Ophthalmology off the Grid
Episode 52

An Interview With an Ophthalmology Podcaster

Host Gary Wörtz, MD, sits down with Jay Sridhar, MD, Associate Professor of Clinical Ophthalmology at Bascom Palmer Eye Institute and host of Straight From the Cutter's Mouth: A Retina Podcast. Dr. Sridhar talks about starting his own podcast and sheds light on his own journey into ophthalmology, his passion for working with residents, and what he thinks makes a good trainee.

Gary Wörtz, MD: In an effort to make more meaningful use of our spare time, we’re increasingly seeking out podcasts as a way to stay informed and be entertained.

Dr. Jay Sridhar was one who enjoyed listening to podcasts while on a run or during long commutes. However, he wanted to be able to spend that time listening to something related to ophthalmology, specially, his subspecialty of retina. When he couldn’t find what he was looking for, he decided to fill the podcasting gap on his own.

Jay, an associate professor of clinical ophthalmology at Bascom Palmer Eye Institute, is here today to talk about starting Straight From the Cutter’s Mouth: A Retina Podcast. He also talks to us about why he wanted to go into medicine, and what got him hooked on the idea of pursuing ophthalmology.

He also discusses his passion for working with residents, what qualities he values in trainees, and the importance of honesty in ophthalmology.

Coming up, on Off the Grid.

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

Gary: Welcome to Ophthalmology off the Grid. This is Dr. Gary Wörtz, and today I have the distinct pleasure of interviewing Jay Sridhar. Jay is a Miami native, and he has done his undergrad, med school, and residency in Miami at Bascom Palmer. Then, [he] did his fellowship at Wills Eye Hospital and is now back at Bascom, where he is an Associate Professor of Clinical Ophthalmology. Jay also is a podcaster extraordinaire, and if you'd like to listen to some of his great content, you can find that at Straight From the Cutter's Mouth: A Retina Podcast, where they have actually over 100 episodes. So, a lot of good content there.

With that preamble, Jay, I just want to say thank you so much for being willing to come on my podcast, where we get to flip the microphone around, and I get to interview you a little bit today. Thank you so much.

Jay Sridhar, MD: No, Gary, thank you for having me. I'll just start again by thanking you. You were kind of the trailblazer that set the way for the rest of us who are now doing ophthalmology-related podcasts. It was really your model and your success and what you brought to the table from an educational standpoint that inspired a lot of us, so thank you.

Gary: Well, you know, it's really funny. I guess, maybe now we kind of know what we're doing, but we really, I think, we all just stumbled into podcasting. At least that's how it happened with me. I saw this as an avenue for maybe some real-time content to get out to folks. How did you get into podcasting? Maybe just start there. How did you get into this medium, and why have you enjoyed it? What has it brought to you professionally?

Jay: I think, like a lot of us, I started as a consumer, and I was probably late to the podcast revolution as a listener. I was listening to things off of my desktop. It started as business or sports things and radio shows. About a year into fellowship, I was starting to run more religiously. Some people listen to music when they run; that's probably more typical. I would listen to podcasts to try to give the time more meaning for me. That's when I started listening to podcasts. That's probably 2014, 2015—that's late to the show.

Like you said, you kind of stumble into this. [I] never really planned on doing my own podcast. It was actually when I was planning on my job. My job was initially going to involve a lot of commuting. The way it was set up personally, it was me driving close to 120 miles roundtrip twice a week to one of our satellites, and I was just like, "Man, I cannot listen to the radio for that time. I can listen to these great podcasts, but I don't really have anything ophthalmology-related.” I had your podcast, which was a great resource, but I really was looking for something that more related my subspecialty of retina. In the process of looking, I discovered there really was a need there and an emptiness. I spoke to a couple of my mentors, asking what they did. They were just like, "Why don't you pursue this on your own? Why isn't this something you should do on your own?"

