Training Day

Thomas Oetting, MD, speaks with Gary Wörtz, MD, about the value of promoting individuality when mentoring trainees. Dr. Oetting explains that education is the most important aspect of training, regardless of how the trainee learns a particular subject. Joshua Frenkel, MD, a senior resident at Tulane, also shares his perspective on ophthalmic training today.

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

“The delicate balance of mentoring someone is not creating them in your own image, but giving them the opportunity to create themselves.” Sadly, not a Wörtz original, but a thought-provoking insight from Steven Spielberg.

This respect for individuality is something most of us seek in our careers. We can accept and even embrace that, compared with our colleagues, we may learn differently, think differently, and act differently. Today’s ophthalmology trainees are no different, and the successful mentors are catching on.

“I don't really care how somebody learns about multifocal choroiditis. I just want them to learn about it. Whether you come in and do a lecture and listen to our faculty or whether you sleep in and then learn it at night, the only thing that really matters is, do you know how to take care of patients with that problem?”

That’s Dr. Thomas Oetting, of the University of Iowa. In this episode, I sit down with Tom to talk about his views on mentorship and why he feels it is important to give trainees room to think differently. We’ll also hear from Dr. Joshua Frenkel, a senior resident at Tulane, about what it’s like to be in training today. First up is Tom.

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

Gary: This is Dr. Gary Wörtz with another episode of Ophthalmology off the Grid, and I have finally tracked down Tom Oetting. Tom is someone who I have been a fan of peripherally for quite a long time. All the stuff he does with teaching residents and making our profession better, it really is inspiring. We are really excited to be able to talk to Tom Oetting today on Ophthalmology off the Grid. With that being said, Tom, thank you for carving out some time to come and talk to us today.

Thomas Oetting, MD: Thank you, Gary. Gary, I just want to tell you right up front, we really appreciate the times that you've grabbed our residents at various meetings and sat down and had a drink with them and did informal mentoring. It really means a lot to those residents and to our profession to have folks like you that take the opportunity to informally mentor people. Certainly this podcast is a way to spread that sort of mentoring across the world. I really appreciate all you're doing for us.

Gary: When you're raising such good and developing such good residents, it's really selfish for me to be around such high-quality people because I actually get more out of it probably than I give, but thank you for saying that. I really appreciate it.

Let's dive right into a topic that I think uniquely is suited for your experience and expertise, and you even brought it up initially, and that is what do you think makes a good mentor? Mentorship is so important. I've been so lucky to run into the right people who have invested in me, and so I know the value of that and sort of try to pay that forward now. Why do you think mentorship is important, first of all, and what do you think makes a good mentor, either in residency or out?

Thomas: I think mentoring is really important. I think that's why we're all here at the academy this year and why we go to meetings is because we sort of crave the idea of live interaction with people. I think what makes a good mentor is, first off, you have to give darn. You have to care about that person. Sometimes it's helpful if they go to the same program as you. Sometimes it's helpful if they have some other interesting connection with you, maybe they both went to the same undergrad, like they're both Hawkeyes or something. The idea is that you want to give a darn about that person.

Then, secondly, as a mentor you have to have some connections. You have to have some leads or some people or some resources that you can share with your mentee that are valuable. I think those two things are an important combination. If you're a developing faculty member or a developing surgeon, I think it's important to take opportunities to get to know people so that you do have resources available. To me, this is a great opportunity for me to meet you, and hopefully I can say that I know you. Maybe I can use you later as a resource for one of our residents that wants to do complex cataract surgery or refractive cataract surgery, that kind of stuff. I think it's important for us to have a stable of people that you can go to.

One of the things that's interesting about mentoring is it's important to develop these relationships when the seas are calm and not just when things are crazy. That's one of the things that sometimes you forget about is it's important to establish relationships when things are going well. Sometimes you may have a complicated case or you may have a problem with a coworker or something, but it's very hard to just all of a sudden call somebody that could be a value to you if you haven't already developed a relationship with them.

