Smart Investments

Steven Dell, MD, sits down with Gary Wörtz, MD, to discuss investment strategies--some financial, some mental, and some professional--for ophthalmologists. Dr. Dell also explains his motivations for creating the Dell questionnaire and offers insight into the future of presbyopia correction.

Gary Wörtz, MD: Open, outspoken. It’s Ophthalmology off the Grid—an honest look at controversial topics in the field. I’m Gary Wörtz.

From the pages to the podium, Dr. Steven Dell has long stood out as a true voice of reason in ophthalmology. He has made significant contributions to the field, built a highly successful practice, served many times as an innovator and key opinion leader, and seems to always have the perfect pearl of wisdom to share for any given situation.

In this episode of Ophthalmology off the Grid, I sit down with Steven to talk about his strategies for making smart investments—and not just financially but mentally and professionally as well. We also chat about what, in his practice, motivated him to create the Dell Questionnaire and his predictions for the future of presbyopia correction. Here we go.

Speaker 2: Ophthalmology off the Grid is an independent podcast supported with advertising by Alcon.

Gary: Well, welcome back to another episode of Ophthalmology off the Grid. I'm Dr. Gary Wörtz, and today I'm really excited to talk Dr. Steven Dell. Dr. Dell's been a mentor I think to all of us through the pages and through different talks that he's given through the years, and so this is a great opportunity for me to ask him all those burning questions that I've had when I've read some of the articles and listen to him speak.

I would say that Steven is a man of few words, but those words are highly impactful, and so I'm really excited to see where this conversation takes us. That being said, Steven, thank you so much for being willing to come on and share some of your thoughts with us.

Steven Dell, MD: Happy to do it.

Gary: All right, so let's just dive right in. One of the things that I've, I think when I first was coming out and was trying to figure out the whole premium IOL game, so to speak, I ran into your name with the famous Dell Questionnaire, and I found it to be really, really interesting how it really probes patients not only in their lifestyle but what kind of person they are. So, if you're willing, I'd love to sort of get your thoughts on how you came up with that, how maybe it's evolved over the years, and how do you talk to your patients about the premium choices? Especially considering there's been a lot of advancement, especially recently, in presbyopia-correcting IOLs.

Steven: Those are great questions, Gary, and thanks for having me here, first of all. That questionnaire came into existence in about 2004 in response to basically a crisis in my clinic. We were involved early on in some clinical trials for presbyopia-correcting IOLs, and so were really excited when we had commercial availability of those lenses in 2004. But what I found was that very quickly my clinic was getting bogged down with these very complicated and sometimes circular discussions with patients about what their various options were for IOLs, and I was spending a lot of time educating patients in the lane about things that would probably be better explained in another setting.

I found that I needed a way to very quickly ascertain who wanted to see what and where, and I also needed to establish a common vocabulary with patients really quickly. Because when I talk about intermediate vision, you talk about intermediate vision, you know what you mean by that. You're talking about something that's at the distance of perhaps a laptop or maybe a desktop computer, but intermediate to someone who comes in for an exam, they may be thinking that that means the TV 15 feet away, not a mile down the road. So, we needed to establish a common vocabulary quickly, establish whether the patients had any interest in spectacle independence, and that was sort of the genesis of it.

Now, what I've learned over the years, and we just this year released a new version of the questionnaire, which you can find online, is that we've learned that in fact, the secret to it is that it subtly alters the patient's expectations about what can and cannot be done and what type of visual compromises they might be forced to make because that questionnaire asks them to make difficult choices. Would they be willing, for example, to give up full stereopsis if you have to do a little bit of mini-monovision? Would they be willing to tolerate some dysphotopsias if they're using a multifocal or EDOF lens? Those are the kinds of things that we like to know about along with a general assessment of their personality. Because, if you think about it, a lot of these patients we're meeting for the first time and they're making a permanent and really vital choice about what they want their vision to be like for the rest of their life, and we don't know these people very well in many cases. So the more we can gather about them in a short period of time, the better.

Gary: You know, I think that's a really interesting point that you bring up. We're asking patients in the span of maybe a couple of hours to make a life-altering decision based on optical properties that they've never considered before. So they sometimes just look at us like a deer in the headlights. They just don't understand what we're trying to explain to them. They don't understand the idea that a lens can't necessarily do all things. So it's very interesting that the questionnaire becomes a tool not only to gauge expectations, but, as you mentioned, it can actually drive them or prime them for the conversation that we do have compromises to make, and these decisions are really important and will impact your life, and these are maybe perhaps the ways that they will do that.

