Trusting Your Gut: Investing in New Technology

When it comes to the evaluation of a new approach in ophthalmology, surgeons must be confident in their ability to make an informed decision. Robert Weinstock, MD, speaks with Gary Wörtz, MD, to explain his innovative mindset toward investments in the field. Listen as the two surgeons discuss how physicians can learn to trust their instincts when it comes to the investment in new technology.

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

Gary: In a perfect world, all the decisions we’d make in the care of our patients would be the most informed decisions possible. We would have long-term data, clinical and experiential validation, and an unwavering certainty that our next step was the right step. But, as we know, many times, our decisions are not made this way—they cannot be made this way. Sometimes, we lack one or all of these checks and balances, and, for the time being, our most-trusted source becomes our gut instinct.

One surgeon whose gut instincts seem to always be in check is Dr. Rob Weinstock. Rob is a very successful high-volume surgeon with a patient-centric practice and an innovative and progressive mindset toward ophthalmology. But he also has conviction. When Rob speaks in favor of a technology or approach, the authenticity is clear—it’s obvious he feels it in his gut.

In this episode of Ophthalmology off the Grid, we’ll hear from Rob on how he has learned to trust his instincts when it comes to investing in new technology. He’ll also weigh in on putting patients first and finding the right partner in Dr. Neel Desai. Here’s Rob.

Speaker 1: Ophthalmology off the Grid is an independent podcast supported with advertising by Alcon.

Gary: This is Dr. Gary Wörtz for another episode of Ophthalmology off the Grid, and I am, once again, really excited. Today, I have the opportunity of interviewing Dr. Robert Weinstock, and Rob is one of those guys who in my mind I envy, I look up to, and I just kind of know I'll never do it quite as good as Rob, though I will constantly try, so it's great to have Rob on here so I can pick his brain, maybe distill out some of the techniques and philosophies that he lives by and operates by. Maybe we can all get a little bit better and become a little bit more like Rob by the end of this. So, with that said, Rob, thank you so much for spending some time with us this morning.

Rob Weinstock, MD: Well, that's very kind of you, Gary. It's a great honor to be here, and I think this work you're doing with these podcasts is innovative, and there needs to be more sharing of information in a casual atmosphere in a way people can feel comfortable because we all have so much to learn from each other, so it's great.

Gary: Well, thank you. You know, I'll kind of get back to the original concept for the podcast. I realized at meetings you go to, a lot of the most important pearls are shared really in the hallways, not always from the podium. A lot of people don't have time or can't break away from clinic to go to all of the meetings and don't have that opportunity to have those casual conversations with people, and so that's really what we're trying to do here. We're just trying to have casual conversations about what works in your practice.

I also want to know a little bit more about you and what makes you tick, so we'll get into all of that, but I'd really like to start by getting a sense of your practice. I know a little bit about it, but I'd like the people who are listening to kind of get a sense of the style of your practice and maybe we can talk a little bit about how you have been able to create a really, really nice system for patients to come in, have a beautiful experience, but also efficiently get their surgery taken care of and maybe the way you've built a system around high-volume surgery.

Rob: Sure. Well, you know, it's a long story, and I'm very, very fortunate to have been able to step into a very well-organized, successful practice that my father started in 1972, so there's a tremendous advantage for a surgeon to be able to step into a platform that is already up and running and has learned a lot of the mistakes the hard way and already has a footprint of how to do some things right. I dropped into a well-evolved, multispecialty practice, and then that became a platform for kind of taking it to the next level, so that is a gift and I'm eternally grateful for everything he's taught me because he also was a mentor in terms of not just how to talk to patients, not just how to do great surgery, but also how to be honest, gain trusts not just of patients but build relationships with the industry, build relationships with your management team, and be visionary somewhat.

You have to be visionary if you're going to be successful, no matter what you do. If you want to lead, if you want to break new ground, if you want to be at the top of your game, you have to have some type of why or some type of vision of how you want it to be and then make incremental steps towards that. Some of the things that happened along the way was, it just became very obvious to me that cataract surgery really was going to be the area of innovation, and when I got out of training, there was more LASIK being done in my practice than cataract surgery.

