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Gary Wörtz, MD: Open, outspoken. It's Ophthalmology off the Grid—an honest look at controversial topics in the field. I’m Gary Wörtz.
For most of us, our paths in ophthalmology, and really life in general, are driven by a series of events, some fortunate and some not-so fortunate. We all inevitably hit those bumps in the road, but sometimes the events we perceive as unfortunate turn out to be quite fortuitous in the end.
In this episode of Ophthalmology off the Grid, Dr. Arthur Cummings takes us on his fascinating journey, starting in urology, migrating to retina, and landing in refractive surgery. Hear what makes Arthur tick, how he feels about his home country of South Africa, what he loves about Ireland and what excites him most about ophthalmology today. Here we go.
Speaker 2: Ophthalmology off the Grid is an independent podcast supported with advertising by Alcon.
Gary: Welcome to another episode of Ophthalmology off the Grid. I have Dr. Arthur Cummings with me today from Dublin, Ireland, It's a real pleasure to get to know you today, Arthur, and hear a little bit about your back story, about what you think is interesting about ophthalmology, perhaps in Europe and maybe a global perspective, and also just to hear a little bit about what makes you tick and the things you love about ophthalmology.
I think it's really interesting because, we were talking before this, a lot of the great wisdom and the great conversations happen in the back hallways of meetings. That's really where I feel like people who don't get a chance to go to meetings maybe miss out a little bit. I was just hoping today maybe we could have a conversation just like we were at a meeting and really talk about the things in our practice that we love, maybe some new products that are coming down the pipeline. And really just to know each other a little bit and find out the state of ophthalmology from a global perspective. With that being said, thank you for coming on the show today.
Arthur Cummings, MD: Thank you, Gary. Very nice to meet you and thank you for the invitation.
Gary: As I have been doing a little bit of research, I know that you started in South Africa, is that correct?
Arthur: That's exactly right, yes. My goodness.
Gary: Tell me a little bit about your journey growing up and how you ended up in Dublin from South Africa?
Arthur: I did medicine in South Africa. In South Africa, we were conscripted to go to the army, so at the end of our medical training, I went into the army and then you'd spend a year sort of in really heavy duty and then you'd spend a year in a military hospital somewhere. I started working in urology, and my best friend that I knew from swimming days at high school, he was doing ophthalmology and we’d been close friends all our lives. He was in ophthalmology, and he knew me really well, and he said to me, "Take time out, you can spend a day with me." We only got 7 days leave at that time. I took a day off and that was the best day off I'd spent. So, a really, really good investment and fell in love with it immediately. Gave up the position I had in urology. I'd sort of set up something to go to a residency, and I had to wait 4 years then to get into ophthalmology. So, it was an 8-year training program, but, yeah, the best decision of my life.
Gary: So, you put your career on hold for 4 years in order to get an ophthalmology residency?
Arthur: Yes, but worked in ophthalmology as what they call a medical officer. So, you did cataracts, and you did a few things, and you were involved, but your time wasn't counting,
Gary: Wow. We feel like in the US we have a hard go, but it sounds like that could be a really almost indefinite waiting period for some.
Arthur: Yes, it could be. Sometimes it never happens. In South Africa, the training would typically be 4 years and waiting 2 or 3 years to get onto a program. My son is doing his training as an ophthalmologist in Ireland now, and their program is a 7- or 8-year run-through program. So, they start knowing it's going to be 7 years before they finish.
Gary: Is that combined with medical school or is that after medical school?
Arthur: That's after medical school.
Arthur: After their internship.
Gary: Wow, wow. That's incredible. You finished your training in ophthalmology in South Africa, and did you practice in South Africa for a bit?
Arthur: I did, I did. I had done a retinal fellowship, so I was trained as a retinal surgeon. I was doing a lot of retinal surgery, a lot of LASIK, and a lot of cataract. What I would do, on an annual basis, is spend some time abroad in retina clinics, seeing how we could improve retina. We sort of thought we were doing a lot of cataracts and how much could you improve that is what we thought. We were doing a lot of LASIK at that time too so again, we thought it's a simple procedure, and we don't really need to try and improve it further.
