by GD Schiff & DW Bates, NEJM, March 25, 2010, Vol 362 (12), 1066-1069.

Not everything about a patient’s life can be gathered from a brief consultation in a clinic. Dr. Berland has devised a fascinating method of looking into the personal lives and troubles of her disabled patients – encouraging them to carry a video camera with them. Read about the unique insight that she gained through this novel, simple idea.

by JK Inglehart, NEJM, March 24, 2010, Vol 362 (12)

John Iglehart reports on the passage of the health care reform bill, the first piece of major social legislation to be enacted on a strictly partisan basis.

by P Hartzband & J Groopman, NEJM, March 25, 2010, Vol 362 (12), 1063-1066

Medicine has built on a long history of innovation, from the stethoscope and roentgenogram to magnetic resonance imaging and robotics. Doctors have embraced each new technology to advance patient care. But nothing has changed clinical practice more fundamentally than one recent innovation: the Internet. Its profound effects derive from the fact that while previous technolgoies have been fully under doctor’s control, the Internet is equally in the hands of patietns. Such access is redefining the roles of physician and patient.

Diagnostic imaging is a process in which doctors use medical images to determine the source of medical problems in patients.  From its first uses, it has come a long way from the archaic but reliable X-ray to the extremely advanced and high tech magnetic resonance imaging (MRI).  Though these advances have revolutionized diagnostic imaging, it is only the beginning. I had an opportunity to discuss the future of Diagnostic Imaging in an interview recently with Dr. John Jordan, Adjunct Clinical Associate Professor of Radiology at Stanford University Medical Center, and Chief of Neuroradiology and MRI at Advanced Imaging of South Bay – Los Angeles.

The future of diagnostic imaging looks to further the trend of finding the problem in a patient early, before any insurmountable damage has been done.  However, future methods look to take this a step further.  While traditional imaging has focused on the anatomical level of specific organs or parts, future imaging looks to observe patients at the molecular level, by looking at specific cells or proteins.  The future of diagnostic imaging “aims at defining how things function when it comes down to the molecular level” says Dr. Jordan.

The potential uses for this new type of technology are numerous.  For example, molecular imaging may be able to detect cancer markers prevalent in the proteins of a specific cancer based on the specific antibodies made to fight the cancer.  Diagnostic imaging at the molecular level may one day be able to elucidate the way the brain works and many of the microscopic processes that remain ambiguous.

The demand for this technological expansion in the United States is largely the result of the aging baby-boomer and echo-boomer population. As the general health of these groups deteriorates with age, greater medical attention and medical resource utilization is required.  In addition, the average life expectancy is rising, resulting in a larger population of elderly patients.  The demand for improved health care and quality necessitates development of technology that is more advanced and efficient.

With all of this progress in technology, one might think that the old methods of imaging would become obsolete.  On the contrary, the new forms of imaging would act as an alternative pathway and supplement the current forms of imaging.  In addition, the idea that man would be replaced by computers in regards to imaging is not in the near horizon.  Computers may be able to pick up some of the abnormalities seen in the image.  However, only human intuition can truly identify problematic abnormalities and interpret visual abnormalities into recognition of disease processes. Nevertheless there is technology where computers serve to supplement physician interpretation such as mammography.

Though progress can be seen as only advantageous, there are some caveats that come with it.  For one, cost will play a major factor into the use of this new technology.  The expenses for this new technology will undoubtedly be high, necessitating “cost containment and a check and balance to the proliferation of technology” (Dr. Jordan).  That is, there needs to be a control on how the technology is distributed in order to assure that patients care is the best care and the most cost-effective care

Yusef Jordan is a writer for the Next Generation and a member of the Harvard class of 2013.

An Overview of Healthcare Reform:

The healthcare reform proposed by the Obama administration is one of the most significant movements in the history of the medical field, with tremendous implications for both patients and physicians. Despite its widespread media coverage, a recent poll by CBS indicated that 67% of Americans remain “confused” by the underlying premises of the reform¹.  This article appears in two installments, which aim to clarify the confusion surrounding these reforms by supplementing the political hype with first-hand insight from several medical professionals.  The first part includes an overview of the reforms as of March 2010 and an inside perspective on the medical implications of these changes provided by Dr. Delbert Wigfall (a nephrologist at Duke University Medical Center).  The second part, which will appear in the April 2010 publication, will include an alternate medical perspective provided by Dr. Marybeth Spanarkel (a gastroenterologist in private practice) and a discussion of the medical professionals’ concerns from the political perspective of Dr Paula D. McClain (a professor political science at Duke University).