Gary: Really?

Rob: Now, it's obviously, like most us, was completely flip-flopped.

Gary: Right.

Rob: You know, it’s just, when I saw the Crystalens come to market and that we had kind of a LASIK-like implant where we had been sitting on these patients who came in wanting LASIK, but we didn't have a solution for them because they were hyperopic and they were presbyopic, and we couldn't address the needs. They thought they wanted LASIK, and then all of a sudden the Crystalens came along, and all of a sudden the Crystalens replacement came and the refractive cataract surgery light bulb went on. Then it was just game on, shifting our practice towards a LASIK-like experience for our cataract patients, but if a practice or a practitioner has never offered refractive surgery in the form of LASIK and doesn't know what that customer-driven experience needs to be like, it's very hard to just start that de novo in a practice.

You would have to go do your research and see what that's like, so I think a refractive background and a customer service-driven background aspect of your practice is critical for making that transition into that in the cataract side of things. That's been a huge push in the past decade to create a practice where the patients have an amazing customer experience-driven process and be pushing for outcomes like LASIK.

Gary: It's interesting the you bring that up. I've been noticing a pattern, and maybe everyone knows this and I'm just late to the game, but it seems like the practices that did really well with LASIK and really started to understand the refractive mindset of patients have been those same practices who have been able to more seamlessly shift into the presbyopia-correcting premium IOL category, and I don't know if it's that there's a refractive mindset. I think that's part of it.

I think it's really trying to nail all the details, but you brought up a really interesting point, which is it's also about the customer experience or the patient experience, so I think that those are two sides of the equation, but I think they're both critical and so you bring up a really, really good point. I think it's maybe harder for someone who's only ever done cataract surgery and comprehensive practice to sort of re-gear or change their culture to become a premium IOL practice than it is for a guy who's been doing a lot of LASIK and doing some cataracts to shift into that premium IOL space. You agree with that?

Rob: I do, and industry would love to see all cataract surgeons promote astigmatism correction and promote presbyopia-correction within their practices, but most cataract surgeons were not trained in that arena, and it's very hard to teach an old dog new tricks. It's just, we get very easily trapped in the behaviors that we're comfortable with, and it becomes overwhelming to try to change those, so you have to, again, have a vision of what you want to do, have the motivation, and then take incremental steps like start offering torics or take one surgical counselor and train them, take them under your wing and tell them your vision, and implement that that's the one that you start sending certain patients to talk about these particular options, and then start to develop just infrastructures and protocols in your practice to help deliver those outcomes and implement that.

One thing that we started very early on along that line was this concept of the red coats. We just happen to have them in our practice. Basically patient liaisons opening the door to let the patient in, walking around handing out coffee, cookies. If they see somebody that seems lost or displaced, they engage with them, you know? If somebody looks like they're upset, they go up to them. So, adding some expense, but in the mindset of trying to provide a better atmosphere for patients, and have them have a meaningful and positive experience because all of us today are delivering great outcome, so really you have to go above and beyond that, and have this experience for the patient, so I think it's worthwhile investing in those processes and you don't have to do it all at once. You just bite off one thing at a time to try to get where you're going.

Gary: Right. I mean, I've been on the other side of this, so I started a practice right out of residency. Having limited capital and resources, it was really tough for me to say, "What are the essential pieces of equipment that I need and staff, and how many lanes do I need, and how do I run a lean operation and what is critical?" Because if you have a small practice that's doing okay, it's almost a catch-22. It's sort of like you have to take a step backwards financially to invest in some of the infrastructure or personnel or equipment to then take two or three steps forward. That can be really tough because maybe you're at a point in your practice or others and things are kind of okay, and you just don't want to take that financial risk, and so it seems like there may be some opportunities now with private equity. We were talking about this yesterday, that maybe there is an opportunity for private equity to help surgeons bridge that gap. I mean, what are your thoughts on that? I mean, that's a topic we can talk about briefly.