Steven: You know, sometimes if you start explaining something to a patient, you assume that they have the same vocabulary that you have. For example, we start talking about nondominant eyes to patients. There are many patients who are learning at that moment that they have a dominant eye and a nondominant eye. That's news to them. So it's very difficult for them to process that along these terms like extended depth of focus, or multifocal, or perhaps brand names that they're not familiar with. So it can be bewildering and also they just learned perhaps 10 minutes earlier that they have a cataract.

Gary: Right, right. So are we making a mistake in some regard to try to gather all the information and have that conversation? I don't know that there's a ... I mean this is something I struggle with, so I'm just kind of showing you what I think. It's necessary that we have these discussions with patients but sometimes I'm sitting there in the lane or I'm sort of processing after a conversation. I think, man, did they really understand what they're getting into? I tell them, "This isn't ... you're an adult, this is an adult decision, and it's just like I'm a contractor for the house. I can pour the basement wherever you'd like, but once the basement is poured, there are some things that you're going to have to ... you're the one who has to live in the house." So I try to let them know that these decisions will impact them, but it is always a little bit of a conundrum to know to what level are they really understanding the decisions that they're making.

But, I do think the tools such as the Dell Questionnaire are very helpful for me to gauge what their wants are and really pair them up with a lens that I can kind of infer that will hopefully give them what they're wanting.

Steven: Yeah, I think it's important that I've evolved over the years to almost de-emphasize a discussion about technology. So, we don't market technology, we market outcomes. We ask the patient, "Where do you want to see without correction?" And how we get to that goal is really sort of my end of the equation, not so much the patient's end of the equation.

The other thing that I do that I think is different than most surgeons is that we use what I call the upside-down approach to discussing these technologies. Let me start by saying what the right-side up approach is, what most people do. They say, "Well, you can have a standard lens, or you can pay a little extra and you can get some astigmatism correction, or you can pay a lot extra and you can get a toric lens with great astigmatism correction. If you pay even a little bit more than that, I can give you near vision as well. If you pay the most, I can give you all of the above, plus I'll use my special laser for the cataract surgery, which is less risky and has better outcomes," or whatever it is that surgeons say.

I think that if you went to a heart surgeon and they gave you a similar discussion like, "I can put in a decent valve and you'll be able to sit in a chair, or I can put in a better heart valve and you can walk around a little bit. I'll put in a super-duper heart valve, and you can run. And if you really pay extra, I'll use my good heart and lung machine, which causes fewer strokes." Now, you'd look at that surgeon like they were out of their minds.

Gary: Right.

Steven: So, I turn that upside-down. Our assumption, our default condition is that the patient is going to get our top-shelf technology. That they're going to get a presbyopia-correcting solution if they're medically a candidate for it, and, if they need to work down from there for medical reasons for financial reasons, that's fine. But we don't offer upgrades, we offer downgrades. It's a very subtle but very important distinction because there are many patients who believe that by opting for these add-ons, they're tempting fate—that they're saying to themselves, "Well maybe I shouldn't try to go for that fancy lens," when, in fact, that is state-of-the-art cataract surgery in 2017.

Gary: I think it's also interesting the way we talk about vision, and I think this is something I've learned recently with the Symfony lens. I really have enjoyed looking at defocus curves, maybe I'm the only one. But I think it's interesting when you look at the defocus curve because you get an idea of area under the curve vision. And I really have been trying to have a conversation with patients who are maybe early presbyopic, early presbyopes and say, "You've already lost perhaps half of your vision." If you look at it quantitatively, from near to distance, they have a large chunk of their vision that has been compromised. Instead of saying, "Well, you're still 20/20, what are you complaining about? Get some reading glasses."

I think that if we can show patients sort of their overall quantity of vision, you know, where they can see maybe in different conditions, near, intermediate, distance, light, dark, etc., we're giving them more of a quantity of vision that, or a state that they're at currently. We can then also show them the desired state. I think you're exactly right. If you're a patient who has lost all this quantity of vision, why would you not opt of the opportunity to regain as much of that quantity of vision as possible? So I think your approach, again, you're right. It's the same conversation, but having it in the opposite way sort of primes them for making a choice that will give them more vision.

I'd like to talk a little about, I know this is sort of segueing into some of the work you've done with accommodating lenses. Give me a little bit of background on that. I know that's an area of interest for you and just walk me through sort of where you think things are now, maybe where things have come from, maybe where they're going.