I do think it's something we all have to work on. I have mentors myself, even though I've been in the business 25 years, and even though I've got a lot of gray hair, there's a lot of people that I really look up to and I use to give me help and advice. I think it's important for us to develop mentors and also for us to have mentees that we take care of.

Gary: I think in residency programs there are definite cultures that form. It's usually based on the attendings and the residents that are there, but, generally, the program director or the chairman sort of set a culture. We definitely had a culture of mentorship at the University of Kentucky, not only with our faculty members, but it was really like a family of residents where the upper-level residents really looked out for the younger residents and really showed us the way and showed us the path forward. Walk us through in your program maybe what that looks like or a little bit of the culture of mentorship that's there at Iowa.

Thomas: I think some programs will have a formal system for mentoring, where you come in as a first-year resident and you're assigned to somebody. Our program tends to not have formal mentors, but instead people develop those with time. The important thing is to try to get people connected with people in various ways so that those informal mentoring relationships can start. Oftentimes it's related to fellowship interests or other interests that crop up that make it mutually beneficial. Research interest, for example, is a great one.

Within our program, though, I think some of the most important mentoring relationships are more senior residents to more junior residents. Those relationships form, in a lot of ways, with social activities that are often done at times of less stress so that you can develop strong relationships. When the going gets tough, you really don't want to start developing relationships then. For example, if somebody has an illness and you have to cover a call, if you've developed tight relationships within the organization, then those things are more easily managed. We really try to focus a lot on, as best we can, of trying to develop those relationships. Having the class tight within itself and also having good relationships with more senior to more junior residents—we do that, and one way we do that is by having a junior resident and a senior resident that rotate through together in various rotations, and so they're called buddies or big buddies or big brothers, big sisters, that kind of thing. That's been a useful tool.

For faculty, it just kind of grows out of more, sort of related to, interest as opposed to related to more structured things. I do think we're lucky we have our chairman now, Keith Carte. He is the president of the Academy of Ophthalmology this year. He just took over with this meeting. Clearly, he has developed this unbelievable network of relationships, and it's a model to us. It's a model to how you can have your life, how you can have your career. You can't walk with Keith Carter more than four steps in this meeting without having five people come up to him and hug him and say hi to him. That just doesn't happen. It's just not instantaneous, it's because he's worked on it.

Gary: Right. Makes sense. Iowa is just one of those programs that year-in, year-out attracts the best people, the best and brightest. I think beyond that it has a track record of producing incredible clinicians and scientists. What do you look for? We do have sort of a wide range of people who listen to this. I know there's some med students who listen, there's residents who listen, there's people in every stage of their career. What's the secret of attracting good residents and building good clinicians? That's a very nebulous question, but are there characteristics that you see or maybe traits that you try to develop in people that, once they're done, they're not just going to be a 9-to-5 ophthalmologist, they're going to go above and beyond?

Thomas: I think it's hard. We're right in the middle of our search for our next class. Everybody gets 400 or 500 applications, and everybody only has five or six residents they take, and so there's a job of sort of sorting through. Not every program is for every person. We certainly encounter people that we don't think would fit, and they don't think would fit. It's often mutually exclusive. What we try to do is we look for integrity and passion. We look for a desire to take care of patients. A lot of the other things come later or come around that, but the important thing is that our primary mission, even though we're a teaching institution, is to take care of patients. We're looking for people that have shown aptitude in that area, maybe have some spice, like, they really had passion in some area or have done service work in their community or church that gives us a sense that they've made the places they've been better. If we bring in people that make our place better, then Iowa will continue to get better and better, so we're looking for that sort of stuff.

There are so many people that have enough brain power, I hate to say this, but have enough brain power to be in ophthalmology. It's the people who are successful in ophthalmology have other intangible skills. It's not like physics or something like that where you really have super brain power. It's more about people skills, taking care of patients, working in a team, having passion, having energy. A great example of this is our mutual friend John Kitchens…

Gary: I love John.