Rob: Yeah. I mean, even before private equity, there is some logic behind smaller practices partnering with a larger practice to gain access to some of the cultural aspects that that practice offers, the technology that that practice has, and become like a satellite or an outpost and even maybe get some mentorship from one of the surgeons within the practice. That could be a win-win for both the doctor who's out in practice that wants to move in that direction and for the practice that is wanting to grow. That might be a pre-stage process even prior to private equity becoming involved because then there will be a bigger infrastructure already in place.

The private equity companies at this moment in time, in this snapshot of time, they seem to be going after larger platform practices, multispecialty practices, footprint practices that have a very good hold in a geographic region and are looking to grow even larger across that geography, and add more providers and grow an even bigger platform because it starts to be very expensive as you start building more surgery centers and open satellites. But prior to that, for some of the smaller practices to partner up with a medium- to larger-sized practice that, say, is already in the space of multispecialty eye care, is already in the space of premium IOL surgery, refractive outcomes, already has a lot of the technology pieces, you could have a win-win because that general ophthalmologist who wants to move forward and step up their game could become a satellite per se or an outpost of that larger practice, get access to those pieces of technology, maybe even get some guidance, some fellowship, some ...

Gary: Mentorship. Yeah.

Rob: ... mentorship in how to do that from one of the surgeons that's been trained or is offering that. Then it becomes a win for the bigger practice because, you know, one guy can't do it all and have another surgeon in a more remote area or across the region, or across the city or town who, also offers the similar services. That's going to be a benefit to the larger portfolio, and then maybe even make it more attractive and more valuable to a private equity firm when they come along. That speaks a little bit to starting to ... and if we're really talking about providing patients in this country a little bit more access to standardized quality of services, it's kind of sad and unfortunate that patients don't understand like we do the difference between an extracapsular cataract surgery and, say, a microincisional cataract surgery.

They just think cataract surgery is cataract surgery, and it's almost unfair for patients not to have a standardized set of benefits that they can expect or achieve, and a lot of it is word-of-mouth, but it's hard for the patients to do their homework, so if we can work more towards raising all ships, raising everybody's skillset, and then even making hard decisions where you split the care and you let people do what they do best, and then kind of have a shared care philosophy in eye care much like we do with optometrists helping us. That's very important and there's a lot of areas of this country that that is looked down upon comanagement, and optometrists and ophthalmologists don't have good relationships. All that does is negatively impact the patients.

Gary: Right, and it draws lines, and it's a battle that I feel like should never have happened and it does no good for anyone.

Rob: No. You have to put the patient, and this is something my father taught me. If you try to take money out of the equation and politics and competition for space and really just focus on what's best for the patient, that's really where you make the best decisions because you're not jaded by trying to look at it from a different perspective, because we're the doctors. It's our responsibility to figure out what's best for the patient.

Gary: Right. I agree with that. Here's a question on that, a little bit on that line. I know you're a practice that has invested deeply in technology, and I'm sure that always follows that same philosophy of what's best for the patient. When you're presented with a new technology, maybe it's a new topographer, maybe it's a new laser, fill in the blank, what is your thesis on when you double on a technology and you acquire it versus saying, "I'm going to take a wait-and-see approach on this"?

Rob: Yeah, that's a very tough question, and there is no easy answer. I can tell you that, for me, a lot of it becomes very guttural and instinctual. I look at something, and I try to look if there's a delta between what is currently being done and what this new technology offers. If there's a real difference where I say like, "Wow, this is missing, and, if this does work, this fills this gap," then I find it. I mean, I can give you some quick examples. I watched Howard Fine, for example, start to do bimanual phaco when AMO invented the WhiteStar software, so when that WhiteStar software was invented, that made the phaco needle not become hot during cataract surgery. I realized that it would be safe and not have a wound burn risk if you separated the irrigation, so I went and I watched Howard. I took a course and I watched Amar Agarwal, and I watched.

