient that I did surgery on today. The zonules, which hold that lens in place, that keep it stable and allow me to operate on the cataract.

That, that fibroloam material, that pseudo exfoliation material just covers those zonules. It can be found on the cornea, the iris, basically anything inside the eye. We don't really see it on the retina, which is kind of interesting, but, uh, but all the other parts of the kind of anterior, the front part of the eye, and there's a really high risk of glaucoma, about 50% of these patients with pseudo exfoliation syndrome are

they have glaucoma, 50%. So it's a really, and they can get very high pressures. It can be very hard to treat. And the reason they get glaucoma is because that flaky material, it builds up in the trabecular meshwork, in the drainage system. It plugs up the drain. Just like a bathtub, that water's going to rise. You know, you plug up the drain. So you get, you can get people with pressures in the 50s, 60s with sewage exfoliation. It can be pretty bad.

And so other risk factors of this, obviously, you know, age is a big one. There might be a genetic prevalence to it. There probably is, but we see it a lot in patients as a very high prevalence in Scandinavia. So Northern European, Northern European ancestry, like that's who you see this with. And so it's a pretty common disease and it doesn't always cause problems.

Sometimes people just have it, but they have cataract surgery just fine. They don't have glaucoma. They do okay. But sometimes it doesn't go well. And so one of the biggest risks, other than glaucoma, we're going to set that aside because that's not the point of this. The biggest problem and the biggest headache that this causes ophthalmologists is

is when you're doing cataract surgery. And that flaky material affects the zonules that's stabilizing that lens so much that it causes those zonules to fail very easily. And so I'm seeing this patient in pre-op and I see the pseudoexfoliation. I know it's there. I've done surgery on a lot of pseudoexfoliation eyes and it's gone both ways. Just fine to, uh-oh,

And so there's ways to try to figure out if that's going to be the case. One thing would be, do you see when I'm doing an exam just at the slit lamp, do I see the lens jiggling inside the eye? That's what we call pseudophacodonesis, not pseudophacodonesis, phacodonesis. Pseudophaco would be the artificial lenses jiggling inside the eye. Phacodonesis is the natural lens. The cataract in this case is shaking.

with each eye movement, that indicates that the lens is loose and that you're going to have some big problems on surgery day. That doesn't always happen. You don't always see that. And in this patient, I did not, unfortunately. So I knew the zonules were affected because she has this disease, but it seemed to me that things were pretty stable inside the eyes. Like, okay, well, this might be one of those cases where they have pseudoexfoliation, but

And the dilation was not bad either. So I was like, I, you know, I think it might be stable enough to just do a normal routine surgery. Well, my friends, that was not the case. Uh, and so I got in there, I started doing the surgery and, um, uh, as soon as I, so the way this, the way the cataract surgery works, everything was going great. I was, I made my, my, what we call capsular rexus, because remember the, the lens inside the eye,

Think of it as a peanut M&M, right? I need to open up the outer candy shell so I can scoop out, making it sound really gross. I scoop out all of the inside of the peanut M&M, the inside of that lens. I leave that candy shell intact. That's the way it's supposed to work. You remove all that inside stuff and then you put the new lens inside that candy shell, which is basically translucent. So,

I do the first step of it, which is just removing the top of the candy shell so I can get access to the stuff that's inside. And then as soon as I put my FACO needle, the thing that cuts up the lens, that disassembles it into a bunch of different pieces, as soon as I put it in and started what we call FACOing, I put my foot on the pedal, I started cutting into the lens.

half of those zonules just melted away. They were just lost. And what happens? So there was literally one half of the lens. So I saw, I watched as this happened. I started my groove. I started cutting into the lens. I was very careful, right? I was like trying really hard not to put too much pressure. It just, the lens just went

I could see it started falling into the back part of the eye, but only half of it. Half of it was good, but the other half was falling into the back of the eye. And so this was a moment where all ophthalmologists are like, well, that's just great. Now we got to deal with this. Let's take a break. I'll tell you what happened next.

