From Engineering to Vitrectomy
Gary Wörtz, MD: Open. Outspoken. It's Ophthalmology off the Grid—an honest look at controversial topics in the field. I'm Gary Wörtz.
As ophthalmic surgeons, we live incredibly busy but rewarding lives. As we go from patient to patient, it is sometimes difficult to imagine finding the extra time to dedicate to new challenges and opportunities. In those moments, it's important to step back and become inspired by some of the more brilliant, hardworking minds in our field.
In this episode of Ophthalmology off the Grid, I speak with Dr. Steve Charles about his remarkable career, from his beginnings in engineering school to how he became the accomplished retina surgeon he is today. If we simply listed all of Steve's accomplishments in medicine, this episode would be several hours long. As one of the brightest minds in the field, it is an honor to gain his perspective on how the industry has evolved, as well as hear his overall philosophy regarding his work ethic and dedication to helping others. Listen in.
Speaker 3: Ophthalmology off the Grid is an independent podcast supported with advertising by Alcon.
Gary: Today, I have the distinct pleasure of talking with and interviewing Dr. Steve Charles. Steve has been impactful, I think, in everything he's done in ophthalmology and even beyond ophthalmology. I think everyone will be delighted and interested to hear his story and also hear about what he's doing currently. Steve, without further ado, thank you so much for taking some time out of your schedule to talk to us today. Really appreciate it.
Steve Charles, MD: My pleasure.
Gary: Steve, I'd love to start from the beginning, just really getting a little bit of a historical perspective on your career, maybe what drew you to ophthalmology. Maybe give us a little bit of a historical perspective of where things started in your career and how you've seen things evolve, and maybe where we are now and where things are even going.
Steve: Sure. I went to engineering school first. My mentor was my maternal grandfather, who was a mechanical engineer. I spent a lot of time with him growing up. There was no question from day one that I would go to engineering school. Never thought about being a physician, even though my paternal grandfather, who died before I was born, was a surgeon. My dad's oldest brother, my godfather, was the most famous colon and rectal surgeon in the United States. I really didn't think about that career.
In engineering school, I kept looking for, if you will, the right space, the right application for engineering. I have a certain moral underpinning, I guess you will, for how I do things. I knew full well, there's no way I'm going to design a machine that makes cigarettes, or supports gambling, or makes alcoholic beverages, or anything like that, that I just don't believe in. Or even working in Hollywood, frankly. I didn't want to do anything like that. I wanted a meaning for what I designed. I guess junior year in engineering school at the University of Oklahoma, it occurred to me that I could go to engineering school, finish engineering school, and then go to medical school and specifically focus on microsurgery and designing medical devices. I decided to do that before I even got to med school.
I knew I wanted to be a micro-surgeon. I love to work under the microscope in the lab, working on printed circuits. Even when I took embryology, I loved it. I didn't have any money when I was in med school. I lived in the VA hospital in Coral Gables, so I went to med school, hometown, at the University of Miami. The residents took me under their wing. Within a week of starting medical school, I decided on ophthalmology, and I hung out with the Bascom Palmer residents.
I started within a few months working at Bascom Palmer in the lab. They gave me, from the VA, all the broken equipment from the operating room, and I would fix it because I've been a machinist, a welder, an electrical engineer, and mechanical engineer. I would fix up all these instruments. I ripped off the Peyton Stilwell atlas out of the VA library, taught myself on dogs, how to do glaucoma filtering procedures, extracaps, lid procedures, with nobody with me. Then, I'd go scrub with the residents. I started learning ophthalmology from day one.
Within 5, 6 months, Dr. Norton, who is the professor and chair, basically the founder of Bascom Palmer, gave me an indirect ophthalmoscope. That was a real turning point, and who could be more fortunate than to have Dr. Norton, the most amazing guy ever, give me an indirect ophthalmoscope. At the end of my sophomore year, I was working constantly in the lab at Bascom Palmer, hand built machines from scratch, worked on ultrasound machines, television systems for the operating room, etc.
Norton said, "Do you want to be a resident here?" I said, "Yes, sir. If you want me to, sir." He said, "Do you want to go interview at other places?" I said, "Only if you want me to." He said, "Okay, you're accepted." I said, "Do I need to apply?" I said, "Everybody in my class seems to want to go here." He says, "No, you're in."
Those were the turning points. I never looked back. I decided on the retina halfway through medical school. Bascom Palmer was known for retina with Norton, and Gass, and Curtin, etc. Of course, then Machemer came along and started vitrectomy, so I got involved in that.