I said, "From a fluid dynamics perspective, it makes sense to keep irrigation separate from aspiration for fluid dynamics so you're not repelling things away from you, and you're able to keep irrigation high in the anterior chamber while you work deep in the capsular bag." Once I figured that technique out, it worked for me and then I started training people in my practice and my fellows, and everyone who's done it has never looked back. Yes, there's a transition curve, but to me that represented a clear delta between the way something was being done and making it better. The same holds, for example, when I was asked to evaluate the prototypes for ORA intraoperative aberrometry. You know, we have this stagnant preoperative testing that we do, and then we go into the OR, and we try to execute on that plan. Why not have more information available, more metrics, more biometry to help us make good decisions intraoperatively?

That resonated with me. I said, "You know what? If this does work, this prototype, this is going to give me more information to make refractive decisions around." I saw the wave of refractive outcomes coming for cataract surgery, so it was obvious to me that there was a potential benefit there, and I didn't know whether we'd be able to figure it out and whether the prototypes were actually going to work, but it seemed like a viable project and worth my energy and time. The same thing held with TrueVision and operating heads-up. When I first saw that there was an ability to operate off a screen, have greater depth perception, and not be tied to the microscope, and have my team around me engaged in the surgery for instrument passing and be more comfortable when I operated, that is a type of leapfrog game-changing technology that is disruptive and has applications that are well beyond things that could be offered through the conventional way things have been done for 100 years.

So now when I'm faced with new technology, it has to have some of those key features. It clearly has to be disruptive, it clearly has to fulfill a need, and it clearly has to translate into better outcomes, and a better experience for the patient and the doctor. Again, I try not to look at what the financial modeling is going to look like because my philosophy is that ultimately, maybe not short-term, but ultimately the money issues will sort themselves out if the technology truly has a benefit to the patient.

Gary: Right. I agree with that. There are some real-world applications where you always have to keep your eye on the dollars and cents, but we were talking about this, I think yesterday. To me, femto is one of those sort of no-brainer technologies that I can clearly say the laser does a better job than I can do manually, and does it always translate into a better refractive outcome? I can't say that it always does, but what I can say is if I'm betting on a long-term benefit of a technology that can use OCT guidance to perfectly do a capsulorhexis of any size, centered on the capsule, it can pre-chop my lens, it can make arcuate cuts for correction of astigmatism, this technology is something that I can bite into. You know, this is something I can really sink my teeth into.

Rob: It's a very interesting perspective, and I couldn't agree more with you. It brings up a broader challenge that we have, and that challenge is to make decisions that historically we make based on science and data, and medicine, the way we've been taught, our minds have been trained, the way science has evolved has been based on data, but we get into situations clinically in the real world, where sometimes it's not possible to show the data, but yet we know instinctually that it's right. Even the best cataract surgeon in the world occasionally screws up a capsulorhexis or patient moves during it or the anesthetics drops a clipboard, and the patient jerks their head while you're holding the capsule and you have a complication. Even if that's once a month or once a year, if there's a technology that can prevent that from happening, that's ultimately going to benefit to that patient. That's a person's eye and their vision.

Gary: I always tell patients it doesn't matter if something happens one in 1,000 times. If you're that one in 1,000, it is you.

Rob: It was you.

Gary: It was 100% chance for you.

Rob: We know we don't need science to tell us that this laser is better than the human hand. Everybody knows it. You know it. We don't need science and data to tell us that if you soften up a dense 4 NS cataract first or provide some cracks or cuts, it's going to be easier to dismantle that cataract with less risk and less manipulation out of that. You don't need science to tell you that if your cataract procedure now when you get in the OR, parts of it are already done, that it's going to take the stress off the surgeon to be one less thing they have to worry about and they're going to have more concentration on what they're doing, and be able to last longer in the OR without the stress and the fatigue. These are challenges because our convention is to wait for the science and the data, but many of the more innovative surgeons, and many of the things that we see today that have been proven by science and data and are standard of care, they didn't start out that way.

Gary: It took a lot of time.

