Flipping the Script

In celebration of 30 episodes of Ophthalmology off the Grid, Gary Wörtz, MD, trades in his host status and is interviewed by Sean Ianchulev, MD, MPH. Listen as Dr. Wörtz shares insight into his background, the influential figures he has met throughout his career, and how he merges the mindsets of ophthalmologist and innovator.

Gary Wörtz, MD: Open. Outspoken. It's Ophthalmology Off the Grid—an honest look at controversial topics in the field. I'm Gary Wörtz.

Hello, and welcome to episode 30 of Ophthalmology off the Grid. Over the past 2 years of this podcast, I've hosted nearly 50 interviews. Of course, that was the point of this project—to take the thought-provoking, valuable conversations I was already having with my colleagues and open them up to a wider audience. Through this venture, I've enjoyed sitting in the host seat, asking the tough questions, and encouraging my guests to open up about what makes them tick.

Today, however, we're flipping the script. In this episode of Ophthalmology off the Grid, Dr. Sean Ianchulev asks me the tough questions about what makes me tick. We'll discuss my background growing up in Michigan, the moment I was told I did not have what it takes to be successful in med school, and influential figures in my life. We'll also delve into, as Sean puts it, Gary the ophthalmologist and Gary the innovator. Here we go.

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

Gary: Welcome back for another episode of Ophthalmology off the Grid, this is Dr. Gary Wörtz, and today we're going to try to do something a little bit innovative. With it, fellow innovator Dr. Sean Ianchulev who's been on the program before, if you haven't checked out that episode, I'd encourage you to go back and download it because there's a lot of great pearls that he shares.

But Sean and I were talking and he said, "Hey, it's time to flip the microphone. I want to interview you and I want to see what makes you tick." So, without further adieu, I'm handing the microphone over to Sean, and he's gonna really grill me on all the things that he wants to know, and hopefully we get into some good conversation. So with that, Sean, here's the mic.

Sean Ianchulev, MD: Good morning, Gary. And last time you interviewed me I felt you were a little too comfortable in your seat, so we figured time to flip the microphone and put you in the spotlight a little bit.

I would like to really take this opportunity to get a little deeper into who is Gary, and what drives you, what is your background. So, first, I would like to also start with how we met. Which was actually recently, a few months back at 6:30 am at the miLoop user meeting.

Gary: That's right.

Sean: And again, very few people wake you up early in the morning and you want to follow up with later. So, you definitely came through as somebody that I wanted to go out and have some dinner. And we did, and we had sushi in New York City which I ended up paying dearly for because I lost the bet to John Berdahl.

So, with that little introduction, let's get into it.

Gary: Sounds good.

Sean: Again, you're a very successful cataract and refractive surgeon from Lexington, Kentucky. Actually, Kentucky, I'm very fond of that geography because I have a very close friend from there that was a great innovator, unfortunately passed away, Tom Zimmerman from Louisville. So I wanted to really first talk a little bit about your background.

Let's get the mundane out of the way. So, if you can tell us, what is your background? How did you end up in ophthalmology? It seems like it was a bit of a circuitous path.

Gary: That's right.

Sean: And then let's dive very quickly into Gary Wörtz the innovator.

Gary: Okay, sounds good.

So yeah, actually, I grew up in Michigan and, at age 18, came down to Lexington, Kentucky. Not shortly after that my parents actually, my dad's an internist, he sold his practice and they moved to Kazakhstan to do full-time medical missions. So, I found myself at 18 years old, really kind of on my own and ready to make my own path.

Interestingly though, as I came to college and met with my undergrad advisor, before my first class even started as a chemistry major, pre-med, had a smile on my face, and ready to go and he just looked at me and said, "You know, I just don't think you're ever going to have what it takes to get into medical school. And I think you should probably change your major and quit before you start." And the horrible thing, or maybe the good thing in retrospect, was I kind of believed him. I thought, wow, this guy knows way more about life and he's seen people try this path and fail, and so why would I want to spend all this time and effort trying something just to get to the end of a hard road and be disappointed.

