The Newsletter of the Senior Ophthalmologist Spring 2020 | Volume 24 | Issue 2 SCOPE Richard K. Forster, MD: A Life Through which furthered his interest in bird anatomy. Although he did some the Lens of an Ophthalmologist hunting, trapping and fishing in his and Nature Photographer youth, he decided at the age of 11 to restrict his enjoyment of the out- By M. Bruce Shields, MD doors to observing his surround- ings and wildlife and participating s ophthalmologists, we in the woods and fields of his fam- in environmental conservation. have spent much of our ily’s 68 acres, enjoying the wildlife Acareers looking through that included a variety of birds: This early decision to admire and lenses in the office and the operat- chickadees, nuthatches, blue jays, preserve the wonders of nature, he ing room. And I suspect we have crows and occasional pheasants. In reflects, may have had something all shared the sense of awe as we 1949, he won a trip to the Eastern to do with his choice of medicine beheld the exquisite beauty and Poultry Judging contest in Boston, as a career. After graduating from intricacy of the human eye. Dartmouth College, he earned his medical degree at Boston University The thousands of examinations School of Medicine and, follow- that each of us have performed ing an internship at Boston City over the years have not only Hospital, joined the U.S. Public given us a respect for the Health Service and was fortu- elegance of nature, but itously assigned to Miami for has sharpened our two years. While there, he ability and inclina- undoubtedly noticed not tion to appreciate only a decided difference the subtlest aspects in the weather between of all that we see. Florida and New Hamp- It is not surprising, shire, but also a vastly therefore, that many greater variety of avian of us have adopted species. In any case, he hobbies or avoca- returned to the Sunshine tions that incorporate State for his residency at a careful examina- Bascom Palmer Eye Insti- tion and appreciation tute and, after a fellowship at of the diverse marvels the Proctor Foundation in San throughout this world in which we live. An excellent example is our colleague, Richard his issue contains the biographical sketches of two major K. Forster, MD, who has spent Tfigures in ophthalmology: Drs. Lorenz Zimmerman and countless hours looking through Claes Dohlman. Both articles were written by one of their chil- the lens of his camera at the wad- dren: Mary Louise Z. Collins, MD and Henrik Dohlman, PhD, ing birds and shorebirds of Florida. respectively. “Zim” and Claes were good friends for many years, as well as competitors on the tennis court. Dr. Zimmer- Dr. Forster’s love of nature man passed away in 2013. Dr. Dohlman remains clinically active began at an early age. Growing up at Harvard and the Massachusetts Eye and Ear Infirmary. on a small poultry farm in New Hampshire, he spent many hours WHAT WE ARE DOING TODAY

Richard K. Forster, MD of which he purchased last year. it into two DVDs, which he did The tradeoff for quality record- in 2017. Since then, he produced ings with the new camcorder has another DVD in 2018, “Wad- Francisco, came back to Bascom been the weight of the camera, ing and Shorebirds of Florida: Palmer as chief resident in 1969. which requires the use of a tri- Favorite Feeding Behaviors,” and He remained there on the fac- pod, except when photographing earlier this year completed his ulty for 50 years and counting. diving or quick-moving birds. latest, “The Herons of Florida.” During his long tenure at Bas- In 2016, he began to organize Now, you may be thinking that com Palmer, Dr. Forster rose to his videos into DVDs with the 30 minutes of watching birds enjoy international prominence as a professional assistance of a vid- their dinner could be a bit tedious. leader in external disease and con- eographer and a recording studio. But having viewed several of his tributed to establishing his insti- After completing an hour of videos, courtesy of Dr. Forster, tution as one of the finest in the recording in the field, I can report without country. He only left for a five-year Dr. Forster edits the fear of being disin- period (1987-1992), when he was footage, listing genuous, that it recruited as medical director of the the specific is really quite a King Khaled Eye Specialist Hos- birds and pleasant expe- pital in Riyadh, Saudi Arabia. He the date, rience. The returned to the faculty at Bascom time and cinematog- Palmer in Miami and served as location of raphy is of interim chair and medical direc- each film- professional tor from 1999 to 2001. In June of ing. The quality, 2016 he “retired,” but continues videogra- the natural to see patients two days per week pher then settings are at the Bascom Palmer facility in downloads lush, and Palm Beach Gardens, an arrange- the edits to a the birds are ment that has allowed more time work DVD, from not only beauti- for his joy of bird watching. which Dr. Forster ful and exotic, but selects footage and also intriguing, often Although an appreciation and designs the sequence for the humorous and altogether enjoyment of nature has been part final, refined DVD. He then writes entertaining in their behavior. I of Dr. Forster’s life since child- and personally records a narration highly recommend the videos. hood, it took on a more active to fit the footage. The results are form in the early 1980s, highly professional DVDs Although most of the Forster’s when he and his “directed, filmed and birdwatching and photography wife, Janet, began narrated by Rich- has been done throughout Florida, attending bird- ard K. Forster” they have also made several trips ing field trips with acknowl- outside the state, such as Machias and photo- edgements Seal Island on the north coast of graphing of his video Maine to observe Atlantic puf- birds in the editor and fins and to the Galapagos Islands surrounds narration with their daughter. Also, while of Miami recorder lecturing in Trinidad, he filmed and Sanibel and, most oil birds at the Asa Wright Nature Island. He importantly, Center and scarlet ibis at Caroni began with his “bird- Swamp in the Port of Spain. In still photog- ing partner addition to producing his DVDs, raphy, but an and wife, Janet Dr. Forster has made presenta- interest in bird F. Forster.” tions at assisted-living facilities behavior, especially and museums and has more the feeding habits of wad- Dr. Forster’s first DVD scheduled for this year. His videos ing birds and shorebirds, led him is entitled “The Feeding Behav- are available at the J.N. “Ding” to get out the family camcorder to ior of Wading and Shorebirds of Darling National Wildlife Refuge document their foraging behavior. Florida,” which includes 62 spe- on Sanibel Island and the Elliott Over time, he transitioned from cies at various locations in Florida Museum in Stuart, Fla. They the analog camcorder to a Sony and runs for 61 minutes. Janet can be purchased online from Digital 8 Handycam and then a Forster felt this was a bit too long the Historical Society of Martin for viewing in one session and County, which operates the Elliot Sony digital high-definition video 2 camera recorder, the latest model convinced her partner to divide Museum http://www.hsmc-fl.com. know would fall apart. The same within our current family units could be said for our solar sys- and plan and hope for the best for From the tem, as the planets maintain their our future generations. Much the Editor’s assigned orbits around our sun. same can be said of our connec- We continue to learn how every- tions with our dearest friends. Desk thing in our universe appears to be connected by forces that are As I have thought about all still only vaguely understood. these human connections, I am reminded of how fortunate you and As I have pondered this appar- I have been to enjoy the associa- ent connectivity of every physical tions we have experienced in our thing in our world, I couldn’t help medical careers and especially as being struck by the parallel relation- ophthalmologists. Again, there has ship within the human race. We are been the sharing of ever advanc- certainly dependent on each other ing knowledge and technology in many ways. I guess this is one over the generations, to which we of the reasons that I enjoy reading have been privileged to contribute Connectivity history, in that it gives me a sense with the hope that it will add to By M. Bruce Shields, MD of our connectedness throughout the foundation on which continued all the generations that have gone advances will be made. On a more ne of the decided luxu- before us, not only in passing on personal level, I suspect we can ries of retirement is the ever advancing knowledge and tech- all look back to role models who Oopportunity to read for nology, but also in the basic hopes got us started long ago and to all pleasure in the middle of the day, and dreams that have been shared the priceless friendships we made which probably doesn’t come by societies down through the ages. with colleagues along our profes- natural to most of us. It took me sional journey. Now, as we ease quite a while to overcome a sense into our retirement years, we can of decadence and guilt when I sit all take pride in the new genera- down in an easy chair with a good I don’t have a clue tion of ophthalmologists whom we book in the middle of a workday. may have influenced in some way But I’m getting there. My prefer- what all this means, as the connectivity continues. ence for reading is history, with occasional fiction. And I still enjoy So, as we sit back in our easy scientific literature, although I find but I vaguely get the chairs in the middle of the day that I understand it less and less. with a good book in our lap, idea that everything hopefully without any sense of I have recently become fascinated guilt, maybe we can pause for a in reading about the controversies in the universe is moment to reflect on how fortu- among physicists concerning how nate we have been to be a part of everything in our universe seems this continuum of humanity and to be connected, from the con- somehow related of our distinguished profession. cept of quantum entanglement, in which paired particles are some- P.S. I wrote this before the coro- how dependent on each other’s Of course, examples of human navirus became such a dominant behavior; to the string theory, in connectivity closer to home are part of our lives, but somehow it which particles that are separated the relationships we enjoy within seems to make thoughts of human by vast distances seem to be influ- our families and close circle of connectivity all the more important enced by each other. Now believe friends. The recent advances in (although, for now, we must reach me, I don’t have a clue what all human DNA testing have not only out with our hearts and not our this means, but I vaguely get the provided a blueprint for the evolu- hands). Just today, I saw the follow- idea that everything in the uni- tion and migration of our race but ing quote by Thomas Merton, which verse is somehow related to and have allowed each of us to go back seems to bring our current situa- dependent upon everything else. through our generations to discover tion into focus: “You do not need to where we have come from. Who know precisely what is happening, Certainly, atomic particles can deny the intimate bonds that or exactly where it is all going. What are related. If electrons didn’t connect us within our immediate you need is to recognize the possi- maintain their assigned orbits families as we hold in our hearts bilities and challenges offered by the around their nucleus of protons the memories and lessons of those present moment, and to embrace and neutrons, everything we who have died, support each other them with courage, faith and hope.” 3 OPHTHALMIC HISTORY Lorenz E. Zimmerman, MD: A the U.S. Army Reserves in 1943 during medical school and because Legacy in Ophthalmic Pathology it was wartime, completed medi- By: Mary Louise Z. Collins, MD cal school in two years. After an internship at Gallinger Memorial y father was born on Nov. my father, even before it was in Hospital in Washington, D.C., his 15, 1920 at Columbia vogue. He was also a great sports original interest in the field of inter- Hospital in Washing- fan, and in high school and col- nal medicine waned. He stated that M he realized that much of internal ton, D.C., and it was his home lege was a vendor at the old Griffith for more than 80 years of his life. Stadium in Washington, D.C., so medicine was an “overlay of psy- His parents were Swiss and Ger- that he could observe Redskins and chosomatic medicine and that, if I man immigrants; they owned a Senators games. He was a lifelong did not want to see patients whose bakery, and my father was raised Redskins fan, and was known to problems were more in their heads in a home above the shop. embarrass my mother at social than in their bodies, that I ought functions by seeking out a televi- to stick with genuine pathology.” The discipline and work ethic sion to watch a game. He even got instilled in him as a child working After serving as a general medical in trouble along with Bob Ellsworth officer at the Pentagon, he com- in the pastry shop greatly influ- at Bob’s daughter’s wedding because enced his career in ophthalmic pleted his residency in pathology they were caught in the bar watch- at Walter Reed Hospital in June pathology. In fact, he liked to say ing the Redskins-Giants game. that he chose a career in medicine 1950 and was sent first to Tokyo because he did not want to work Fortunately for ophthalmology, and then to serve in the Korean as hard as his parents. Fortunately, my father pursued medicine, gradu- War as the pathologist in charge he could not shake the work ethic, ating from George Washington of a mobile medical laboratory. determination, self-discipline and University (Bachelor of Science, On return to the states in 1952, motivation that were integral por- 1943 and MD, 1945). He entered he was assigned to the Armed tions of his personality and influ- Forces Institute of Pathology enced every aspect of his life. (AFIP), rotating through various Sports were always a big subspecialty departments until part of my father’s life. he landed permanently in He played football ophthalmic pathology, and baseball in one department where high school and he had no experience. considered play- In the early 1950s, ing beyond. At there were few age 40, he was general patholo- introduced gists inter- to tennis. ested in ocular He pursued pathology. tennis in None with the same experience way that he were available applied him- at the institute. self to every Many years other interest later, my and became father wrote: “I a very com- thought it was a petitive player. stroke of real good Much of the later fortune for me per- social interac- sonally, not because tion at ophthalmol- I had any preconceived ogy meetings revolved notions or interest in around early morning pathology of the eye, but I just tennis matches with col- knew that it was a gold mine … leagues and friends. Many who in the figurative sense ... in terms of admired him called him “Zim.” Lorenz E. Zimmerman, MD at having a wealth of material avail- Physical activity, as a part of a work at the Armed Forces able and having this tremendous 4 healthy lifestyle, was routine for Institute of Pathology. inflow of material, not only from OPHTHALMIC HISTORY

