Ophthalmology off the Grid
Episode 64

Visual Learning

Host Gary Wörtz, MD, sits down with Uday Devgan, MD, to discuss his dedication to teaching others through surgical videos, methods for navigating surgical complications, and the importance of recording and sharing all cases-from basic to complex.

Speaker 1: Welcome to another episode of Ophthalmology off the Grid.

Today, our host Dr. Gary Wörtz sits down with Dr. Uday Devgan, a cataract surgeon in private practice at Devgan Eye Surgery in Los Angeles, as well as a clinical professor of ophthalmology at the Jules Stein Eye Institute and chief of ophthalmology at Olive View-UCLA Medical Center.

Listen as Dr. Devgan talks about dividing his time between his surgery center and a public hospital and the sacrifices and rewards that go along with balancing these two very different positions.

Dr. Devgan also discusses his passion project, cataractcoach.com; the importance of teaching residents to cope with stress; and the benefits of recording and sharing surgical cases.

Coming up, on Off the Grid.

Gary Wörtz, MD: Welcome to another episode of Ophthalmology off the Grid. This is Dr. Gary Wörtz, and I am so pleased to have Uday Devgan, MD join us tonight. Uday is in private practice at his own facility at Devgan Eye Surgery in LA, near Beverly Hills. He's also a clinical professor of ophthalmology at Jules Stein Eye Institute at UCLA School of Medicine, as well as chief of ophthalmology at Olive View, also at UCLA Medical Center. It's a mouthful, Uday, but thank you so much for taking time out of your busy schedule doing all the things you do to carve out some time with me tonight.

Uday Devgan, MD: Yeah. I think the neat part about all my crazy titles there is that I'm lucky enough to spend half my week with my private practice and half the week with my residents. They couldn't be more different. My private practice is in a fancy part of town, the surgery center is in Beverly Hills, but the patient population is kind of demanding and maybe not quite as appreciative or sweet as our county hospital.

With my residents, which are the UCLA residents, we're at a big Los Angeles County public hospital. These are the sweetest patients ever, but they also have the most severe disease. Ruptured lobes are routine for us, Ahmed valves for neovascular glaucoma. Residents literally each do thousands of diabetic lasers and individual injections. It's a tough population in terms of disease, but what a sweet population. I love to be able to work with my residents to teach them. As you know, to be involved in the early part of someone's career is just magical.

Gary: So, that's really interesting. There may be other guys out there, or gals out there, like you who have done this, but I don't know too many KOLs who are literally half and half. Half of the world is the normal private practice, running a surgery center, dealing with all the private practice stuff, and the other time—you really have two full-time jobs, and they couldn't be more different. How did you decide to do that? Because, most people will pick one or the other, and it's sort of like you said, "I'm going to have my cake and eat it too." Tell me a little bit about the genesis of that.

Uday: Well, like we all know, when you get into a practice, your practice evolves over time. I didn't start off doing so much time with the residents. I started off doing one half day per week. Then, it grew to one day per week, then it was a couple of half days here and there. I just kept adding more and more, and I just really, really enjoyed it. I found that it really helped balance out my week. I became very lucky that I could have an involvement in both.

It does require some sacrifices in my private practice. My practice is now only surgical. The only new patients I'm seeing are new patient consults who are going to have either cataract or refractive surgery. Then post-ops, I'll see you for a limited basis, but then it's kind of catch and release. Once your bilateral pseudophakia, you got to go.

Gary: Right. Are you basically sending those back to the referring doctor at that point? Is that kind of the idea?

Uday: Yeah, I will spread them out. A lot of them have existing doctors. I'm not a big co-managing doctor, so I don't have that kind of business-type network. Mine's mostly just word of mouth, actually. So, after I see a patient and their surgeries are done, if they need follow-up for any other issues, I'd just send them off to, let's say if you're a diabetic, I'll send you to a retina doctor to see once per year. If you have glaucoma, you can go see the glaucoma doc and do that follow up. I'll send you out. I probably send out more patients than I get referrals.

