"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). 

"...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). 

"The only thing worse than being blind is having sight but no vision."  -Helen Keller

Jay talks with Mike and Louie about which skills best carried over between medical school and ophthalmology residency. They realize how important it is to stay connected to other specialties. 

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LC: Dr Sridhar, for someone going into ophthalmology, which skills from other clerkships helped you out a lot during residency? 

JS: Thats a phenomenal question Louie. The cop out answer is all of them contribute because the most important skills to develop are a strong work ethic and a dedication to approach patients compassionately, intelligently, and efficiently. You gain that skill over time via repetition regardless of subspecialty rotation. I will say that the major principles I learned in general surgery about hemostasis, minimizing surgery duration, and tying good square surgical knots all were extremely applicable during ophthalmology residency. Understanding internal medicine is critical given how many systemic conditions manifest in the eye. You would be surprised how often you are the first doctor to tell a patient they have hypertension or diabetes. Even malignancies such as leukemia may be first noted on funduscopic examination. 

MV: I just started Internal Medicine today and have my Surgery block next, so I’ll definitely keep those points in mind throughout these rotations! I often hear others claim that ophthalmology is this isolated niche where you “put away your stethoscope” and forget about the rest of the body, but it’s great to hear how that is far from the truth. Thanks for the great perspective, Dr. Sridhar.

JS: When I interviewed Dr. Craig Greven he referenced how ophthalmologists sometimes isolate themselves from other parts of medicine and how we cannot forget the importance of communicating with our non-ophtho colleagues. Never forget how frustrating it could be as a student on a primary care rotation to either not know what happened at a patients subspecialist appointment or to not be able to reach the subspecialist with questions. This will reinforce your feeling of responsibility to send accurate and useful letters to your referring primary care physicians as an ophthalmologist. 

LC: I completely agree. It's so easy to forget how specialized the knowledge is. Our acronyms make documentation more efficient but often make it less interpretable for general practitioners. I'm starting to realize how important it is to effectively communicate the implications of the diagnoses and management plans we create .

JS: And acronyms vary from institution to instruction! I did not realize this until I started fellowship, but even similar programs can have very different ways of saying the same thing. Similar to how a sub sandwich in Miami is a hoagie in Philadelphia. 

LC: One thing I noticed on my clerkships was that whenever a patient has anything eye related, ophthalmology is consulted. What criteria would you say warrants a consult? For example dry eye or viral conjunctivitis could potentially be managed by the general team. Or is it better to be safe than sorry? 

JS: A great question and one we should save for a bigger piece next week. Come by for next weeks post and we will discuss inpatient consults.

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). 

"Our eyes are placed in front because it is more important to look ahead than to look back..."

Jay talks with Mike and Louie about their experiences with ophthalmology rotations during medical school. They realize how much of an influence residents and attendings have on a medical student's decision to pursue ophthalmology. 

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Jay: What are the challenges you two have encountered as students on an ophthalmology rotation as opposed to your core clerkships (e.g. internal medicine, general surgery)?

Louie: For me, the biggest challenge was the learning curve needed to perform a good slit lamp and indirect exam. In medical school, we often spend a lot of time honing our history taking and physical exams, but we never get a lot of practical training on the basic eye exam beyond direct ophthalmoscopy. I felt that I was more of an observer and learner on my first ophthalmology rotation whereas on my core clerkships, I was more quickly involved in the entirety of patient care.

Mike: The biggest challenge for me was the inherent difference in the structure of the patient visit, particularly the physical exam. By the time we start clinical rotations we had been practicing the Internal Medicine-style H&P for a few years, but I had only spent a few minutes on the slit-lamp. Instead of seeing patients on my own, I spent more time observing, learning about different conditions, and exploring different parts of the field. Unlike for core clerkships, scrubbing into and physically participating in surgeries just isn’t as feasible in ophthalmology.

Jay: I agree. I remember as a student how difficult it was to feel helpful as a student on an ophthalmology block elective. However, being on the other side now, I've seen that certain students do integrate themselves into the clinic, which is remarkable. Probably the most important thing I notice is how attentive and courteous the best students are to the patients. The next thing I look for is genuine interest (and not in texting!). And finally the best students ask intelligent questions at the appropriate times. 

Jay: How as an attending can I help involve students on an ophthalmology rotation? What have your favorite clinic or surgery attendings done?

Mike: My best experiences were with those attendings who either were very open to questions, asked me questions to bring up teaching points, or discussed cases between patients. If there was a teaching scope in the room, it was very helpful to hear the attending’s thought process during the SLE, and I enjoyed opportunities to give the exam a try on my own once the “real” physical exam was complete. For surgery, my best experience was a case one-on-one with an attending - he had plenty of time to talk about each step and his decision-making. Similarly during cases with residents, I enjoyed when they chimed in once in a while to make sure I knew what was going on. This really helped connect my book-learning with the real-world procedures.