Obviously, we were wrong on both those counts but 1 year in 1997, spent a month in the UK doing retina. The family had come with and we just realized, this is a place you could live. South Africans think they've got a monopoly on good weather. That year was the best summer in UK history for, I think, 30 years. The summer of '97. Lo and behold, 6 weeks later, I saw an advertisement in a medical journal in South Africa for a fellowship in Dublin in refractive surgery. I sort of thought that Dublin would be the same as the UK. But it was completely different. We went for 18 months, fell in love, and never came back.
Gary: Never came back? So, you're a former urology trainee, a former retina surgeon, fellowship trained, perhaps through one of the longest residency periods, if you want to count, and then you did a refractive fellowship on top of that and landed on your feet in Dublin in the end of the 90s. Is that about right?
Arthur: That's exactly right, in ‘98. Then, something further happened. It's interesting how careers are. We all think we work hard, and we all think we're smart but it's shaped more by luck and serendipity and, you know, circumstances. So, what happened is when I got to Ireland, I was told clearly that I wouldn't be doing any retina. I was quite happy with that because I was doing a lot of retina. My back and my neck were getting sore. I wanted to spend some time at home again in the evenings. So, that was the first thing. Now it was just cataract and refractive. Then, to my dismay, I couldn't get operating rights in a hospital for 8 years for cataract. Which meant, we now had the decision, do I go back to a very comprehensive practice in South Africa? I had eight partners at that point, there are now 27 or something. They're a big group. Or, do I stay and wait to get cataract operating rights but, in the meantime, just try and take LASIK to the best that I could take it. Because the family was so happy there, we decided to stay. Yeah, because 8 years before we had operating rights, but again that turned out quite interestingly. Having spent all of my time doing refractive, you develop this refractive mindset.
Gary: That's right.
Arthur: So, from the first moment that I did a cataract again, I'd forgotten what cataract surgery was. This was just refractive surgery to me. So, that really drove a lot of my further career, thinking of cataract surgery from way back when, as refractive procedure.
Gary: I think that's so interesting. I sort of have a personal philosophy that I see play out time and time again in different people’s stories and their life. I call it the competitive disadvantage. If you read Malcolm Gladwell or some other popular authors, you find that there are people that have something that happened to them that could be taken in a negative direction. So, the fact that you had to wait 4 years before you could get into a residency and then to go all the way to Dublin and move your family. Then, for someone to tell you that you can't get operating rights. For no good reason. You would think about that as just, almost devastating. At the end of so much investment and training to become an ophthalmologist. For no good reason to be restricted from having right to do cataract surgery. But yet, instead of pitying yourself and getting down about the situation, you said, no, I'm going to make the best of the situation. What a career that's turned into, where you've really honed your refractive skills and probably not even realizing the dividends that would pay later on in your career.
Arthur: Absolutely, I think you've summarized it so well. I think, it's always good if you keep perspective. Even though, that might have looked like a challenge, there are people facing bigger challenges on an hourly basis. So, in perspective, you know what, it's still a good position to be in. Just figure out the best path.
Gary: Were there times that you doubted yourself, throughout, that you doubted the path? It had to be a little bit rough. It sounds like you have a family that went through this process with you. Just a little bit on my background, I got married right out of college. We had both our children in medical school. We were trying to raise a family during medical school and had young children through residency. So, I kind of have a little bit of a peek of what it's like to go through training with a family. That's our number one job. All the other things we do is really secondary to keeping the family unit together. Were there times when you kind of questioned your decision? Or were you always pressing forward?
