October 2014




Chief medical editors corner of the world

Sitting down with Senator (and ophthalmologist) Rand Paul

by David F. Chang, MD


Sen. Rand Paul, MD (R-KY), is an ophthalmologist who practiced for 18 years in Bowling Green, Ky., before being elected to the Senate in 2010. He has been a strong legislative ally for physicians and was a keynote speaker at the 2014 ASCRS•ASOA Symposium & Congress in Boston, where he received several standing ovations. As a physician, he both understands and articulately advocates for our positions on many major issues. As a result, many ophthalmologists are excited that he is considered one of the early frontrunners for the 2016 Republican presidential nomination. Earlier this year, Sen. Paul approached ASCRS Director of Government Relations Nancey K. McCann about doing an international cataract surgical outreach trip. Although senators are barred from receiving outside compensation (e.g., for practicing medicine), Sen. Paul maintains his surgical skills by performing occasional pro bono cataract surgeries in his home state of Kentucky. The logical choice to organize this trip was the University of Utahs Moran Eye Center. Their highly acclaimed international outreach division has operated in every corner of the globe, and Sen. Paul joined their August trip to the small town of Salam, Guatemala, where only one ophthalmologist serves a population of 800,000. Under the leadership of ASCRS past president and current ASCRS Foundation International Committee member Alan Crandall, MD, a small team of ophthalmologists performed 250 surgeries during the week. Moran has a 5-year commitment to assist, train, and support the local ophthalmologist and his rotating resident at this eye hospital. As a participant, I was privileged to see Morans amazing team of surgeons, nurses, technicians, and coordinators in action. I was also quite impressed with Sen. Pauls surgical skills under challenging conditions. Not only were these among the most advanced and challenging cataracts that any of us would ever encounter, but the press was literally embedded in the operating room with us as they learned about cataract surgery and sized up his performance. Sen. Paul is ambidextrous enough to alternate doing phaco right- and left-handed according to the eye, and it was obvious that he missed performing surgery and practicing ophthalmology. Our trip was reported on by the Washington Post, National Review, Meet the Press, NBC Nightly News, and the Today Show. Although the political angles made this newsworthy, the coverage certainly increased awareness of global cataract blindness and cast our profession in a favorable light. I took advantage of this opportunity to interview Sen. Paul for EyeWorld.

David F. Chang, MD, chief medical editor

Ive felt a connection to Guatemala for a long time but have never been here. I was told by [Dr. Chang] and Dr. Crandall that theres only one eye surgeon for 800,000 people, so theres just too many cataracts that go untreated. Its exciting to be a part of such an esteemed group to try to help these people.

Sen. Rand Paul, MD


Sen. Paul performing phaco in Salam, Guatemala, with assistance from Alan Crandall, MD.

Source: Jeff Pettey, MD

Left to right: Jeff Pettey, MD, David Chang, MD, Susan MacDonald, MD, Roger Furlong, MD, and Alan Crandall, MD

Susan MacDonald, MD, examines patients at the hospital in Guatemala.

Dr. Chang: I am conducting this interview with Sen. Rand Paul in Salam, Guatemala, where we are operating with the Moran Eye Centers International Outreach team. Senator, whats your impression of the setup here so far?

Sen. Paul: Its been exciting to do it. Ive felt a connection to Guatemala for a long time but have never been here. We have a neurosurgeon in my town in Kentucky who was born in Guatemala, and Ive done surgery on some kids from Guatemala, but Ive never been here. Were in a town about 3 hours away from Guatemala City3 hours by car through some very winding mountain roads. I was told by you and Dr. Crandall that theres only one eye surgeon for 800,000 people, so theres just too many cataracts that go untreated. Its exciting to be a part of such an esteemed group to try to help these people.

Dr. Chang: Weve seen all sorts of pathology here today, and these are really tough cases. However, watching you, you seem very comfortable operating here. How are you keeping up your surgical skills? It isnt like riding a bicycle!

Sen. Paul: Yes, but I think you guys have been cheatingI think youve been giving me the easier cases! Like Theres one where you can see a red reflex, so maybe he should do that one! But no, Ive done some white cataracts, too. Im maybe not quite as good as the pros yet, but Im trying to get there, and its exciting to be able to be a part of it. At home I do some charity surgery in different parts of Kentucky, and Ive become friends with ophthalmologists in different parts of the state, so every couple of months we go to a surgery center and do 4 or 5 cases.

Dr. Chang: A lot of ophthalmologists dont know about your background. You did your residency at Duke and then went out into private practice. How long did you practice?

Sen. Paul: I did my residency at Duke. I got out in 1993 and my wife was from Kentuckyand you know how that works! So I came to Kentucky and we wanted to live in a small town. Our town has about 50,000 people, with the university [Western Kentucky University] adding about 20,000 more. I did private practice but was always interested in the Lions Club. As a member of the Lions Club, we had our own Lions Eye Institute. Not only did we collect glasses, but we did some pro bono surgery on folks who came up here, mostly from Latin America and some from South America but also some people from the community as well. We have this debate about healthcarehow much should the government be involved and how much should private enterprise be involved? We lose track of the fact that all of us [physicians] feel an obligation to help people whether they have any money or not. I think it gets lost in all the debate about healthcare and Obamacarethat ever since I was a kid, doctors have been trying to help and have always felt an obligation to help the poor members of their community.