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Love Lids, L-O-V-E-L-I-D-S.com to learn more about Demodex and Demodex Blufferitis and how you can get rid of it. All right, so I'm sitting there. I basically don't have any of this lens removed, any of this cataract removed. And the lens is like half of it's hanging down into the bottom of the, into the back part of the eye.

Now, one of the basic rules of cataract surgery as a cataract surgeon is you don't go fishing for things in the back of the eye. That's a totally different area of the eye. You can cause retinal detachments. You can cause all kinds of problems. You can increase your risk of a post-op infection. Bad things can happen when you try to venture too far into the back of the eye. And I know this sounds ridiculous. How big is this eye?

Why you're so fragmented in ophthalmology. Yeah, it's true. We get the retina specialists do amazing work. I don't want to do their job. That seems hard. All right. I'll stick with the front part of the eye. Thank you very much. And so and so my my my priority here, I already know like, OK, this lens is going to remember only half of it is kind of falling into the back.

I don't want the whole thing to fall back there. I don't want the entire lens to fall back in the back of the eye because that would require a second surgery in a more urgent manner. If I can at least get this cataract out of the eye

Then we have some time before the patient's going to need a special lens that gets sutured into the eye, what we call a secondary IOL. There's no way I can put the normal artificial lens like I normally do inside the eye because I've lost that candy shell. There's no stability to it. There's no stability. The zonules are gone.

I can't put a lens in there like that. And so my priority at this point, I just need to get the cataract out any way I can. Because if it falls into the back of the eye, you're talking about a second surgery. This patient is going to need a second surgery anyway. The issue is timing.

Because the eye does not like having a cataract in the back of the eye. It's going to incite a ton of inflammation, probably cause the pressure to go really high. It's going to be hard to control. The eye won't be able to heal from the initial surgery as well. And so now you're looking at doing more of an emergency surgery.

kind of a subacute surgery under less than ideal conditions for the retina surgeon who's going to be doing it. So I got to get the cataract out. And by miracle of miracles, I mean, I was kind of proud of myself for this. I was able to, I basically prolapsed the lens. I was able to get a hold of it with my cutter and bring it up in front of the iris

where I was able to get the lens out. So not the way you're supposed to do it, but I was able to get 98% of it out. There was this one little fragment of the cataract that did fall into the back of the eye. But in general, I was able to get the vast majority of the lens, which I think will definitely help the patient in the long run.

The second thing you want to try to do when you have a complication like this is not only just get the cataract out, you want to try to get an artificial lens in the eye however you can. There was really no way I was going to do this. 30 years ago, I probably would have done like a giant 6mm incision and put an anterior chamber lens in the eye. That means a lens, an artificial lens that goes in front of the iris.

But now we have such good technology and amazing techniques that I don't do. I don't do secondary lenses where you can suture the lens where it's supposed to be, even without that candy shell framework we talked about. So I was like, okay, that's what this patient's probably going to get because otherwise the eye is healthy. And so I just closed up the incision. I finished the surgery. I cleaned everything up the best I could, took out a little bit of the vitreous that had come forward.

And the patient post-op this afternoon looked pretty good. Pressure was a little high. We're dealing with that with drops, lots of steroid eye drops. She's going to see my retina colleague in about five or six days, and they will plan on doing a secondary sutured artificial lens inside the eye. So

Sometimes it doesn't go your way and you just do the best you can under the circumstances. And part of that is just experience. I've been in this situation not a lot, but a few times before. I have the techniques down to be able to do the best I could.

Would other surgeons have done it slightly differently? Maybe. Some surgeons might have the ability to just suture an IOL right there. That would have been a very long surgery, and I was not prepared to do that. I don't have the—my partners do that a lot better than I do. They do a lot more of those types of lenses. So anyway, we made the most of a tough situation. Here was the key, though. I had a feeling this might happen.

And so, so much about surgical planning is the consent, setting expectations. This patient, I had a good rapport with her and with her family. And I told them before, I was like, there's this disease. I explained pseudoexfoliation to them. And I told them that this was a possibility. Like there is a chance that there could be a second surgery that's needed if that lens, if that cataract is unstable.

