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Subspecialties Professional Development, Glaucoma

Celebrate Life!

How did it feel to be voted number one on this year’s Power List?

It’s surprising, and also very gratifying. It suggests, to some extent at least, that what I’m saying – what I’m trying to get across to people – is of importance to my colleagues. To have the respect of the people you work with is important, and very lovely.

What do you consider the most important thing you’d like to communicate to your field?

In many ways, there is no principal thing - in fact, that itself might be the principal thing! But overall, it’s that every patient is a unique individual, with a distinct situation. And we need to take a thoughtful, caring approach to each person, and recognize our own biases or judgements.

Often, I think we tend to be confident that our take on something is the correct one, and it can be easy to forget that our first job is to help the patient – what the patient wants comes first, and our response to them should not be related to surrogate markers, such as visual acuity or intraocular pressure, but how the patient feels and functions. I think ophthalmologists often think they know what is best for their patient, even if the patient doesn’t agree – such as a patient refusing glaucoma surgery even though their doctor believes they need it. This is a constant dilemma we face in medicine: what we think is right, versus what the patient thinks is right. And we have a huge obligation to understand what is good for each patient, from their own perspective.

I grew up in a family that spent a lot of time talking about values, and that’s something I’ve carried with me; just this morning I moderated an ethics session here at Wills Eye. Years ago I was taken by some of the writings of Emmanuel Kant – the height of our considerations has to be respect for the person, respect for every person. You manifest that respect by taking into account your patient’s wishes.

You have a very holistic approach - is this something that some ophthalmologists miss?

I think we miss it in the way we live, and in medicine generally. We frequently hear that the goal of glaucoma specialists is to control pressure. Then we could expand on that a little and say our goal is to preserve vision. But these are not the primary goals at all, they are methods that you use to pursue your real goal, which is to ask – is this patient able to celebrate and enjoy their life? And what can we do to make that as achievable for them as possible?

What informed your philosophy on medicine, and how to practice it?

It’s very hard to answer that! I’m sure it’s got to do with some very fundamental things about me - my genes, my early experiences, and my upbringing. I went to a Quaker school, and I think that was very instrumental. We were taught that there is god in each person. I believe that, and I think every person has a good aspect in them that you can appeal to. We were also taught that service is an important part of life.

I find it interesting that my oldest brother, who left to go to college when I was very young, became a lawyer, and then a judge. I became a physician. And although it wasn’t something we’d ever discussed, we both pursued the study of ethics – obviously his interest was legal ethics, and mine was medical, but it really struck me that we both went in a similar direction. I think there must have been something that sent us both down that path.

You’ve done a lot to further the field of glaucoma, and you have an impressive history of publications…

When I was a resident at Wills Eye, Irving Leopold, who was in many ways a mentor to me, asked why I wasn’t publishing papers, and I replied, “But I’m only a resident!” He told me, “There’s no reason why you can’t start right now, there are things that need to be known.” He was right – publishing papers isn’t about getting recognised and promoted. You do it to contribute to your field, and add value by increasing medical knowledge and answering important questions. Awards and promotions are just side effects of that.

During my time at the National Institutes of Health (NIH) I became interested in some esoteric things that we’d been observing. So at that point I published quite a few articles on metabolic disease, and things like that. And when I went into practice, there were some areas that seemed deficient to me, such as how to examine the anterior chamber angle. I didn’t think there was a good system available, so I decided to work on it and try and figure out a better way. When I came across gaps, I aimed to study and publish on them.

Why glaucoma?

I originally majored in history at Yale. I took pre-med courses, really because I think I was expected to. When I finished at Yale, I didn’t plan to become a physician. I wanted to be a poet or a composer, but I didn’t have enough courage to pursue it. So I went to medical school because I thought it would be safe, and simple, and give me a chance to help people. I chose ophthalmology partly because it’s a field with a strong aesthetic component – the eye is a beautiful thing.

I became involved in glaucoma because I didn’t want to go to the Korean War – I don’t think war is a good thing, and I didn’t want to participate in one. I chose public health service instead and went to the NIH, where I was assigned to glaucoma – so it wasn’t a field I chose.

After your time with the NIH, you returned to Wills Eye – and never left. Do you ever wish you’d travelled more?

I came back to Wills because my family is here, and it’s my home. And I really enjoy working at Wills – so I had no reason to leave! Wills allows its physicians a lot of autonomy. It’s a clinically oriented environment, full of amazing clinicians who excel in their jobs and put their patients first. I also love the teaching focus here, and being able to train residents and fellows.

Do you have any advice for managing and teaching fellows?

Two things: you have to have something to teach, and you need to have people who want to contribute. We have fellows come here to become glaucoma specialists, and very early on I talk to them, and say “I’m glad you’ve come here, and we want you to become the best clinicians and the best surgeons that you can possibly be. You have to learn about the nuts and bolts of the field, and become knowledgeable and procedurally skilled, and we’ll work hard to teach you these things.”

But there’s a third component, which is more important – who you are as a person. Because who you are will determine how much you value learning. If there’s a procedure you need to learn to help your patient, you’ll learn it. If there’s something that comes up that you don’t understand, you’ll develop a research project to try and answer your questions. The main thing is your intent to be helpful, responsible, and do a good job - that has to come first, or nothing else will follow.

And above all, I’d advise people that mentorship is wonderful. The mentor always grows as the trainee grows, and it can then become reversed, and the mentee can end up mentoring you. It’s one of the loveliest relationships I can think of. There is a group of people who trained with me called the International Society of Spaeth fellows. Recently I’ve been travelling a lot, and visiting many of my old fellows, and being invited to stay with them. There are not many things in this world nicer than visiting a former mentee, and seeing all the wonderful things they’ve gone on to achieve.

I originally wanted to be a poet or a composer, but I didn’t have enough courage to pursue it.

What motivates you in work and in life?

I believe in living with enthusiasm and optimism. Humour, and having fun, are so important. You need to try and live in the moment and enjoy things. For example, I like to drive to work with the top down on my car every day, unless it’s raining. Just driving along, watching the birds and smelling the scents, is a wonderful way to experience the world, rather than being cooped up in your car. I try to live my life to the fullest extent possible, but I’m still learning, and I’m sure I could do better!

As for how I ended up where I am, doing what I do, it’s hard to say. I think the simple answer would be fate. I don’t think I can take any real credit for it. I was given a lot of gifts: some intelligence, some curiosity, an excellent education. I had no control over those things. All you can do is try and do your best with the gifts you’re given.

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