Lorenz E. Zimmerman, MD military institutions all over the world, but from the civilian sector.” Due to the war, many of the civil- ian institutions that had been doing subspecialty pathology had shut down due to lack of manpower, but he delighted in his inheritance of an instant backlog of 5,000 cases! My father was fortunate because tackling a backlog of this magni- tude in a field he knew little about could have been a disaster. But Helenor Wilder, the ophthalmic pathology technician who led Lorenz E. Zimmerman, MD and his wife, Anastasia on their wedding day. the department during the war, mentored him, introduced him The backlog of cases meant that, which he had no prior interest or to the key people in academic by the time my father rendered knowledge, set the stage for a series ophthalmology and arranged for a final report, it was often five to of more than 50 years of profes- him to be her successor in one of six years after the specimen had sional contributions to ocular the elite eye pathology clubs. She been submitted. He routinely pathology and oncology, including facilitated his acceptance into the added a comment at the end of the education of ophthalmologists field of ophthalmic pathology at each report stating, “We would in eye pathology. His position at a time when he had never writ- appreciate your providing follow- the AFIP allowed him to educate ten a paper on the subject. He also up information.” It was in this residents, fellows and practic- considered himself fortunate to manner that he developed a wealth ing ophthalmologists to varying have several military ophthalmolo- of clinicopathologic informa- degrees. He was able to do this gists assigned to the Ophthalmic tion with significant follow-up. because of relationships between Pathology Department early in his the American Registry of Patholo- My father’s willingness and tenure; these men taught him some gy, the American Academy of Oph- enthusiasm to pursue passionately clinical ophthalmology, as they thalmology, funding through the a subspecialty in pathology, about were all learning eye pathology. National Institutes of Health and,

Lorenz E. Zimmerman, MD in Korea as a Pathologist in a mobile army hospital.