And it certainly helped. It helped just set the expectations. And so when I, after the surgery, right after the surgery brought the family member back, I sat down in the post-op area and I, I just had a conversation. I told them exactly what happened, what the next steps were. I told them, you know, this is not how the surgery is supposed to go. This is not what I planned, but you know, you know, considering, you know, the, the challenges that we were facing, um,

I think it's a pretty good outcome. And so had to talk through all of this and it's just about communication, you guys. Like it's, it's, you know, and I've had, you know, a number of complications in my career as every surgeon does. And so communicating,

pre-op post-op that's just so key and i saw them again later on in the afternoon went over the the all the drops and everything and fortunately actually i'm on call this week so if something happens i'm going to be the one that that takes the call from them um and uh so even though i feel like it went as well as it could could there have been things that i i could have done a

Yeah, I need to think about it a little bit more. Not a whole lot, but there's got to be a way I could have. There's definitely ways that I could have avoided that altogether, but some of that might have been just I had to know that there was that much weakness. It doesn't make it easier, though. It still sucks. And so one thing I want to talk about briefly, and I've talked about this before, is just dealing with complications, surgical complications, mentally.

And, you know, before when I was in a residency, like a complication like this would have just sent me spiraling. Um, it's like learning how to be a surgeon, really just a doctor in general. It's like when you're early in your career, like you're, you can think of your confidence as like you hanging onto the side of Mount Everest, right?

in like a sheer cliff and you're like free climbing this cliff and anything that goes wrong, any complication, the first thing that where you screw up and you hurt somebody,

It's like something knocked you off the cliff and you just fall. And your confidence, you had made all that progress, all that education, and now you feel like you're back at zero. You fall, you don't die. You just fall to the bottom of the mountain and you got to climb back up. You got to build up your confidence again. But then as you get higher up, it's no longer a sheer cliff that you're just hanging on for dear life.

As you get experience, as you get through training, as you get into the, through the first few years of practice. Now I'm eight years into my, my career post residency. I'm no longer hanging onto the side of a cliff. It's still a little bit of an uphill climb because I'm still getting better. We got to improve. We got to improve all the time as physicians. We got to learn more. We got to develop new techniques. We got to stay up with the latest advances and advancements, and we just got to get, get better. If you're not getting better, you're

What are you doing? And so you got to work at that. You got to get the experience. You got to do the hard cases. You got to experience some of these challenges. But now, because I have all that experience, I'm not hanging on for dear life on the side of a cliff. It's it. I'm like uphill. I'm like on a slope, you know, but I'm stable. And so when something happens, when a big gust of wind comes, it doesn't knock me off the cliff and I fall back to the bottom.

I lose my footing a little bit, fall a few feet, and then catch myself. I still have confidence because I know I'm still a surgeon. And then I keep climbing. I don't know if that metaphor made sense, but that's how I think about it in my head. That's how I think about where I am now when I have something that doesn't go right in the operating room or in clinic or just anything versus when I started. When you get hit with something, when you make a mistake,

It doesn't just completely deflate you and you don't completely lose your confidence. When you have that experience, you still have your confidence. You just take a little bit of a hit, but then you can come right back. So anyway, uh, that's, um, that was my morning and that was, that was my, my third case of the day. My third of 10. I don't know if it's better to have that happen at the beginning or at the end. Um, I want to say probably at the end is better cause you, you know,

I feel like I was behind and there's nothing you can do. Like you're, I'm going to get behind after having a, you know, it was like a 37 minute case was, which doesn't, doesn't sound like a long time for a, for a surgical case, but in ophthalmology, whenever we can do six and seven minute cataracts, it's like, it felt like an eternity. So,

But it's not, you know, those types of cases can easily go 30, 40, even up to an hour, you know, and that's just the way it is. You got to do what you got to do. It's just harder because the patient is awake, right, during these. And so it does take, not only are you managing the complication, you're managing the case, right?

