81: A Chairman Of Ophthalmology Talks About His Specialty

 

Session 81

Dr. Nicholas Volpe is the Chairman of Ophthalmology at the Feinberg School of Medicine. He joins us today to discuss his journey and his 25 years in the field! Today, we talk about the things necessary to match into this specialty and how to become successful in it.

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[01:44] His Interest in Ophthalmology

During his second and third year rotations in medical school, Nicholas discovered his fascination with vision science. He liked procedures while recognizing that just being a surgeon that intervenes and disappears wasn't quite as satisfying as the kind of relationship that Ophthalmologists can have with their patients. So it was a unique blend of primary care of dealing with chronic patients with everyday needs and then superimposed on that is the chance to intervene surgically.

[03:00] Traits that Lead to Being a Good Neuro-Ophthalmologist

Nicholas describes this as a somewhat eccentric subspecialty within Ophthalmology as there are not that many Neuro-Ophthalmologists. It's one of the less popular subspecialties. In terms of choosing Ophthalmology, you have to have a certain interest, dexterity, and desire to do microsurgical procedures. In most Ophthalmology cases, it's 20% of their life. Unlike many other surgical specialties where you're operating three days a week and seeing patients one day a week, in Ophthalmology, there's still a fair amount of outpatient work in addition to the surgery.

Moreover, you have to have a true interest in vision and helping people see. It's a lot more fun to be fascinated in the eye and how it works and understand the kinds of things that we can now do for people's vision.

"You have to have this love for the primary care aspect of medicine."

There are also pieces of the field beside vision science, which is public health issues, care delivery issues. The burden of blindness in the world is very different than the burden of blindness in developing countries. So there are great opportunities to provide insight and actual care to underserved people.

[05:40] Types of Patients and Cases

What Nicholas didn't initially recognize was that it was the most complicated aspect of Ophthalmology and interaction between the vision system and the brain. Currently, he's interested in the diseases of the optic nerve.

"There are neurons that make up the optic nerve and there are lots of interesting and not well understood or well-treated conditions that affect the optic nerve."

The second group of patients that he sees the most are those with acquired eye movement problems and misalignment resulting in double vision. Currently, his surgical expertise is limited to realigning or straightening eyes in patients with acquired misalignment of the eyes as adults so they're seeing double.

A third of her patients he considers as challenging as they'd have to put up historical clues, exam findings, and diagnostic imaging. On the other end of the spectrum, there are patients that are packaged coming from other health conditions such as from a resected tumor that caused double vision. And then in the middle, are those people who thought they knew what they had or their doctors thought they knew what they had but had it wrong. These could also be things that were overcalled and got better on their own.

"There's a good mix of diagnostic dilemmas within ophthalmology that make it a particularly challenging field."

What's good with such field is they can take a picture of almost all their diseases so they can see what's happening, although there are still lots of nuances to consider when observing which patient is actually having such disease or which ones may require a different treatment.

[09:10] Academic vs. Community Setting

For Nicholas, the complexity of neuro-ophthalmology is often best served and best done in an academic medical center. That being said, his own preference has always been to practice in the enriched and more complicated environment which you can find in an academic medical center since they have learners, research, new knowledge they're trying to apply, and the most complicated patients.

That said, there's a wide variety of things that he does making things very interesting for him with all the challenges and new learnings he faces each day.

[11:00] A Typical Day

As the chairman of an academic department of ophthalmology, he's responsible for the students, residents, fellows, faculty and all they do as researchers and educators, how their service interacts with the medical center, the community, the university. There's fair amount of fiscal responsibility as he runs a department that breaks even and is able to pay its salaries and take care of its patients at the same time.

He also facilitates the work of lots of great doctors, scientists, residents, students interested in the field. Additionally, they're also responsible for many regulatory things they need to do as part of their stewardship of the academic unit in their department.

"It's an incredible privilege to be able to be in a role where you are able to have a vision to take all these wonderful people, put them in that vision, and create something that is far better than any of us could do alone."

[15:20] How to Stand Out and Get a Residency Spot in Ophthalmology

First and foremost, you have to have a competitive board score. Be some kind of a researcher or be affiliated with the ophthalmology department of your school earlier on.  Just be able to demonstrate that you have the capacity to multitask and that you're really interested in this and you want to learn more about the field and you've immersed yourself in a project that's relevant.

"There is a necessity unfortunately to create some type of a sorting process at everything in life."

The ability to get honors in your clinical rotations helps to distinguish yourself from the rest as well. And the board scores are important too and there is a sorting process by way of board score cutoffs or thresholds since they're only able to interview people at a certain level. That being said, they have interviewed people with average board scores and don't stand out just based on their board scores, but for certain other reasons. So don't think that just having a low board score won't get you in. It may not get you to the most competitive programs but if you continue to demonstrate that you're great and interested with high emotional intelligence and are doing it for the right reasons, then you will get good letters and get noticed by the program that knows you until you make your way into Ophthalmology. Just recently, they had their matching at their program and 87% of first time U.S. senior allopathic applicants matched.