Thomas: …who's just an absolutely super energy, passionate guy that changed our world at Iowa when he came there as a resident. He went on to have great success at Bascom as chief resident. Now he is quite a famous retina specialist. He just was a great example. From the minute we interviewed him, we knew he had a lot of passion, integrity. We knew that he was going to be a team player, and we knew he was going to take care of patients. That's just a great example of the kind of person we're looking for.

Gary: Now, I've got to interrupt. I'm sorry. I've heard that John played some practical jokes as a resident. Is that true or false? Is there anything you can share, or is it all past the limit of what you can share?

Thomas: He certainly enjoyed making fun of us. He would do videos where he would do things like make fun of Dr. Hayreh our very famous researcher who did a lot of work on monkeys and had, for a while, a stable of monkeys there in Iowa. He would dress up like a monkey and go around with one patch on and really kept us thinking about what we were doing. Mainly, things like that bring you together. When he teases Dr. Hayreh, who's almost unteasable, he's one of the most famous ophthalmologists in the world, he keeps us all down to earth and grounded, and we remember that we're people and we're part of a family and we need to stick together.

Gary: I'm going to ask at some point offline that we dig up those videos because I think that would be fantastic to see those at some point. Earlier, before we started the program, you were talking about a philosophy about developing internal motivation among your residents, rather than just sort of this external carrot and stick approach, and sort of this idea of residents being, in your words, the captain of their ship. Can you just expound on that a little bit and explain that philosophy and why that seems to be such an important factor in the way you try to motivate residents as they go through?

Thomas: I think this is one of the hard things about medical education in general is that we go through these very scripted courses where we go to undergrad then med school, all sort of going through the motions to get our residency. When we get into residency, we have this very scripted, very externally motivated course of study that we do. Then, a lot of times, by the end of that—many, many years if you think about it, we're talking about 12 years of this sort of work—a lot of people lose their ability to motivate themselves. They kind of forget that they should be thinking about, "What are my gaps in my education? How can I make myself better?" As opposed to there's a tendency to think a little bit with our training system of, "Is anybody detecting my gaps? If they have detected my gaps, I'd better be careful."

Gary: Right, keeping up the appearances.

Thomas: Yeah. What's important is for us to be the captain of our educational ship. If there's something that you know that you don't know how to do, then figure out a way to get better at it, as opposed to worrying about what your professors think and so forth. I've come to this conclusion more and more as my own children have been in the high technology industry and finance industry, and I see how much freedom they have within the goals of what their job is to figure out how to do it. They've been very innovative, and they're very open to various ways of learning.

For example, I don't really care how somebody learns about multifocal choroiditis. I just want them to learn about it. Whether you come in and do a lecture and listen to our faculty or whether you sleep in and then learned it at night, the only thing that really matters is do you know how to take care of patients with that problem? There's a million examples of things like that. We've been trying to do more and more things along those lines to encourage people to be their own boss of their education. One selfish reason that that's useful is if we give people time to be the captain of their own ship, and then, 6 months later, they say to me, "I don't know about OCT. What are you doing about it?" And I'm saying, "I'm not doing anything about it. You're the captain of your ship. You had some time to do it, now you learn about it. That's your job." I think the more we can sort of reinforce that with people and say, "Oh, that's right. I'm the captain of my ship. I need to figure out how to move forward."

I'm not saying you totally remove all structured training. I would never say that. I'm just saying just introduce a little bit of this idea of being the captain. I think if we do more of that, we're going to get more people like you, Gary. More people that are innovative and thinking about how to do things differently and in exciting new ways, and less people that are just going through the motions, totally beat down by the system when they get out.

Gary: I think that if that culture is fostered and you have those educational habits of being curious, self-directing your learning, we want to build lifelong learners. We don't want to get people who are just there to pass their boards and where they mail it in for the next 30 or 40 years. I'm glad you mentioned it because it's not something intrinsically obvious to me. I've just never put it into a concise thesis like that, but I do think that that is something we all need to be reminded of, that this is an ever-growing, ever-changing specialty. They told me in med school, "50% of what we teach you is wrong. Your job is to figure out which 50% that is." As we go about learning throughout our career, it's important that we do take that responsibility so seriously because it ultimately impacts how we're able to care for patients.