So for a year, I really floundered, trying to figure out, is there another path for me that would be better, and I tried business and accounting. And actually I got to a point where I was actually going to transfer to Belmont University in Nashville, and I decided I was going to become a music producer. It's a whole other story we don't have time for but, finally wrapped my head around the idea of no one is going to tell me what I can or can't do. If I fail, I fail. But I don't want to not try and wonder the rest of my life if I could have made something of myself in medicine.

So after a year, I decided to go to summer school between freshman and sophomore year of college, got right back on track, and I kind of had this theory that maybe I don't have all the same talents that other people have and that's okay. But, if I'm going to make this work, it's going to be based on really working harder than everyone. So, being humbled, I think, at the beginning of my college experience was probably the greatest gift anyone could give me. Because it forced me to deal with the variables that I could deal with which was the amount of effort I applied towards the task, and thankfully I got right back on track, got into med school, and the rest is history.

Sean: Interesting. Interesting. So, did you send your advisor a copy of your diploma when you graduated?

Gary: So my advisor is one of the most sincere and nicest men you'll ever meet. Actually, he was my advisor again because I loved chemistry, and I came back and took chemistry. And he actually, when I graduated, he gave me the Outstanding Chemistry Graduate Award on graduation day. So, it was sort of poetic justice a little bit, that I showed him I had what it took.

Sean: Well, that's good to know and again, it seems to me, and one thing that I noticed about you very early on was that you just don't take no for an answer easily. So, tell us briefly about Gary the physician, the ophthalmologist, and then let's go quickly into Gary the innovator.

Gary: Sure, well, you know I love ophthalmology. I love cataract surgery and LASIK, and I think it's very clear that we have a unique opportunity to impact people's quality of life in a way that's very quick and tangible. And there's a real exchange of enthusiasm and joy when you can help someone in such a tangible way.

And so when I was in medical school I was able to see Asim Piracha, who's a fantastic cataract refractive surgeon in Louisville, operate. He's like an artist. And so when you see someone at that level operate and you see what they're doing, it casts a clear a vision of what you might be able to see yourself doing. And so I really followed his footsteps in residency. And so today I find myself in a practice situation that is very similar to what Asim was doing and is still doing. He's a colleague and friend at this point still.

So I really love doing cataract surgery. I find a lot of joy in looking at cataract, looking at that, and figuring out what techniques I'm going to use to most efficiently remove it. I love thinking about unmet needs, I love thinking about the optics, even while I'm doing surgery. I like to sort of think about what's going on, the physics of the experience. As you do this over and over again, you start sort of identifying unmet needs and maybe that's a good segue into the innovative side of my brain. We've tried to move some things forward.

Sean: Yeah, so cataract surgery is a therapy for a restless innovator. That's good to pick.

Gary: For me that's very true.

Sean: So, when we met, and one of the things I never told you, but it was really interesting you meet a lot of colleagues and ophthalmologists and I wanted to say to everybody that the conversations with Gary were always different. We didn't talk as much, or probably at all, about what is the preferred chopping technique, and how to optimize my premium reimbursement. Conversations with Gary are questions like why are masses biased toward inaction? Why chase the possible? Why compete with others versus our dreams?

So can you talk about your philosophy and how you look at challenges in life? What drives you ultimately?

Gary: Yeah, I guess I'm a mountain climber in terms of challenges. I like to be challenged. And as soon as we solve one challenge, there is going to be a new unmet need that unveils itself. And so I kind of have a restless mind, and I think we all do. I think it's either something you sort of tune into those questions and they bother you to the point of you have to do something, or you just settle on the fact that maybe we'll never know. Or someone else will solve that problem.

But, I think that it's ... things bother me. It bothers me that we can't do better at cataract surgery right now. And you can look at the flip side of the coin and say we do really, really amazing things with cataract surgery, and it's better than it's ever been, and it's fantastic. I like to be an optimist about things. But, those things gnaw at me, especially when I sort of feel like I might have a better way of doing things. And I think those are the ideas that if you can't shake them, and John Berdahl has sort of said the same thing, it's like if you have an idea for something new, a new innovation or a problem, sleep on it. And if after a couple of days if you still are thinking about it at night, you wake up in the morning thinking about it, it's going to drive you crazy until you decide to actually do something with it.

I guess that's kind of where I landed on some things when I decided, I don't think anyone else is going to do this, I think it's something that needs to be done, and I guess I'm gonna raise my hand and try and do it because I think it's important.