Arthur: You know, when we made the decisions to move to Ireland—it's so long ago, I had a black-and-white Acer laptop—we were on holiday putting together a spreadsheet. I'm quite impressed that I could do it those days. I put together a differential list of the important things to us and weighted them. Ireland only won by something like 53 to 47. So, there was a really close call. We had other ties in South Africa and family and friends and everything. We'd spent our lives there. I'd played sport for South Africa. So, I'm a really committed South African and decided to go. I think what changed things for us, what helped us get through it, my wife was busy with her PhD then. She'd started a audiology program in South Africa and Victoria. She had to give that up for the fellowship. When we'd made the decision to go, it was never about us. It was always about our sons and about thinking we'd provide them a better future.
Fortunately, for the moment, it seems like we made the right decision. Things are quite tricky in South Africa. It's not well known, the media doesn't cover South Africa much any more. Life is tough in South Africa.
Gary: Let's dig in to that. I think this conversation transcends ophthalmology. What do you wish that people would know about your country, that you clearly love? It sounds like there's complicated history with civil rights in the US. There's a complicated history around the world, it seems like in some ways is getting more complicated right now. What do you wish that people would know about your home country, that they maybe don't know?
Arthur: I think, as you said correctly, the history is very, very checkered and very difficult. You can totally understand the hatred on some sides of the spectrum. I think we had an amazing miracle come along in Nelson Mandela. He really brought people together. We became what was called the Rainbow Nation. I think it was a very good path at this point, a very good trajectory.
But, I think was happened was, unfortunately, any of these movements don't change people's lives in the space of a few years. It's normally a few generations. I think many promises are made to disenfranchise people. It just got to the point where there's really more racial issues than I've ever seen. There's a lot of goodwill, obviously. It only takes a small percentage of people who really committed to bring the process down to make life uncomfortable and dangerous for people. I think that's the one thing, when you think about South Africa now, you think about great weather, beautiful country, and a Rainbow Nation. I think what's not known is the quality of life for many South African's is poorer than prior to Mandela's becoming president. I think on the security side is both black people and white people, the entire spectrum, also far less secure than they've ever been. So, that's sad. That's really sad.
Gary: It sounds like there's uncertainty. It's hard to build a future in a country where there's uncertainty and safety issues and not knowing what the next day is going to hold.
Arthur: Yes, there is and it's difficult. It makes you hearty in many respects. It also creates a sense of humor. South Africans have an amazing sense of humor. I think that's why we enjoy Ireland so much. They also have a great sense of humor.
Gary: I trained with a gentleman from Ireland. Peter Timoney. So, Peter, if you're listening to the podcast, just want to say hi. I don't think I've laughed as much around any other person than Peter Timoney. We were always laughing. We had to be serious from time to time in training. It was so fun to go through training with an Irishman. As we were kind of talking earlier, too, any funny stories that come to mind? Through this crazy journey you've been on? Anything stand out?
Arthur: Some crazy, crazy stories. So many, I can't tell you. I'm trying to think of one that would resonate from a medical point of view. I was doing urology. We were in one of the rural hospitals. We were doing our block of urology. Someone had told us how to do a PR examination. The urologist, he said, well, this is how you do this; you have to insert your finger, you've got a glove on, and the prostate is going to feel like the tip of your nose. So, everyone's feeling their nose to feel what it feels like. Then he said, I'll be back in half an hour, you guys all examine this patient, and I'll come back and see ...
Gary: Wait, wait, wait. Just for perspective, how many students were in the room?
Arthur: Well, I'm telling you now, at least five or six. So, this is Africa.
So, at the end of it all, he came back and said, "Well, what did you feel?" We all genuinely said, "Well, it sort of felt like the tip of our nose." So, we figured this is a normal prostate. He looked in his chart and he said, "No, no, no, no, no. You guys didn't do the examination." We said, "We promise we did." He said, to the patient, "What's wrong with you?" The patient said, "Nothing. I just came to visit my brother."
Gary: So, he just, wrong place, wrong time?