According to the Organization for Economic Cooperation and Development, the United States has the highest per capita spending on healthcare in the world ² .  From prescriptions to doctor’s visits to surgical procedures, the price of modern medical attention can be staggering.  In fact, healthcare has become so costly that 62% of the American bankruptcies in 2007 reportedly resulted from medical bills³.  In light of these high prices, American citizens maintain a disproportionately poor quality of health.  The United States continues to have the greatest number of deaths due to coronary artery disease, the highest prevalence of diabetes and obesity, and one of the lowest life expectancy rates among industrialized nations⁴.  A recent study done at Harvard Medical School found that approximately 45,000 people die annually due to a lack of basic health coverage⁵. The shocking disparity between these worrisome statistics and the high price of American medical attention has incited government officials to re-evaluate the current healthcare system of the United States.

In the early 1990s, President Bill Clinton attempted a large-scale healthcare reform, but his initiatives failed miserably and ended in the Republican Revolution of 1993.  Disparities in the American Healthcare system were largely laid aside until the recent election of President Barack Obama. Throughout his campaign in 2007 and 2008, then Senator Obama promised that he would address the rising costs of healthcare in the United States and provide broader access to the restrictive system.  In the summer of 2009, President Obama urged Congress to begin drafting legislation, with the intent of having a bill passed by fall of the same year. However, this deadline has already been passed and the bill is still going through multiple changes.

According to President Obama’s campaign website, the goals of the healthcare reform bill were manifold.  A list of the initial goals of Obama’s plan (in no particular order) can be seen in the the table below.

The Senate Healthcare Reform Bill, however, is receiving criticism for its failure to support many reform ideals.  Some of main concerns voiced by the media are the lack of a public insurance option to compete against the private market and reduce premiums. Individual mandates are also a part of this healthcare reform bill, which will eventually make it a law that everyone must buy health insurance from private insurers.  Despite the reduced price of newly created plans, some argue that forcing people to buy health insurance will nonetheless place many under undue financial strain. Medical malpractice reform is also ignored in the current bill, which has come as a disappointment to medical professionals.

The state of healthcare reform evidently has significant consequences of both patients and physicians. Physicians, however, have a unique perspective on the way specific aspects of the healthcare system affect their patients’ health.  Several physicians accordingly offered NextGen their opinions on the current state of the reform.

A Physicians Perspective

Dr. Delbert Wigfall, a Nephrologist at Duke University Medical Center, offers his insight into the current state of healthcare reform. He proposes that basic needs among pockets of the American population need to be addressed in order for larger problems to be ameliorated. To begin, “children need immunizations, well-checks, and more preventative care so that they avoid complex problems as adults.” In his opinion, keeping children healthier earlier in their lives is imperative to controlling costs. In addition, little attention is paid to middle aged individuals who are “…relatively healthy but need better care to prevent morbidity and mortality.” Another problem of prime importance is insurance coverage and it is changed or dropped. To illustrate this issue, Wigfall presents the instance of more physical laborers who lose their coverage because of an illness and their employer is unable to help. “There are stories I have heard about painters. You fall off your ladder and you break your arm. Well, you can’t paint. What do you do? Who do you turn to? Your employer can’t do anything for you because he can’t. So, there are a lot of people who need help. None of this has necessarily been a part of the discussion on either side of the debate.”

A proposal presented by Congressman Weiner of New York may add to the problem, adds Wigfall. The Congressman advocates the expansion of Medicare so that anyone may buy into Medicare and use it as a pseudo-single payer health plan. Wigfall explains that Medicare, although popular among some, is not without its problems. “In reality, Medicare does not reimburse at the same rates as private insurers. By the same token, there are healthcare groups that do not reimburse for certain procedures. There is a trade-off of reimbursement between private and public programs. This discussion spawns many questions about professional reimbursement. For example, private insurers base their reimbursement rates from those given by Medicare. Rather than discussing the two separately, maybe we should be talking about them at the same time. We may be comparing apples to apples and think we are comparing apples to oranges. The question of reimbursement may not be as big a problem as it may seem.”