Sean: Yeah, it's so funny, I've learned the same thing. Because we get a lot of ideas and some of them are worth pursuing and others are not. So I've learned the overnight discharge test. If you can't discharge an idea after a good night's sleep, or a few of them, then really pursue it. Because it will really ultimately frustrate you that you didn't do it.

Gary: That's right.

Sean: Well, that's very interesting. I wanted to briefly talk about another ... it's quite innovative what you're doing with Off the Grid by itself, and we'll talk about the other ones. We live in a time where there is a lot of media, a lot of noise, and most of it commercial.

Gary: Right, right.

Sean: And what you're doing here, is you're taking a lot of your time and effort to give a voice to different people, and ophthalmologists, and colleagues in a unique way. From another ophthalmologist, and it's not driven by any commercial intent. And that's why when I came last time, I really appreciated that it was very different than other interviews. Tell me what made you do that, and really, congratulations on doing it. Because it's not easy, and it's something that you're really taking a lot of effort and time to do.

Gary: Well, I think in some ways I'm a little bit lazy, and I'll clarify that. I was getting asked to write articles from time to time and I was happy to do that. But I was also simultaneously connected to a lot of really interesting people in ophthalmology and I found myself throughout the week, or throughout a month, having a number of phone calls with Daniel Chang, or John Berdahl, Bill Wiley, or George Waring, or Elizabeth Yeu, or Neda Shamie, whoever it is. All of some great colleagues, we have a really cool group of people that are sort of friends, and I liked to pick their brain. I liked to know, "Hey, what's working in your practice? What makes you tick?" Sometimes it's really helpful to have a colleague pick you up when you're down, if you had a bad day. You know, it's nice to have someone who's been there.

So we're having some conversations anyways, and I thought to myself, you know, these conversations they benefit me but it's a little bit selfish that it couldn't benefit a wider group of people. At the same time I thought, you know, writing articles in the trade journals it's great, but there's really this space out there for busy ophthalmologists who are commuting or who maybe don't have time to flip through the articles and read what I would have to say anyways. And so, I just thought, you know maybe we could just have some honest conversation between colleagues and talk about the things that matter in their practice. And I thought it would be beneficial, honestly for me, to just learn from other people. So there's definitely a selfish element to this. And it was maybe an easier route for me than to just keep pounding out the articles.

And here's another sort of philosophy. You know, when you ask people for something you don't risk a whole lot, because all they can say is no. And if they say no, you're really no worse off than you are now.

So, I had this idea for a podcast, I decided to call David Cox from BMC, who is fantastic and a tremendous person, ubiquitously loved. But I called David and I said, "Hey, I've got this idea for a podcast, can we do it?" And he sort of, "Yeah, let's do it." I mean the calculation was, well, we've got the equipment, what could go wrong? You know?

So, 2 years ago we started with just doing some interviews with folks, and it's kinda caught on and it's kinda taken on a life of its own, and, to me I feel like it has been a very self-indulgent process where I've gotten to have amazing conversations with people that I'm very interested in, and thankfully I feel like other people are benefiting from those conversations.

Sean: Great. Well, please keep on doing it and keep it intimate as you do because it definitely has a different style and it's something that we don't have.

Gary: I appreciate that.

Sean: ­­­Let's talk briefly about Omega Ophthalmics. What you mentioned early about cataract surgery, we're right now at the 50th anniversary from the introduction of phacoemulsification.

Gary: Right.

Sean: And in 1967 by Dr. Kelman. And we know how transformative that innovation was. It was a new idea that created a new product that created a new industry.

Gary: Right.

Sean: At the same time, it's been 50 years and I totally understand why you say that currently we continue to incrementally improve that technology, and we probably have plateaued. And we may be at a point where we would like to get something disruptive or look at it in a different way. So, tell me briefly about what you're doing about that, how you're trying to solve that problem. And what do you think the future is and how Omega fits into that.

Gary: Yeah. So, you know I was, this was actually about 5.5 years ago, and I'd just attended an innovations summit and it was probably a really good time in my life to hear a lot of things about how as a physician you can be an innovator. And that was an ACOS meeting in Orlando. And as I was leaving the meeting, I was on a plane, my daughter was actually asleep next to me, and my wife and son were in front in the plane. And I just sort of had a moment to decompress, to think about the meeting, and it had been bothering me for a while that we had sort of plateaued with IOL calculations.

