Two Very Different Trips, One Very Similar Message
"Though we use quantifiable outcomes and definitions so that our research and science is sound, let us never forget the most important outcome is to patient lives, because our patients are our families, our friends, and ourselves." ####################################  

"Though we use quantifiable outcomes and definitions so that our research and science is sound, let us never forget the most important outcome is to patient lives, because our patients are our families, our friends, and ourselves."

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My two most recent trips took me to opposite sides of the world. Towards the end of October, I spent some time with my grandparents in India, and in early November, I traveled to New Orleans for the American Academy of Ophthalmology  (AAO) meeting and Retina Subspecialty Day. I enjoyed good food and excellent company on both journeys, and also had the opportunity to see modern ophthalmology from two very different perspectives.

On one hand, AAO and the Retina Subspecialty Day represent the culmination of innovations that drive our field forward. There we learn about the science that will define our recommendations - whether multiyear randomized controlled trials showed differences between pro re nata (PRN) and fixed-interval dosing of anti-vascular endothelial factor (VEGF) agents, what an IRIS registry database retrospective chart review revealed about outcomes of scleral buckling versus pars plana vitrectomy for rhegmatogenous retinal detachment, or whether that phase 3 trial of the newest age for dry age-related macular degeneration and geographic atrophy showed efficacy. Behind the scenes, the connections and relationships between motivated and hyper-intelligent physicians (not me!) stimulate innovation and progress in the form of new project ideas and collaborations. This side of ophthalmology we deal with extensively on the podcast, and it is no doubt invaluable.

On the other hand, in India I was placed on the patient side of the fence. By becoming the unofficial retina consultant for multiple relatives, I had to take a step back and remember why on an individual human level we do these exhaustive and detailed research endeavors to define treatment options and strategies. Moreover, it was also a reminder to recognize that what the physician views as success is not always appreciated the same way by the patient.

For example, one family friend spent an hour with me reviewing OCT scan results that documented his progress over months as he received treatment with anti-VEGF and then steroid injections for macular edema due to a central retinal vein occlusion (CRVO). Medically speaking, he had a great response to steroid treatment: complete resolution of macular edema and significant visual acuity improvement from 20/400 to 20/40. However, over the course of the conversation, I began to realize that while he was thankful for his treatments, he was frustrated with being possibly married to injections simply to maintain a level of vision which he felt was only 80% of his original vision. Though we have made significant advances in the era of anti-VEGF drugs that have given these patients a chance at better vision, we must continue to strive for more - drugs that last longer, agents that do not require injection, and ultimately a treatment that completely restores the function of damaged retina.

Later on, I had another long conversation with my 90-year-old great-uncle who has advanced dry age-related macular degeneration with geographic atrophy. In a clinical trial database or a quickly reviewed chart, his visual function would be reported with numbers such as “20/400 visual acuity” or “OCT central retinal thickness of 200 micrometers.” In person, however, his functioning is much more nuanced. While he does have ambulatory vision that allows him to independently navigate his house without falling, his devastatingly frustrating eyesight prevents him from reading the books he used to spend hours reading. This is a story that the numbers and studies will never be able to tell. Like many informed patients in this information age though, he has kept his ear to the ground. He asked me astute questions about intravitreal lampalizumab, an anti-complement factor D agent under investigation for dry AMD, which unfortunately did not meet efficacy in a recent phase 3 study. When I and other retinal specialists speak on the podcast about the disappointing results of a study, we are sincere, but one really gets a taste of tangible regret when speaking with a human being hoping only to see again. Despite not qualifying for many clinical trials due to his advanced disease, my great-uncle remains optimistic. He sees every victory against AMD as one more step towards regaining the sense he regards as most critical to his identity.  

Perhaps others never lose having a balanced perspective, but as retinal specialists, it is easy to forget why we do what we do in the daily grind of clinic, research, and teaching. We review charts and publish not only to repair retinas, but also so that someone’s brother can see to play with his nephews and nieces. We support studies of new dry AMD drugs to not only to decrease the area of atrophy on autofluoresence pictures, but also so someone’s grandmother can read her newspaper (or iPad!) every morning. Though we use quantifiable outcomes and definitions so that our research and science is sound, let us never forget the most important outcome is to patient lives, because our patients are our families, our friends, and ourselves.

          -Jay Sridhar

Jayanth SridharComment
Reflections after One Year of Retina Podcast
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"Thank you for listening and for all you do. We truly appreciate what you brought into all of our lives."