5 OPHTHALMIC HISTORY

Lorenz E. Zimmerman, MD about the success of his trainees with pathologists in efforts to better than in his own accomplishments. understand disease processes and Fred Jakobiec, MD recalled, “While improve treatment for our patients. other national eye societies, and some leaders in their fields are the emphasis that the American threatened by the most talented Although my father’s professional Board of Ophthalmology placed young people they have trained, life was busy, he was very much a on candidates learning eye pathol- Zim has exhibited the trait of pro- family man. He met my mother ogy as part of their education. moting their careers at every turn.” in Korea where she was serving as an Army nurse. They reconnected His reputation as a teacher was In his retirement, my father seven years later when both were unsurpassed partly due to his quali- continued to be concerned about stationed in Washington, D.C., my ties of both humility and perfec- the education of ophthalmologists father at the Armed Forces Institute tionism. He demanded even more in ophthalmic pathology, espe- of Pathology and my mother at of himself than he did from his cially with the economic realities of Walter Reed Hospital. They mar- fellows. Dr. Fritz Naumann said healthcare in the 21st century. He ried in 1959 and together raised of him, “I only recall one situa- was clear about his wish that col- six children. The last of their six tion which would annoy him – if children is my brother Larry who his fellows would not criticize a was born in 1967. Larry’s birth rehearsal of one of his major lec- begins an ironic story of intermix- tures. Not criticizing him was ing of professional and personal interpreted as intellectual laziness challenges and contributions in and lack of interest in the subject.” the field of retinoblastoma. His greatest passion was teach- My father’s first paper on reti- ing. Daniel Albert, MD observed: noblastoma was co-authored with “Zim had the ability to look at Marshall Parks, MD, and was slides from diseases that had been published in 1960. His subsequent studied for over a century and landmark work in retinoblastoma make new observations and cor- became intimately intertwined relations. Examples of this can with his personal life when Dr. be seen in his reports on ocular Parks diagnosed Larry with toxoplasmosis, angle recession bilateral retinoblastoma at age 4 glaucoma, phacolytic glaucoma, months old. This began a series of hemolytic glaucoma, retinocytoma, ironies and contributions, includ- melanocytoma, juvenile xantho- Zim with son Larry (6th child) at ing several “firsts” in retinoblas- granuloma and many others. His his high school lacrosse game. toma science, nomenclature and vast knowledge and insight into the treatment by three generations pathology of eye diseases, backed of the Zimmerman family. by his total mastery of the basics laboration between clinicians and pathologists continue in ophthal- of pathology, made him a uniquely Larry was one of the first babies mology for the benefit of patients. qualified mentor. This knowledge treated with intra-carotid chemo- was combined with his gifts as a In his acceptance speech for therapy and subsequently bilateral clear and precise teacher, patience, the 1999 Helen Keller Award, he external beam radiotherapy — both intellectual honesty, and humility.” stated, “Many highly significant experimental at the time. Larry’s daughter, Perry, survived trilateral Over the years, his former fel- advances and the development of new concepts have evolved merely retinoblastoma — a rare condition lows developed active ophthalmic even among bilateral RB patients. pathology laboratories at major as a consequence of the comingling of clinicians and pathologists in the A second irony involving the Zim- institutions across the country. My merman retinoblastoma story — father noted, “My entrance into retrospective clinicopathologic dis- cussions of cases thoroughly stud- the term “trilateral retinoblastoma” the field was made comparatively was coined by my father, based on easy by the fact that I hardly had ied at academic centers. It doesn’t always require the latest in extreme- basic science research conducted any competitors. There were very, in his laboratory in collaboration very few people who were well- ly expensive high-tech equip- ment and the use of experimental with Mark Tso and my brother, trained who were in the field of Brian, who was a student researcher ophthalmic pathology, and really animals to make major advances towards the prevention of blind- at the time. Another contribution none of them doing ophthalmic to the science of retinoblastoma pathology on a full-time basis.” ness.” It was his wish that future clinicians continue to be well- prevention occurred with the birth But my father had the uncommon of Larry’s second daughter, Lizzie, trait in great men of caring more educated in ophthalmic pathology by having opportunities to interact who was born via pre-implantation 6 WHAT WE ARE DOING TODAY Lorenz E. Zimmerman, MD

genetic diagnosis (PGD) to pre- vent the transmission of the RB gene. Her birth marked the first child born via PGD, not just for retinoblastoma, but also for any cancer-related genetic disease. Through this journey of compil- ing our family’s contributions in the field of retinoblastoma, it has become clear to me that my father’s passion for his work was driven not only by his love of science, medicine and pathology but also by his personal challenges in the field. His life’s work was devoted to a triad of clinicopathologic cor- 1996 Zimmerman Family reunion. relation, teaching, and research with the hope of giving others He had hobbies, and he pursued ism and ethical conduct he taught what his family had enjoyed — the them passionately. He could be all who connected with him. ability to overcome a potentially found almost every morning gar- In the AJO tribute to him at his fatal illness with useful vision to dening or tending to the fish pond 70th birthday, letters from col- enjoy all that life has to offer. he dug himself. After his death, my daughter Stacey wrote this about leagues discussed these personal My father did enjoy life. He cher- him and my mother: “The most attributes. An example from Fred ished family time with my mother, remarkable thing about Nana and Jakobiec, MD, “His personal and their children and grandchildren Grandpa’s hands, though, was professional lives have been a para- and even their great-grandchildren. what they did for the world. The ble of strength, decency, and accom- He taught all of us the value of hard work of Grandpa’s hands in his plishment.” And, my sister, Barb, work and discipline — in physi- breakthrough research in pathol- “Whether it be an awesome perfor- cal activity, competition, diet (well, ogy is the most obvious, and that mance as third baseman or win- except for the volume of ice cream humble handshake we see in the ning a tennis match or the honor he could consume) and keeping old photographs of him accept- of another professional award, his balance in life. He could be a fierce ing prestigious awards is a testa- humility has always amazed me.” competitor in sports. He played ten- ment to his self-effacing character. At a time when he received nis into his 80s and fast-pitch softball Cool Papa took this beyond his a string of awards, his young into his 60s. My brother Skip recol- career, however, creating beauty granddaughter asked, “Cool lects, “to me, he is the greatest third for everyone’s enjoyment in his Papa, I forgot, what made you so baseman I ever saw play fast-pitch garden and backyard pond”. famous?” His answer, “because softball. People call him the vacuum I’m your grandfather, Lauren.” cleaner — nothing gets by him.” For my father’s work in oph- thalmic pathology, he received This was Zim as we knew him. My father was known to be quirky. the highest honors in our field: Editor’s Note: Mary Louise Growing up during the Depression Jackson Lecture (at age 40), Ernst Z. Collins, MD is an Academy caused him to adopt a “waste noth- Jung Prize in Medicine, Donders Trustee-at-Large and Chair of the ing” mentality. He used to entertain Medal, Jules Stein Award, one of Department of Ophthalmology, the grandchildren and their friends the 10 Most Influential Ophthal- Director of Pediatric Ophthalmol- by eating part of the corncob after he mologists of the 20th Century ogy and Strabismus, and Direc- had finished the corn! His soup bowl (ASCRS), Helen Keller Prize for tor of Resident Education for the was mostly filled with bones, which Vision Research (ARVO), Howe Ophthalmology Residency Program he would enjoy chewing down to the Medal (AOS) and the Academy’s at Greater Baltimore Medical Cen- marrow … and as much as he loved Laureate Award. Although he was ter (GBMC) in Maryland. We are the meal, he cherished even more the appreciative of all the recognition grateful to her and our History of laughs it generated among the kids. he received, it is possible that his Ophthalmology editor, Daniel M. This knack for entertaining grand- greatest legacy is not in the science Albert, MD, MS, and his edito- children earned him a name change or medical advancements but in the rial assistant, Ms. Jane Shull, for from “Grandpa” to “Cool Papa.” lessons in humility, professional- contributing this article to Scope. OPHTHALMIC HISTORY Claes H. Dohlman, MD, PhD — A tions with my father at home, and highlight three physician- Leader in American Ophthalmology scientists who had a unique and Proud Son of Sweden impact on his professional growth and development. By Henrik Dohlman, PhD FIRST: GÖSTA DOHLMAN y father, Claes Hen- have gone entirely to support rik Dohlman, is a new research and education. My father’s father (“Farfar” Swedish-born oph- in Swedish), Gösta Dohlman, M My father is particularly proud thalmologist and a founder was professor and chair of ENT of the cornea subspecialty. of the individuals he has trained at University of Lund. He had and mentored over the past six gained early recognition for his For more than 60 years he has decades. These include more research discoveries working been affiliated with the Depart- than 200 cornea fellows (clini- with Róbert Bárány at Uppsala ment of Ophthalmology at Har- cal and research), nearly half of University in the 1920s. vard Medical School, and for 15 of whom are now full professors. those years served as department But how did he get his start? Who Bárány had previously received chair and chief of ophthalmol- mentored the mentor? His path the Nobel Prize in 1914 for his ogy at the Massachusetts Eye and to a legendary career in oph- work on the vestibular apparatus. Ear Infirmary. Prior to becoming thalmic science included work My Farfar was his only doctoral chair, he established the world’s with some legendary academic student “Medicine Doktor”, work- first cornea service, something researchers including Erik Jor- ing on fluid flow in the semicir- that today is ubiquitous among pes, MD, Edward Maumenee, cular canals and its influence on U.S. eye departments. He is well MD, Jonas Friedenwald, MD, the cupula. Although he published known for his contributions to Charles Schepens, MD and Endre just four papers on the topic, the corneal biochemistry (1950s), Balazs, MD, to name a few. impact of his discoveries earned surgical practice (1960s), teach- him a professorship at University ing and administration (1970 The following reminiscences of Lund. It was not without some and 1980s) and the development come from occasional conversa- setbacks along the way, however. of a practical artificial cornea As my father recalls, “When I was and its postoperative manage- 3 or 4 years old, I wanted to pet ment (since the early 1990s) the rabbits that he had been – with over 15,000 devices working on in the labora- implanted worldwide. tory. He had operated on them for hours My father per- and experimented formed surgery with them for well into his months. I took ninth decade, it upon myself and at 97, he to open their continues to cages so they train young could enjoy scientists, a bit of the develop new outdoors, and technologies they quickly and produce hopped away innovative into the coun- treatments for tryside,” putting the most hope- an end to the less cases of cor- experiments. neal impairment. Most recently, his My father efforts to prevent enrolled in medical complications led to school in 1943, with the identification of a his own father as one novel mechanism of glau- of the professors. While coma. His innovations have in medical school at Lund, he restored vision to thousands, and was drawn to biochemistry and revenues from these inventions Claes Dohlman MD, PhD. was chosen to be a teaching 8 OPHTHALMIC HISTORY