Arthur: Yeah, exactly right. There you go. Sometimes it's the right place and the right time, and sometimes it's the exact opposite.
Gary: Oh my goodness. That is unbelievable. There are a lot of stories throughout training. Especially in med school and internship. I won't share any of those right now. Maybe for another podcast.
So, it sounds like, throughout your training process and throughout your evolution of your career, you focused on the bigger why. That bigger why was, you wanted to provide a future for your sons. Tell me about your children.
Arthur: I've got two sons, and they were 9 and 5 when we landed up in Ireland. Brendan's the oldest. He's now 27 and he's doing ophthalmology. He's been going for 7, 8 months and loving it.
Arthur: Thank you.
Gary: That's huge.
Arthur: He's a super guy. He's got an interesting story. One day, before he started medicine, he went to China to teach English, just a different experience, and met his wife, a lady who'd never heard English. Today, they're happily married and are a fabulous couple.
Arthur: The younger son, he spent 6 years in the states. He finished high school in the states, playing golf at a golf academy. Then he secured himself a scholarship at UNC, Chapel Hill, on the golf team. He's just returned to Ireland. My wife, both of us, are delighted to have him back at home again.
Gary: That's wonderful.
Arthur: For the next couple of years, I guess. Then he'll be doing his own thing.
Gary: Yeah. That's wonderful.
Arthur: Both of them, interestingly, both of them have on a number of occasions totally unsolicited, have said, " Mom and dad, we're so grateful you brought us to Ireland." So, I think it's just expanded the world for us.
Gary: That's awesome. I think when you can focus on the bigger why, there's almost no pain that you wouldn't go through yourself, especially when you're thinking about providing a better future for your family and for your children. I've heard so many stories. I think that resonates, with me definitely.
Let's shift gears a little bit. We, in the US, I think unfortunately have a view that we're the best ophthalmologists. Although, it's a very myopic view. I think it's unfortunate. A lot of ways Americans have this sense that we're the best. Probably for no good reason. What's funny is I've interacted with a number of ophthalmologists from around the world. I've been supremely humbled at learning of the deficits in my skillset, compared to what others are doing. What the deficits are in my tool bag, in terms of the laser technology, the lens technology, etc. Actually, I've kind of come 180 degrees and sort of think, we have got things maybe perhaps backwards in the US and have so much to learn from our international colleagues. Erik Mertens was on the program and few times ago, and I was just so impressed with what he does in his practice.
That's really what I'd like to know about your practice today. When you look at the global landscape, you probably have a very different perspective than I would have because of your experience. What are you see are the main differences from your local market versus what you see going on in the US?
Arthur: I think your perspective's interesting, but I think if you ask 10 people, you'd probably get 10 different perspectives. So, I think, we all have a certain bandwidth. In South Africa, it was just service, delivery. I did thousands of cataracts in my training. I did 200 retinas in my training, but not always being taught exactly the right way. Where, every year, if you look at the quality of your top units, they're absolutely world class. You get different things from different experiences. One of the things that keeps me focused is the fact that I go to meetings and I see 70-year-olds who I think are completely accomplished and can't learn anymore. Yet, they're at the meetings.
Gary: Asking questions.
Arthur: Yeah. So, we continue to learn. It's an evolving process. The day you think you know everything is the day you probably should retire.
Gary: That's right.
Arthur: I think it's a continual learning process. I think the big differences I see is that, because of the regulatory process in the US, things take a lot longer to get you. Many of the technologies we use originate here, leave the US shores to go to Europe and other parts of the world for the first in human experience. Then they come back here eventually and then go through the FDA process, which sometimes is years later. Something I do a lot of is topo-guided LASIK. We did that for the first time in 2004.
Gary: So, that's old news?
Arthur: Yeah, very. It was approved a year ago. Yet, when it went through the FDA process, we all learned something again. So, there's a lot to be said for the rigor of the FDA process. I think it really finds the benefits and what their shortcomings are in a way that we don't have in the rest of the world. So, I think at the end of it, the fact that the systems are different, probably help us all become better ophthalmologists.