Steven: I'll start out by saying accommodating lenses are really hard. It's a very, very difficult thing to make work. I started early on in the process with what was at first CNC Vision and later became Ionics, and later was acquired by Bausch + Lomb and Valeant. So I was involved early on in understanding how the Crystalens actually worked. It became apparent to me that there are forces inside the eye that are available to be harnessed that can be used to manipulate the position of a lens. That led to a number of designs that I've created over the years that we've put in patients outside the United States. That is, once again I'll say, it's very difficult to make these things work because you have a moving structure in the eye, and yet you want good refractive predictability for distance vision. So those are, in some cases, competing forces. So there are accommodating lenses that move a lot but they have poor refractive predictability. Then there are accommodating lens designs that have very good refractive predictability, but they don't have great accommodation.

I think where we are right now is that really no one has come up with the ideal solution, at least that I've seen, and I certainly haven't. But we're getting closer each year to the reality of being able to harness those forces. You mentioned earlier about quantity of vision. Really, the other side of that equation is quality of vision. So, when you make a quality/quantity compromise, in other words, somebody you can give a huge quantity of vision but their quality of vision is poor, that might be ... an example of that would be an early-generation multifocal. That can be a good trade for some patients but maybe not so great for others. The holy grail is going to be a high quality of vision and a high quantity of vision. I think that's where we're headed, but it's a very difficult space.

Gary: What do you think, and I'm not sure if you've looked into this, maybe you have, maybe you haven't, but what do you think about the electro-accommodating options that are out there? Is that something that you think is in the future? I know that there are some companies that have come up with some designs and as computer chips are getting smaller and sensors are getting smaller. Do you feel like that may be a viable option in the future as well, or who knows?

Steven: Well, you know it's been pursued by two groups really. One of them seems to have kind of abandoned it, and the other is proceeding ahead. Conceptually, it makes a huge amount of sense. From a regulatory standpoint, I think there are some possible challenges. I don't think we've ever had an electromechanical device or battery-operated device implanted intraocularly. So, I think there are concerns about long-term stability, safety, efficacy. You know, what do you do-

Gary: If it breaks.

Steven: You need to go recharge your eye, or whatever it is. I think that conceptually and from a biomechanical standpoint, it makes perfect sense.

Gary: Okay. Well, I agree. I think it's interesting to follow the progress and see the things that eventually come to market so we'll just kind of keep watching and waiting.

Here's maybe a little, a different question, and it maybe gets the root of maybe a lot of decisions that you've made in your life. You've built a very successful practice, you've worked as a key opinion leader. I'd just kind of like to get your thoughts on how do you, what's a decision tree or decision process making investments? Not necessarily monetary investments, but investments in your time and investments in your mind because those are very limited resources. We just have so much energy and time, and you are very active and you're obviously in practice and also with the industry. How do you make decisions on when you're going to say yes to an idea or a company and then also on the flip side to say no to some things?

Steven: Well, it's a really great question. It's a complicated topic. I think I'll start by talking about investments outside of ophthalmology because many of your listeners reached the point where they have a fair bit of disposable income and they're wondering what to do with it. Sometimes people ask me what to do with their disposable income, and I don't know.

Gary: You say give it to me, I'll take it. I'll be happy to take it.

Steven: I don't know, I have no idea. I can tell you that particularly when people come to you with an investment that is, for example, a closely held business or an idea for a company and they come to you as a source of capital, I can pretty much assure you that everybody else has already turned them down. If they're going to doctors for capital all of the venture firms, all of the traditional sources of funding…

Gary: The smart money has said no.

Steven: Has said no. So sometimes ... you've heard the expression there's a sucker at every poker table and if you don't see them…

Gary: If you don't know who it is it's you.

Steven: It's you. So, I think you need to be very careful because, by our nature, physicians are not in an adversarial sort of mindset when we interact with patients. We are in a trusting mindset. We trust what the patients tell us, and the patients trust us. So, that is a little bit of a different mindset than the mercantile environment of business deals. We tend to believe what people tell us. That can get you in trouble. I think that's one of the reasons that physicians have a reputation as being poor investors because we are trusting and we assume that people have our best motives at heart, and that's not always the case.

But, it is very true that ... why would a startup company or someone who needs capital go to a relatively wealthy individual for capital when they can go to a more sophisticated investor who might have strategic value and could introduce them to other folks down the road who could help their business grow? So that's one caveat that I would throw out there because I've seen it happen many, many times.