What are the additional problems? The lack of tort-reform in the current healthcare reform bill raises a concern for Wigfall. Medical malpractice insurance is a “heavy” financial burden on medical practitioners. In many cases, this is passed on to patients because of overhead costs. The original Obama plan did address this issue, but Dr. Wigfall is disappointed that the Senate bill neglects to include tort-reform. The problems associated with medical malpractice, lead to increased costs for patients, as physicians are forced to practice defensive medicine and order extemporaneous tests which may not be necessary.  Annual premiums of malpractice insurance can reach “…hundreds of thousands of dollars for some physicians.” In order to maintain their livelihood, physicians must request higher wages. In his opinion, Dr. Wigfall finds a true ethical problem for lawmakers, because malpractice law is a lucrative field. In order to reform this aspect of healthcare, lawyers “…would be stepping on their friends’ toes and taking money out of the pockets of lawmakers living on malpractice law.”

Dr. Wigfall remarks that the current picture of healthcare reform focuses on patients and doctors, but largely ignores the chasm in between these two pillars of the healthcare system. This chasm is composed of large corporations, the source of the problems with a profit-based healthcare system.

(Part 2 of the article, with further insight from by Dr. Marybeth Spanarkel and Dr. Paula D. McClain will be published in the April 2010 issue)

* Editor’s Note: Prior to publication of the March 2010 issue of NextGen, the house passed the health-care reform bill.  Therefore, the article serves as a retrospective overview of the proposed reforms at the time, with insight

Ibtehaj Naqvi is a writer for the Next Generation and a member of the Duke class of 2010.

by David A. Lieberman, NEJM December 20, 2007, Vol 3561 (12), 1178-1187.

A healthy 76-year-old woman presents as a new patient for primary caree. She has no family history of colorectal cancer. Would you advise this patient to undergo colon-cancer screening, adn if so, what test would you recommend?

by John K. Iglehart, NEJM, September 14, 2009

In a rare address to Congress on September 9, President Barack Obama sought to rebuild momentum among legislators for pursuing reform and setting out his basic notes.

by Tadataka Yamada, NEJM, September 17, 2009, Vol 361 (12)

The prospects for developing an effective vaccine to prevent infection with the current H1N1 virus are excellent. Dr. Tadataka Yamada roposes a set of principles to guide global allocation of a pandemic vaccine.

Modern medicine is becoming increasingly diverse with more specialties and ways to practice. Physicians can work in large insitutions as researching academics, or spend the majority of their time in a traditional clinic setting.  Programs, such as Doctors Without Borders, also provide physicians with an opportunity to practice medicine while donating their time to impoverished communities.  The Next Generation caught up with Dr. Mohammed Mirza, who decided to combine a these pursuits and open a clinic in Pakistan.  Dr. Mirza shares his experiences helping impoverished patients in his native community and the decisions that ultimately led to this unique career path.

Dr. Mirza grew up and completed his secondary education in Pakistan. After earning his MD from the University of Maryland School of Medicine, he received lucrative offers to work in hospitals throughout the country. Dr. Mirza thought deeply about what he wanted and which path would suit him best. The domestic offers would have provided him with enriching opportunities to further his career.  However, he remembered the poverty and lack of doctors in the neighborhoods of Pakistan.  He wanted to help improve the situation and ultimately decided that his dream was to return to his homeland and open a clinic that would treat these patients with everything from cuts to chronic diseases. “I believe in what my mother always taught me: You can never forget those who are less fortunate and you should always remember to repay what you have received by helping others. My roots in my native country and my upbringing brought me back.”