Dr. Chang: This year, the ASCRS Foundation is launching an initiative to facilitate and support ASCRS members and their ASCs who want to operate on cataract patients who cannot afford care in the United States. Our eventual goal is to eradicate cataract blindness in the U.S. As you said, a lot of ophthalmologists have already been doing this all along, but this is a way to network everyones efforts.

Sen. Paul: One of the patients we did recently was a veteran who could go to the VA but it would have taken 4 hours to get thereso even when you have complete access and complete coverage for everyone, there are still people who are going to have trouble. We had a patient last week in Louisville who had insurance but had a $6,000 deductible. A big question I have about the healthcare bill is that you can give people free insurance, but if its free insurance with a $6,000 deductible, where are they going to get the money? So I think were still going to have an access problem. I think the other problem were going to have is that as we pay hospitals less, hospitals are going to have to let people go. Thats what I really fear is that some of the good paying jobs in our country, particularly in rural communities, are people who work for the hospitals.

Dr. Chang: The ASCRS Foundation is involved with a number of international partners and NGOs working on cataract blindness. Have you done international trips before and whats your impression of the Moran team? Were in a pretty remote, rural area of Guatemala right now, and its pretty amazing what theyve put together.

Sen. Paul: This is my first international trip. Dr. Crandall and his team have done a great jobwe have sophisticated microscopes from North America, weve got 2 phaco machines, and its running like clockwork. It really takes a lot of effort. I contemplated doing this on my own and said, Ill get together a team, but then thought, No, I dont want to reinvent the wheel. They do a great job because theyve done dozens of missions, probably nearly a hundred missions around the country and around the world. We also enlisted help from localsfor example, the Lions Club. Theres a lot of work that goes into finding out who the patients are who need the treatment.

Dr. Chang: How did you decide in the midst of being a busy private practitioner to run for office?

Sen. Paul: My wife still thinks I was a little crazy to do this. I had just opened up a practice. I bought my own building because I always wanted a small practice where I was in charge of everything, and I had done that for about a year and a half. Then the Senator from Kentucky was waffling on whether he was going to run or notand I thought, Maybe Ill run. After I said this to a reporter, it sort of steamrolled and there was no looking back. It was the first time I had ever run for office and everyone, including myself, thought it was unlikely that I would win. I thought all along as I ran for office that Id still be allowed to practice medicine part time, but I discovered that the rules are different between the House of Representatives and the Senate. In the House of Representatives, the doctors still can practicetheres about 15 or 20 doctors in the House. Some of them practice part time, and they can still cover their malpractice insurance. In the Senate you cant practice at all and I cant bring in any income to offset my malpractice insurance, which is not a great business model.

Dr. Chang: What do you miss most about ophthalmology now that youre no longer practicing?

Sen. Paul: The difference between politics and medicine is this: In politics, sometimes people know of a solution, but we rarely ever execute the correct solution. Groucho Marx said, The art of politics is looking everywhere for problems, finding them, misdiagnosing them, and then applying the wrong solution. But in medicine you get feedback immediately. Most of it in ophthalmology is positive feedback, and I think thats one of the reasons I really like ophthalmology. There are very few sad patients, and 99% of them are going to see better.

Dr. Chang: Looking at your career as a senator, are there situations where being an ophthalmologist has been helpful to you?

Sen. Paul: Im very aware of what the reduced payments are doing to physicians practices and their ability to pay employees and continue to stay in practice. The formula for how we pay doctors out of Medicare means reimbursement has been going down every year. Right when I started practicing, reimbursement started going down and its been going down every year ever since. So thats an issue that I have some perspective on. [The SGR] was always a bad formulanow everyone acknowledges it because every year weve repealed the formula for about 14 years in a row. My point is, being a logical person [and this] being a bad policy, why dont we repeal it? They say, The way the formula is scored by the Congressional Budget Office [CBO], we have to please the score peoplebut nobody elected the CBO. They elected you to make decisions, so lets fix it. If its bad law, lets get rid of it. Theres getting to be a little more of a consensus on that, but its like pulling teeth to get anybody to allow a vote and to allow it to move forward. Probably the biggest frustration in Washington is that even when we agree, we still cant get something done, largely because the leadership doesnt allow any votes. So you cant even vote on the things you might agree on.

Dr. Chang: I want to thank you again for speaking at our ASCRS annual meeting, where you were the guest speaker at our Government Relations session. We had a packed audience, and they really enjoyed hearing you speak. It seemed like you were giving people a little bit of a hopeful message, in terms of the future direction of medicine.

Sen. Paul: I think there is, and I tell physicians you need to be involved. Your congressman needs to know your namenot just that you need to know your congressmans name, but they need to know your name. They need to know what youre interested in, they need to know the hurdles that physicians have to overcome. You dont have any right to complain if you dont get involved. Every physician should be involvedemails, writing to your congressman, calling themand they do listen. Most of them are not dead set against what we would like to have happen in medicine; they just need some explanations.

Dr. Chang: Finally, I want to thank you on behalf of ASCRS and on behalf of all physiciansbut particularly ophthalmologists. You have been such a great ally to us, and youve helped us with a lot of issues where we simply needed help to explain what the problem was. This has been invaluable for us and for our patients, so thank you.

Sen. Paul: Well, you know the real reason I came down here is I figured I could get a free phaco course from you and Dr. Crandall!

Sitting down with Senator (and ophthalmologist) Rand Paul Sitting down with Senator (and ophthalmologist) Rand Paul
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