Gary: That is a perspective that I've never heard before, but it makes a lot of sense. Maybe because of the slow-down of the FDA, you sort of get a second bite at the apple to re-evaluate the technology and learn, maybe, better ways to apply the technology. Even after you've been doing it for a decade or so, you might say, oh you know, there's some data now and this is a rigorous process. Actually, it makes a lot of sense. I've never heard that perspective before, and I appreciate your sharing that.
So, let's talk a little bit about the pipeline. That's something I always love talking about with my European colleges. What things are you doing right now that are maybe in the pipeline in the US? Or things that we all see in the pipeline that we all are excited about? So, you can take it in either direction. But, what products are you most excited about, right now?
Arthur: There are a lot of products that are exciting at the moment. Ophthalmology is probably the most exciting specialty there is, and right now to be an ophthalmologist, I don't think there's been a better time.
Gary: I agree.
Arthur: So, there's so much going for us to give better outcomes. I think one of the tricky things is I don't know if you've ever seen the podcast or the TED Talk on the paradox of choice. When you have so much choice things become more difficult. So, it's trying to keep perspective there. I think what keeps me most excited is, I was never a big user of multifocals, really.
Arthur: No, not in a big way.
Gary: When did that change for you? Or has that changed?
Arthur: It has changed slightly. I think one of the reasons I wasn't is because monovision works so well. I've got a really unique way, not unique, but a lot of people haven't heard of, how I assess monovision patients. The success rate is very, very high, the quality of vision. So, that's a go-to. Whatever people don't like about monovision, you can correct with spectacles.
Gary: I want to unpack that a little bit more. That might be even more interesting than where you're going with that. I want to hear, just out of curiosity, how do you approach monovision?
Arthur: The first thing we would do is try and determine dominance. Normally, in terms of dominance, it's not motor dominance, which is what we're taught to do, it's sensory dominance. So, which eye do you feel more comfortable with as the lead eye. That's the first thing. Then the second thing is once you fully corrected the patient, to put up a stereo chart. In front of the eye you've chosen as the reading eye, to start defocusing in quarter increments—plus 0.50, plus 0.75, plus 1.00, plus 1.25. The moment the patient says I've lost the stereo, I'm no longer seeing stereo, you take it one back. So, there you determine the level at which your patient can have stereoacuity for distance. You don't have it for near, obviously. You do for distance. So, it means these patients have zero trouble driving at night. They go to 3D movies and have no problem seeing the movie. They simply never ever complain about their distance vision.
Gary: I’ll tell you, in my experience, Jay McDonald is one of my heroes. He has done so much research, and he actually came on a podcast earlier and gave his breakdown of monovision. We were kind of talking about monovision versus multifocals. So, that's an area that I'm still very interested in. But, he taught me that if you keep the defocus at about -1.25 in the nondominant eye to -1.50, that, in his experience, was sort of the sweet spot for monovision. When you're doing the defocus at the phoropter, what did you find?
Arthur: Much the same. There's a very, very large variation. You get some patients who within 0.50 D defocus in the nondominant eye are unhappy. They've lost stereo already. Then you get some who can go to 2.00 D of defocus and they’ve still got stereo.
Gary: What do you think explains that?
Arthur: Well, it's the way your brain's processed vison and the way you learn vision. Your first 7, 8 years of life when you were learning how to process vision. It's those experiences.
Gary: Now, have you done that with multifocality or extended depth of focus and picking lenses based on the disparity that a patient can tolerate perhaps. I know it's different because we're talking about the adds at different levels and focusing on the retina. Do you have any unique ways you're picking different types of multifocals?
Arthur: I just want to come back to, you asked what happened with multifocal. So, multifocals, my uptake has increased because we've started using trifocals. Incredibly the trifocals are giving a better visual performance and less dysphotopsia. So, trifocals, I think, are going to start competing with monovision for me.
