The Winning Formula
Sitting Down With… Douglas Koch, Professor and Allen, Mosbacher, and Law Chair in Ophthalmology, Cullen Eye Institute, Baylor College of Medicine, Houston, Texas, USA
When did you first think of becoming a physician and an ophthalmologist?
My father, a radiologist, talked of how he loved patient care and the intellectual stimulation of practising medicine. Becoming a physician appealed to me from a young age, but I was a latecomer to ophthalmology as a career choice. In my small hometown of Port Huron, Michigan, one of our parents’ friends was ophthalmologist Nicholas Douvas. Nick developed one of the first vitrectors and ophthalmologists from around the world traveled to Port Huron to learn from him. This was incredibly unusual for our slightly rural small town. Nick was also my ophthalmologist and fit me with PMMA contact lenses when I was 13; that was life-changing.
Despite all of this, I wasn’t exposed to ophthalmology in the clinic until the start of my fourth year at Harvard. I took a rotation at Massachusetts Eye & Ear and was astonished by the magic of examining and treating the human eye and the unbelievable intricacies of eye surgery. I had applied to pediatric residency, but I immediately pulled those applications in favor of ophthalmology. Of course, I misspelled it “opthalmology” on my applications…
My subspecialization in cataract and refractive surgery was even more serendipitous. In my final year of residency, I secured the fellowship I had sought in pediatric ophthalmology and strabismus (yes, kids again…). However, a few months before graduating, as I was scrubbing with Jared Emery – our amazing faculty cataract surgeon – he paused, looked at me, and asked if I would consider joining him as a partner at Baylor in Houston, Texas. By then, I was committed to Marcia, my future wife and a native Houstonian, and a week later the pediatric fellowship program informed me that my funding for the fellowship “fell through.” It was a dream choice for me… and another abrupt career change.
When did you know you had made the right career choice?
On the first day of my ophthalmology rotation, when I looked at an eye with the slit lamp. Over time, I have come to realize that I am very visually oriented. I am pretty hopeless at memorizing syndromes, but images stay with me. I love the visualization our field allows. I was incredibly fortunate to find such a great fit.
Do you ever imagine having followed a different path?
In college, I toyed with the idea of becoming a professional French horn player, but I saw the challenges such a career entailed. I have many friends who are musicians and love their careers, but I have no regrets about my decision. Music remains an important part of my life, though; I help run Bach Society Houston and play the piano (at a very amateur level).
Who do you see as your most valued mentors?
There have been so many, but I will mention three: i) my chairman of 30 years, Dan Jones, who taught me the importance of painstaking attention to detail and was remarkable for the personal touch in the care he provided for his patients; ii) Jared Emery, who taught me so much but, above all, the elegance of surgery performed with precision and grace; and iii) Stephen Obstbaum, who brought me onto the editorial board of the Journal of Cataract and Refractive Surgery and mentored me in the nuances of editing, managing a journal, and more.
What is your greatest achievement?
That’s an easy answer: teaching students, residents, and fellows. This is the most deeply satisfying part of my career. I have had the opportunity to work with so many spectacular students and young physicians. Seeing them flourish, become brilliant clinicians and surgeons, and make meaningful contributions to our field is the greatest reward I could ask for.
From a research standpoint, I would list two things. The first is my interest in improving the accuracy of IOL calculations, especially in challenging situations. In 1989, my colleagues and I published the first paper showing the unexpected outcomes of IOL calculations in post-RK eyes, which started my career-long work in this area. My second is my team’s work pointing out the impact of posterior corneal astigmatism on astigmatism management in cataract surgery; this has transformed the way toric IOLs are calculated.
Are there any aspects of your job you dislike?
The hardest part of my job is guiding patients to set appropriate expectations. You can never tell what will make a patient upset or afraid. Yesterday, in succession, I saw a 20/40 post op patient who was ecstatic and a 20/20+ patient who was miserable. Helping patients work through these issues is a huge part of caring for them.
Do you remember any individual patients your work has helped?
In the mid-1980s, my chairman, Dan Jones, referred a prominent patient to me. He had undergone cataract surgery in New York City, and the surgeon targeted both eyes for myopia instead of targeting the monovision that the patient had achieved with contacts and had requested. At that time, there were some uncertainties with IOL labeling; there was no ORA, no formula for calculating IOL exchanges, and no proven formula for calculating IOL power in a pseudophakic eye. And, of course, the IOL had a 6-mm PMMA optic. I removed the IOL, placed it in a water bath, read the power with a lensometer, and made an educated guess for the new IOL, all under the watchful eye of my chairman. The patient was 20/20 on day one and has been an incredibly generous supporter of our research ever since, culminating in the huge 10-year grant I received last year. So much for early retirement…
What are you working on right now?
I am blessed to work with many amazing colleagues, especially Li Wang, Mitch Weikert, Sumitra Khandelwal, and Zaina Al-Mohtaseb. Two of our areas of work are studies to improve the accuracy of IOL calculations and a large project to evaluate the impact of ocular aberrations on vision quality and depth of focus in patients implanted with different types of IOLs. We hope to provide clinicians with guidelines to enable them to personalize IOL selection for any given patient.
Please share your predictions for the field…
The overall thrust of care for cataract patients will be to better meet patients’ expectations through superior technology and personalized solutions, including IOLs that can be adjusted throughout the patient’s lifetime to address changing visual needs.
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