We've got the IOLMaster, we've got the Lenstar, but it just frustrated me. I felt like I do a good job with cataract surgery, I'll do a good lens calculation, all of the variables that I can control have been controlled, and yet there were too many patients coming in who were still not refractively where they would want to be, or where I would want them to be, or where we talked about they should be. And, I just hate it. I hate having that conversation with a patient, premium or not. I just try ... I want to do better. I want patients to see their best. It bothers me when they don't.

So, I just started doing some thinking. I'd been thinking for a few months on why IOL calculations aren't better, and I realized that all the formulas ... the reason why you ever have multiple formulas is because there's not one that really works all the time. So, all the formulas essentially take the variables: axial length, ACD, corneal curvature, age, refraction, all the variables. And they're basically trying to place a bet on where the lens is going to sit inside the capsular bag once it's all said and done.

Some formulas, their bets are better for shorter eyes. Some formulas perform better for longer eyes. They all do fairly well for normal eyes. But I just didn't like the variability there. And I said, if we could establish a plane for the lens to sit in, and we knew where that was, and had an opportunity to actually intervene in surgery after we established the refractive plane or actual lens position rather than an effective lens position, and we could leverage that information with ORA, for example, or intraoperative aberrometry, we would have a really unique opportunity to fine-tune patients' vision in a way that had not been achievable before.

And so the thing I loved about intraoperative aberrometry is it really can give you, as you had mentioned in our interview previously, it's a privileged state where we have an opportunity to intervene when we have an aphakic patient. You know, the whole theory and thinking about posterior corneal astigmatism, well there's no better time to measure the true corneal value, then when the lens is out of the equation. Because the only thing that's providing refractive power at that point is the cornea. So the entire corneal power puzzle is sort of solved at that point. The only other variable left, really, is effective lens position.

With Omega, we have had the working theory that if we can take effective lens position and turn it into actual lens position with a lens that goes in and fills and opens up the capsular bag, but we retain some real estate or space inside of our device for the additional implantation of other technologies? That can be refractive technologies like add-on lenses, like piggy back lenses. But we also realize throughout this process that the space that we had originally reserved for additional lenses, that's prime real estate that could be developed for so many other things.

What started off as trying to solve one problem of effective lens position and trying to leverage technologies that exist, like ORA, with lens technologies of the past and sort of bringing those two technologies together with a new lens design has really evolved into a platform for the tunability of refractive outcomes. But we really feel there may be more value in retaining this open real estate inside the capsular bag for pharmaceutical delivery, biometric sensors like glaucoma pressure sensors, etc., and even some futuristic thinking about augmented reality and where does that go after the goggles and glasses are miniaturized. That's kind of the start of the journey.

Sean: Well, you definitely are innovating in a very challenging space because this is not the 510(k), or it's not a small instrument, it's an implant, and IOL innovation is probably one of the most challenging ones. It takes a lot of development in addition to just the idea.

So what have you learned about that? About taking technology from idea through the productization pathway and developing it in this highly regulated environment with your IOL idea?

Gary: So I think you have to have a good dose of naiveté. You've gotta be naïve about how hard it's going to be before you start. Because, you know, as I had this idea I thought, okay, well it's just a monofocal lens and the pathway of monofocal lenses are very straightforward. Material science has already been worked out, we understand that are very biologically compatible materials that are open source.

When I started this idea, I thought, man, this is gonna be so easy. And the reality is it has provided numerous challenges, none of which has been insurmountable, and each one of those has taught me something along the way. I'm not an engineer by training, I feel like I may have some of the qualities of an engineer thinking about design, but I'm not an engineer.

So the things I've really learned about this process is it's harder than you think it's gonna be. If you knew how hard it was at the beginning that may be a bad thing, because you may decide not to do it. I think you need to be more engaged.

But also, I would say, there are so many kind and generous people in our industry that are willing to help, even beyond what you would think. Even the highest luminaries in our field are all very approachable and want to give back and are looking for opportunities to help.