Claes H. Dohlman, MD, PhD

assistant setting up experiments for the medical students and administering examinations. “Back then it took seven or eight years to get an MD, and consisted of often needless accumulation of trivial knowledge. My career path was greatly influenced by my good friends since grade school Arvid Carlsson (who later won the Nobel Prize for the discovery of dopamine) and David Ingvar (who went on to become a prominent clinical neurophysiologist). Both were heading for medicine from the very start,” he recollected. “After medical school, for my residency, my father suggested I should be an ENT surgeon (as he was), but it was the only time I dared to object. I had several friends in the ophthalmology department, and I found the eye to be a particularly interesting organ, with neurology in the back, transparent connective tissue in the front and the optics of the lens. In 1952, my parents Carin and Claes touring the U.S. Capitol during a I approached Professor Sven Lars- fellowship year at the Wilmer Institute at Johns Hopkins Hospital. son, who was very popular among the students. He agreed with some about what to do. In retrospect I had stacks of green cards with enthusiasm and I started in 1950. should have applied to work with nobody to take them, so they him, but I was fixated on the cor- were happy to give them to us.” “However, soon after I started nea because of some histochemi- Larsson had a heart attack, which cal interest I had. I wanted to go SECOND: JONAS according to my friends was so the U.S. and asked Barany, ‘Who FRIEDENWALD severe they had never seen any- should I go to?’ He recommended “We sailed (in 1952) on the body survive one like it. After that, Jonas Friedenwald at Johns Hop- Queen Mary from Southamp- he promised to be ‘the laziest pro- kins University in Baltimore. I ton, England to New York City fessor in Sweden,” and he kept that wrote to him, and he agreed to take through a February storm. We promise! But that was fine with us me on at a salary of $250 a month. because we took care of the work lived in Baltimore for a year and ourselves. At that time there were “Before traveling we had been a half in a bungalow, a shack only four salaried positions in instructed to go to the U.S. consul- really, up on Joppa Road. the department, and in our spare ate in Gothenburg to get a student “Friedenwald suggested that I time we could do some research in visa. The man at the desk looked work out a histochemical method the basement, on corneal edema, at our application and said, ‘A for organic sulfatases (which act which eventually became one of student visa? Oh no Dr. Dohlman, on keratan sulfate, chondroitin my strongest lines of investigation. take this. It is a green card, it is sulfate, and other glycosaminogly- much better.’ This happened in cans) in the eye. He had done some “In 1952, I had eight months 1952, and then again in 1958. In experiments with lead precipita- before my next appointment and those days, there was a severe bias tion, using heparin as a substrate thought I should break out and against the Eastern and Southern that bound to proteoglycans. Pro- see something new. I asked Ernst Europeans, so there were gener- teoglycans were important in the Bárány (the ophthalmologist son ous allotments to other countries cornea and also in the kidney. So I of Róbert Bárány) who was bril- including Sweden. The consulate liant, and worked on glaucoma, worked on that for a year but could 9 OPHTHALMIC HISTORY

Claes H. Dohlman, MD, PhD

not get any free sulfate to prove that the assay worked. I then real- ized this was a histochemical arti- fact and that I was staining lead phosphate and not lead sulfate. So, I was measuring the wrong enzyme! It took me a year to find this pitfall in histochemistry. I was a bit disappointed at the time, but it was very educational and set my own ambitions for the future. “Friedenwald was an unusual man, a brilliant, but shy and introverted scholar. Despite his In 1939, my father at 17, with my grandfather and his whippet “Jack”. prominence, he was never pro- As my father describes, “we were most likely discussing one of many moted beyond associate professor middling report cards from school!” and had a salary of only $4,000. He had a private practice with his archipelago.” As my father tells it, “Jorpes was a political radical, father in the morning, research the famous German Field Mar- having grown up on the island of at the Wilmer Institute in the shal Moltke is said to have smiled Åland, between Sweden and Fin- afternoons, and in the evenings he only twice in his life. First when land in very poor circumstances, was home reading. His laboratory his mother in-law died and again which marked him for life. He was miserable by modern stan- when he surveyed the Swedish was a medical student in Helsinki dards, but he himself was quite defenses at Oskar-Fredriksborg! in 1917, and when the Russian an inspiration, and it was a very Revolution started, he became educational time for me. It was an THIRD: ERIK JORPES the leader (with Kuusinen) of the entirely new world that opened up. Finnish Communist party, rising “At Oskar-Fredriksborg there up against the government. He were two physicians on duty, “After that, I went up to Boston was at the front of the barricades with nothing to do, so we divided for 8 months in 1953 and worked of Hälsingfors, fearless, in a very the days, 24 hours on and 24 at the old Retina Foundation (now bloody and serious revolution. hours off. I traveled into town Schepens Eye Research Institute) But the Germans were called in on a boat and worked for 24 with Endre Balazs (who later puri- and crushed the rebellion, making hours at a stretch in Erik Jorpes’ fied and commercialized the natu- short shrift of the communists. ral lubricant hyaluronic acid) on biochemistry department at the the biochemistry of the cornea, I Karolinska Institute. After a long “Jorpes fled to Russia and found learned a bit and had a good paper day in the lab I returned to the himself sitting in a muddy bor- there. Charles Schepens encour- fort and slept on the job. This was der village waiting for his great aged me to balance patient care the time when 35S radioisotopes return as president of Finland, and research. Then I thought it had just arrived, and I realized which didn’t occur. With a death was time to go home with (third what had previously taken years sentence on his head, he smuggled child) Ebba coming and continue could now be done in minutes. himself across the border and my career there in Sweden.” One time in the laboratory I made it to Sweden. He went up was centrifuging samples at 3 in to the faculty of the Karolinska Back home, my father contin- the morning and got so sleepy I Institute and announced his grand ued his residency in ophthalmol- thought I should take a rest. There return. After some hesitation, he ogy, but had the opportunity to was only one sofa in the entire was allowed to start as a lab tech- also continue his research on the institution and that was in Jor- nician but quickly rose through metabolism of corneal proteogly- pes’ inner sanctum, in his office. the ranks to become Chair of cans. During that time, in 1956, You can imagine what happened department. He clarified the struc- he was drafted to serve as a medi- next. I woke up the next morning ture of heparin, worked on insulin, cal officer to Oskar-Fredriksborg, with Jorpes’ icy blue eyes star- made a lot of money and became a coastal artillery station outside ing down at me. But he thought a capitalist (Jorpes studied the of Stockholm, which he often in his skewed mind that this preparation of insulin at the Con- described as “a dilapidated for- was a sign of devotion to science naught Laboratories in Toronto, tress, with a few rusty cannons, and came back to that incident under the guidance of the Nobel- 10 at the entrance of the Stockholm repeatedly in promoting me.” OPHTHALMIC HISTORY