Louie: I agree with Mike. My best experiences were with attending physicians who always appeared open to questions. I also really appreciated when attendings and residents never assumed what I knew and explained from the most basic level. A quick refresher only helps to solidify knowledge. Other than that, simple things like welcoming and acknowledging the presence of a medical student goes a long way. We already feel slightly uncomfortable when we're shadowing, and a simple gesture like that can really put us at ease.

Jay: I think as a last point you both have mentioned how important residents and fellows can be to the student experience. I would not have gone into ophthalmology if my first experiencehad not been with two incredible residents: Will Parke and Ryan Isom. Students are extremely impressionable and seeing someone extremely generous and willing to act as a bridge to attendings can be inspirational.

Louie: Absolutely. I was in between many specialties when I started medical school, and the people I met in ophthalmology strongly motivated me to choose this speciality. There is a tradition of teaching that we have a duty to pass on.

Mike: That's an excellent point. It's important to have great attendings as mentors, but at the end of the day it's from the residents that students will learn what their day-to-day life will be like for the next number of years. Whether it be from attending or resident, one thing that really stood out during my rotation was how passionate everyone was for the field. I can't tell you how many times I heard "Ophthalmology is an excellent field!" or "This was definitely the right choice for me." When your mentors are excited to teach you and excited about their job, that gets me excited about a future in the field!

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). 

Da Vinci' kept detailed notes of his ideas, experiments, and inventions. 

Whether you are an athlete, a businessman, or a surgeon, it is important to track your prior efforts in order to improve and progress. As a retina fellow, keeping an accurate log has multiple benefits:

1)      Requirement: All AUPO programs (and many non-AUPO programs) will require submission of a log upon completion of fellowship to earn graduation certification. In addition, the American Society of Retinal Specialists (ASRS) has partnered with several programs to standardize a more detailed logging of surgical cases. Fellows who complete the ASRS blog can become fellow members, bypassing normal application process to gaining full membership.

2)      Privileges: As a newly minted retina attending, you will need a surgical log of some sort to provide most hospitals or surgery centers before obtaining surgical privileges at that site.

3)      Self-Improvement: Your memory will play tricks on you. On a micro level, unless you record a log you will forget individual cases that may have taught a great deal. On a macro level, examining all of your surgeries will help give an honest general sense of how your results are with different surgical techniques.

4)      Research: Often reviewing one’s log will lead to innovative and interesting research ideas and data that may contribute to the field.

5)      Habits: Talk to any of the best-known retinal surgeons and they dutifully track their results over time by logging surgeries. Building good habits early in your career will serve you for a lifetime.

Before moving forward please note that it is critical to make logs HIPAA-compliant, whether by de-identifying patient data completely or storing a log in a secure, HIPAA-compliant encrypted server or computer.

Logs also lend themselves to controversy. Applicants often ask the question: how many primary surgeries do fellows graduate with from each program? How many assists? The answers you will receive as an applicant are variable and that can make it extremely difficult to compare different programs. Fellows and programs are not intentionally trying to make things confusing. In contrast, the major issue is the lack of standardization individual to individual about what constitutes a primary surgery.

The AUPO log, similar to ACGME log systems for general surgery or neurosurgery, simply uses a binary system. Each trainee surgery is classified as 1 or 2, 1 indicating either a primary role as the surgeon (or a teaching role) and 2 indicating role as assistant. Retinal surgery is often not so easily defined, however. If as a fellow you complete the vitrectomy and fluid-air exchange but not the laser or closure is that primary or assist? If you place a scleral buckle but the attending does the external drainage is that 1 or 2? Ask different individual physicians, both out in practice and in fellowship, and you will get many different answers.

Simply put, perhaps the most important factor is to be internally consistent with yourself. As long as your log is internally consistent, and we understand implicitly that we cannot compare one fellow’s log to another, then the log still serves all five of the purposes listed above.

To help track your progress, it may be useful to further subdivide cases in a 1-5 numerical score. As fellows we utilized this scale, and while it still leads to individual decision making on what score to assign a case, it helps better define for yourself how you are improving over time:

1: primary or teaching surgeon

2: assist with more than core vitrectomy, including membrane peeling

3: assist with core vitrectomy

4: assist with entry/closure

5: primary assist

The hardest differentiation will be of course between grades 2 and 3 and 3 and 4. That’s where each of the fellows in our program differed in interpretation. All systems will have flaws, and I encourage you to develop your own methodology and share it. But, as long you are logging faithfully, honestly, safely, and consistently (and you review your log regularly!), you will provide better and better care for patients over time.

Jay Sridhar