So, I've been very fortunate to have an audience with some of the most amazing ophthalmologists in the world, explain my idea, and have them say, "Yeah, I'll help you. No problem. How can I help you? If I don't know who will help you, I'll connect you to someone who might." And then it just becomes a series of being willing to connect the dots. So I'm not an engineer but I have friend who knows an engineer and now he's working with us on our team.

So it's really just being able to extend yourself, I think. Being willing to put your reputation on the line. Because it's hard to divorce yourself and your own pride, and your own professionalism with an idea. That's the challenge I think, that people feel like, if I tell someone my idea and they hate it, it's going to reflect upon me badly.

But you know, I just didn't care that much about that. I believed in the idea and I felt like, all right, well if this doesn't work ... again, sort of like going back to my undergrad experience ... if it doesn't work, it doesn't work. But I'm going to try it. And we're going to work really hard at it until someone tells us we can't go anymore. And that's kind of how we applied ourselves at Omega.

Sean: Yeah.

Gary: And so just to kind of go full circle, last November I was able to go down to El Salvador and do our first human implantation. So, for me, that was really a professional mountaintop experience. Because I had been thinking about this and dreaming about this for 5 years. And we've gone through a lot of design iterations trying to optimize for getting this through a small incision and making sure it's going to be robust enough to hold the capsule open, and have enough space to hold a traditional lens or other technologies, and it's sort of like solving a Rubik's cube where anything you move, you're moving the entire cube around.

But it was really amazing to go down there, to do the surgeries, everything went just flawlessly. We're just so happy that we're in a position now where we've taken an idea all the way through proof of concept. There's still work to do but we feel really confident of the path we've been on, and it really helps define the path forward for us.

Sean: Bringing technology forward, obviously you need to innovate technically and invent something or start with a new idea, but then you have to take it through.

Gary: Right.

Sean: And that involved management leadership. Tell us about what you've learned. Because you're the CEO of Omega as well, right?

Gary: Well, I was the CEO, I founded the company. But I was extraordinarily fortunate and blessed to meet Rick Ifland, who is our current CEO and really has been our CEO for almost the entire time. So he's really been in lockstep with me from very, very early on.

Rick is a serial entrepreneur who has a private equity firm, has done a lot of entrepreneurial deals over the past 25 years or so. So I think, maybe part of this whole conversation is, I think you have to be very honest with yourself if you're going to innovate, what are your strengths? What are your weaknesses. And I know what I found at Omega is I did not have all of the skills that one would need to take this idea forward. I've always kind of said, the idea's too big for one person to develop on their own. So I really said, all right, these are the holes, these are the gaps in my resume, I need to find people who are experts to fill those gaps. And Rick is just a real ... he's a business guru. He taught entrepreneurship at West Mont College, which is a Forbes Top 10 school, he's got a law degree in international law from Oxford University. He's just incredibly sharp and has done this multiple time.

So, for me to say, "Hey, Rick, I can do the medical side of things and if you can do the business side of things? And I'll teach you the medical side, and you can teach me the business side so we can kind of overlap a little bit. It's just been fantastic. So I would say one of the key differentiators of Omega is I didn't trust myself with a business to run. I knew I needed someone to come and help me. And I really have learned so much about the process just be working with Rick, he's been fantastic.

Sean: That's great to hear. A lot of innovators obviously, founders of companies, have a hard time giving up control. Not to mention ophthalmologists, we like to be in control.

Gary That's right, that's right.

Sean: We have to be in control. So, was that hard? Realizing that, okay, this is what I can do and somebody else maybe has to step in?

Gary: It wasn't ... I don't know, it wasn't hard. I feel like I had a clear vision of ... The other side of the equation is I wanted to continue practicing ophthalmology. So I wanted to have this company as a portion of what I do, but I wasn't really ready to give up being an ophthalmologist to pursue the idea full time. So I realized that I have to carve our capacity to do some of the things in Omega, but I don't have the capacity to do all of these things and continue running a practice. So I think it was fairly easy for me to say, oh, if you'd be willing to do the business side of things, I've got enough capacity in my life to take on the medical and continue being a practicing ophthalmologist.

