The guidelines are a practical, inspirational contribution

The only time is now. Every “now” is unique. Responsible persons ask themselves, “How can I act well now?” The answers will differ for every person, because just as every situation is unique, so is every person different from every other person. But surely there must be some algorithm that will assist us in coming to the right answer. Unfortunately, no, for there is no right answer. There is only an answer that is as appropriate as we can conclude at that moment in that situation. No written guidelines can apply appropriately to every unique situation. Unfortunately, we physicians have been suckled on a fallacy: “What’s good for the goose is good for the gander.” Phrased in medical terms, “normal findings are good, and abnormal findings are bad.” This is too simple, and often wrong. Good clinicians know that care must be personalized for it to be optimal. So-called normal findings give rough guidance, sometimes applicable to groups, but frequently wrong for individuals. We are so bombarded by the myth of the sanctity of the standard distribution curve that it is hard to think independently and specifically. Also, unfortunately, doctors are prone to decide for patients, often on the basis of normative data that is not relevant or important for that particular patient. That we do this is not surprising, as we want to help, and so we default to what seems to be the easy, safe (nonthinking) way, in which we do not have to hold ourselves accountable for the outcome.

We need, also, to remember that diagnoses are generic, and that within every diagnosis there are differences. For example, what does a diagnosis of primary open angle mean? Some of those affected will rapidly go blind despite the most thoughtful treatment, while others will keep their sight even without treatment. What does a diagnosis of Chandler’s Syndrome mean? In some, surgery works well, and, in others, poorly. So one never directs diagnosis and treatment at a condition, but rather at the person --- the objective being the wellness of that person.

George L. Spaeth, BA, MD. Esposito Research Professor, Wills Eye Hospital/ Sidney Kimmel Medical College/Thomas Jefferson University