Tom, thank you so much. I don't want to take too much of your time at this point. I would love to have you back on, maybe with some of your residents if that's ever an opportunity to gather some and have maybe even more of a roundtable about what it's like to be a resident nowadays and what it's like to learn as the captain of the ship. I think that could be a really important topic to expound upon.

Thomas: We'd love to participate. We, again, really appreciate all you've done for ophthalmology, and thank you for taking time to be with me.

Gary: Awesome. This is Dr. Gary Wörtz with Ophthalmology off the Grid with Dr. Tom Oetting. Thanks so much, bye.

Gary: Now that we have heard from a successful mentor, let’s move on to Josh to hear more about residency today.

Gary: Well, this is Dr. Gary Wörtz, once again, and now I have a chance to interview someone who's become a friend over the past year or so, Dr. Josh Frenkel. And Josh is a senior resident at Tulane, has been going through the whole medical education process, and is really getting ready to reach the end of the residency journey and actually looking for fellowships right now.

So, I thought it'd be a good idea to bring Josh on to remind us of the struggle of being a resident and giving us a real-time update, for those of us who have been removed from residency for a while, at just how hard it is right now, this day and age, to be a resident. So, I thought it'd be a good update and really to get a encapsulation of what it's like, a day in the life of a resident in 2017. So, Josh, thanks so much for taking a little bit of time, and coming in and talking to me today. I really think this is gonna be an important segment.

Josh Frenkel, MD: Well Gary, thanks so much for having me. It's really an honor to be here. I'm actually a huge fan of the pod, and a listener.

Gary: Thank you. Thank you. Well, there you go. I'm glad, really happy that you were able to work this out. So, give us a little bit of a background. I know that you grew up in Madison, you went to Overland, in Ohio, great school. And then you migrated further south, all the way down to Tulane. And then you've been at Tulane med school and residency, is that right?

Josh: That's correct, yeah.

Gary: Okay. And so, when in your journey did you decide ophthalmology was gonna be your specialty?

Josh: Well, Gary, I went into medical school. I didn't have a specific field in mind. I really became interested in ophthalmology about third year, early on in third year. I met a gentleman, Blake Williamson, you may know…

Gary: Ah, Blake. Yes. The man, the myth, the legend.

Josh: Absolutely. Blake was an intern. I was a third year. And Blake told me, "Josh, you have to check out ophthalmology." He said it's an incredible field. And, fortunately I listened, and I did a rotation, and I was instantly hooked.

Gary: That kind of mirrors my experience. Unfortunately, Blake was not around for me. It would have been a lot more fun. But, as a third year, it was right after my OB rotation, I was questioning my decision to go into medicine in general and got to see cataract surgery for the first time. And I said, "I can do this. I think I could do this every day the rest of my life." And I was actually right about that. I really ... I still love it. I've been doing it for 8, 9 years now. But so, third-year med student, you said, "All right, I'm going on this journey." At that moment, that you can remember, what was your impression of what it was gonna be like to be an ophthalmology resident? Was it just rainbows and unicorns?

Josh: Oh, yeah. Absolutely. It was, I think they called it, the road. There's radiology, ophthalmology, anesthesia…

Gary: The road to success?

Josh: Dermatology, all the ... just get in, and once you get in, you're great. You're done.

Gary: Right, right. Exactly. It's not that easy though, is it? It's not that easy.

Josh: No. No, apparently not.

Gary: Yeah. So, give us a little bit of an encapsulation of what your journey's been like. And Tulane's a fantastic program, so we know you've gotten good training. But, with good training, that means you're gonna be stressed a little bit. You're gonna be stretched. And probably stretched in ways that you didn't even anticipate. So, walk me through what your journey's been like at Tulane.