Now, in terms of where things are going, obviously incisions got smaller and smaller over the years. Conor O'Malley was a huge factor. He came up with the three-port, 20-gauge vitrectomy, and I consider that a huge turning point from the single probe approach that Machemer had. Then, the other major thing in our field, other than minimally invasive vitrectomy surgery is obviously the advent of anti-VEGF compounds. When I spent 2 years at National Eye Institute, post residency, I was looking for what later became known as vascular endothelial growth factor, VEGF. I built the vitrectomy program at NEI, nobody had ever done a vitrectomy there, specifically because they allowed me to do PVR and PDR. The PVR being the controls, because I was looking for what we then called basic proliferative factor. I was able to take human patients with diabetic retinopathy that was florid and cause iris neovascularization in monkeys, so it kind of satisfied Koch's postulates.
We were never able to purify the compound and figure out what it was. Of course, Napoleone Ferrara did that and should get the Nobel Prize, I hope. Think about it, we've just virtually eradicated that diabetic retinopathy, retinal vein occlusions, retinopathy of prematurity, and wet AMD with these anti-VEGF compounds. That's the kind of once-a-100-years advance, just like vitrectomy was, and just like, of course, cataract surgery; and all the work that you and your colleagues do in small incision cataract surgery with intraocular lenses.
Gary: What's interesting about that, and what really strikes me, is you wasted no time when you got to med school making yourself a linchpin for the residents, for the OR staff at the VA, and even for, it sounds like the chairman at Bascom Palmer. You found ways, you found little ways to create value. I really think that in some ways, there's no magic to becoming successful or having a great career if you apply yourself to being useful in every situation you can find. You don't waste your time. You don't have a lot of idle time. As we've talked in the past, and recently, I know that idle time is not something that you tolerate. You may have the least tolerance for idle time of anyone I've ever met because you are so ... You want to make an impact. Talk to me a little bit about that. What's your life philosophy on idleness, or not applying yourself to things of impact?
Steve: Well, I am single and I don't date or anything much. I work long hours. I haven't been on vacation in 21 years. I haven't seen a movie in 30. When I go to dinner or somebody will sit next to me, typically some business man or maybe a lady. They'll say, "What do you do?" I say, "I do surgery, engineering, and teaching." They'll say, "What do you do for fun?" I'll say, "Well, I just told you." They'll say, "So, it's your passion." I'll say, "Well, yeah, I enjoy it, but does it occur to you that there's a moral imperative to do things that help other people? So, if I work really hard and don't make any money on it, or get credit for it, but somebody in India can see, or China, or across the street from where I live, can see because I invented some technique or technology, then I've done the right thing." People say, "But, don't you want to just get away from it all?"
No, I don't want to get away from it. Why would I get away? If I could read on photonics, or read on fluidics, or control theory ... there are many social issues I'm concerned about, but if I read fiction, or I watched a movie, or I played golf, or I fished, that's a distraction from my mission. I think you ought to do a mission, these sorts of things, without a press release, without a photo op, without getting credit for it, without a pat on the back.
I often will tell the fellows, "Be nice to the nurses. Be nice to the secretaries. Why? So they'll help you? No, because it's morally right." That's what drives me is to not waste time. Now, meanwhile, I fly a jet, and I read about avionics. I read about all aerodynamics, and I try to transfer the technology from the cockpit into the operating room, which, in terms of an operating metaphor, they're quite similar.
Gary: Absolutely, absolutely. I'm actually reading Checklist Manifesto right now, which my partner, Lance Ferguson, is a pilot as well. It seems that there are a lot of things you can do with checklists that really translate from not only the cockpit and flight safety, but also surgical safety. We really have that similar approach.
Steve: Let me embellish on that.
Steve: In addition to the checklist notion, there's the notion of complete and total focus, where if when you're ... for example, in flying jets, there's what's called the sterile cockpit rule. Below 10,000 feet, you simply don't talk about where did you park your car, where are you going to have dinner, or whatever. You simply focus on everything having to do with getting that airplane airborne or on the ground in a safe manner. In the operating room, it's the same thing. I don't play music in the operating room. I used to, years ago, but I want to hear what the patient says. I want to hear if there's a conversation between the CRNA and the MD anesthesia people.
If the circulator says, "We're running out of such-and-such." I want to hear all that. I want to be able to talk to the patient. That doesn't happen if you're playing music. When I walk in the operating room, and the fellow maybe started a case, I look at every little thing. How they sit in their chair, how their hands are held, where the drape is, where the EKG leads are. I just keep watching all that stuff, sort of in an high alertness, awareness state. I think that's crucial to do a good job. You have to be very flexible to fly a high-performance aircraft and in the operating room. If this happens, you'd go that path. If that happens, you go this way.