Claes H. Dohlman, MD, PhD

winning biochemists Frederick Banting and John Macleod. After returning, he launched the pro- duction of insulin by the Swedish pharmaceutical company Vitrum. “The royalties made him wealthy, but rather than keep the money for himself, he supported his department. To think if they had caught him he would have arrived in Sweden ‘a head shorter’. But he made it, and as far as I know he continued to have a death sentence on his head, which not many department chairs have! In 2002, celebrating my father’s 80th birthday, at our family’s summer “My interest in proteoglycans home in Sweden. continued as a PhD student at Lund, working in Jorpes’ Biochem- would prove permanent. He took a and the Gullstrand Medal (2012) istry Department at Karolinska faculty position at Harvard Medi- which is given once per decade and later with Professors Lenn- cal School, first as an instructor by the Swedish Medical Society. art Rodén, Harry Boström, Sven (1961), then assistant professor Gardell and Torvard Laurent as (1968), associate professor (1969), At the age of 96, he was con- preceptors. Rodén helped me the professor (1973), chair (1974-1989) ferred an honorary doctorate most in practical terms. He later and professor emeritus (1993). and delivered the commence- moved to Alabama in the U.S. ment address at the University For 16 years my parents lived of Montreal. He could well hold “Laurent was a physical chem- in suburban Arlington, first with the record as the oldest gradua- ist of the highest caliber, and a three children. Soon after, there tion speaker in history! He has friend from my time in Boston. were six. Those were magical continued to champion aca- Boström was a clinician interested years living on Pleasant Street demic medicine and has authored in the metabolism of proteogly- in a converted carriage house almost 400 articles, including cans and later became Professor by Spy Pond, and they were fol- more than 60 after turning 90. of Internal Medicine and Dean lowed by 45 years in Weston. at University of Uppsala. Work- Most summers we had family Most important is his legacy ing in the evenings back in Lund, reunions at our ancestral family of mentorship. It is important sometimes in Sune Bergström’s home at a small farm in Sweden. to remember that the many lab, I later found the sulfatases by In 2019, the family gathered there residents and fellows who trained using chemical isotopes instead of to honor Mamma Carin, who with my father are also part of crude histochemical techniques. died at age 91 from complica- an eclectic scientific family tree, Bergström was mostly interested tions of Parkinson’s disease. one that includes the senior in prostaglandins, for which he Professor Dohlman, Frieden- later won the Nobel Prize, but I What did my father learn from wald, Jorpes and many others was not part of that team, and his three most influential mentors? who have helped to shape the he showed no interest in me.” As he puts it, “They advised me discipline of ophthalmology. to focus, focus and focus, respec- After that, my father returned tively — although I didn’t always Editor’s Note: Henrik Dohlman, to doing translational research follow their advice.” Nevertheless, PhD, is Claes H. Dohlman’s fourth in Stockholm and finalizing his my father’s career accelerated after child and is the Sanford Steelman thesis, which was presented at Uni- 1958, and there have been many Distinguished Professor and chair versity of Lund in 1958. That same laurels along the way, including the of pharmacology at the University year there was a career-changing Friedenwald Award (1971), Castro- of North Carolina. We are grate- opportunity; he was recruited viejo Medal (1981), ASCRS Oph- ful to him, and our History of back to Boston at the invitation of thalmology Hall of Fame (2004), Ophthalmology editor, Daniel M. Balazs, Schepens and Edwin Dun- Laureate Award of the American Albert, MD, MS, and his edito- phy, then chief of ophthalmology Academy of Ophthalmology rial assistant, Ms. Jane Shull, for at Mass Eye and Ear. This move (2007), Helen Keller Award (2010) contributing this article to Scope. 11 Ergonomics is Everything! most commonly in EyeNet maga- zine. In a SO-sponsored Learning By: Samuel Masket, MD Lounge session on Ergonomics at AAO 2019 in San Francisco, the t an early stage of my have hand/wrist pain and 3 times prolific anterior segment surgeon career, I performed and as likely to have lower back pain1. Steven Safran, MD, described his taught anterior segment These disconcerting figures are A experience with horrific work- surgery — particularly as it related likely higher in female than male related neck pain that ultimately to cataract. In teaching, I always ophthalmologists due to differ- required cervical fusion (Figure 2). stressed the importance of surgi- ences in physical stature and other cal ergonomics: positioning the factors. In a 2005 survey of rough- Suffice it to say that our profes- patient in a way that maximizes ly 700 ophthalmologists, 52% self- sion places us at great risk for their comfort and aids the surgeon. reported neck, back or arm pain, musculoskeletal disorders (MSDs) and 15% sensed that their work later in life. However, the subject Proper positioning of the 2 was affected by these symptoms . should be of even greater sig- recumbent patient enhances Indeed, across multiple studies, nificance to our young colleagues. surgical exposure and helps at least 50% of ophthalmologists One might hope that increased alleviate patient anxiety; both report chronic back and neck pain. attention to these concerns could make the surgeon’s task easier. prevent long-term physical harm If the surgical experience is Moreover, the incidence of symp- and MSDs, allowing careers to good for the patient, it is likely toms increases with work volume be prolonged as desired rather to be good for the surgeon. and time. This is of considerable than limited by physical ailment. relevance to senior ophthalmolo- I often said to the learner, “Ergo- gists (SOs), whose careers may be The Academy has had a long- nomics is everything.” How cor- affected over time. Near the end of term interest in physician wellness rect I was. But in retrospect, how my surgical career, I experienced and ergonomics, particularly with little I knew about the subject. neck pain and finger numbness regards to MSDs in ophthalmolo- I neglected the musculoskeletal and tingling upon head turning. gists. Earlier, an AAO Task Force impact of practicing ophthalmol- An MRI (Figure 1) confirmed on Ergonomics was formed and ogy and ophthalmic surgery, disc and bone changes, along with led by Jeffrey L. Marks, MD, a and the central role of ergonom- moderate to severe multilevel cer- vitreo-retinal surgeon at the Lahey ics. Ergonomics (from the Greek vical spine stenosis. Remarkably, Hospital & Medical Center who words “ergos” and “nomos,” which the symptoms disappeared shortly has published on the subject3 and respectively mean “to work” and after I stopped performing sur- has spearheaded the Academy’s “study of”) is far more significant gery. Other colleagues have related efforts in this arena. A number of and encompassing than simply their stories in a variety of forums, articles have appeared in EyeNet positioning a patient for surgery.

The Board of Certification for Figure 1. This MRI (lateral view) reveals. significant stenosis in the lower Professional Ergonomists (BCPE) cervical spine.

defines ergonomics as “a body of MD Masket, Samuel of courtesy Image knowledge about human abilities, human limitations and human characteristics that are relevant to design. Ergonomic design is the application of this body of knowledge to the design of tools, machines, systems, tasks, jobs and environments for safe, comfort- able and effective human use.” Most ophthalmic diagnostic and surgical equipment has been designed without consideration for the comfort of ophthalmologists’ necks, backs, shoulders, arms, wrists and hands. Compared with family medicine practitioners, ophthalmologists are more than twice as likely to have neck pain, 12 more than 2.5 times as likely to Ergonomics is Everything! tilted to reduce neck strain dur- IMPROPERLY ADJUSTED ing temporally oriented surgery4. CHAIRS AND TABLES IN and there are annual courses More recently, there is interest in THE OPERATING ROOM and lectures on the subject. digital operating microscopes that don’t require viewing through Depending on the height and That said, the message does fixed oculars; rather, the surgeon body habitus of the surgeon and not appear to have reached a suf- views a large freestanding screen patient, the surgeon may sit in ficient base of the AAO member- while wearing 3D glasses in what awkward positions that primar- ship. It appears that physicians is called “heads up” surgery (Fig- ily stress their back muscles but have little interest in the matter ure 5)5. Moreover, digital surgical may also stress their neck and until they are symptomatic. The microscope substitutes are now shoulders. This is particularly good news is that there are now available with a virtual reality (VR) true for temporally oriented pro- alternatives to traditional operat- headset, freeing the surgeon from cedures. During my surgical ing microscopes that stress our fixed oculars while not requiring career, I always set the gurney, necks and backs. Industry, in gen- surgical viewing of a remote screen. chair and microscope to match eral, seems motivated to develop the patient’s anatomy to my ergonomic surgical tools to help COMPUTER MONITOR SCREENS position of comfort prior to the reduce the likelihood of MSDs. prep and drape. While those The physician’s neck and shoul- maneuvers added a few minutes Awareness of the potential for ders are potentially challenged to the surgery, I always believed physical harm is a good starting while working at computer ter- that it was time well spent. point for prevention. In a 2009 minals. This effect is exacerbated EyeNet article, contributing writer while wearing bifocal spectacles, MICROSCOPE AND Linda Roach consulted with Acad- as they cause the user to extend MACHINE PEDALS emy members Jeffrey Marx, MD, their neck to bring the screen into the near-vision “sweet spot.” Ide- Again depending on the sur- Wayne Fung, MD, and Martin geon’s height and habits, it may be Wand, MD, to offer advice on risk ally, one could use single-vision glasses aimed for computer dis- difficult to arrange the operating factors for — and strategies to pedals in comfortable positions prevent — work-related injuries. In tance or bifocals with the upper segment set for computer viewing. when operating temporally. This addition to suggesting stretching is most stressful on the lower and motion exercises, the article proposed seven risk factors and potential solutions for MSDs in Figure 2. This X-ray (lateral view) reveals the “surgical hardware” after ophthalmologists, as noted below: cervical fusion in an ophthalmologist with severe neck pain. Image courtesy of Steven Safran, MD Safran, Steven of courtesy Image SLIT LAMP