-Jay Sridhar

Hello Listeners,

As we mentioned two weeks ago in Episode 70, November 3rd marks the one-year anniversary of SFTCM: A Retina Podcast. I already brought Louie Cai and Mike Venincasa on the show to discuss the show's origins and what we plan to do in the future (link), but I still wanted to take the time to write out a few thoughts about what it means to our whole team to reach one year of podcasting.

First, the show would be impossible without the generosity of the guests who take the time to come on our program and share their wisdom and expertise. I am often asked if it is difficult to find our contributors. While there is certainly pre-planning involved in recording the episodes in advance of release to allow time for editing and fine-tuning, I have heard such amazing responses from the physicians and other healthcare professionals we have approached for the show. So thank you to all of the guests from our 72 episodes.

Second, I have to reiterate how critical Louie and Mike are to what we are able to provide. I feel embarrassed at times at how much credit I get simply for hosting and how little credit the two unsung heroes get for editing and producing episodes in a consistent and professional manner. Several of the ideas, such as the blog and the social media sharing, were purely derived from their more creative instincts. Thank you to both of you for what you have brought to this endeavor and the commitment you have made for the future.

Third, there is no joy in producing and creating a podcast that is not consumed. Each and every person who has reached out to me and the rest of the team to communicate your feelings (positive or negative) about the program has brought tremendous satisfaction and meaning to what we do. It is humbling to think that we have been able to cross national, generational, and cultural boundaries to bring people together in a mutual love and respect for this wonderful field.

Going forward we promise to deliver at least 4 episodes a month with a goal of 5. We have toyed with different constructs for each month but in general, we will plan on 1 journal club and 2 faculty guests as the backbone of each 4 week period with the other 1-2 episodes kept as wild-cards or for our collaboration with Retinal Physician.

On a personal note, we still do not derive any profit or advertising revenue from the show. While this may change in the future, we will always prioritize providing content as unbiased and disclosure-free as possible and maintaining our independence over content. 

Finally, whether you have listened since the beginning or just started with Episode 72, we need to hear what you want. This survey (link) will be critical to shaping the future of our program and what we can bring to the table. The beautiful thing about being a small organization is mobility and flexibility. So please take 2 minutes to respond (it will take less time than it did to read this soliloquy!).

Thank you for listening and for all you do. We truly appreciate what you brought into all of our lives.

Jay Sridhar

Jayanth SridharComment
The Interview Trail: How to Succeed on your Residency/Fellowship Interview
"All of the above being said, you should enjoy the interviews as well and be yourself. You are being fed well, shown the sights, and you are meeting applicants from all over the country with vastly different medical school experiences."           -Jay Sridhar

"All of the above being said, you should enjoy the interviews as well and be yourself. You are being fed well, shown the sights, and you are meeting applicants from all over the country with vastly different medical school experiences."

          -Jay Sridhar

Whether you're applying for residency, fellowship, or even medical school, interviews can be a busy time full of preparation and excitement, stress and uncertainty. Today, Jay shares a few tips on how to excel on an ophthalmology interview. However, his pearls of wisdom are also applicable outside of ophthalmology to any field of interest! Thanks for joining us today!

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We are entering the heart of surgical retina fellowship interview season. Nipping on its heels is the ophthalmology residency interview circuit. In a prior blog post about residency applications in general we briefly touched on interviewing, but here are some specific pearls to remember before you take that fancy suit and new dress shoes on the road:

1)    Mock, mock mock: Practice makes perfect. Practice interviewing with your medical school classmates, mentors, significant other, whoever. Everyone has different comfort levels with interviewing. Just like you would not expect to pick up a tennis racquet for the first time in your twenties and play like Roger Federer, you should not expect to walk in cold and nail every interview.

2)    Common is common for a reason: While it may come across as mechanical to memorize responses, you should be prepared for the most common questions you may be asked. Here is a list to practice:

     -Do you have any questions about the program? (the most common question)

     -Why did you go into ophthalmology? Who were your biggest influences?

     -Tell me about yourself

     -Tell me about X activity/interest/hobby (from your application)

     -I have to sell you as an applicant to the rest of the residency committee. What should I tell them? Give me a 2 minute synopsis.

     -Why are you interested in our program?

     -Have you visited here before? If not, how do you find this city? Why would you be happy here?

     -Why are you a good fit for our program?

     -What are your three biggest strengths? Your three biggest weaknesses?

     -How can I convince you to come here? (not a promise)

     -I saw that you did a presentation on XYZ topic during your ophtho rotation. Tell me more about this. What do you know about current research on this topic?

     -Where do you see yourself in ten years? Why (academics/private practice)? Do you want to do fellowship?