Having contingency is crucial.
Steve: To have that flexibility.
Gary: Absolutely. Your moral compass is highly tuned. I'm not saying that just as a pat on the back. I see it really as the big “why” behind the things and the activities you choose to do. A couple questions. You are someone who is been highly active industry. You've developed your own innovations. Where do you see industry getting it right? Keeping the big “why” questions right? Where do you see industry maybe getting it wrong sometimes? Maybe we can talk about that a little bit.
Steve: Sure. I am very active in the operating room. I've done 37,000 vitrectomies, and I'm very active in engineering. I spend a ton of time studying engineering. Why? If you don't know both of those spaces, if you don't know both of those disciplines, there's not a chance of doing something really significant. Let me give you an example of things that are, I think, overly inflated right now.
"Oh my god, digital health. It will be wonderful. We'll manage all this congestive heart failure. We'll manage diabetes with digital health."
Gary: Meaning algorithms that detect and try to ...
Steve: Well, the notion of the patient's at home.
Steve: You're managing them in that manner. "Oh, it's all about wearables. So they're going to have ... " Well, when you really get down to it, you've still got to say, either they take insulin or some of the medications, or they don't. They either restrict salt, and take their hypertension medicines, or they don't. They either do whatever they need to do for, say, COPD. At the end of the end, is digital health going to solve a hip replacement, a knee replacement, a lens replacement, an abscess, a gallbladder, an appendix, a stent, or intervention? The answer is no. But we're so trendy ...
Let me give you an example. There were 40-some odd companies that worked on renal denervation for hypertension. Then, the Medtronic trials showed that it didn't work. Then, all the other companies ... every one of those companies patted themselves on the back. They had all rotor cuffs from doing so, claiming that they were disruptive and paradigm shift, and sea change, because they went to Stanford and got an MBA after their engineering degree, and walked around with a blue blazer without a tie. When you look around, excuse me, all of you got it wrong. Forty companies, they can't all be disruptive. One was, and it turns out, it didn't work.
Steve: Same thing happened with TAVR in the endovascular aortic valve replacement; and Edward Life Sciences got it right, picked the one company. Medtronic, as I recall, infringed. They had to pay a big check for infringing on the patent, and all the other companies disappeared into the wilderness. Problem number one, “me-too technologies.”
Huge amount of “me-too technologies.” Secondly, overemphasis on digital health defined as “remote care.” I get it why if there's ICUs over the place, and nobody will go look at ROP babies; my associate does telemedicine for that. Makes sense.
Steve: It doesn't solve all problems. When I hear “big data” … well, if we all practice electronically as opposed to document after the fact, and without using the model of genome-wide association studies, which Greg Hageman knocked it out of the park to figure out how do we get AMD by doing ... he took 4,000 some odd patients, whatever it was, that had known AMD, 4,000 that didn't, and looked at SNPs, single nucleotide polymorphisms, of the genome associated study and figured it out.
Steve: Everybody else's mutative genes that caused it were wrong. Okay, got it right. Well, if you take that sort of non-structured approach into data mining and say, "You know, we found out that everybody that needs toast before they have a refractive cataract surgery gets a quarter of a diopter of error," and nobody in the world would have thought of that. We said, "Well, stop eating toast."
Steve: "It will be better." I get that. That sort of data mining does make sense, so I'm not down to digital health across the board; but you have to practice electronically with real data from machines tied into it, and not record after the fact, to make that work.
Gary: Right, got it. In your career, what areas of innovation would you say you're most proud of, that you made the biggest impact? What things, when you look back over a really storied career, ... and that can either be surgically with patients or engineering, what are the things that you have spent the time on that you say, "Hey, I got that right. I really am glad I did that."
Steve: Well, on the techniques side, I invented fluid-air exchange, internal drainage of subretinal fluid, forceps membrane peeling, scissors segmentation, scissors delamination, linear suction; which is on all phaco machines, or linear aspiration, if you want to call it that. I may have mentioned, endophotocoagulation, punch-through retinotomy for subretinal surgery retinoectomy. That's the technique side.
On the technology side, I alluded to linear suction. I did a startup called MID Labs with the late Carl Wang. That was the first disposable vitreous cutter that was self-sharpening, the first lightweight little pneumatic cutter. Then, on the systems integration side, I was the principle architect of both the Accurus and the Constellation, which have 86% worldwide share preference, with Alcon Laboratories. Those machines are the best-selling vitreoretinal machines in the world. I was involved in the fluidics as well as the cutter, and the illumination, as well as the man-machine interface. I would say those are the main things.