Stretching one’s neck into extension to reach the patient can be very stressful to the neck. Colleagues have modified slit lamp tables (Figure 3) to make it easier to reach the patient. Steve Safran, MD, has increased the length of the patient head strap to bring the patient and exam- iner closer to one another.

OPERATING MICROSCOPE

Once again, stretching the neck and working in awkward posi- tions can have deleterious effects on the entire spinal column, from neck to lower back (Figure 4). Tra- ditional remedies include oculars that can be reclined at variable angles. Alternatively, the patient’s head can be turned toward the sur- geon and the microscope further 13 Ergonomics is Everything! prolonged contact with edges of the tables or other equipment. back. Where possible, surgeons Padding and proper position- can evaluate several operating ing may obviate these concerns. room table designs to best fit In addition to the risk factors their anatomy. Some foot ped- listed above, ophthalmologists als have variable tilts or may be place their bodies in uncomfort- elevated on lifts as necessary. able, strenuous and risky posi- Figure 5. During a “heads-up” COMPUTER KEYBOARDS tions when performing other tasks such as indirect ophthalmoscopy surgery, a vitreoretinal surgeon The wrists and forearms are with the patient erect (Figure 6), views the screen while wearing particularly vulnerable to fatigue minor surgical procedures and 3D glasses rather than viewing and damage if the keyboard and contact lens exams at the slit through a microscope. This allows mouse are not placed at the proper lamp and office-based intraocu- for an ideal operating posture (5) height and working distance. lar injections. Moreover, training new surgeons at the microscope EXTERNAL CONTACT STRESS can place severe physical stress on the observer or supervisor. Working with a hyperextended wrist can stress tendons and There is a shifting demo- induce pain, numbing or tingling graphic among AAO members, when tendons are stressed when as we note a “greying” of the working with a hyperextended Academy along with the aging wrist. This may also occur if the of physicians and society in gen- hands, wrists or arms come into eral. Consider the following: • Academy SOs older than 60 years account for approximately 40% Figure 6. Indirect ophthalmoscopy of membership; with the patient erect is particu- • About 25% of U.S. physicians larly onerous to the physician’s are 65 years old or older. back, neck, arms and hands. • Ophthalmologists are working longer than ever and adher- laborate on a variety of seminars ing to the concept that “60 is and educational opportunities. Image courtesy of Steven Safran, MD the new 40.” For that reason, among others, physical health Additionally, ophthalmology and physician wellbeing are residency programs through the of paramount importance. Association of University Profes- Figure 3. The custom design of sors of Ophthalmology (AUPO) this shortened slit-lamp table The good news is that increased can consider adding ergonomic and allows the examiner to get closer awareness of the impact and wellness concerns to the teaching to the patient, reducing stress on incidence of MSDs on oph- curriculum. There is a clear need the neck. thalmologists has led to action to involve young members of the across several fronts. Industry Academy in the development of a has demonstrated keen inter- comprehensive ergonomic program est in the subject by redesign- that will benefit all age groups. ing workspace products, such as improved stools, and by develop- REFERENCES: ing tools for “heads up” surgery. 1. Kitzmann A.S. et al. Ophthal- New microscope concepts can be mol. 119, 213-220 (2012) expected to help save the necks 2. Dhimitri K.C. et al. Am. J. Oph- and backs of eye surgeons. thalmol. 139, 179-181 (2005) Moreover, the Academy has 3. Marks J.L. Ophthal- shown interest in resurrecting mol. 119, 211-212 (2012) the now-inactive Ergonomics 4. Wallace B. R. J Cataract Refract Task Force and there are plans Surg. 25, 753-762 (1999) Figure 4. Poor posture at the for the SO and Young Ophthal- operating microscope can affect 5. Eckardt C. and Paulo E.B. mologist (YO) Committees to col- the neck and spinal column. Retina 36, 137-147 (2016) 14 The Present Crises in Confidence published books that converge on these topics, but could not be more With Medicine different in style, content and tone.