You're also kind of managing the patient. You're updating them. You're reassuring them. You're talking to whoever's doing the anesthesia, asking if they can give some more. Usually they're on top of it because they know they've been in enough eye cases that they know when something's not going right. And so it's really a team effort and helping the patient stay calm, reassuring them that everything's under control. It's just going to take a little bit longer. It's going to be a few more steps. It's going to be a few more minutes.

Um, and, uh, and so, yeah, it was toward the, toward the beginning of my day, everything else went without a hitch. Um, cause you gotta, you gotta, you know, kind of compartmentalize a little bit in the moment, you know, deal with that case, talk to the patient, talk to the family, and then you gotta just set it aside for a bit because you gotta focus on the next, I gotta focus on the next seven cases I gotta do, which also takes experience to like learn how to do that.

You know, that's something that I found very difficult to do early in my career. And fortunately, these types of things are pretty few and far between at this point in my career, but it's happened enough over the years that I've gotten used to, I know how to say, okay, like that this happened, you know, the patient's in a good spot right now. They'll be okay. Let's focus on the next case.

I don't know. That's just, you know, every specialty has their, has their challenges. And, um, and so I still love it. I still, even on days like today, which just kind of suck. I, I still, I still love cataract surgery. I still like doing surgery. All right. That's my story for today. And that was in clinic this afternoon. So there's been a long day. And, um, uh, now I'm, I'm in my parents' guest room recording and telling you all about it. So, um,

I don't know. Let me know what you thought. Any of you healthcare professionals out there who have mistakes and bad things, how do you deal with it? What do you tell yourself? Have you found that it gets easier over time? Because I assume it does. And do you have any things that you can...

Any tips, any ways of dealing with it, of dealing with the mental stress of doing something that didn't go quite right? Because I'm sure we all have our own unique ways of handling those challenging situations. All right, let's take one more break and we'll come back with a little healthcare stuff.

All right. I want to, I want to talk about something really fun here at the end. Just a little bit about the affordable care act. Just real fun stuff. Excellent. Just great stuff. First, let me, I just want to address or just point out a couple of great comments that I received. Again, a comment on the podcast episodes on our YouTube channel at Glock and Fleckens. I always check those out. I love to see your comments.

This is a great one from at log homeboys. 6806 said, I've been listening to you for a long time. You finally mentioned bilateral microphthalmia. He called it micro eyes. I like that micro eyes much easier than microphthalmia. Too many consonants, too many vowels that we force into every word.

I have bilateral microophthalmia. Left eye is 13 millimeters, right eye is 14 millimeters. That is incredibly short, you guys. So less than 18 millimeters is what we call a nanophthalmus, which is typically, it's a small eye, but functionally...

Usable, typically. Like, you can still see, you still have normal architecture, normal anatomy inside the eye with a nanophthalmic eye. Microphthalmia typically is you have like more of a disorganized eye and it doesn't always see well. This is a remarkable individual who's writing this comment because he says, I am legally blind, but correct enough to, drumroll, drive in Wisconsin.

A while back, I did an episode about driving laws and like the vision requirements in each state. And Wisconsin is one of the most lax states in terms of vision requirements for driving. I think it is. It took the K. I think it was like, you have to have one eye that sees 2100 or something. So.

Uh, congrats. I hope you're driving safely. I hope you have enough adaptive devices, um, uh, long homeboys to, to, to allow you to drive relatively safely. But that did make me laugh. I like that. Um, this person says, I believe I am one of five adults in the country with bilateral microphthalmia with vision. That's very, very unusual. So thank you for sharing. Uh, I love to hear that.

I had this was an episode as well where I talked about Southwest Airlines selling out to private equity.

And, um, at that climbing girl said, and meanwhile, us Europeans flying easy jet or Ryan air are only allowed to take a small backpack on board for free. I've, I have flown Ryan air before it was, it was interesting. They have a good social media presence. They're very self-aware in their, uh, budget status as a European airline. Uh, people bemoaning, lots of people bemoaning the, um,

The change to Southwest of requiring you no longer will get two free bags starting in May. That's what it's happening. May. Get ready, guys. Here's a good question. At Mr. Wheel 74. As you age, is it possible for your site to get better or does it always get worse slash stay the same? I would say as you age, your vision will not improve. Just change.

on its own. Like you don't become myopic, nearsighted, and then get better vision. One thing that can happen though, is as you age, you can become less farsighted because the eye might get bigger as you get older.