I thought about it, and then I started my job. I was busy. I didn't do it. Then again, I was speaking at Academy with one of my friends, Will Park, and he again brought it up. He was saying he drives an hour to one of his satellites once a week and how a lot of people in our field—retina's a very commuting-heavy specialty, and I don't know if that's different than comprehensive ophthalmology or cataract surgery, but for us, we commute a ton because we drive to where our patients are to give them their medical retina therapy, such as injections. He again brought up the idea of doing it on my own. I said I didn't really have the resources or the knowledge. He said, "Well, I'm sure you could figure it out," and we did the research and we started in November 2016. So, it's been about a year and a half.

Gary: Well, it's really impressive, the amount of content you've been able to create in that amount of time. What's interesting about that, as a cataract surgeon, for the first 6 years or so, I commuted very heavily. I sort of had the same experience, where I was on the road a lot, at least an hour each way, and found myself getting pretty bored with either listening to the radio or just the standard music, etc. Like you said, with your runs, I wanted to make more use of that time. I wanted to, in some way, invest in myself during that time, whether that was books on tape or other things. That's when I found podcasting. My first podcast that really got me hooked was Serial. Have you listened to Serial? Did you ever listen to that one?

Jay: No. What is it about?

Gary: Serial is not ophthalmology-related, so if you're strictly interested in medical content, it's not for you. But, it got me hooked. It's one of these [shows] where every week, they unpack this long-form storytelling, and it was about a crime that was allegedly committed and a lot of the controversy surrounding that. There was a second season. It was actually about Bowe Bergdahl, the army deserter. There's been two seasons, but that really is what got me hooked into this media.

The other thing was, simultaneously, I had a friend who was an ER physician who had his own podcast, who actually invited me to come onto his podcast and explain a little bit about some pearls for ophthalmology in the ER. Those things happening almost simultaneously, I thought, "You know, maybe there's room for a podcast in ophthalmology." I guess the rest is history. Now we've got a lot of different podcasts in our field, and I think that's just fantastic.

It's interesting, when we have good ideas, I think everyone's natural inclination is to try to convince someone else to do that.

Jay: Right, right.

Gary: A lot of times, you present the good idea, and people say, "Well, go for it. You should do that." Then you're stuck with this go, no-go decision on whether you're going to pursue your own idea, and I just want to applaud you for being willing to be the author, be the creator, and actually put yourself out there a little bit. That's my history that's a little bit shared with yours.

Jay Yeah. Again, I think a very valuable piece of advice one of my friends gave me, I self-produced the first couple of episodes, and he was like, "Look, as you get busier clinically, if this is something you’ll want to consistently make, you need to recruit people to help you." That's when I reached out through the medical school, University of Miami. We started with Louie Cai, and he was a third-year medical student at the time, who had a background and interest in audio engineering. It was something he did for fun, and he was also going into ophthalmology. Now, we have a team of three medical students, Louie, Mike, and Angela Chang. Those guys are invaluable. It's invaluable to have some support in doing this. Because, at some point, it's just not feasible, especially [in] ophthalmology; it's not like we're neurosurgeons, where we're in the OR for 10 hours at a time. We do have sometimes unpredictable schedules and call, and that can affect how consistently we can produce the content.

One of the things we really strived to do from the beginning was to be consistent—to try to create a consistent workflow that, at least once a week, there would be an episode, which is ambitious, but doable with all the support we have from everyone in the team pitching in.

Gary: Yeah, that's hard to do when you're a one-man show. I may need to take your advice on that and recruit some other co-contributors because it's a lot to try and keep a show interesting and fresh.

I want to get into your background a little bit. This is sort of a standard question, but I want to hear your history. How did you decide to become a doctor? Was medicine something that you grew up knowing you wanted to do? Was it something you came to later in your academic career? When did you decide that being a physician was going to be the right decision for you?

Jay: It's funny, the cliché is your second-generation Asian immigrant with two physician parents, as I was. I'm one of five, my oldest sister was going to medical school, people assume that this is something that your parents push you into, or you always have an idea you wanted to be a physician. To be completely honest, neither of those is true. My parents didn't really push me to do anything in particular. My dad passed away when I was young. My mom had her hands full raising five kids. In terms of me, what I wanted to do, I didn't really think about becoming a physician until late in high school. It was something I thought about, but really it was in college that I made that final decision. Again, it was born out of a lot of things that drove a lot of us to medicine. It was desire to be in the field where we can make a tangible difference in people's lives and give back and help, while combining that with our own passions for science, medicine, engineering, whatever our passions may be.