Rob: They started out by the leaders knowing with gut instinct and following their dreams and doing it because in their hands it worked better and conceptually it was better to them. Kelman did it. Ridley did it. They didn't wait for data and science, and the guys that were right behind them, they didn't wait either, but they were the first ones to give the benefits to their patients.

Gary: That's right. That's right, so I think it's always a balanced approach. You know, we would love the data, but sometimes it takes time for tools to evolve and become better, it takes people using those tools in new and different ways to figure out how do we move the needle, how do we create a real delta? So, I agree with you. We would all love the studies to show that this is reproducibly better in every single patient. I really firmly believe that is going to come. I don't think we're there yet necessarily, but I'm happy to provide those benefits to my patients at this point because, just like you, I'm very confident I'm doing the best thing for my patients. Let's move a little bit. This is kind of good segue into where do you feel like there are some unmet needs the biggest unmet needs in ophthalmology right now? If you were sort of surveying the landscape, where do you see opportunities for improvement?

Rob: You know, I don't think that I'm going to say anything revolutionary or new. I think it's rehashing, but it's reinforcing. I spend a lot of time looking at outcomes, dealing with patients postoperatively who are not exactly where they need to be, and seeking 20/happy and not seeking 20/15, so there's a lot of stress, there's a lot of psychology and psychiatry and anxiety around patient care because of the lack of perfection of cataract surgery outcomes.

Gary: Right. I agree with you.

Rob: If something like Perfect Lens or Light Adjustable Lens or some other type of new technology, maybe a new trifocal lens or multifocal or accommodating lens, something to take the stress off of us surgeons, that we don't have to work so hard to deliver that great outcome to the patient, that's going to be a huge change. We're going to start doing cataract surgery sooner on younger patients, be able to do more of it because we don't have to manage the problems postoperatively. That in my mind is the biggest need.

I also think that these devices need to be consolidated. I mean, the time it takes a patient to get through my clinic because they need to get a topography, a tomography, an OCT, a biometry device, and then get dilated, and then I have to look at them and maybe order something else because I see something, there's no physical way we're be able to take care of the volume of patients that are coming through based on the demographic projections with our current portfolio of technology. I need one machine that a patient can sit down at as soon as they walk in the door, attached to the slit lamp or swung in like a slit lamp, and it does all five of those tests that I mentioned in 1 minute. That would be a huge help.

Gary: It's very user-independent, you know?

Rob: Yes. I mean, so there's so much room for improvement to flow in terms of the clinic side, and there's so much room for improvement in the lens and implant technology in terms of giving us great outcomes. Those are the biggest needs in my mind.

Gary: I agree. I mean, I think that having technology that makes it really, really easy and noninvasive perhaps to correct maybe, not adverse outcomes, but less than 20/20 or less than 20/happy. Being able to get those patients corrected, that's a huge stress for us, a huge unmet need. I think it's coming with RxSight, with Perfect Lens, ClarVista has a product that's great. We're working on a product with Omega that hopefully solves some of the challenges as well, so I would totally agree with you.

Rob: And for preventative solutions for other things that both you and I are worried about for our own eyes: glaucoma, macular degeneration. It seems like everything we have is reactive. It's not proactive. What do we have? Vitamins? Okay. Green leafy vegetables for macular degeneration. We've got deposition in the retina of byproducts of metabolism. We've got to come up with solutions to prevent the deposition of those metabolites. Glaucoma we know is a perfusion problem. We need to figure out how to change the perfusion to the optic nerve to allow better perfusion to prevent glaucoma. These are the biggest unmet needs maybe even beyond what I mentioned for the refractive side of things.

Gary: Yeah, I totally agree with you. I want to talk about one of my favorite people, and that's Neel Desai. That's your partner.

Rob: One of my favorite people.

Gary: If you don't like Neel Desai, just don't listen anymore to my podcasts because he's fantastic. I got a question. How did you find Neel Desai? How did you recruit him? How did that whole story come about? Because I would love to find ways to maybe translate your search for a great young surgeon for maybe other people who are out there looking for a partner to join their practice.