That usually stops, you know, when you're a certain age, when you're in your adolescent years. But also as you develop a cataract, if you're farsighted, as you develop a cataract, you can actually start gaining distance vision. You're like, all of a sudden people are like, oh, I can, all of a sudden I can see better. Well, that's actually because the cataract is making you more nearsighted. That's the thing that happens. So people who are farsighted,

All right. As they become more nearsighted, they actually get closer to zero. So farsighted, you're like a plus. Say you're a plus two. Nearsighted people are minus, minus two. Well, if you're plus two and you become more nearsighted, you could end up at zero. What we call emetropic. People that don't wear glasses are emetropic.

And so it's like, I have people that come in and they're like, oh my gosh. I mean, they were farsighted. They're a plus two. And after a couple of years, wow, they're, they're in my trophy. They don't have, they're not plus two anymore. They're zero. And they're like, my distance vision is pretty good. It's good for now.

But the reason that's happening is because you're developing a cataract and that's going to cause problems like glare. Eventually it'll cause your vision to actually decline. Either you're going to become nearsighted or just the quality revision is going to degrade so much because of the cataract that you're just going to need cataract surgery. So it's like a fake improvement in your vision. So I would say, no, as you age, your sight does not get better, but fortunately, you

Through the magic of modern medicine, we can make it better when it gets worse. So thanks for that. Thanks for that comment. All right. And then a few thoughts here. I'm not going to spend a lot of time on this as the episodes. I spent a lot of time talking about pseudo-exfoliation today. So I've used up most of my time. But I want to just make a, you know, I'd say on social media every now and then, you know, I see people complaining about the Affordable Care Act.

And for good reason, for good reason. And this ties into the reason I've been thinking about this is just because of the physician shortage. The fact that there were like 800 unfilled positions for family medicine in the match. And I feel like I'm always seeing people talk about so-and-so's leaving medicine or, you know,

My doctor's retiring. I hear that from my patients all the time. Well, my doctors keep retiring. They keep retiring. They keep quitting medicine. They keep doing other things. And sometimes it's not even people in retirement age. They're just sick of it. They're just sick of medicine. They want out. They're sick of the bureaucracy. They're sick of the paperwork. They're sick of the, just the way we have to practice medicine now, which is awful like that. What a loss to society to have someone who's highly trained,

who spent their entire 20s learning how to be a family practice physician or a pediatrician or a neurosurgeon or an ophthalmologist. What a loss to society to just lose all that valuable expertise. The years, the things I talked about,

The years of experience and learning how to deal with difficult situations or knowing how to treat certain diseases that maybe not that many people in the world know how to treat, to lose that expertise is devastating and it adds up over time. So why is it? Why are doctors leaving medicine? And I've seen some posts recently from people talking about

the Forable Care Act and how it kind of kick-started this process of physicians leaving. I think there's some truth to that. And I remember when I was an intern, I didn't know anything. I'm an intern, right? But I had a long commute. I was in Chicago. I had a long commute for the year. And I would listen to NPR. And this was the time. This was 2013, somewhere around there.

where Obama was trying to push through the Affordable Care Act. And so there was a lot of debate about it. It was just constantly, everyone was talking about all the time. And the spin or whatever you want to call it that I was hearing made me think as an intern who didn't know anything, like this is a great thing. I support this. I love the Affordable Care Act. It does amazing things. And it did do a couple really good things, right?

It got rid of the, it allowed people to stay on their parents' insurance to 26. I think that's great. It allowed, it took away the whole preexisting condition thing and forced insurances or didn't allow insurances to just drop people because they had cancer, which is the kind of thing that was happening before the Affordable Care Act. But I also didn't know anything as an intern. And it really wasn't until,

I really got into practice years later and I started seeing the downstream effects of some of the majorly harmful aspects of the Affordable Care Act.

that I started to kind of change the way I thought about it. First of all, the ban on physician hospitals came out of the Affordable Care Act. It was kind of pushed in there very quietly, very surreptitiously. And now, for really no good reason, physicians are not allowed to own hospitals, even though physician-owned hospitals have better outcomes for certain measures compared to other hospitals. And why should physicians not be able to own hospitals when insurance companies can own hospitals?

