Ophthalmic practice in former East Germany is challenging but rewarding

A professor who went from West to East after reunification says he faced difficulties, but has no regrets.

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Prof. Dr. med. Theo Seiler, chairman of the University Eye Clinic in Dresden since 1993, is well known for his early clinical work with the excimer laser and photorefractive keratectomy (PRK). When many surgeons were still learning what an excimer laser was, Dr. Seiler had hundreds of patients on a waiting list to receive PRK at his clinic in Berlin. To this day he continues to perform research work in refractive surgery.

Dr. Seiler received his PhD in physics in 1976 and his MD in 1981 at the University of Berlin. He performed his residency at the University Eye Clinic in Berlin from 1981 to 1985, and remained at Berlin until 1993 when he was appointed to the chairmanship in Dresden.

Dr Seiler spoke to Ocular Surgery News at this year’s meeting of the DOC in Nuremberg. The conversation ranged from his experiences practicing in the former East Germany to the focus of his current research.

East and West

OSN: You have practiced in both the West and the East; how do you find the experiences different?

Dr. Seiler: First of all, in how the patients behave. The typical West German patient is demanding. They come in and ask for something and want to know whether you can give it or not. And you do your very best and then they leave. It is a kind of contract.

In the East it is quite the opposite. The patient comes in and seeks help, and you do it if you can. So the relationship between the physician and the patient is different. That is one of the good things.

Another thing in the relationship between the physician and the patient is that in the East, patients usually would not tell you that something you did was wrong. I would say it is a facet of the same characteristic. If you tell someone in the West, “You should not have sex for 6 weeks and this and this and this,” the patient says, “No, no, no, no. Wait a minute.” Not in the East. In the East, the average patient takes your advice and does it.

That is a consequence of the education of the last 50 years, which was very hierarchical in some respects. So you have to be more responsible for your patients in the East than I would be in the West because whatever you say, they will do their best to do it.

What else? We have almost no private patients in the East, which means that the income of a professor, as well as of a physician, is substantially lower than in the West.

The relationship between Westerners and Easterners is difficult, as well. In the very beginning, right after reunification, a lot of people that we might call sharks went from the West to the East. And then administrators came from the West to the East to help out. However, as you might imagine, the best of our administrators did not go to the East. And so the image of the typical Westerner is rather negative to the Easterner.

This has changed during the past 10 years a little bit, but not much. Easterners are usually very reserved because they are always suspicious that they might be cheated. So that is the relationship between the West and the East right now.

It took nearly 3 years until they accepted me and realized that I am a very hard working person — I start at seven in the morning and I am in the clinics every night until midnight. They now realize that I am trying to do the best for all of us. But it took 3 years until people came to me and were open, and even with colleagues it took some time.

OSN: That is probably natural when you go from one area to another.

Dr. Seiler: Yes, but I went also from Heidelberg to Berlin and there it took only half a year or so until you knew everyone and you found the right tone to talk to this person and that one. But 3 years is a long time.

OSN: What differences did you note between medical standards, standards of equipment from West to East?

Dr. Seiler: I went to the East in 1993, about 3 years after reunification. And when I went to Dresden, I realized that ophthalmology was at the level of Western practice of 10 years before. When I was a young assistant, I saw about the same type of ophthalmology in the West that I met in Dresden in 1993. Not in all facets of ophthalmology, but in the major parts. Refractive surgery was nonexistent in East Germany. Cataract surgery was performed as extracapsular extraction, and only 4 years earlier they had been doing intracapsular. So it was more than 10 years behind, actually.

There was no phacoemulsification. I was one of the first surgeons to do phacoemulsification in the East.

And the next thing was the instruments. I have a story about pseudoexfoliation syndrome. In Berlin when I did my rounds at the slit lamp and I saw patients prior to surgery, about 5% to 10% of our patients would have pseudoexfoliation syndrome. When I went to Dresden, there was zero. I said this is not possible — but then I realized that the slit lamp had such poor optics that I just could not recognize it.

It took a while until the new equipment came in — about 6 months. During that time, we did a study of this. When we looked at our operative records for how often pseudoexfoliation was documented prior to and after the new slit lamps came, there was a difference of about a factor of 10. That demonstrates how poor the equipment was.

But all this was quite in contrast to what we used to read in the papers in the West, you know. When we compared our health system with that of the communistic system, they always had better numbers. They had more physicians per population, they had better facilities, more facilities, they had better equipment — everything was better. These figures were announced every other year by the West German government, and we always felt guilty. But once you went there, you realized that everything was only written on paper. In reality, it was totally different.

OSN: When you got there you were able to order the equipment you wanted?

Dr. Seiler: Oh, yes. Whenever a professor gets a call to become chairman, you have negotiations. I asked for totally new optical equipment and some reconstruction of the clinic and renovation of the surgery area and so forth. Everything has been done during the past 5 years, and the money was there.

Refractive surgery

OSN: In Berlin, before your move, was your practice mostly refractive surgery?

Dr. Seiler: No, as a professor I was always a general ophthalmologist. A professor in Germany has to have a national standard in all areas of ophthalmology. You can subspecialize yourself and do something internationally recognized, but you have to do everything.

So I did retinas, as well as glaucoma, as well as cornea, as well as cataract and refractive surgery. And I felt refractive surgery was interesting and profitable, so I concentrated on it.

But now I am doing, for example, more than 1,000 cataracts a year and say 100 retinas a year. This was true in the days when I was in Berlin and nowadays in Dresden, as well.

OSN: And are you still doing as much refractive work as you were?

Dr. Seiler: Yes, that is a constant volume. Three days a week I do refractive surgery, about five to 10 patients a day. That is the same volume I have been doing for 10 years.