By Alfredo A. Sadun, MD, PhD THIS IS GOING TO HURT: THE SECRET DIARY OF hysicians in the U.S. are every time we fail to look at our A JUNIOR DOCTOR going through a trying time. patients due to our preoccupa- By Adam Kay (2019) P We see a great deal of tran- tion with the computer screen sition in workstyle, in culture and and the EMR. Our differential This is an international best- in our medicine zeitgeist. The cor- diagnosis, once a complicated seller that describes the life poratization of medicine has gen- calculus and an expression of the of Adam Kay as he was train- erated a tidal wave of frustration. art of considering the common, ing and working in the United the severe and the urgent, is now Kingdom as a house staff officer. We are witnessing a great shift largely driven by what bills best. The book is hilarious. We learn in our culture further distancing about the trials of young doctors us from the classical doctor-patient How did we get here? What in training though, in this case, relationship to that of being part lessons can we take from physi- it’s through the lens of social- of a business and even more so, of cians from the past? What about ized medicine in the U.K.: the being an employee. We sense that other health care systems in other National Health Service, or NHS. we have become a small cog in a countries? How can we best cope? It is largely about how big mod- very big machine. Changes in tech- And perhaps as important, can ern medicine and health care nology have also impacted how we we take some refuge in humor? delivery systems are and how think as well as practice medicine. These and similar questions small a doctor can feel. Much I have a particular perspective have been addressed by recently of this is the same in the U.S. as a neuro-ophthalmologist who The book is a journal. His diary mourns our lost habit of analytical entries were sometimes very thinking. It’s much easier to just short, but very comical too. order more tests. We are con- Shocking, brutal and often stantly reminded that time sad, but almost always is money, and medical funny. You follow his organizations, wheth- life along through er HMOs, hospital his clinical train- based or academics, ing. Despite the put a premium side-splitting on throughput. humor, you Efficiency comes can feel his at many costs, slow descent including that into burnout. doctors should Fortunately, now minimize just when you socializing with think that his the patient. writing is too Overshadowing bitter, his humor all this is the big saves it all, for issue of electronic a time. Consider medical records this quote from (EMR). EMRs are Kay when he was advertised as optimiz- asked what is it like ing patient care, providing to go to medical school efficiency, screening medical and then clinical training. oversights and mistakes and giv- “So I told them the truth: the ing us data for epidemiology. Alfredo A. Sadun, MD, PhD, visits hours are terrible, the pay is ter- Perhaps. But in fact, the cyni- the remains of the ancient Greek rible, the conditions are terrible; cal reality is that EMRs were temple/hospital of Asclepius you’re underappreciated, unsup- designed mainly for one thing: (circa 500 BC) in the ancient city ported, disrespected and frequent- the maximization of billing. We, of Troezen located in the North- ly physically endangered. But as physicians feel this cynicism eastern Peloponnese, Greece. there’s no better job in the world.” 15 The Present Crises in THE RHETORIC OF MEDICINE: main goal was to examine how Confidence With Medicine LESSONS ON PROFESSIONAL- physicians worked and competed ISM FROM ANCIENT GREECE in the pre- and early-classical Kay’s book provides insights By Nigel Nicholson and Greek periods of about 550 to into how the U.K.’s NHS works Nathan R. Selden (2020) 400 BC. This was the period that in showing us what the life of conceived the Hippocratic Oath. a junior doctor there is like. It Before reflecting on this book’s The authors felt that in examin- describes a life not dissimilar to content, it’s important to under- ing this time and place, we might that of what interns, residents and stand something about the two gain instruction for modern medi- fellows in the U.S. go through. In authors. They are scholars. cine as practiced in the West. the U.K., training is probably even tougher. After all, our U.S.-based Jumping to the meat of their Accreditation Council for Gradu- Evidence-based issues, they tell us about how some ate Medical Education (ACGME) ancient Greek physicians worked has made a number of changes medicine had a primarily for money and status. following the famous Libby Zion Even in ancient Greece, there were legal case, whereby a civil law- form of its own, physicians who saw medicine as a suit was made against a New business and used their advantage York hospital blaming a patient’s in ancient Greece, for personal gain. These physicians death on overworked residents. were also accused of selling snake oils, literally and figuratively. In the interest of full disclosure, and it pitched itself I was privileged and honored to Against this, many other physi- work for the ACGME as the chair against alternative cians made the case for profession- of the Resident Review Commit- alism. Ethics, values, and medical tee (RRC) for several years. Our medical approaches codes, were argued over and pre- ACGME has addressed the stresses scribed to the profession. This led and work hours of interns and to competition between groups, residents. As physicians know, the Nicholson is a classics profes- as well as collaborations that ACGME has limited work hours sor and an expert in ancient might have been to help restrict (to about 60 hours/week) and Greece. Selden is a neurosurgeon trade as much as providing for the limited continuous work without and past president of the Con- maintenance of ethical conduct. sleep for U.S. residents in train- gress of Neurological Surgeons. Evidence-based medicine had a ing. In the U.K., the NHS has not Their partnership in this enter- form of its own, in ancient Greece, yet done as much for junior doc- prise is, in itself, remarkable. and it pitched itself against alterna- tive medical approaches, even then. tors. Which brings us to one of the What these two attempt to do is main reasons Kay wrote the book. Related issues included the neces- address the zeitgeist of medicine sity for teaching and mentoring It was in response to the attitude from ancient times by telling us (and the expectation that students of Jeremey Hunt, who was, at the stories from antiquity. They use show respect and gratitude to those time, the Health Secretary for the the term rhetoric to use this pro- that supervised their professional U.K. Hunt claimed that physicians cess in consideration of the social development). To what extent did in the NHS were “greedy” and did and ethical issues experienced the physician act on his own, or not have the right to complain by ancient Greek physicians and within the context of his profession about their terrible work condi- patients. Hence, we can compare and the needs of his colleagues? tions and hours (many were work- and contrast these issues to those ing 90 hours/week). Kay uses the confronting modern physicians This was also a time when Greek book as a form of rebuttal. (More and patients. Particularly interest- culture was obsessed with athlet- will be said about Kay’s important ing is the common perspective ics. Consequently, the physician points after these book reviews.) of needing to support physi- was regarded as an important cian wellness, then as now. resource in helping the athlete The specific stories of Kay as a with information regarding house officer in ob/gyn lends the This book occasionally drifts to training, diet and the treatment book credulity and the sense that the pompous and pedantic. That of injuries. It was interesting to it’s only a little exaggerated. Kay’s might be expected, as the authors me to see that even then there book, for me, has a sad conclusion are both academics and intellectu- was competition between physi- as he ends his medical career and als. They support every argument cians and athletic trainers. moves on to become a comedian, with evidence, and often do so TV writer and producer. At least repetitively. It is good scholarship, Their rhetorical approach dem- he kept some of his skillset. but sometimes a bit tedious. Their onstrated that the problems we are 16 The Present Crises in put it down, thus spoiling my only ues and administrative stupidity Confidence With Medicine vacation as an intern. Though have both hindered the efficient the book was satire, it touched application of medicine and also confronting in modern American on many truths, and I was frus- undermined compassion and the medicine are not so new. I was trated by the same sorts of insti- individual physician’s autonomy. amazed to read several excerpts tutional absurdities. “The House from ancient Greek physicians that of God” revealed to me some By now, you will recognize these I regard as lessons. As an example, personal rage I didn’t know I had. themes from the first two books the ancients taught the value of I’ve reviewed. Only Shem takes removing the physician as a par- everything too far. Sometimes ticipant when writing the medical This is a story, it works, and you laugh. Other note by writing in the third and times, it’s just silly. Shem shows not the first person. Third-person particular sensitivity to the subject clinical notes lessened the physi- like the first, of of physician health and burnout. cian’s emotional ownership and When he’s funny, we feel a little was designed to reduce physi- institutional evils. relief from our own miseries. But at cian burnout. This was recom- other times, he’s preaching a return mended 2,500 years ago! Shem points out to medical ethics, values, compas- sion and sensibility that we know One interesting and scholarly and condemns is improbable. One of his medical point of the professors, is that students is a computer whiz who ancient Greek doctors found corporate greed, manages to disable the entire EMR themselves at a crossroads. They system. Not only do the patients were about to break from their ver- get better, and the physicians feel sion of superstition-laden ancient bureaucratic idiocy, better off, but productivity and medicine to their form of modern even billing improves. Eventu- medicine. Likewise, we are at a branding and the ally, of course, the EMR system crossroads with the introduction is fixed and everything returns of modern technology and new newest disaster in to the abysmal state of serving ways of delivering medicine. only one real end: The maximi- medicine, the EMR zation of profit for the hospital At the core then, as now, was system. You laugh and you cry. the question of a physician’s iden- tity. How did a physician meet Shem almost did it again. In Taken together these three the demands and needs of his his new novel, he picks up the books explore identical issues patients, of society, and of his story 40 years later with the same but from very different points of teachers, against personal needs characters and the same outra- view. Like the authors, we fear that included money, status, health geous satire. This time, the title these changes, we try to avoid and the challenges of aging? character Basch and his colleagues burnout, and we mourn the loss are late in their careers as physi- of humanity in medicine. We Remarkably, the profes- cians. They are brought back physicians must transition to the sors did not address these deep together to work in another medi- new way medicine is practiced in and complex issues on a meta cal center — formerly known as the U.S., and in that crossing find level. Rather, they examined the MBH (not MGH), which formerly our North Star again. We must mundane, everyday practices of stood for Man’s Best Hospital. But learn to cope with EMRs, with medicine. That made the book now, national rankings are every- the corporatization of medicine and the ancient Greek zeitgeist, thing and it has fallen to fourth. and with all the other issues of much more approachable. health care delivery as it is today. This is a story, like the first, of All the while, we must keep our MAN’S 4TH BEST HOSPITAL institutional evils. Shem points out old values of prioritizing patient By Samuel Shem (2019) and condemns corporate greed, care, compassion and taking pride For young doctors of my genera- bureaucratic idiocy, branding and in our own work and profession. tion, Samuel Shem’s (pen name the newest disaster in medicine, the EMR. While the interns and So, we struggle to find a new of Stephen Bergman) “The House compass for these uncharted of God,” was a watershed event. residents of “The House of God” were powerless, the attendings of waters, pointing us to the central “The House of God” came out “Man’s 4th Best Hospital,” seem value, which remains the precious- during my internship in medicine less sympathetic. But it’s still ness of life. It is a challenge. For funny and we are still outraged me, humor, as exemplified by these in 1978. I found myself shaken to 17 the core by this book. I couldn’t by how politics, corporate val- books, is part of the solution. BOOK REVIEWS by the U.S. military or large audi- What We’re Reading This Spring 2020 ences. Local newspapers didn’t Book Review Editor, Thomas S. Harbin, MD, MBA report the Wrights’ accomplish- ments. Ultimately the Smithsonian enior ophthalmologists build a biplane. They were fre- Institute was embarrassed, as it had share the best of what they’re quently back in their hometown experimented with expensive, gov- Sreading this Spring. Share of Dayton, Ohio to redesign and ernment-funded flights that flopped what you’re reading and send sometimes rebuild damaged plane into the Potomac River after being your review to [email protected]. parts. Their love of reading, tin- launched in Washington. But the kering and experimentation led French government and early them to build and pilot the first French aviators cooperated with powered machine. They were cou- the brothers. Wilbur demonstrated rageous yet cautious. Until their many flights near Paris in front last few flights, they would never of famous Europeans, including travel up in the plane together but kings and queens. His record- instead take turns transporting breaking flights in France lead to a other passengers into the sky. hero’s welcome back in America. The thread that connected the Wright brothers’ love of bicycles to the construction of a plane was the fundamental principle of main- taining equilibrium or balance. The book doesn’t dig deeply into the engineering and aerodynamic principles of flight, but the reader is given a description of wing warp- ing, which the Wrights learned from watching giant seabirds soar The Wright Brothers over the beach. Wing warping by David McCullough was a precursor to the aileron, a Reviewed by: John R. hinged panel on the wing’s edge. Stechschulte, MD Once the brothers gained steady balance of a glider, they felt confi- This history book tells the story dent that they would soon conquer of two brothers who dreamed to sustained flight. They only needed fly like the birds. In accomplish- to add power, which proved to be ing manned flight, they taught the a mere 12 horsepower engine. The Second Mountain: nation much about aviation while The Quest for a Moral Life fascinating the entire world. By David Brooks Reviewed by: M. Bruce I enjoyed the audiobook, Their love of Shields, MD recorded by the author David McCullough, because it was reading, tinkering A senior person reading this book like listening to my grandfather may find the concept of a “second tell a story. His voice, though and experimentation mountain” to be quite familiar. It is, raspy, made the pronunciation as author David Brooks describes of numerous early French avia- led them to build it, the journey we take after reach- tors’ names very distinctive. ing the top of one mountain and finding the view less than satisfy- Wilbur and Orville were and pilot the first ing. Our first mountain, or first inseparable brothers with fairly half of life, includes years devoted unremarkable personalities. Yet powered machine. to education, career, family and our McCullough’s descriptions of their quest for success and happiness. family, home and bicycle shop leads Of course, there is nothing wrong the reader to understand how their The Wright brothers repeatedly with that. In fact, the most fulfilled quiet, intense single-mindedness offered their technology to the people are those whose lives begin and humility led them to succeed. U.S. government. But the govern- with a single mountain. But there They went to windy Kitty Hawk, ment declined their offers because comes a time when other centered- 18 NC, to develop gliders and then the flights had not been witnessed ness becomes more important than BOOK REVIEWS