Before opening his clinic, Dr. Mirza started his career by working in local Pakistani hospitals. Though long shifts and grueling rotations are expected by any physician, Dr. Mirza had to deal with the additional stress of inexperienced staff and power failures that plagued the hospital. However, this provided him with a reasonable salary, which he used to purchase supplies and save up for the establishment of his clinic.  His tenure at the hospital also allowed him to establish vital connections with other physicians, to whom he could direct his patients for specialized care.   After working for six years in the hospital, he accumulated enough resources to open his clinic in Karachi, Pakistan.  He continued doing hospital rounds in the morning and tended to the clinic in at night, until his clinic provided enough revenue to take care of itself.  This financial independence was especially difficult to obtain, as Dr. Mirza promised himself that he would never charge anyone more than 100 Pakistani Rupees (the equivalent of  $1.25). He likewise committed to an honor system that provided free treatment to those who said they could not afford the fee. This commitment, he said, came about because of a specific patient that he met almost 20 years ago.  “One day as I was seeing patients, a middle aged man came to me with a child in hand. The boy had a respiratory infection and needed antibiotics. After I wrote the man a prescription, he told me that he couldn’t afford to pay me. I gave him some antibiotics out of my stock and told him to go home. He was the first patient that told me of his troubles. I have tried to help others like him ever since.”
In response to the possibility that some may take advantage of his generosity, Dr. Mirza says, “There will always be people who try to take advantage of you. They will be there no matter what you do. I just cannot find myself in a position where I stop helping others because of a few bad apples. God has provided me with enough to offset those who try to cheat the honor system.”
Dr. Mirza’s clinic has been so successful, in fact, that has been able to expand expand his establishment and provide specialized care for those who have chronic illnesses, such as diabetes.  As a diabetic himself, Dr. Mirza decided to establish a specialty clinic on Sundays that focuses on treating patients with diabetes.  About six years after founding his clinic, he gave a home to diabetics who were otherwise lost. Dr. Mirza has found that some of the major health problems in his community stem from a lack of education, especially about diabetes. Many of his patients come to his clinic complaining of symptoms, such as pain and blurred vision, but they don’t even know what diabetes is. Dr. Mirza says, “I grew up in this country and I know there are those who advertise cures for illnesses such as diabetes. I believe that the best way to move people away from these potentially harmful medicine men is to expand education about diseases such as diabetes. I know how difficult it is to manage my diabetes and I don’t want people to hurt themselves or their family members because of a lack of knowledge.”
His clinic, therefore, offers tutorials on how to monitor diet, test their blood sugar, and administer insulin shots, among other important tools.  Because of the respect that Dr. Mirza earned in the community, he was further able to work with local pharmacies to provide insulin and other medication to his poverty-stricken patients at a reduced cost. Without the help of Dr. Mirza’s clinic, these patients would be forced to resort to ineffective, and potentially dangerous, home remedies.

While Dr. Mirza feels confident that he is helping the community, he realizes that there are larger bureaucratic problems that still need to be resolved.  In addition to the general lack of education, citizens suffer from limited rights and poor labor laws that result in increased competition for grueling, low-paying jobs.  Communities are over-run by unemployment and minimal wage positions, which hardly provide enough income for basic medical needs. While Dr. Mirza can help people medically, he finds it especially frustrating that these socio-political issues are often beyond the realm of what he can control. In some cases, Dr. Mirza even feels that the political system is taking advantage of his services. The government, for example, uses clinics that help the poor as an excuse to forego universal healthcare.  In his opinion, there are not nearly enough clinics like his for this to be a reasonable solution to the lack of health care – as the sheer number of patients waiting outside his clinic every evening attests.  While Dr. Mirza agrees that there needs to be action at a higher level, he believes that change must start from the ground up. In his opinion, it would be helpful for officials and fellow physicians to spend some time in a clinic like his so they can witness the issues first-hand.  “I don’t think that this problem can be solved by people with only superficial knowledge. The lack of medical care is not only a Pakistani or American issue. It is a global issue. Politicians and even my colleagues in medicine need to get into the trenches to fully understand the problem. It is only then that we can find bigger and better solutions to this global issue.” The bureaucracy cannot improve these conditions until the fundamental problems are legitimately acknowledged.

Dr. Mirza says that if he had to start over again, he might have tried to do more from a public health standpoint, perhaps getting a masters in public health or working for the department of Health and Human Services. In fact, he believes that every medical student should have some background in public health, so they understand how socio-political issues, such as those in Pakistan, affect health care on a local and national level. “Medicine cannot be a treat the patient and you’re done job anymore. There was a time when the physician could end his job there. Modern medicine requires a multi-faceted approach. We have to be able to understand the socio-economic conditions of patients, the problems associated with the health care systems of our respective nations, and be able to find solutions to these problems by working with others. I would love to be able to work at that type of level, but I would still choose to do what I am doing because I love every moment of my job.”
Though it may have taken longer to achieve, Dr. Mirza believes that even if he had pursued these alternative goals, he would still have ultimately fulfilled his dream of opening the clinic in Pakistan.  Dr. Mirza believes the choice between these paths is analogous to the choice between research and practicing medicine. He says that when they are asked, many researchers regret their lack of interaction with patients, but are nonetheless confident that they would have still chosen to do research if they had to start over.  While choosing a path may be difficult, it is reassuring to know that many doctors, such as Dr. Mirza, ultimately find comfort in their decision, whatever it may be.