Gary: Interesting. That's really interesting.

So, you have a project that I want to talk about. It's called Cataract Coach, CataractCoach.com, correct?

Uday: That's right.

Gary: This is something that I think I was a little bit late to the party on. Maybe you had posted a hundred videos or something. I watched one of your videos, and I just thought to myself, "This really is a total paradigm shift, in terms of how education can happen nowadays." I was blown away, not only by the fact that it was only a few minutes long, but the amount of content, the little pearl that was hidden, not hidden but really on full display, in that little clip. How did you decide to do this, and just give me a little bit of the background on the genesis of this idea, because I think it's just really interesting. It's definitely the new wave.

Uday: I think really, it's a passion for me. It's a heck of a project. It takes a ton of my time, but I just love it. I first have to give credit where it's due, and that's got to go to Bobby Osher, MD. Decades ago, he started the Video Journal of Cataract, Refractive, and Glaucoma Surgery. I remember when I finished my residency, and it was a long time ago, it was the year 2000. Twenty years ago, I was hunting around for VHS tapes—something that my kids don't understand— of his video journals so that I could play it and watch it and learn from it, and God, I just soaked it up. I know that for ophthalmology, Osher's right. You learn by watching; videos are very powerful. It's the best way to learn a surgical technique, especially in the eye. We're naturally suited to that because our procedures are brief, and that it's through a microscope, so it's very easy to record them, especially now when there's HD video.

Gary: Right.

Uday: So, I definitely like learning that way. You see at all our meetings, everyone posts videos. Then, I learn of something else too, though. I wanted to post a pearl of a video, and I had an original YouTube channel more than a decade ago, which garnered almost a million views.

Gary: Wow.

Uday: Yeah, but it was the older stuff, non-HD. I'd kind of post on it sporadically. That's back when posting videos was novel.

Now, I need to make a commitment, though. If we're going to do this, I need to be able to teach my residents to have a concrete topic. The key is, I need content on a daily basis. If I go to any other news website: LA Times, New York Times, The Atlantic, any online place that has good media, if there's not new content, I'm going to be bored. I don't want to read the same articles every time. So, I decided I have to publish on a routine basis. First, I thought once a week would be good, but then I said, "You know what? Let me just suck it up, man up here. Let's just do one every single day. Saturday, Sunday included. Holidays too." I was evacuated from my house for 5 days because of the wildfires here in Los Angeles. I did not miss a day.

Gary: That's just kind of crazy to me. Podcasting, for me, is also a passion. I love talking to people because, for me, this is really how I learn. I think I'm a verbal or auditory learner. I love talking about things. I'm also a visual learner, but I really love talking to people. But, doing a couple shows a month, it can be hard to keep it fresh. It can be hard to find some new angle on a topic. Doing something every day, how are you able to look at cataract surgery and keep it fresh in terms of...all right, this would be an interesting topic, because I think as you get into cataract surgery, sometimes you forget what it was like not to know, and then you don't realize what would be novel to someone who's maybe at a different phase of their training. Is it something that the residents, as you're teaching them, you say, "Okay, this is something that they need to know." Do they help with that?

Uday: Absolutely. The cases are a mix. Some are very basic. There are some that are resident cases, a lot of complications there as you know, early in the learning curve. A lot of them are my own patients and my own complications. One of the very first videos I ever showed on this site, on CataractCoach.com, was me dropping an entire nucleus onto the macula. I hadn't done that in thousands of cases. A case of prior trauma that I didn't know about, beautiful rhexis, I go there to chop it and boom, the whole thing's on the macula. Took a breath or two, cleaned it up, sent it to my vitreo-retinal colleague, and the patient came back, of course, thrilled to say, "You know, I see great. And guess what? I have zero floaters now."

Gary: Right. Glass half full.