So I think to me it was lot about having capacity to continue being an ophthalmologist and if he was willing to take on that challenge it was great. Because I also try to be a good dad and a good husband, that's a huge part of my life we haven't talked about. But, you know, professionally, that's like second or third on the list of my priorities of getting right. And I try really hard to get that right. But, there are two layers above that: my faith and my family. I have to get those things right. Everything down stream of that is really just supporting those other priorities for me. So I think that also kind of helps not feel like I have to be in control. Because it's not everything for me, it's very very important but I have sort of a different why that sort of gets me out of bed in the morning.

Sean: Yes, and Gary how do you maintain balance?

Gary: Yeah.

Sean: You have a family, you have a successful career, you have innovation, a lot of things going on.

Gary: When I find out I'll tell you.

No, I look at it ... the term balance in semantics. But I feel like balance can be a misnomer, because, you know you can be overloaded on both shoulders and be balanced. You know, if you try and squat too much weight, you can be balanced and you can be on the floor with a bar crushing your back. And so I think a lot of times we think about balance like I have to do a certain amount of work and a certain amount of family time and I've gotta sort of divvy my world up. And in some ways you're just overloading yourself on both sides.

So I like the term capacity. And capacity is, you know if you're running a car, you don't want to run it red line the entire time. Because you may need to pass someone, you need to have a little reserve in your life because you don't know what's coming around the corner. So I try to carve out capacity where I'm not always running in that red line. Because I did that for a long time and we have to do that sometimes to make it work. There was about a 2-year period where I was simultaneously doing two satellite clinics that were 2 hours apart and flying back and forth to Florida to do locum tenens. And it was just what I had to do at that moment of my life to sort of make things work for me and my family. So you can work too hard for a while if you realize it's just for a season.

But to the extent that people can carve out capacity, and maybe that's taking one day a week off to pursue other pleasures, hobbies, or just deal with the things in life that need tending to. Taking your wife out for lunch, do the taxes or go to the doctor, go to the dentist, make sure you're working out. So I try in my life to have capacity which allows me to keep things in focus and in control even when they get crazy because I'm not already at red line. So that's kind of how I try to approach things.

Sean: That was great. Well, what is ahead of you in the next 5 years?

Gary: Anytime you have a plan, the only thing that really defines is that exact thing is not going to happen. So I would say this, I always see myself being deeply invested in my patients, in my practice, in doing surgery, and always trying to think about doing things different and better and more efficiently. I think those are the guiding principles of my practice. From an innovations side, we're going to keep taking the ball down the field as far as we need to with Omega, and hopefully within before 5 years, I'll have the opportunity to start using my own product in my patients.

And if those things happen I'm already the luckiest guy on the planet, I don't feel like I deserve any of this, and really if I only had just the friendships I had in ophthalmology it would be more than I deserve. But the professional satisfaction I get from ophthalmology is on a whole nother level of what I feel like I deserve. So I already feel like the luckiest guy on the planet. I've got a fantastic wife. I've got wonderful kids. So I think I will probably always continue keeping my toe in the water of innovation. I like to teach and I like to share ideas, so I think the podcast hopefully will continue to live on in perpetuity and I'll always be looking for opportunities to help my patients. So, I think it'll kind of look like this in 5 years, but maybe with some new interests or new endeavors that fill that innovation space.

Sean: Gary, I think that's a good point of closure, and again, thank you. It's been great actually meeting you and really turning into a friendship here with another like-minded ophthalmologist, and I cannot tell you how that resonates with me because in many ways we're driven by the same things. Keep on doing what you're doing, and I hope in 5 years we'll have the Omega Lens and we'll be solving some of the really hard problems. And I hope that now you have 30 people you've interviewed, you're one of them, you're the 31st, and maybe you can say how does it feel on the other side?

Gary: Yeah.

Sean: Being the patient a little bit.

Gary: Yeah, exactly, yeah. I've been under the bright lights here in the hot seat, and I've actually enjoyed it. So, thank you.

Sean: Okay.

Gary: Sean, thank you so much.

All right, now I'm back in the host seat, and I have to say, what a change that was. I'd like to thank Sean for his idea to flip the script and for allowing me to share some of my insights in my life and work. And thanks to you all for listening.

This has been Ophthalmology off the Grid with Dr. Gary Wörtz. If you like what you hear, head on over to iTunes to rate, review, and subscribe. And check out past episodes including my Dr. Ianchulev at eyetube.net/podcast. See you next time.

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