OSN: Both PRK and laser in situ keratomileusis (LASIK)?

Dr. Seiler: The trend is the same as in the United States; everyone is going toward LASIK. We expect that some of the LASIK indications will come back to PRK after a while; that is what is happening here in Germany at least. The majority of cases will be done by LASIK as it is in other countries. Not 100%, but perhaps 90% of the myopic cases and maybe 100% of the hyperopic cases will be done by LASIK and the remainder will be done by PRK.

OSN: What research are you now involved in at the university?

Dr. Seiler: Currently, we are working on so-called aberration-based LASIK or PRK. It is not corneal topography-based. It is a kind of computer-assisted PRK or LASIK. We measure the aberrations prior to surgery and then we correct these aberrations with a goal to give you a visual acuity of 20/5.

You know that the retinal limit of resolution is about 20/5, but most of us get only 20/20. We could see much better if only we had no aberrations. We are trying to compensate for these aberrations.

We are not the only ones doing this. There is the group around Marguerite McDonald with Autonomous (Orlando, Fla.) doing the same thing we are trying to do in Dresden. To my best knowledge, we are the only two groups working on this project.

This will change refractive surgery totally. Today, people come in and say, “I want to get rid of my glasses.” In the future, people will come in and say, “I want to see better.” Maybe then we will be able to read a newspaper at a distance of 5 m.

When I wrote my first editorial 2 years ago about this subject, guess who was the first to call me — the Ministry of Defense, because fighter pilots need good uncorrected vision. Do not forget that fighter pilots do not lock in their missiles to an enemy by a joystick anymore, they do it by looking. They have CCDs mounted to monitor their eye movements, and the computer calculates the target based on where they look. Then they blink twice and it is locked on. And three times and it is firing. So it is essential that these guys see very well.

Without aberrations, it could be the difference between seeing your enemies at 2 miles distance or 8 miles distance.

OSN: How do you read the aberrations?

Dr. Seiler: We just redesigned an old aberroscope that was invented 100 years ago by Tscherning in Austria and modernized it with a low-light CCD camera and fuzzy logic.

OSN: When will we be hearing more about this?

Dr. Seiler: At the Academy. Actually, Autonomous already had a meeting at the American Academy of Cataract and Refractive Surgery about aberration-guided PRK chaired by Ron Krueger.

University practice

OSN: We have all heard about the power structure in German universities, that there are the old conservative professors and then there are younger folks who challenge them with new ideas. You used to be among the young challengers as a proponent of refractive surgery. Now you are a department chairman. Are things changing?

Dr. Seiler: Of course not. There are already younger people coming after me who are even more demanding, pushing more, but that is okay. By now I am considered to be one of the old guys after all.

OSN: How many ophthalmologists do you have on your staff?

Dr. Seiler: 25.

OSN: Your practice setting is completely in the university?

Dr. Seiler: Yes, I am state employed. But I have two types of income. I am state employed and I also have, in the university, some private patients, but only refractive patients who come there mostly from the West. I am the only one in our department who has permission to treat private patients. That is the kind of privilege you have as the chairman.

Ophthalmologists are still considered to have a fair amount of income; however, professors in otolaryngology, neurology and gynecology are all suffering. They have minimal income, which cannot be compared with an income of a standard private practice in the West.

In addition, I am cooperating with industry, of course, and we have some support from the development of laser systems and new instruments and so on.

OSN: I understand that government insurance reimbursement is done by a point system in Germany and that the points are valued differently in different states, and are lower in the East.

Dr. Seiler: Yes, but this does not affect me at all. As a state employee, I do not get any insurance reimbursement from the national health patients coming in. Only those who contact me directly can be treated as private patients. All other income goes directly to the institute.

OSN: So you are completely unaffected by current reimbursement changes?

Dr. Seiler: Yes. Which makes sense in some respects, because I can make decisions without considering the money issues. So it is right from a strictly medical point of view.

On the other hand, it is a pity because some physicians are becoming lazy because they get the same salary whether or not they do a lot. That is a problem.

OSN: What about physicians outside the university though, in the East?

Dr. Seiler: Compared with the West, they have about 60% of the income. First of all, they have an official reduction of their fees by about 15% to 20%. But also, East German patients do not go as frequently to see physicians as West German patients do. Physicians are complaining a lot about this situation lately.

Now that we have a socialistic government in Germany, they will want to squeeze it even a little bit harder. And of course, this hits someone who is not earning a lot much worse than someone who is already doing well.

That is a development I think in the wrong direction. They should raise the Eastern income compared with the Western, but instead it is just the opposite. It is still the poor brother.

OSN: Given all we have talked about, do you see yourself moving back to Berlin or the West at some point?

Dr. Seiler: There is no way to go back to Berlin because that is one of the unwritten laws in Germany, that a professor coming from one university should never go back to the same university. You have to increase your experience, you know? The people in Dresden may have learned a lot from me, but I also learned a lot from them.

Right now I have a choice. The University of Zurich in Switzerland has asked me to come there next year. But the people in Dresden also want me to stay there. So it is undecided right now.

You should know that, although the situation in East Germany was very difficult at some times, especially in the beginning, I never regretted going to the East. Not for one second, because of the people. The entire clinic is now standing behind me like an army. That is how they learned it in former times. And I appreciate this type of loyalty very much.

For Your Information:

• Prof. Dr. med. Theo Seiler can be reached at University Eye Clinic, Fetscher Strase 74, Dresden, 01307, Germany; +(49) 351-458-2388; fax: +(49) 351-458-4335. Dr. Seiler has no direct financial interest in any of the products mentioned in this article, nor is he a paid consultant for any companies mentioned.