     -Tell me about your research. How do you think this will be applied in the future?

     -What problems did you face in your research? What were your results? What would the follow-up project try to achieve?

     -If you were not a doctor what would you be? Why?

     -What are your hobbies (or questions about hobbies listed on your application)?

     -What is your favorite book? Why?

     -What is your proudest achievement? What was your biggest failure and how did you learn from it?

     -What is the future of this field? How will healthcare reform affect us?

3)    Be enthusiastic: No matter how high or low a program is in your mind, remember always that if you are visiting a place that means on some level you are seriously considering working there. So “turn it on”! Be excited, smile, be interested in the program because THIS MAY BE WHERE YOU TRAIN! You put in all the work to get to this point and now you get to see your future as a resident first-hand. You may be tired from a long day’s travel, you may be sick of seeing another examination room with slit-lamps, you may be sick of answering ‘Do you have any questions for me?’, but always remember to be enthusiastic and polite. This is the beautiful place you may be privileged enough to call your home program in the future.

4)    Be prepared: Given that this is YOUR program of the future, you should be well-prepared in advance about the program. At the bare minimum know how many residency slots there are, who the program chair and residency director are, who the coordinator is, and any other information available on a program’s website. Asking any of the above indicates to faculty/residents that you have not done your homework. In addition, talk to residents at your home program who may have interviewed there in the past. Read all feedback about the program posted online at Student Doctor Network or match applicants. All of this will help you come up with specific questions about the program that show how interested you are. And you should be interested, because this may very well be the place where you train. Better yet, these questions will actually be legitimately thought-provoking to you and your interviewer as opposed to the standard ‘What are the biggest strengths of this program?’-type questions asked by everyone.

5)    Carry on, carry on: Always carry extra photos, copies of your CV, and any of your publications (if you have them) on interview day. I stopped doing so about half-way through (since they were never used). Then I wound up interviewing with a faculty member who was pinch-hitting for a colleague and had never seen my application. That CV would have really come in useful.

6)    Do not sweat the small stuff: There are debates how “even” applicants are when they arrive for an interview. The best philosophy is to consider it dead-even and treat it as such.

7)    Have fun: All of the above being said, you should enjoy the interviews as well and be yourself. You are being fed well, shown the sights, and you are meeting applicants from all over the country with vastly different medical school experiences. Talk to them and learn about them! You will meet some very cool people who will be your colleagues for the rest of your life. You will see the same people at national conferences as a resident and then perhaps in fellowship and beyond. Some of them will be your co-residents! I made some very good friends on the trail and we wound up helping each other out throughout the season.

 

Note: much of this article I previously wrote up in a now defunct “Updated Unofficial Guide to the Ophthalmology Match.” Stay tuned for more excerpts in the future!

-Jay Sridhar

 

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Jayanth SridharComment
Prof & Pupil: From Preferences to Career Paths
"In medicine, however, you cannot afford to be poor at any aspect of your work because in most instances it directly influences someone's health."    -Jay Sridhar

"In medicine, however, you cannot afford to be poor at any aspect of your work because in most instances it directly influences someone's health."    -Jay Sridhar

Jay continues the convesation with Mike and Louie about clinic vs. OR, and how preferences can shape your career.

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LC: Do you find it's common that people tend to shape their careers around their forte or do most ophthalmologists have relatively balanced practices? Also a related question: If during my training I discover that I'm better in clinic than in the OR, would it be more effective to hone that strength or spend more time improving my weaknesses?

JS: Tough questions that I will not pretend to be smart or wise enough to answer well. The most I could say is that when you read about or talk to successful people in general life they talk about maxing out strengths. The more you do something, the better you get (see Malcolm Gladwell's 10,000 hour theory) and if you are good at something already the ceiling should be higher.

In medicine, however, you cannot afford to be poor at any aspect of your work because in most instances it directly influences someone's health. What you can do is tailor a career to strengths; maybe stop operating and focus on research if that's your love and strength, or refer complex ocular oncology patients to another doctor who is a specialist. Maybe the most important talent you can have as a physician is to know your limitations, work hard to improve what you can, and ask for help when you need it.

However, as a resident your goal should be to be as good as possible at everything. It's too early in your training to punt on operating, for example, and the ACGME has basic requirements in terms of knowledge base and skills that are necessary to graduate an ophthalmology residency. So if you realize you are deficient seek help from mentors and work to improve.

LC: Those are wise words and very applicable to our medical training now as well. Even if we know we're going into ophthalmology, we have a duty now to excel as medical students for we never know when our knowledge may be useful and aid in the care of a patient. Who knows how the future of medicine may be like, and we have all the possible tools to be prepared to handle anything.