Josh: So, I did intern year there as well, and tremendous experience. When I got to ophthalmology, it was almost like being an intern all over again, except this time, I didn't even have a medicine knowledge to fall back on.

Gary: Yeah. One of my residents told me on my first day, they said, "You're gonna be humbled this year, because you went from being able to save people's lives in a code to not being able to run a refractor and actually prescribe people a pair of glasses. And it's gonna be incredibly humbling for you." And it was. Now, did you find that same? It's kind of what you're describing, it seems.

Josh: Yes. 100%. It was the most humbling year of my life, I would say. It felt like I'd been thrown into a pool, just the deep end, and I was just trying to get on to the ledge, trying to find my way, and catch my breath. Because not only, you have the responsibilities of call, and you're trying to learn your field, learn your craft, you want to maintain your responsibilities at home. I'm a husband, I have a wonderful wife, and I want to try to maintain those responsibilities while being the best resident I can.

Gary: Right. And I think the struggle for me was, really, I think my expectations were upside-down. Because I had the same thing. I was like, "Man, as soon as I get into residency, all my wildest dreams are gonna come true." And really, you get no respect from everyone else. They really love to throw shade at ophthalmology. They're jealous, it's fine. We get it. We know. Unless you're an ophthalmology resident, unless you've been through that first year, you don't really know what it's like to go back to square one, after your intern year.

Josh: Yes. The struggle was very real.

Gary: So, first year, I know was probably difficult just like everywhere. Walk me through the progression, through your training, and how that works at Tulane.

Josh: So, at Tulane, we're very fortunate to have a lot of surgical experience. And part of that is we travel. We go to three different VA hospitals, two of which are outside of New Orleans. So, I'm spending about 2-, 2.5-month blocks away from New Orleans my first year.

Gary: And that's not 20 minutes away from New Orleans, right? This is an hour to 2, 3.

Josh: Yeah. One of them is in Mississippi, and it's about an hour and a half. The other's in Alexandria, Louisiana, so it's about, almost 4 hours away.

Gary: So, that does bring into the whole work-life balance situation. I think if you're single, maybe it's easier, although I think we sometimes, we write off the experience of folks who are single, and, if you're married you think your life is harder automatically. But there is something to leaving home when someone's waiting for you. I've felt that stress myself, and how is that? How do you maintain that work-life balance?

Josh: It's been a real challenge. It's something that I try to be aware of, and again, it's another humbling experience. Because we're used to being smart. We want to be good at our craft. We want to be the experts at things. And you realize there's some things that you don't know how to do, and you're trying to figure out, how do I balance my career and becoming what I've always dreamed of, what I want to be, with the person I am every day, and the person who I've committed to, who I've chosen to spend my life with, and how do I find that out, on the fly?

Gary: Right, right. You're making real-time decisions, where you have a certain amount of resources, and you're trying to figure out how you give 100% of those resources to both things that you love. And it's just an impossible situation. So, I've met your wife, and she's fantastic. And my wife was extremely understanding that this was a season, and that there was going to be no real sense of balance during this season. If there was any balance, it was just that we were spinning together, and the thing that kept us afloat was our centripetal force, that just kept us like a gyroscope, from falling over. Because we were spinning together. So, I totally get that, and I understand that tension.

Tell me about, and this may be unfair question, so you don't have to answer this if you don't want to, but what was it like your first time, or maybe your first few times, doing cataract surgery? That's one of those sentinel moments for me. I'll never forget it. What was it like, man?

Josh: It was incredible. I remember, like you said, my first time watching cataract surgery. I was like, "Wow. This is amazing. That's what I want to do."

Gary: And it looks easy, right?

Josh: Yeah. Oh, it looks so easy.

Gary: Right. It is so underappreciated by the novice.

Josh: And then you get in, first time you're in the eye, and you're like, "Whoa. My hands are moving different ... this is not…" ... It's like a fish moving through water, almost. It's totally foreign. And your movements are…

Gary: are amplified.

Josh: Yes. Yes. So much so. And it was ... talk about a humbling experience.