Gary: Gotcha. In any career that has spanned as deep and as wide as yours, surely there have been things that haven't worked out. Sometimes those are the things in our life that teach us the important lessons. Anything stand out in your career, where maybe you thought you had it right, but maybe you ...
Steve: Absolutely. Well, I invented sheathotomy, which is actually not ... I call it branch vein decompression, except it doesn't work.
Steve: I was an idiot because I only did a few cases and then stopped, instead of doing a randomized trial and then publishing. See, don't do this.
Steve: I also invented macular translocation, presented it at Bascom Palmer. Machemer was in the front row, heard the presentation, and then he invented it. Others adopted it. I didn't do it in humans. My final talk was this causes PVR in animals, don't do this in people. A lot of people got blinded and got macular folds and a variety of other problems from having translocation. I would have been far better off to publish the negative data from the animal studies. Yes, those were two creative ideas that made sense to try them. Fortunately, I stopped one without hurting any patients. The other one, I never tried on a patient; but a lot of patients got hurt by that, by the latter one, by translocation.
Then, on the other side of it, persistence is crucial. My medical robotics company that I built for neurosurgery, because my dad died of a brain tumor. I got that acquired by Stryker. Fifty-two venture capital companies turned us down before Medtronic, and Baxter, and Allegiance, V. Mueller, and finally, Stryker invested. So, persistence. If you know it needs to be out there, the technology, if you know that the clinical need must be met, you just push until you get it done.
Gary: Right. A couple other areas I'd love to dive into. I know that you're avid athlete. You're religious about your workouts. I think too many times, surgeons, we like to take care of our mind, we may neglect our body a little bit. I've, over the past couple of years, have really been trying to strike a better balance there. What advice would you have? What is your workout regimen look like? How do you take care of yourself and keep active, not only mentally, but physically, and keep your body ready to go to work?
Steve: Well, I do. I lift weights three times a week. I don't want a trainer because I want to have thinking time and no trainer would allow me to work out as heavy as I do. I'm benching 250 in my workouts. I'm leg pressing 500. I weigh 189. I'm 74 years old, so I really push it hard when I lift. No steroids, no HGH, no testosterone, no trying for max, no competition; just absolutely steady working out. Then, I do cardio twice a week. I broke my neck a couple times, broke my leg; so I have bone grafts. I don't want to run anymore. I used to run a lot. Now I ride a recumbent bike, a stationary bike. That's safe, and I can burn 600 calories in an hour. You got to have a mix of cardio and resistance training.
Using light weights and high reps is just plain stupid. The guy, that Ellington Darden, that invented Nautilus came up with the notion that it's about horsepower, which is force times distance times time. Some people call that super slow. Good idea, move the weight slowly so you don't rip tendons and get rotator cuffs and things. You got to push it, or you're not going to ... I grow a beard the three mornings I lift and not the two mornings I do cardio. Why? Endogenous HGH, important.
Gary: Interesting, very interesting. Things outside of medicine and engineering that you're passionate about, I know that you give back to the community. I hope I don't embarrass you by talking about this. I know you don't do it for the pat on the back. You do it because it's the right thing to do. Talk about the social impact that you try to have, that you try to invest in, in your community. I think that's another thing that, as surgeons, as doctors in our community, we're looked up to lead, not just our patients, but also to step up and speak out on issues that are important to us. What issues are important to you that you're trying to move forward in Memphis?
Steve: Well, I know a lot of physicians will go to the heart gala, the cancer gala, or the American Diabetes Association, all which are good things; that walk around in a tuxedo with a champagne glass in their hand and donate $200. It's better than not doing that, but that doesn't appeal to me. It's too much show and not enough go.
Steve: I didn't do this intentionally, it happened serendipitously, like many things do. I walked out of my office, it was after a long day, saw 60 some odd patients, and there's a police officer, great big huge guy in uniform, African American guy, tutoring his son in algebra.
I started to walk past him, and I said, "Man this is awesome." I went up to the guy and I said, "I don't have any power. I'm not in charge of anything, but I'm going to give you an award for real dad."
He said, "Well, see this badge?" He said, "That's for Officer of the Year. You know what I do? I do community outreach." He said, "Did you hear about that 10-year-old girl that got shot in the head and killed yesterday?"
I said, "Yes, sir."
He said, "I spent all night with the five friends of hers trying to keep these 10-year-olds from trying to kill the perpetrator, because they knew who it was." A couple weeks later, he and his partner that also played college football, about 6'6", 240, the two of them pulled me over.