As far as ophthalmology, ophthalmology was a late decision for me. I think most medical students will decide before I did. I decided toward the end of my third year, which puts you in a little bit of a time crunch when you're applying. But, I had signed up for an elective, again, kind of fishing, not knowing what I wanted to do, and I did that elective [in] February of my third year, and within a week, I was hooked.

It's funny you brought up, "Why not cataract surgery?” You're a cataract surgeon, I’m a retinal surgeon. It was really cataract surgery that hooked me, just watching cataract surgery, watching them. I was in the OR watching the residents do cataract surgery at the VA, and I thought it was exceptional. I just thought seeing them postop day 1, postop week 1, you can see that impact you have. And the objectivity, nothing in ophthalmology is completely objective. It was really the objectivity of a lot of things versus the nebulousness of a lot of other areas of medicine that really attracted me.

That was my ophthalmology origin story. The people who inspired me, again, were the residents at that time. Will Park, Ryan Eisen, Kara Cavuoto, who were, at that time, first-year residents I had worked with in the clinic who really took me under their wing. Then the attendings I worked with, Carol Karp, Byron Lam, and Tom Johnson, who, ironically enough, none of them are retinal surgeons. Carol Karp is a corneal surgeon; Byron Lam, a neuro-ophthalmologist; and Tom Johnson, an oculoplastic surgeon. Those were really my primary mentors as a medical student who inspired me.

Gary: Yeah, cataract surgery is the gateway drug. Don't you think? For ophthalmology.

Jay: Yeah. If you don't like cataract surgery, you don't end up going into ophthalmology, I think. That's a reasonable thing to say.

Gary: You're right. There's something really beautiful about the objective nature of cataract surgery, where you can see it, and it's not a question of whether someone has a cataract or not, and really, day 1, you see the result. For me, I loved sports growing up. I was an avid baseball player. I played basketball, I played soccer, but baseball was really my sport. What I liked about baseball was keeping track of my batting average, keeping track of my on-base percentage, keeping track of errors, all those things.

I find that cataract surgery, and maybe this is a weird thing that only I think of, but I think cataract surgery, if that's what you do primarily, it's the closest thing to sports we have in medicine where you are a performance-driven practitioner. You know really quickly whether you hit a homerun or a strikeout, whereas a lot of other surgeries, you really have to wait weeks or months to know how you did. Personally, I like that immediate gratification of knowing, "Did I do a good job, or did I not?"

Jay: Yeah, that's interesting. I think that the other thing that's interesting is, for example, I think one of the failings of retina, at least through the traditional imaging system, I remember watching one retinal surgery as a medical student and I had no idea what was going on. I thought cataract surgery was so beautiful, also as a medical student, because you can watch on the screen and you can see every step as they're describing it. Dr. Karp would push me and say, "Okay, this next one, I want you to tell me all the steps. Tell me paracentesis, the viscoelastic, and the main wound," etc. You can see and visualize all that.

Not only in retina, but in other fields, general surgery for example, as a medical student, especially if you're assisting, you can't quite see everything that's going on. That tangible, immediate gratification from putting a lens in a bag, and then also just being able to see what's going on and being able to recognize, "Hey, I can identify the steps that the surgeons are doing." There is a very linear kind of algorithm where we get from point A to point B, and we know at point B, like you said, where we are.

Gary: I totally agree with that. Switching gears just a little bit, I know that you're in academics. You're at Bascom Palmer. How often are you involved with the residents there? Is that something that you are doing rather frequently? Is that an occasional interaction? How involved are you with the residents there?