Dr. Mirza also recommends that medical students volunteer as much as possible in clinics like his in order to gain a deeper understanding of global medicine. In his opinion, traveling outside of the United States and observing global health problems is just as important as research. As Dr. Mirza says, “the heart of medicine is still caring for others.”  Though his path may not have always been easy, Dr. Mirza’s story is an inspiring example of the way a career in medicine can allow one to make a genuine difference in the community.

Janoo Naqvi is a writer for the Next Generation and a member of the Duke class of 2010.

Introduction:

Almost anyone would agree that our sense of vision offers the most useful information about our world. In the second century AD, Galen once referred to the eye as “the most divine organ” – after all, despite the eye’s drastic importance in our everyday lives, ophthalmology as a science is only about 200 years old and many of today’s standard surgical methods were only developed within the past 5-10 years (The History of Ophthalmology). With a unique blending of both medical and surgical techniques in their art, ophthalmologists enjoy a world of clean, efficient microscale surgeries and medical interventions in one of the most exciting sectors of modern medicine.

Ophthalmology Today:

Modern ophthalmology encompasses a wide range of conditions and their respective treatments, including glaucoma, cataracts, diabetic retinopathy, retinal detachment, macular degeneration and refractive conditions – the extent of treatable conditions and treatment plans is growing dramatically. As previously mentioned, the treatments for these conditions include both medical and surgical means, making an ophthalmologist’s treatment repertoire remarkably broad. Dr. Christopher Andreoli of The Massachusetts Eye and Ear Infirmary noted that the scope of treatable disease is continually advancing and that many of these conditions were not considered surgical diseases 5-10 years ago.

Surgery:

I had the opportunity to observe Dr. Andreoli during a surgery to correct an elderly patient’s diabetic retinopathy and retinal detachment. The surgery was performed in a darkened operating room – the patient lay on the table completely draped except for her affected eye. The surgical site had been given local anesthetic and the patient was awake as the surgery progressed.

The operation itself was conducted under a powerful microscope with 3 viewports – one for the physician, one for the resident working with him, and a vacant port through which I was able to observe. This surgery involved accessing the vitreous chamber of the eye via a series of canulae less than 2 millimeters in diameter, through which the physician was able to insert a light source, infusion tube and a series of tools, ranging from an ablating tip, to a combined suction/cutting instrument, to a microscale laser tip for sealing the damaged areas during the retinal reattachment. Like laparoscopic surgery, the procedure caused minimal external trauma relative to the extensive work done within the vitreous region. In the end, sealing the wound simply required a few microscopic sutures – with the smaller canula size, the wounds are frequently self-sealing. The entire surgery was remarkably clean and despite the considerable damage her eye had sustained, the patient would regain partial vision and keep the eye.

Dr. Jennifer Sun of the Beetham Eye Institute at the Joslin Center for Diabetes noted that “Everything is getting miniaturized – smaller instruments create smaller incisions and wounds. Much of the surgery, because of miniaturization, involves less manipulation of the eye. Patients recover much more quickly, both anatomically as well as functionally.” Dr. Sun also noted recent advances in surgery site visualization, including brighter light sources that can be inserted into canulae, such as the source utilized in Dr. Andreoli’s procedure above. Such improvements allow hands-free operation, while new lenses allow better wide-field visualization inside the eye to improve surgeons’ mechanical ability to perform surgery while minimizing patient trauma and discomfort from surgery.

Medicine:

Meanwhile, medical interventions for eye conditions are becoming increasingly popular. Dr. Joan Miller, the department chair of Ophthalmology at Harvard Medical School pioneered a photodynamic therapy for the treatment of macular degeneration – a debilitating and blinding condition that used to render patients “untouchable” by ophthalmologists.