Uday: It all works out. Yeah, so I think it's important to learn from that. We have the full spectrum. If you're an advanced surgeon, I got great advanced crazy cases for you. If you're a beginning surgeon, I have very basic stuff. The last couple of months, every Wednesday, I've posted a video about the basics of fluidics and power modulations. I don't want you to use someone else's settings, I want you to use your own judgment and make your own settings. I go through that step by step, 5 minutes at a time. It's a neat resource.

Gary: I want to talk to you a little bit about phaco settings, because this is something that, when I was maybe getting in and just out of training, it seemed like phaco settings were everywhere. You couldn't go to a lecture without hearing about phaco settings. Everyone was talking about their phaco settings, chop settings, divide and conquer, stop-and-chop, all these things, and it seems like over the past few years, we just don't hear as much about phaco settings. Have you noticed that also?

Uday: Yeah, I think it was also part of the timing. A decade ago or a dozen years ago, the machines were just coming out with the idea of burst mode and a pulse mode and different kind of power modulations. It was new, and so the companies were certainly happy to sponsor more of these things to get that message out. Over the last decade, you're right, that has kind of fallen by the wayside, and there are, unfortunately, too many ophthalmologists now who aren't as comfortable choosing their own settings or changing them on the fly.

Gary: Right. It's sort of like set it and forget it, and just drive the car in automatic.

Uday: Right. Actually, that’s the same analogy I use. When you drive the car, please, the first thing you ought to do is adjust the seat, the mirrors, the steering wheel, maybe even the radio and the air conditioning too. Then let's start driving.

Gary: Right.

Uday: To me, that's the phaco settings. Then yes, you change the settings as the driving, as the terrain, requires, or in surgery, as the clinical situation requires.

Gary: I want to hit some of the modules that you feel are most useful, some that are either the top viewed or ones you feel like are most beneficial. Let's say someone hears this podcast and they say, "You know, I'm going to check out CataractCoach.com." There is, I think you said, there's over 400 videos on this site?

Uday: Yeah.

Gary: …Which is actually just unbelievable, it's kind of insane. Where would you say is a good place to start?

Uday: I'm in the process now of organizing the whole thing into book chapters. Right now, you have to kind of search for the videos that you want, kind of like blogs. There may not necessarily be an order to them. They may come out in different orders than you anticipate. I think the key thing is to learn that I have a few basic categories. One is for beginners, basic stuff, and that's very clearly delineated. That's choosing your settings, how to learn various techniques of chop, or divide and conquer, stop-and-chop. Then, I've got ones of interesting or unusual cases. We have probably ten posterior polar videos of all different types, including guest surgery. We do feature guest surgeons. I'm going to have to pester you later for a nice video.

Gary: I will do that. Yes, no problem.

Uday: Another challenge was white cataracts. As we talk, in the background on my computer, I have a video editing software rendering a video of a run-out white capsulorhexis in a resident case. Runs all the way to the zonules. Well, “how do I recover it?” We'll go over that. I have on this site, gosh, at least 20 white cataract videos of all types: femto, double rhexis, run-out rhexis, everything is there. I think the last thing that we have that is very important is complications. I'm not afraid to show you any complication. We have a lot of anonymous submissions which are really good. We try to feature one video per week of a complication. The one we had yesterday was a new surgeon whose IOL, believe it or not, got stuck in the incision. He couldn't get it out.

Gary: Yeah, I'm looking at this on the site right now. I've actually had this happen.

Uday: Right. So, imagine this. You're a younger doc, in training, or just a couple years out, and you just, one day with your morning coffee before work, you look at this video and you see this. Now, 6 months from now when it happens in the OR, you know how to deal with it. You've seen that video. Basic stuff is one aspect, the other one is unusual cases: posterior polar, white cataracts, bad zonules, pseudoex, small pupil. Then, the last one is complications. Whether it's capsule rupture, we have plenty of those, run-out rhexis, iris damage, we got the works.