Jay: That's one of the primary reasons I wanted to come back. As a fellow at Wills, I worked a lot with the residents; it's one of my passions. Coming back, I actually work with them once a week. I staff the residents' retina laser clinic. This is a clinic that sees a lot of indigent patients or uninsured patients, who have severe, but mostly almost all, severe diabetic retinopathy. Many, unfortunately, were so advanced they presented with neovascular glaucoma and tractional retinal detachments—really, really bad pathology. And it's this mutually beneficial situation, where the residents, I get the experience of teaching them how to laser, teaching them the nuances of how to take care of these patients, and the patients get excellent care. The residents really, really do an exceptional job at taking care of them.

I get that once-a-week exposure. I'll staff their cataracts from time to time, which I have to say, that is one of the most challenging things I've ever experienced is staffing cataract surgery. God bless the people who staffed us when we were in training. But, very, very interesting to staff someone, because cataract surgery, again, is different than retinal surgery, like we said. There's a point A and a point B, and you want to get linearly from point A to point B without a lot of detours. Whereas retina's like a maze, where there are four different ways to take you to the same result.

I love working with them. They're really wonderful people and very, very impressive. I recently joined the residency selection committee, too. That's always humbling just to see the great people who go into ophthalmology. Ophthalmology has never been more popular, I think. I think the reasons are the same reasons that drove us into it, which are this rapidly evolving technology on top of the objectivity and tangible satisfaction that we talked about.

Gary: Yeah. You actually brought up a number of things I want to dive into a little bit. The first one, I'm going to 100% agree, staffing cataract surgery is infinitely harder than performing cataract surgery or learning cataract surgery. The only thing I can compare it to is, I'm teaching my daughter how to drive.

Jay: How to drive, yes. I was going to say the same thing.

Gary: She's doing great, but I'm not. I don't think I'm a great teacher, and that is something I've had to wrestle with because I'm constantly on edge. I'm really not a great attending in that regard. I tried it for a couple of years just as a volunteer faculty. Actually, I'm back on faculty at University of Kentucky, doing some lectures and having residents come over and observe, but it takes a special human being to be able to guide a resident through a cataract surgery. I just want to thank Seema Capoor and Doug Katz and all the attendings at UK who helped me, and guided me, and trained me. It really is unbelievably difficult.

Residents don't really appreciate that. If you're a resident listening to this, thank your attending the next time they're willing to sit in the chair next to you. Just thank them because it's a lot harder than you would believe.

The other thing I'd like to ask is, as a former resident, we both are former residents obviously, and now as an attending, and now as someone on the selection committee, what do you think makes for a good resident? Is there something that you look for or a characteristic that you've seen in residents that you've worked with that makes them a particular delight to work with or particularly effective in their trajectory as they try and get over these steep learning curves?

Jay: Yeah. I'm glad you didn't ask me what I think makes a good resident based on their application because I think that's extremely difficult.

Gary: Right.

Jay: That's a question we're actually looking into right now. We're going to try to do some research into that factor. If I find good residents, at least in my experience, and I'd be open to your opinions as well, I think the best residents [are] really self-motivated and they really care about delivering good care to their patients. Natural ability, what accolades, in terms of their background, pedigree, all those things really go out the window. The question is, when you have a patient in front you, and you're a resident and you’re trying to still build your knowledge base and your skill set, even when things don't go well. Let's say you're a resident and you operate, and you have a complication, what is your approach? Are you someone who does do the utmost to try to get your patient the best outcomes? Do you spend more time with your patients when they don't have the best outcomes? Do you seek out answers? Do you read on your own? Do you go to attendings? Do you go to mentors for advice?

The best residents are the ones who are willing to work hard … and it’s not always in their best interest, but it's in the best interest of their patients and often their co-residents in terms of forming a better team atmosphere in a residency.

Every residency is different. We have a large residency with seven residents a year. Teamwork is super important. Our best residents are the residents who are willing to help others and put their patients first.

Gary: You hit the nail on the head. One thing I would say is honesty, when it hurts. I think that is a key factor that we don't talk a lot about because, I think, we just assume that everyone is honest if you're a doctor and you've taken the Hippocratic Oath. Not to suggest that we are dishonest as a profession; I think we're incredibly honest, but there is a certain characteristic of humility and willingness to take the blame when it's appropriate and willingness to fall on the sword for the patient or for their co-resident and not be sneaky, not trying to shuffle paperwork around to make things look better than it really was.