In terms of investing your own intellectual capital, it's really linked to your financial investment as well. If you're going to invest in something and you're going to put a significant amount of money into it, you better understand that business well and you better be willing to drill down deeply and invest the time to learn about that business. Sometimes there are investments that I'm presented with that are frankly too small to warrant the brain damage that's associated with just learning about the space. Even though it seems like a great opportunity, somebody says, "Well you can own the most successful parasailing business in Texas." You know…

Gary: Right.

Steven: Why ... now I need to go learn all about that?

Gary: You have to go get way into the weeds on the parasailing ups and downs.

Steven: I don't want to do that. I don't want to do that. So that's why sometimes ophthalmologists tend to invest in the ophthalmology space. There's a certain logic to that because you can: You already know the data, you know the space, you know the relative chances for success probably better than most investors.

Gary: Domain expertise. Right.

Steven Yeah. Or you could just, you know, buy an S&P 500 index fund …

Gary: Vanguard fund and let it ride.

Steven: Take a third of your money put it there, take a third of your money put it in Amazon, and take a third of your money and put it in Google, and you'll be just fine.

Gary: You heard it here first, folks.

So what about ideas in industry ... so coming at it from a different angle I guess, more of a time-suck. Let's say that there's a new product that's out there, a lens, a drop, a technology, and you're presented with an opportunity to be a key opinion leader for that. You realize that there's going to be a certain amount of your time, and there may be some travel, there may be some of your life that's tied up in that. How do you make those decisions? You know, on technologies that you're going to be willing to talk about versus other technologies you say, okay I'm not going to be the guy on the podium to talk about this.

Steven: Oh, that's easy. If you're not passionate about the product, don't get involved with it. If you don't truly believe that it works, if you haven't seen tangible benefits for your patients, don't even mess with being a key opinion leader because that comes through to your colleagues. So, I think you need to focus on things that you've seen make a tangible difference in your practice, and those are the things that you should focus your energies upon. There are plenty of opportunities for many of us to be key opinion leaders. Sometimes you can get spread too thinly. So I think it's vital to pick things that you really are passionate about.

Gary: I think that that's ... it's easy to hear that and think you're doing that, but I do feel like that's a potential area, especially for younger physicians when they're given an opportunity to talk on X, Y, or Z. It can be really hard to turn that down, especially when you're kind of trying to build your name and reputation. So the question is, is pursuing excellence enough? In my opinion, yes it is. I think if you do a good job and people see that, industry takes note of that versus trying to throw yourself towards every opportunity that's available to you. I feel like that's a potential area that I see people sometimes getting maybe spreading themselves too thin, maybe losing a little bit of credibility when you're hearing them talk about eight things. Maybe they're really passionate about one, but it's diluted by the other things that they're maybe not as passionate about. What are your thoughts on that?

Steven: It's a good point. I think if you are really interested in being an effective KOL, you need to be willing to talk about the great things about a product, but you also need to be willing to discuss the things that are maybe opportunities for improvement with that product. Your colleagues will be very sensitive to that. If you are nothing but a positive cheerleader for a particular technology and you gloss over the imperfections or areas where it could be better, people pick up on that. So you have to recognize that we work with industry, but we work for patients. Those are the people that we are ultimately responsible to. I have encountered folks who are KOLs who are in some ways indistinguishable from an employee of the companies that they work for. That ultimately compromises their efficacy, and, if you really pay attention, you notice that they don't have the same credibility over the years as their colleagues who are more forthright in the balanced presentation of any technology's merits.

Gary: Well, I think that's very well said. I really appreciate you taking the time to give us your perspectives on all things ophthalmology, from talking to patients and lens designs and even being an effective KOL. So, I'd love to extend the opportunity anytime you'd like to come on again, the door's always open, so thank you.

Steven: Thank you, Gary. It was fun, I appreciate it.

Gary: I’ve often heard Steven Dell be referred to as the Yoda of Ophthalmology, and I don’t think that comparison is too far off. His insights are very valued, and we’re lucky to have been privy to some today.

For more wisdom from the many fantastic contributors to our field, check out our past episodes at eyetube-dot-net-slash-podcasts. And, as always, thanks for listening to Ophthalmology off the Grid. We’ll catch you next time…

Speaker 2: Ophthalmology off the Grid is an independent podcast supported with advertising by Alcon.