Gary: I want to talk to you a little bit about...because of your unique position as an educator and someone who has been in private practice, doing it the right way for a long time, I sort of have this idea in mind, and I want to know what you feel about this, if you would agree or disagree. Do you feel like there are certain milestones in learning cataract surgery, and whether that's a certain number of cases or a certain number of complications or a certain number or breadth of both easy and hard cases? I feel like there's certain milestones in cataract surgery. Have you found that in your training of residents, seeing them sort of progress from their first five to their first 30 to their first 100 and then beyond that. When you see people operating, it sort of seems like there are certain milestones. I think it's probably good to explain that to residents, so they don't expect their very first cataract to be this absolute masterpiece.

Uday: I think you're 100% right. We've actually had a post about this. I also have some articles on there that are more philosophical. One is about finding your state of flow, where the pleasure of the surgery is just unfolding naturally and happening so fluidically. The other one I posted about is, yeah, what is the learning curve? Now, you and I are probably around the same level, 20,000 cases later, you can look back and say, "Yup, there's quite a difference." My residents are lucky. They finish residency with about 300 cases. The danger is thinking that 300 cases gets you most the way up the learning curve, when in reality, it's probably no more than halfway up the curve. I break it up into 200 cases versus 2,000 versus 20,000. I'd say 200 cases, at best, 50% up the learning curve, 2,000 cases is probably more like 80-90% up the learning curve, and then, diminishing returns, I think 20,000 cases, maybe now you're 99% up the learning curve, and I think we’ll never quite reach that perfect plateau of 100%.

Gary: That's what I tell patients, too. They say, "Is this all the same, all day long?" Or, other people who've never seen cataract surgery, if they're in watching. I say, "You know, in some ways yes, and in some ways no." I had a new rep come in last week, or a week or two ago, and he had never seen cataract surgery, new to the field. That's what his question was. He said, "It seems like this is a lot of the repetition."

I said, "Well, it's kind of like golf. You can play the same course every week, and you'll never play the same hole the exact same way. So, you sort of have to have all the different clubs in your bag, you have to know how to use them and in what situation to use them and maybe how to use them in an alternative way, depending on where the ball is lying. So, I feel like that with, after 200 or 300 cases, you know how to use your driver, you know how to use your seven iron, you can chip, and you can putt. There's a lot of clubs in between there that, I think at 2,000 and 20,000, you really start knowing how to use all your clubs, and then at 20,000, you're actually able to use them in unique ways, and you're able to be more efficient around the course. That's sort of my analogy for cataract surgery.

Uday: I love it, though I don't play golf.

Gary: And I don't either.

Uday: But I love the analogy.

Gary: I posted this video on Twitter. My Twitter handle is @cataractMD, if anyone is super bored and wants to follow. There was this video of, it said expectations versus reality, and there was this guy going up the ski jump. He does like two flips, like three twists, lands on the moguls, and is just like a stud. Then, the next video is a guy who goes off this sort of simple little jump, and his skis fall off, and he spins in the air and just yard-sales everywhere. I said, "This is how I expected my first case to go versus how it really happened."

I was actually really lucky. My first two cases I did as a resident, I think it was around August 6 of my first year of PGY2, so, very, very early on. My third case, I dropped the nucleus. I still contend that it might have been the attending who did it. He said it was me. He was in the eye when it happened. It's still a controversy. I'm going to take credit, because he's a really good surgeon. I was definitely a novice.

But, part of coaching is not just telling people what to do and what not to do and giving tips. How do you get your residents through those times when it's not about necessarily their technique, because that will come, but it's really more about their mental state and how they're able to handle themselves in the face of stress, a potential complication, or actually an adverse outcome or a bad complication?