I would much rather have a resident come to me and say, "I blew it. I made a mistake. I was thinking this was the right path, then decided to go this way. It turns out that that was wrong, wrong diagnosis or a surgical error," etc. It's so much better and refreshing when someone comes to you humbly and is willing to talk about their mistakes or areas that they need to improve upon—that's when you can really invest in someone. That's when you can really help them bridge that gap. It's the residents who try to potentially show no sign of weakness and cover up signs of weakness that you, perhaps, worry about because you don't know how they're going to do on their own.

Jay Right, that connects to staffing in the OR because, unlike driving, where you can install a brake pedal on the passenger side, you don't have that option in surgery, except you expect the resident or fellow (in my case, I staff fellows a lot as well) to press that brake pedal when you tell them to. Having someone who's willing to listen but also willing to ask for help when they need it, and willing to take that responsibility to say, "I'm not comfortable right now," or, “I can't see exactly what you're showing me. I don't want to do this because I think it's unsafe.”

Gary: Right.

Jay: Those are the residents or fellows I respect the most. Dishonesty sounds like a really bad thing, but I think we could all be susceptible to it in the right circumstance. Something even as simple as being honest with your patient if something didn't go the way you expect it. They always talk about, for example, malpractice or OMIC-type claims, that one of the biggest problems people have is not necessarily that the doctor was not nice or that the complication was worse than other complications. It was that the physician didn't communicate. That's where I talk about honesty where it hurts. It's really difficult to confront a patient where you've had a complication and have those honest conversations and see that patient and have those conversations.

Even the best of us can feel the urge not to have these conversations or not to be completely bluntly honest. Being bluntly honest and being kind at the same time is something that's critical in retina, for example, because unlike cataract surgery, you put a lens in the bag, you get an idea of how the patient's going to do. I can repair a detached retina, and I tell our fellows this all the time, but I need to be honest with the patient beforehand depending on how long it's been detached or the status of the macula. We don't necessarily know how their vision's going to be. Telling patients that honestly from the beginning is super important to set expectations.

Gary: I 100% agree with you. For some reason, I don't think there's been an overt focus on teaching that to residents or expecting that. I think that may be a little bit of a cultural shift that is really important because if you learn how to be honest when it hurts when you're a resident, I think you're going to be a much better doctor when you are out on your own.

Jay: Right. I think that, going back to your conversation about the best residents, that the final thing again, it's not necessarily how much you read or how much you know, but the best residents, they read for the right reasons. They know stuff for the right reasons. It's not necessarily about ego, but it's about, like you said, "I made a mistake. How can I learn to get better?" One of my attendings in fellowship used to say that complications are part of doing surgery, but if you have complications of the same nature over and over again, then you're not doing your work as the physician. You're going to have times when things don't go according to plan, but that's when you take a step back and you try to figure out what went wrong, what could you differently to avoid it. If you're not doing that as a resident, you're not going to do that when you go out as an attending.

Gary: That's right. That's exactly right. I want to switch gears a little bit and talk about your perspective on the field of retina. Where do you feel like there are the biggest unmet needs in retina? Or you can answer a different way and say, what technology on the horizon most excites you and has the potential to be transformative or disruptive in a good way to your field?

Jay: Retina's in a really exciting time, like much of medicine and ophthalmology. But, I think the biggest things, if you're just talking about overall burden, is from a medical retina standpoint, how we handle patients with macular degeneration, diabetic retinopathy going forward in the future. Anti-VEGF was one of the biggest breakthroughs in medicine when the publication originally came out in the New England Journal of Medicine, the MARINA results back in 2006, I believe. One of the most efficacious drugs ever to be reported in a phase 3 study, and it's dramatically changed that we've had patients who for years were going blind, and now we have therapy that could reverse that. But there's now being developed (A) not every patient responds to these drugs, and (B) these medications don't last as long as we'd like. Patients are now dependent, in a sense, on coming to the doctor to maintain their vision.