Rob: Well, it's a fun story. It's a great story. It really started with, we were looking for ... we had a big cornea need in our practice and because I was so tied up with LASIK and cataract, we needed a cornea person who also had experience and wanted to do refractive surgery as well, so there was unmet need in the practice. That led us to doing a search through the usual channels, through recruiters, word-of-mouth, websites, and also through connections. One of our retina specialists, Richard Hairston, trained at Wilmer, was good friends with Walter Stark. Called up Walter and said, "Hey, we're looking for a cornea specialist. Do you have any fellows or know anybody?" Just an outreach call.

Walter said, "I have an amazing fellow," who happened to be Neel, so there was a connection through relationships because of Richard's relationship with Walter, and he had trained in retina up there. Then we reached out to Neel, and Neel felt comfortable because there was a connection to Wilmer there, so then it just really became building a relationship with Neel. We talked many times over the phone. He came down and visited several times. He had a phenomenal opportunity to actually stay at Wilmer and, right out of the gate, take over like almost a chair position for cornea in one of the top academic institutions in the country. I mean, almost an impossible competitive realm because that is such an amazing opportunity he had, and he is so talented not only as a surgeon, but as a person. Such an amazing person.

I had to resonate with him what the value proposition was of coming to join us, and basically I think what resonated was the family atmosphere that we have in our practice, the culture of being customer service-oriented, highly efficient, highly evolved in operations, and almost being like an academic center in what we offered because of the level of providers we have are at that high level of training, but yet the atmosphere is more run like a well-oiled company instead of an academic environment where things happen slowly and the red tape.

Gary: There's no control over the process.

Rob: Yes, and I can't speak for Neel, but we've talked about this enough, is the drive that he had to be in control of his own destiny not just in terms of being able to get what technology you want, practice the way he wanted, but to have equity and ownership in what he was doing, and be part of this family that would grow together and comradery that was there and the culture, so it was a combination of all that. You know, we have hundreds of pages of documents to sign, but it was really more about the relationship building, the opportunity, and the handshake, and for him to see that the other partners that were now equity owners in the practice, like Richard Hairston and Lenny Kirsch or other retina specialists, and the two glaucoma specialists, it was a track record of success.

Gary: Happiness, yeah.

Rob: Yes, and that's what is my recommendation. Now, the first one is always the hardest, that leap of faith, but after that, if the new guy that came in becomes partner and is happy, and is having a great quality of life and job satisfaction, and feels empowered within the practice, has a sense of ownership, then that's going to be obvious to the next guy that comes along, so when you really want a really talented person, really in my mind you have to offer that ability to stand side by side with them as a partner, make decisions together, and be a team. I really think that that is important if you're really looking to get the best of the best.

Gary: Well, I think you have nailed it right on the head, and you guys are definitely one of the dynamic duos, I think, in ophthalmology. I've told you I'm going to come down to your practice. I'm going to make good on make promise, so at some point in hopefully the near future, I'm going to come down and hopefully see your practice, and maybe spend some time with you and Neel. I know I would learn a lot, and those kind of experiences are invaluable as we all try to figure out how to do things a little bit better. Rob, I just want to say thank you so much for giving me some of these insights. I think it's been very interesting to me. I know it's going to be interesting to others who are listening, and open invitation: if you ever have a topic that you think is interesting or you would like to get out there, we would love to have you back on some time, so thank you.

Rob: Thanks, Gary. I really appreciate the opportunity, and hope it resonates and is helpful.

Gary: Although our instincts can sometimes feel unreliable, one thing is clear: If we put our patients first, if we keep them at the core of everything we do, we can trust that the decisions we make are made with the very best of intentions.

Thanks for listening to another episode of Ophthalmology off the Grid. If you like what you hear, please be sure to rate, review, and subscribe, and if you ever want to chat, we’re here on Off the Grid. See you next time.

Speaker 1: Ophthalmology off the Grid is an independent podcast supported with advertising by Alcon.