Churches can own hospitals? I mean, come on. What are we doing? But one of the biggest things is Medicare Advantage. The Affordable Care Act, it did some great things, but one of the worst things it did was it paved the way for private insurance companies to get Medicare dollars.

It was touted as choice, right? Everybody's got, now you got so many choices. You know, if you don't want just straight Medicare, you can do Medicare Advantage. You can have a private insurance that covers teeth, that covers dental, that covers vision. You know, that things that straight, like traditional Medicare doesn't cover. But people, for some reason at the time, didn't think, oh wait, maybe these insurance companies, these private insurance companies, UnitedHealthcare, Aetna, Cigna,

What if they abuse this power? What if they get all this government funding, this taxpayer money, and just like don't provide, don't pay for the healthcare they're supposed to pay for? What if that happens? Which predictably is exactly what has happened. Medicare Advantage has mired physicians into prior authorization hell, peer-to-peer reviews, endless prior authorizations.

Delaying care. Not only is it bad for physicians, but it's awful for patients too. Like there are some things that people like, some people will like their Medicare Advantage plans, but, and I'd say probably patients like it a little bit more or probably much more than, I don't think any physician likes dealing with Medicare Advantage plans because they take that money and then they just, they don't do what they're supposed to do with it.

They delay care. They just, the administrative burden is pushing a lot of people out of medicine. And so, I don't know. It's such a complex thing and the

I mean, the Affordable Care Act, its legacy is pretty tarnished by this point. And for some good reasons, some not so good reasons, but certainly the Medicare Advantage and what it's turned into in terms of, I understand the thought behind it, let's get people covered. But insurance coverage is not healthcare. Just because you have coverage doesn't mean you're going to get the healthcare you need.

And a lot of that's because we gave the insurance companies too much power. And now we're stuck with it. At least it seems like it for now. So I'll leave you on that uplifting note, everybody.

There is hope. There is hope. PBM reform is coming. It is coming. There are bills that have been introduced reforming PBMs, which is, I think, probably the most unnecessary, the most egregious example of just siphoning money out of the healthcare system into the pockets of people that do jack shit. Absolutely nothing for patients, for physicians. They're just

PBM reform is coming. It is coming. All right. So there's your uplifting moment. And I think that's the start. That's the start. It's going to happen. And I'm just speaking it into existence, but there are bills. People are working on it.

And I would say you'd expect bipartisan support for something like that because God, they don't do anything. PBMs are worthless, but they have so much power and they get so much money out of the healthcare system.

All right. So thank you all for listening to my rant. Thank you for listening to my challenging day as well. I'd love to hear your thoughts again at Glock and Fleckens. Go leave a comment on this video. Tell me what your thoughts are about in hindsight. Now we're 10 years after the Affordable Care Act. Like, what are your thoughts? What are you in your mind? Maybe you're a patient. Maybe you have a Medicare Advantage plan and you don't agree with me.

Please, this is... Healthcare is such a complex thing. I don't expect everybody to agree with what I have to say. I would love to hear your point of view if you agree or you disagree. So leave a comment for me, all right? Let's have a very slow conversation over podcast that might last weeks. So...

Yep, I want to hear from you. So thank you all for being here, for listening. I am your host, Will Flannery, also known as Dr. Glockenflicken. Thanks to my executive producers, Aaron Corny, Rob Goldman, and Shanti Brick. Somebody asked if they're ever going to meet the producers or see them. I might have to have them on one of these episodes. Maybe a little cameo to say hi. Editor-engineer Jason Portizzo. Our music is by Emmy Award winner Omer Benzvi. We're very proud of Omer.

Knock Knock High is a human content production. We'll see you next time, everyone. Bye. Knock Knock. Goodbye. Human content.