MV: I agree with Louie and really like that analogy! It's nice to hear about the variety of exposures we will receive, and also about the ability to customize our career to our interests.

When you were going through medical school and deciding on ophthalmology, did you know/assume that you'd prefer the OR over clinic, or was that a preference that came out during residency or fellowship?

JS: I had no idea because I loved both the clinic and the OR for ophthalmology. As a resident I actually preferred clinic in some ways; the OR lends itself to simultaneous excitement and anxiety when you are starting since the only way to avoid complications completely is to not operate at all. But as a fellow as I gained in confidence operating full-time as a retinal surgeon the OR slipped ahead in my personal rankings.

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-Adapted from a real conversation between The Professor (Jay Sridhar) and The Pupils (Louie Cai and Mike Venincasa). 

 

Prof & Pupil: Finding Your Forte
"...everyone has a forte. It's like saying Michael Jordan's greatest strength as a basketball player was scoring. It doesn't mean he was not a great passer or ball-handler, but his peak was scoring."     -Jay Sridhar

"...everyone has a forte. It's like saying Michael Jordan's greatest strength as a basketball player was scoring. It doesn't mean he was not a great passer or ball-handler, but his peak was scoring."     -Jay Sridhar

 

Jay talks with Mike and Louie about preferences of clinic vs. OR and how to stay interested throughout your career. They realize that while we strive for excellence in all areas, everyone has a forte.

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LC: Things I commonly hear from medical students when I tell them I'm going into ophthalmology include "Eyes gross me out." or "Doesn't it get boring only working on one organ?" How do you usually respond to those sentiments? 

JS: I think all of us in medicine have components of our field which give us more of the “ick” factor than others. For example, I discovered during my trauma rotation that broken digits bother me a bit. Having seen good friends of mine vasovagal seeing eye surgery videos, I can honestly state that being grossed out by eyes may be a legit reason to not pursue the field. Still, unless you have a visceral response, it is worth exploring and seeing if your initial hesitancy is really all in your head.

As far as boredom goes, a wise doctor (an internist) once told me in medical school: everything becomes rote after some time. That is to say, every field has its bread and butter that you will see over and over again, and then its zebras that pop up occasionally and stir that old flame in your soul. The real question is whether or not the rote stuff is still interesting to you after the umpteenth time of looking at a retina. And yeah, being able to directly see part of the central nervous system is still exciting!

MV: That's a really great point. As students, and really throughout the entire career, it seems like that is a goal - to get to the point where you know your field well enough that you're really only "stumped" by the zebras. At that point, there's that risk of boredom. But then again I suppose that's where research comes in - with treatments constantly progressing, those things that were once mundane could become quite exciting again!

LC: I never thought of it that way. In that case the rote things in ophthalmology are pretty interesting. Even a simple slit lamp exam can be performed more efficiently, more accurately. I think the procedural aspects of the field will always be enjoyable as long as we're striving to improve our technique. 

MV: With regards to your comment, Dr. Sridhar, I'm curious if you feel a difference between clinic and surgery. I've heard a number of residents from various fields say something like, "I can't wait to get through this clinic day and get to the OR tomorrow." For you, do "easy" surgical cases remain exciting because of how much attention to detail is required regardless, or are they subject to this "bread and butter" idea too?

JS: Excellent question, Mike. So the fellows used to discuss this amongst ourselves in fellowship. We concluded that each amazing surgeon we trained with had one arena where they were in their absolute element, be it the OR, clinic, the podium giving a talk, or writing a paper. Now, this is not to say they were inadequate or uncomfortable in the other arenas. Retinal surgeons are generally exceptional people who excel across various facets of their work. But everyone has a forte. It's like saying Michael Jordan's greatest strength as a basketball player was scoring. It doesn't mean he was not a great passer or ball-handler, but his peak was scoring.

That being said I think I am not unusual in preferring OR to clinic. I enjoy talking to and seeing patients tremendously, but there is something uniquely meditative and special about the privilege of performing surgery. We talked about retinal surgery at length before (link), so I will summarize by saying that retinal surgery stimulates because every case is its own challenge. 

LC: Thats a really interesting analogy. That's a point I never considered but makes a lot of sense. There are multiple definitions and aspects of what it means to be a good doctor, and it's natural to have a particular strength - whether with clinic, teaching, or research.

 

To be continued...

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-Adapted from a real conversation between The Professor (Jay Sridhar) and The Pupils (Louie Cai and Mike Venincasa). 

Jayanth SridharComment