Thursday is one of my favorite days. Thursday is ping pong club. 5 to 8PM, sometimes later if we're finishing a close match. My alarm rings before dawn, and I drowsily get ready for the day. Planning ahead, I wear my gym clothes underneath my shirt and white coat so I won't have to change later. I'm on long call today, so in the best case scenario, I'll be only an hour late. I'm fine with that. I'll take any opportunity to play. 

I'm one of the few lucky interns who started on an inpatient hospital service. This month, I've gone through a lot of 'firsts.'  Admitting my first patient, discharging my first patient, and then having my first patient come back to be readmitted (I might have discharged her a little prematurely).

I never completely appreciated in medical school how difficult the practice of medicine is in real life. It's an art and science filled with so much uncertainty. I never feel like I have enough time. I need more time to examine the patient, more time to think through the plan, and more time to SLEEP. It's impossible to be a perfectionist; there's just so much to do. More orders to enter, more notes to write, more consults to call. The sense of urgency makes even small moments of idleness feel like time being wasted.

And it just gets worse. Once I could manage 4 patients, my cap increased to 5, then 6, and now 7. Senior residents carry 16 patients at once. Attending physicians don't even have a cap; they just carry as many patients as possible. Of course we'll get better with time, but no matter how much we improve, we'll never have more than 24 hours in a day. 

Spending time with patients is the most fundamental aspect of being a physician.  There's no better feeling then to have the ability and opportunity to provide hope to those in need. Yet this aspect of medicine is often the first to be sacrificed. Unfortunately, physicians in hospitals don't get reimbursed for extra time spent with patients. They're paid for diagnoses made and procedures performed. 

At my first feedback session, my attending criticized me for spending too long taking patient histories. He explained that down the line, I'll never have more than 10 minutes with each patient , and it would be better to get into the habit now. But it's not that I can't be more efficient, it's that I choose not to. Being efficient just means asking fewer questions and cutting off the patient more often. We save time by being less thorough.

It's 7PM, and I'm I'm still wrapping up my last few progress notes. Just as I finish and start to pack up, my phone rings - it's a nurse from the second floor. The husband of one of my patients is here. He and his wife have a few questions. 

I'll make it to ping pong next week. 

- Written by Louie Cai, a new intern at a community hospital in Florida

"The simplest way to approach the process is to rank the programs in the order you prefer, not in the order of likelihood you think you have of being ranked highly by a given program."

          -Jay Sridhar

Happy new year! With January comes resolutions, new Star Wars wall calendars, and yes, ophthalmology residency rank lists. While every applicant’s situation is unique, here are some general pearls of factors to consider when finalizing your rank list:

1)    Rank it the way you want it: The match system was designed to err in favor of the applicant. While there is a Nobel-prize winning explanation of the algorithm somewhere out there, the simplest way to approach the process is to rank the programs in the order you prefer, not in the order of likelihood you think you have of being ranked highly by a given program. This should probably be points 1, 2, and 3.

2)    There can only be one #1: It may be helpful to notify the program you are ranking #1 of that fact. Although the system was designed for both applicants and programs to make independent rank lists with their preferred order, some programs do like to rank applicants highly who are ranking them highly. However, avoid the worst mistake of all: telling multiple programs that they are your one and only true love. Ophthalmology is a small world and cross-talk between program directors will very likely result in you getting tangled in the very web of lies you have weaved. Plus it’s plain dishonest even if you somehow do not get caught.

3)    You rank it, you bought it: Once again, remember how the rank system works. You could theoretically end up at any program you rank, including the last program on your list. That means that if you absolutely will not go to a program you interviewed at for some reason DO NOT RANK IT. It is unprofessional and bad form to rank a program and then drop out because you were unhappy to match there. On the other hand, you better have a really good reason for not ranking a program, because that is essentially a statement to yourself that you would rather not match at all than go to that program. Think long and hard before going down that road.

4)    Four Factors to Consider: Dr. Ruben Sanchez wrote a great article years ago about the top ten factors to weigh when making a rank list for ophthalmology. They were in no particular order: personal goals, family, culture of program, location, program size, surgical numbers and clinical variety, laser experience for residents, call schedule, benefits, and research opportunities. To give a different perspective, I think to simplify there are four major factors when deciding how to construct a rank list.

First is the clinical experience which encompasses all the medical and surgical aspects including volume and variety. Second is the culture and ‘gut feeling’ a program gives you when you spend a day there. We spend a significant amount of time as applicants and interviewers talking about these two points and I am sure you have a good idea how all the programs you saw stack up. Third is what is best for you and your life in terms of family, friends, significant other, location, etc. This is often not discussed at all during interviews but is critical, because personal factors can lead to great happiness or unhappiness. An unhappy resident even in the ‘best’ program can be much less successful and productive than a happy resident in a ‘lesser’ program.

The fourth and final factor which requires a deal of introspection is the learning style of a given program. There is a spectrum of educational philosophy ranging from the autonomous program with higher volume but perhaps less direct one-on-one supervision to the less busy program with stepwise progression in autonomy and skills. Of course, like with any spectrum, there are a wide range of styles across the spectrum which incorporate different levels of autonomy and more hands-on teaching. Still, get a sense of how you like to learn and what makes you personally comfortable. Does autonomy stimulate and excite you or make you feel uncomfortable and unsupported? Does more observation and hands-on teaching make you feel structured or stifled? There is no right or wrong answer to the question overall, just a right answer for you. Once you know how you prefer to learn based on your medical school experiences that can help decide between programs of a similar caliber with different philosophies.

5)    Remember your running rank list: Hopefully you made a running rank list as you went from interview to interview. Even if you did not, you have notes or thoughts jotted down somewhere capturing your immediate reaction to an interview day. While emotions can cloud practical thinking, do not completely neglect those aforementioned gut feelings in favor of on-paper programs strengths and weaknesses. Your running rank list should be not wholly different than your final rank list, which you will only construct after you…

6)    Consult with your mentor(s): Show your rank list to your mentor(s). They will rarely make drastic changes but can give you insights into nuances between places or find out information for you that may help you finalize that rank list.

7)    Put it in early: Put your rank list in at least a few days ahead of the deadline to avoid technical difficulties, and avoid the temptation to fiddle with it. Now congratulations! One more week until the best day of your medical school career: Match Day.

I hope these tips are helpful this year and in the years to come. Best of luck!

               Jay Sridhar

"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

"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

"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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