Uday: I think you're right. I think the key there is equanimity under duress. When you're stressed out, things aren't going your way, take a breath, stay cool, and think calmly. Another thing you have to learn, too, is, a natural human instinct we have to fight is, we need to not have denial. When we're doing a case and we see some complication there happening, we have to say, "Yes. That's a complication. I'm going to have to deal with it."

Gary: When I was a chief resident at Kentucky, I said, "Positive thinking has no bearing on the actual presence of vitreous."

Uday: I like that.

Gary: Right. Thinking positively in cataract surgery is fine, but it's not going to actually determine whether or not you've broken the bag.

Uday: Yeah. I think, too, that everyone should be aware that you do have the ability to get better and better every case. It's up to you as a resident, and then in practice, to make a concerted effort to learn from every case that you're doing. You're like me. I like to record. Twenty-thousand cases and I still record every surgery I do. I may not save the video, but I try to record them so that I can go back and say, "You know, that was an interesting case. Let me learn from that. How did I do that?” I want to watch the game day footage.

Gary: The other thing is, I think for some people who are maybe out by themselves, or they don't have an expert surgeon mentor that they can count on, recording cases is a great way, not only like you said to review it yourself, but to send a fellow surgeon a video and say, "Hey, will you critique this? Will you let me know what I'm doing right and what I'm doing wrong and where I can improve?" That has actually happened to me in my life, where a fellow surgeon has sent me a video. It was actually someone at the other end of the spectrum. This was an older surgeon who sent a video and said, "I want peer review to make sure that my skills are where they should be. I trust you. Will you tell me if you think I should stop operating?" I thought he was doing great and said, "Absolutely, please keep operating. You're a fantastic surgeon."

I thought that that was a really unique situation where someone asked for help, and I was happy to give it. I think at both ends of the spectrum, or anywhere in between, we should utilize each other a little bit better than we do at peer review and critique and giving advice on how people can improve or areas where they're excelling.

Uday: I think you're totally right. I actually gave a resident lecture at the ASCRS meeting a few weekends ago in San Diego. I was fortunate to talk to a group of Iowa residents, and I said, "Let me take a picture with you," and I said, "Please do me a favor. Tell Tom Oetting I want him, I'll pay him, to come to LA to watch me operate, to coach me in the OR." But, only if he's going to be critical of me. I want to learn from him, I don't want him to pull any punches, and I want to be a better surgeon. And yes, even 20 years out, I can certainly still find room for improvement, but I need the coaching of someone like a Tom Oetting. If he turns me down, I'm calling you next, Gary.

Gary: All right. I do get out to LA sometimes, and I would be happy. I would be brutal though. I would be really brutal.

Uday: I'll pay your flight; don't worry.

Gary: I think we've covered a lot of really interesting topics. I want to thank you so much for your commitment to ophthalmology. Just to be honest, when I was a resident, I always loved reading your columns. I always enjoyed learning from you, and I've always counted it as a real privilege to count you as a friend, as well as a colleague, and still as a mentor. The fact that I get to interact with you like this...this is coming from someone who used to just be reading the articles and never dreaming I'd have the opportunities that I've had. So, Uday, thank you so much for giving me this opportunity.

Uday: Listen, when you're in LA, I'd love to host you in the OR, and I want you to watch me operate and be brutally honest. My goal is to be better.

Gary: You know, I'm going to make the same offer, and I think you're going to be coming to MillennialEYE Live as a faculty member.

Uday: I am.

Gary: That's in my backyard, in Louisville. I practice in Lexington, Kentucky, which is about an hour outside of Louisville. If you want to fly in a day early and hang out, that could be really fun. I'm going to throw that out there, so if you're interested in that, let me know. We could have some fun.

Uday: All right, Gary. Always a pleasure.

Gary: Awesome. Thank you so much, Uday.

Speaker 1: Thanks to Dr. Devgan for sharing his cases with the ophthalmic community and for imparting some words of wisdom on us today. And thanks to our listeners for tuning in to another episode of Off the Grid. Until next time.

6/25/2019 | 24:42

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