They say, "Hey, Dr. Charles, let me see your driver's license and registration."
I said, "Come on, guys. It's me."
They're like, "Hey, listen. We've got about 250 inner city kids. Will you come participate?"
I said, "Sure." I said, "I'll fund. I'll speak. I'll hang. I'll chat, whatever."
Steve: I said, "But you need to vet my speech. I don't want to be the big doctor lecturing the inner-city kids. It's not right."
They vetted my speech, and I took a very hard position on an issue I believe in, I work hard on, and that's domestic violence. I took a very hard line position on drug abuse, the idea that marijuana is a gateway drug, which I believe.
He said, "Come get it." I did, and then now I became Santa's Helper for a couple years. Then, I was Santa last year. I work with these two police officers, and then from them, I was on the Board of the National Domestic Violence Hotline. We went to board meetings. We tried to do the right thing, and the organization certainly does, but I didn't feel like I was making an impact. Then, through these guys, I met the, Memphis in Shelby County, Domestic Violence Council, where I live, and I'm a very active helping specific people I know, and social workers, in the whole domestic violence space.
Gary: As I'm sitting here, I'm sort of feeling a little guilty, I think of all the people who have ... who probably don't have time to do those sorts of things, I would probably put your name at the top of the list. Yet, you find time for the things that matter. That's sort of a struggle for all of us sometimes. We feel like we're busy. We might feel stressed, but I think that's a narrative we tell ourselves sometimes to excuse ourselves from inaction, or excuse ourselves from not doing what we know we perhaps should. I think it's a good reminder to me personally, and probably to a lot of folks who are listening. Keep your eyes open.
Steve: You know, but there's also cycles in your life. I have three daughters, two are physicians. They were way up in their class, number two and number ten. The other is a team-building expert. They're just awesome daughters. I spent a lot of time. I taught them how to drive a car, how to drive a boat, how to water ski, how to ride a bike, how to swim, how to ski. I was very active with them, much more so than their mother. Now they're out in the community raising money for charity, working hard, doing the right thing; then that time I spent with them, I can spend with others that need help, particularly these people in the inner city that are just overwhelmed.
Gary: Other question, let's segue a little bit. What's next for Steve Charles? What are the next chapters that you are wanting to write in your book? What are you working on now? What excites you? What gets you out of bed?
Steve: Well, of course I'm working on the next generation machine with Alcon. The Constellation is 8.5 years old; before that, the Accurus. They've expanded. We're now very embedded in this whole visualization space; NGenuity, endoscopy, all intraoperative OCT, a variety of different things to improve. It's simplistic that if you can't see it, you can't do it.
Steve: If you see it better, you do it better. A lot of focus on the visualization side, in addition to fluidics, and tissue cutting, and laser delivery, and illumination are the things that are core to the vitrectomy process, and tighter integration with phaco. We're working really hard on that. That's all of my engineering consulting is all with Alcon, except I built a visualization company for neuro, spine, and ENT. I don't actively run that, although I'm the chairman. That company came about because I built a similar robotics company for neurosurgery after my dad died of a brain tumor. That one is at the stage now where others run it, and I'm not active in that space. Then, I continue to train because I fly a jet, and you either do that like a pro or you die. I'm constantly training in flight, fly a business jet, with pros, and go to the simulator all the time. Then, fitness, and that's work hard. I do 18 vitrectomies a week and work 52 weeks a year.
Gary: That's incredible. Dr. Charles, we could probably continue to talk for hours and get in the weeds about all sorts of things. I would like to say this, any time you're in Lexington, if you want to have a $100 hamburger, and come up and fly from Memphis to Lexington, I would love to take you out and continue more of these conversations. Every time I talk to you, I get a little bit smarter, and I think I get a little bit kinder because that's just what rubs off when you talk to people.
Steve: It's a pleasure talking with you. You're a terrific guy, and I look forward to being your friend over the years.
Gary: It's a tremendous pleasure.
As we just heard, Dr. Steve Charles has had such a fascinating career. It's inspiring to hear how much his hard work and dedication to helping others has paid off over his long and storied history. By following his example, if we as ophthalmic surgeons, can limit distractions and continuously work to improve ourselves, it seems the sky is the limit.
This has been Ophthalmology off the Grid with Dr. Gary Wörtz. If you like what you hear, please head on over to iTunes and rate, review, and subscribe. If there's a topic you'd like to delve into, or a brain you'd like to pick, your suggestions are welcome. That's all for this episode. Thanks for listening.
Speaker 3: Ophthalmology off the Grid is an independent podcast supported with advertising by Alcon.