Additionally, diabetic retinopathies are now treatable by medical means, with the development of drugs that block the production of Vascular Endothelial Growth Factors (VEGF). VEGF is associated with the formation of new blood vessels, including the extraneous vessels that develop in diabetic patients whose bodies are responding to lacking nutrients to eye tissue. However, the presence of these vessels can disrupt a patient’s vision, and this diabetic retinopathy was previously an entirely surgical concern. With new anti-VEFG medications, however, ophthalmologists need only inject these medications and can observe these extraneous vessels’ degeneration soon after.

These and other breakthroughs have radically changed the landscape of ophthalmology, and this fine balance between surgery and medicine creates unique working conditions for the field. The vibrant energy of this rapidly advancing field has created unique opportunities for practitioners – according to Dr. Nicole Benitah, a senior resident at Massachusetts Eye and Ear Infirmary, the field presents many opportunities for research, while also allowing for international work – “(you) can do a lot of good by going to other countries and performing cataract surgeries, essentially curing blindness for people who would otherwise go blind.”

Challenges and Rewards:

Ophthalmology does present its own challenges and rewards. The primary concern, noted by Dr. Andreoli and Dr. Sun, is that despite the amazing capabilities of modern surgery, many patients may eventually go blind, losing the ability to drive or take care of themselves. Dr. Benitah also noted the difficulty for other doctors in properly diagnosing conditions, given their inexperience with the eye and its physiology. Dr. Miller expressed her academic concerns for the future of research and the education of residents and fellows in today’s questionable economic climate.

However, the field presents numerous rewards for its practitioners. Every doctor interviewed mentioned the unique combination of medical and surgical techniques in their work, while also enjoying the ability to work with patients for the long term, sometimes following patients for as long as 15 to 25 years. Moreover, despite the discouraging occasions of patients losing their vision, the opposite segment of patients show the incredible lengths that ophthalmology has come; the happiness of patients who can see when the eyepatch is removed post-surgery carries its own tremendous rewards.

The Future:

The unique climate for ophthalmology creates an exciting future for the field. In an interview, Dr. Miller noted, “as we understand genetic pathways better, we see other useful targets for these diseases. Specific gene therapies may be difficult to apply to many people, but insights from genetics will lead to therapies that can be applied broadly.” The field is growing with leaps and bounds in both surgical and medical techniques, creating a richly diverse landscape for patient care, all the while presenting a tremendously rewarding opportunity to impact patients’ lives while working with them in long-term doctor-patient relationships.

Words to the Wise:

For the current premedical student:

“Keep your mind open and go into medical school with an interest in anything; Have no preconceived notions and try anything that comes your way – you may be surprised at what you like!”
-Dr. Christopher Andreoli

“Make sure you’re interested in medicine for the right reasons! Make sure it’s something you’re passionate about. It’s not as financially rewarding as it once was, and if you go into it without wanting to work hard and without a real desire to take care of people, you’ll constantly feel tired and overworked. If you enjoy taking care of people, it doesn’t seem like much work.”
-Dr. Nicole Benitah

“There’s much ‘doom and gloom’ about the medical field and people worry about change. Medicine encompasses patient care and the ability to improve function and save lives – there aren’t many fields that allow you to do that. Along the way, there are many pieces that can be added to a practice – research, teaching, working in pharmaceutical companies to develop new pathways. It’s a great career path!”
-Dr. Joan Miller

“Pursue other interests in addition to premed studies that you are passionate about because those are the things you can build into your career that are going to make life fun, worthwhile, and exciting.”
-Dr. Jenifer Sun

Justin Koh is an Editor for the Next Generation and a member of the Harvard Class of 2012

Christopher M. Andreoli, M.D. is a Clinical Instructor of Ophthalmology at Harvard Medical School and is an Active Staff Member of Massachusetts Eye and Ear Infirmary

Nicole Benitah, M.D. is a Senior Resident at Massachusetts Eye and Ear Infirmary

Joan Miller, M.D. is the Henry Willard Williams Professor of Ophthalmology & Chair of the Department of Ophthalmology at Harvard Medical School and is Chief of Ophthalmology at Massachusetts Eye and Ear Infirmary.

Jennifer Sun, M.D. is Chief of the Center for Clinical Eye Research and Trials at the Beetham Eye Institute & Eye Research Section, Joslin Diabetes Center and is an Instructor at Harvard Medical School

References:

“The History of Ophthalmology.” American Academy of Ophthalmomlogy. 30 July 2009. http://www.aao.org/aao/careers/envision/history.cfm