[19:05] Elective Rotation: The Double-Edged Sword

In their program, they don't really encourage students to do electives at their institution. Nicholas adds that he actually knows more than half of the people that end up matching the programs. Either they were students at their school or he had met them while they were doing senior electives. There is an advantage in that sense.

On the flip side, if someone comes in for an interview and had done electives at three other Chicago programs that are not his, then he explains it may be obvious they're the student's fourth choice, hence they're less interested. So it could be a double-edged sword in that sense.

Mostly, students undersell themselves that they don't have the confidence they should have based on what they've achieved.

"There's a lot of misinformation out there whether it's on the internet or some website or from a buddy or from a school. They take some information and process it in a way that is not correct."

[25:35] Their View on Osteopathic Schools

Traditionally, Nicholas admits that students from osteopathic schools don't stand out as easily. That said, if they stand out for some reason, it's harder to judge them against the other applicants. There are some osteopathic ophthalmology residencies and have a separate path to be successful ophthalmologists. It's not impossible, but it's a hard position to start from. And this is based on his experience.

[26:33] What Makes a Resident Stand Out

"There are people that have that level of maturity about their learning and patient care that's very obvious right from the start that this person is going to be a great physician."

Nicholas illustrates that in order for a resident to stand out, there should be a level of seriousness, attention to detail, teamwork, interest beyond just getting through, and learning to do extra stuff that nobody anticipates. It's much more about how they delivered care, how they take the responsibility, how they interact with patients and have that emotional intelligence.

Nicholas advises applicants that of all the things they worry about in life right now, they may not be worried about whether they can be nice to patients or they can learn what they need to learn. But the last piece of your life is wondering whether you'll be a good eye surgeon. 95% or more will get there regardless of what you came with. And the reason the other 5% don't end up being good at it has nothing to do with their dexterity, but with something in the operating room that makes them nervous. For ophthalmology, even if they train you to be a surgeon, there are lots of good nonsurgical practices you can be in ophthalmology that only use laser and do incisional surgery.

People will know whether they're good with their hands and you're going to be a good surgeon in general. But people who have tremors would be at a great disadvantage as a surgeon. Or if your eyes are not working together, there is most likely a pathway for you but it's just going to be harder than any normal individual.

"We'll teach you. We'll get you there. And we'll make you into a good surgeon."

[32:17] The Biggest Changes in Clinical Care in Ophthalmology

"Ophthalmology is the home for some of the most incredibly revolutionized treatments that didn't exist for conditions that are the most common cause of blindness."

The field now has a treatment for macular degeneration that prevent people from losing their central vision. They have also incredible advances in the technology they use to diagnose retinal problems. Nevertheless, they're making 10,000 new 65 years old a day for the next 20-25 years or so and how they're going to take care of those patients. So this is a challenge they all think about.

Ophthalmology is the first to successfully treat people with genes. They have gene therapy now that corrects hereditary form of blindness and the eye is the perfect place for gene therapy for stem cells.

On the flip side, they have diabetics who are going blind from a completely treatable condition that was undiagnosed because they didn't go to an eye doctor and there are disparity issues. How they provide care for those patients is an equally important challenge that they have to embrace in their field.

Nicholas sees a huge need for ophthalmologists in the next 20-25 years so he sees the new breed of them to be very busy in terms of the number of patients they have to care for. At the same time, they have to be comfortable working closely with non-physicians in the care of patients. There are great opportunities for synergy with optometry in terms of optometrists being excellent at taking care of the eye. At the end of the day, it's about figuring out a way to care for the population. So the future is very bright for the field of ophthalmology.

"Anybody can be taught anything with the right teacher and the right circumstances."

[39:00] The Most and Least Liked Things

The thing he likes most about the field is the unique ability to recognize life-altering conditions and be able to then alter those conditions that improve people in a way that could change the way they approach their world in the future.

Conversely, what he likes the least is the necessity to have to see large amounts of patients in a short period of time than the time they would have wanted to spend with each patient otherwise.

[42:10] Final Words of Wisdom

This is an incredible specialty that you can get into it. Prepare yourself early. If it's on your list of things you may be interested in, seek out the student group in your medical school. Seek out mentors. Nudge your way in to get to know people so they'll start to see what you're doing. Know that this is an incredible time to be an ophthalmologist because of the clinical need for eye care. While we're also at the time of most exciting precipice of game-changing treatments based on clinical and translational research that is really impacting people's lives.

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