What's interesting about accommodating IOLs is you would have thought that at this point and time, they would have surpassed multifocals. Their biggest competition currently is how good the trifocals are becoming. So, they've got to get better and better and better to compete with the trifocals. As far as trying to figure out which lens to use, it's just a long conversation. It's a lot of work. It's often a contact lens trial for multifocality if someone doesn't like monovision, to put in multifocal contacts. You don't get the same array of different defocus curves with contact lenses as you do with IOLs.
So, someone who you might have spoken to on the program before, Michael Mrochen, has an interesting project he's working on where he's helping patients create their own defocus curves. So, you wear a monitor on your spectacles, and if you don't wear spectacles you wear a pair of spectacles for a day without lenses. This monitor measures the working distance that you're looking at, the tilt of your head, the light conditions. At the end of the day, gives you a very, very good personal defocus curve. So, once you can see how a patient's operating in their environment. I often ask a patient, come sit behind my desk and show me where the computer is for you. It’s not his own place. At home, he'll say well I'm close or it would work further or whatever the case may be. So, now I get real data that supports that person's visual behavior. I think the idea there's going to be that you can look at your personal defocus curve and see which technology, we have so many today, best fits. So, that is just using more data to drive it.
Gary: I think that's so interesting. Because we have such sophistication in terms of diagnostic tools, lenses, obviously surgical equipment. The lacking piece of that puzzle might be the real-world data, and it's an unmet need that we didn't even know we didn't have, perhaps. Yeah, you're right. Michael is fantastic. I don't think we've met personally, but I know him by reputation. That actually sounds very exciting. So, I think that is something that, as ophthalmologists, we could all sink our teeth into.
I just want to say thank you so much for giving us a little perspective on your training, on your family. We're all rooting for your son to, you know, join you some day, perhaps. Or make his own impact in ophthalmology.
Before we wrap up, any parting thoughts on the state of the industry? Maybe things you think the industry's getting right? Maybe areas that the industry's getting wrong? Or any other parting thoughts you have?
Arthur: Thank you very much, I've enjoyed it tremendously. Yeah, I think industry and ophthalmologists have never been better aligned. I think the leadership currently, especially in the big corporates, but also the smaller startup companies, have got a lot of understanding of what ophthalmology means and what it means to our patients. So, we're very well aligned. I think what I'm seeing that I like a lot is not that long ago, if something wasn't invented within the company, it wasn't worth their time. Now, you hear people on the podium speaking about skunk works. They speak about buying startups that they like the look of. So, I think that's very, very good when you are agnostic to where the technology comes from. The moment that you determine that it has value, that you then want to bring that to your patient base. So, I think that's really good, and I think, as I say, it's been a long time since I've been so excited by the leadership in ophthalmology and the eye industry.
Gary: Arthur, I think that's a great place to leave it. I totally echo your sentiments. You have an open invitation. Anytime you want to come on and you've got something you'd like to share with us. I've learned so much, I know that everyone listening is going to love hearing your perspectives. Not only this time but hopefully many more times in the future. So, thanks again.
Arthur: Thank you Gary. Thank you very much.
As evidenced by Arthur's stories, sometimes the seemingly sour events yield the sweetest outcomes. Often it takes that ability to find that silver lining to make this happen. At the end of the day without delays in his residency, the tough decision to relocate his family and difficulties obtaining surgical privileges, Arthur may not be the fantastic ophthalmologist and father he is today—the kind that inspires us all, including his son, to find gratitude and ability to help people get the vision they deserve, no matter what challenges we face along the way.
This has been Ophthalmology off the Grid with Dr. Gary Wörtz. For more episodes like this, visit eyetube.net/podcast. Please be sure to rate, review, and subscribe. As always, thanks for listening.
Speaker 2: Ophthalmology off the Grid is an independent podcast supported with advertising by Alcon.