We also have dry macular degeneration, which is not addressed by any of those therapies and is becoming a larger cause of blindness because, as we've seen in many studies, many patients with wet AMD that's arrested with anti-VEGF end up developing geographic atrophy. I think, from a medical retina standpoint, dry macular degeneration is really going to be critical in terms of what therapies we have to not only arrest it, but could we reverse it potentially? There are stem cell trials, for example, looking into stem cells for geographic atrophy from dry macular degeneration.

Then diabetic retinopathy is not just a national problem, it's an international problem. As diabetes grows worldwide, blindness related to diabetic retinopathy is critical in terms of what it does to our workforce because the patients who get diabetic retinopathy are much younger than AMD patients. The patients who get diabetic retinopathy, again, can have irreversible damage. Longer-term agents will help with wet macular degeneration, they may help with diabetic retinopathy, but that's where telemedicine and screening and identifying these patients at risk not only in the US, but internationally abroad, in rural areas, that's really where a lot of the breakthroughs are happening.

From a surgical perspective, it's never been better to be a retinal surgeon, probably like it's never been better to be an anterior segment surgeon. The technologies that are available are amazing. I think the things that will be exciting, 3D and heads-up visualization have many, many potential benefits, and among them will be integrated intraoperative OCTs so we really get a 3D view of the retina as we work on it. Understanding the dynamics of the vitreous gel, which for years has been better visualized with stains but still is not extremely well visualized in the clinic, and while better visualized, not awesomely visualized in the OR.

Then, how can we improve our outcomes? One of the things that really interests me is retinal detachments, for example. We can do everything right, and the two primary goals of retinal detachment are to fix the retinal detachment but also to get the maximum vision from a patient who's been losing vision. Then macula-involving cases, like I said, can be very unpredictable. Are there things we can do that (A) reduce completely the risk of PVR and scar tissue and things that cause recurrent detachments, and (B) if we can do everything right and take the patient to the OR who presents with macula-involving detachment, what can we do to restore the integrity of the outer retina and give this patient vision? Because, again, the joke about retina’s "anatomic success" is that we say the patient's attached, or the patient is attached but the patient is not necessarily happy because they don't have the vision that they'd like. Sometimes their vision is not very good despite everything we do. If we can figure out a way to pharmacologically, or some other measure during surgery or after surgery to ameliorate that, that will go a long way toward improving outcomes in our field.

Gary: Well, Jay, this has been a fantastic conversation. It's been wonderful to hear a little bit more of your story. I know the residents are getting a great experience out at Bascom Palmer, partially because you're there, along with some other friends down there like Jorge Fortun and Kendall Donaldson, friends of mine.

Jay, I thank you so much for coming on the podcast. We look forward to hearing more from you down the road, and if you ever have any other contributions you'd like to make, you're always welcome to come back, and you're always welcome as a repeat guest on here. Jay, thank you so much. Why don't you give us a little bit of a shout-out, so that if people want to hear more from you and your podcast, how do they find that?

Jay: It's super easy. If you type into any web address bar on your phone or your computer, retinapodcast.com, R-E-T-I-N-A podcast.com. Also, if you go to the Apple podcast app, or if you have an Android, you look in the Android podcast store. Just search for retina podcast; it'll be the first hit, and you can subscribe and listen to episodes there or on the website.

Gary: Wonderful. Jay, thank you so much. Appreciate you coming on. This has been Ophthalmology off the Grid with Dr. Gary Wörtz. Thank you so much. Goodbye.

Gary: The ability to spot a need in your profession is one thing; deciding to meet that need on your own is another. That’s the challenge Jay took on when he decided to start his retina podcast. Thanks to his willingness to take the leap into podcasting, there’s another valuable resource out there for ophthalmologists.

It’s an exciting time for retina, and we thank Jay for offering his wisdom and perspective on the field’s future, and for telling his own story.

This has been Ophthalmology off the Grid. Thanks for listening.

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

8/13/2018 | 29:17

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