Gary: Right. Another one. Right? Every new experience in ophthalmology is, I think, just starting back from square one, and realizing you know nothing. And that's hard on the ego, especially for people who've been pretty driven and motivated to outperform others. It is really hard to recalibrate yourself, at every new rotation, that, "Okay, I'm starting again from scratch." And just have to come to work with your hard hat on, and not worry about it.

So, I know right now you have decided to pursue a fellowship. And you're doing anterior segment, is that correct?

Josh: Mm-hmm.

Gary: When did you decide you wanted to do, first of all, so specialized, in some sort of anterior segment specialty? And walk me through that decision process.

Josh: So, Gary, I felt initially, even when I matched into ophthalmology, I just ... in my mind, I felt like I probably wanted to do a fellowship, because I wanted to be a good candidate, find a good job.

Gary: Differentiate yourself.

Josh: Exactly. And I've been fortunate that I've been exposed to some tremendous people in the field, and I've gotten really excited about things like refractive surgery, refractive cataract surgery, all the new incredible MIGS stuff going on. It was relatively easy for me to say, "That's what I want to do." And so, I've just set my sights on that, and trying to find a good match for a fellowship for me.

Gary: That's awesome. What have you learned throughout the fellowship match process? That is something I did not go through formally. I did a clinical fellowship outside the match, so it was more of a mentor fellowship. What have you learned on the interview trail, maybe that surprised you, or that was unexpected?

Josh: Well, one thing you see is there's a lot of really smart people out there. A lot of really excellent candidates. And that everybody, all these people at the top of their field, do things a little bit differently. There's some things that they all share, some similarities, but you can be successful doing things your own personal way, and you don't have to be a cookie-cutter. You can do your own thing and be yourself and still be incredibly successful.

Gary: Well, Josh, I just want to thank you so much for giving us a little bit of a glimpse. It is a refresher and a reminder for me, of those tough times. I will tell you, it gets better. Hang in there. You're gonna be a superstar. You're gonna be great. I wish you nothing but the best of luck in matching in a fellowship. You've got a lot of guys and girls who are looking forward to seeing you succeed. And if there's anything we can do for you, man, we want to be there. Not just for you, but honestly, hopefully this podcast, in some way, can be an impetus for mentorship, because I really deeply believe that no one makes it on their own. We don't ... we're not self-made. Every single one of us had somebody take a shot, take a chance on us. And I know that's happened time and time again in my life.

And so, actually, through the CEDARS/ASPENS group, we're actually trying to start a more formalized mentorship program. So, anyone out there listening who is maybe in their latter years of residency, fellowship, maybe in the first couple years of practice, stay tuned. There's gonna be more to talk about with the mentorship program. Because we really, deeply care about making this profession just a little bit better than we found it, because that happened to us. So, it's time to pass the baton.

Josh: And Gary, I wanted to thank you so much for having me, and echo what you're saying. You guys and women in the field have made me feel really welcome, and it's very humbling to have such people at the top of their field be so warm, and open, and guys like yourself and Jon Solomon, Greg Parkhurst. All these guys and lovely women, wonderful, smart women who've been so good and so accepting to someone, a resident.

Gary: Well, we are lucky to be surrounded by not only smart and talented people, but incredibly kind people. And that's a culture that we want to continue to foster. So, with that being said, Josh, thank you so much, and we want to check in on you as we follow your career, okay?

Josh: I would love that. Thanks so much for having me, Gary.

Gary: We can probably all remember how humbling those early days of training were and how uncertain the future felt at times. Let’s make a goal to take a page out of Dr. Oetting’s book and help our mentees become the captains of their own ships. Encouraging those in training to embrace their individuality will help them remain passionate and motivated as they forge ahead. From this, the entire field benefits.

With that, thanks so much to Dr. Oetting and Dr. Frenkel for their time today, and thank you all for listening. If there is a topic you want to hear more about, please be sure to leave a review with your suggestion. See you next time, on Off the Grid.

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