What We’re Reading The initial cost is high, but after ic father. The book also delineates joining their list you’ll receive the dehumanizing effects of war and self-centeredness, and interdepen- offers for courses at greatly reduced explains the anger and guilt that dence trumps independence. That’s prices. You’re sure to find some- defined the author’s post-military when we realize that there’s a second thing of interest in their collec- life. O’Brien’s writing skills allow mountain waiting to be climbed. tion of more than 500 courses. him to avoid the maudlin sentimen- And we embark on a new journey. tality inherent in any such project. Brooks suggests that we live in a O’Brien now teaches creative society that has taken freedom and writing at Lyndon Johnson’s alma individualism to such an extreme that it endangers the moral fabric of our culture. He describes four com- mitments that will help us achieve a This gentle book life of greater meaning and purpose — and reach the second mountain. would make a Those are the commitments to spouse and family, to a vocation, to satisfying finale to a philosophy or faith and to a com- munity. Using real life examples, O’Brien’s illustrious he shows what can happen when these four commitments are applied career, as he seems and integrated. Our lives improve when we commit to a cause, root ourselves in a community and bind to have finally dealt to others in solidarity and love. Dad’s Maybe Book with the demons David Brooks has written By Tim O’Brien four other books on society and Reviewed by: J. Kemper unleashed by his culture, but this is his best. Campbell, MD Tim O’Brien is an accomplished military service in The Great Courses® writer with nine published books, www.thegreatcourses.com including his prize-winning novel, Southeast Asia Reviewed by: Thomas “The Things They Carried.” He A. Harbin, MD, MBA was featured in Ken Burns’ 2017 documentary, “The Vietnam mater, Texas State University. His The Great Courses® are techni- War.” O’Brien, like this reviewer, admiration for Ernest Hemingway’s cally not a book, but they’re great was drafted into the U.S. Army craft and his respect for the written for audible fans! When I’m in the in 1968 and his war experiences word are evident in this work. This car or working out, I enjoy listening defined the rest of his life, turn- gentle book would make a satisfying to a book — or, increasingly, to one ing him into a dedicated anti-war finale to O’Brien’s illustrious career, of these courses. When Bill Gates activist upon his discharge. as he seems to have finally dealt enthusiastically recommended with the demons unleashed by his “Big History: The Big Bang, Life on His latest work, “Dad’s Maybe military service in Southeast Asia. Earth and the Rise of Humanity,” Book,” took 15 years to write and In fact, the only discordant chapter by David Christian, I was hooked. celebrates another of life’s pivotal points: fatherhood. O’Brien became in the book is a bitter screed against The premise of the Great Courses a first-time father of two sons at age the evil released by war within is that they search for the best lec- 56. His new book is essentially a the hearts of those who wage it. turers across an array of disciplines love letter to those now-teenagers, This book will resonate with any and subjects, and ask those experts containing the musings and wisdom parent who lies awake at night pon- to record a lecture series. The of a septuagenarian dad who real- dering the meaning of existence series is then available in an audio izes he may not be able to shepherd and the sort of legacy that should or video format. To a large part, his offspring into full adulthood. be left behind. O’Brien’s sons are they succeed. I have listened to The text meanders across the years fortunate. Macho readers should lectures on various topics, includ- of O’Brien’s life, describing wry be forewarned to have a few tis- ing infectious diseases, extreme incidents related to his precocious sues handy for the final chapter, as weather, George Orwell, emergency progeny and vignettes from his own the room may become a bit dusty. medicine, music and history. childhood with a loving but alcohol- 19 Academy Foundation Update

News from the Foundation By Gregory L. Skuta, MD, Chair, Foundation Advisory Board

t is with deep appreciation for port vital Academy programs. the work you do and your gen- erosity to the foundation that This year, we are thrilled to I celebrate David J. Noonan, for- we send this update. On behalf of myself and the foundation mer Academy deputy executive team, we recognize the COVID-19 vice president. To make a trib- health crisis as a pivotal landscape ute gift and have your message of our lifetime. This is a time of included in the Orbital Gala uncertainty and challenge for all booklet, visit aao.org/tribute. of us, especially our members. Purchase tickets after June This Scope article provides you Jay M. Galst, MD, at the donor 17 at aao.org/foundation. with information about our work preview reception, Truhlsen- Marmor Museum of the Eye, San at the foundation, which pre- $1 MILLION REMAINING TO Francisco, Oct. 2019. dates the COVID-19 pandemic. COMPLETE THE NEW MUSEUM

MARK YOUR CALENDARS In late 2017, the foundation IN MEMORIAM: JAY M. GALST, FOR THE ORBITAL GALA launched a campaign to raise MD, OPHTHALMIC HISTO- DURING AAO 2020 $12 million for a new, brick-and- RIAN AND MUSEUM PATRON mortar museum at Academy head- Save the date and join us for quarters. Two generous gifts from The Foundation is saddened by the 17th annual Orbital Gala on members Stanley M. Truhlsen, the loss of our friend and colleague, Nov. 15 at the Venetian Resort, MD, and Michael F. Marmor, MD, Jay M. Galst, MD, to COVID-19 in Las Vegas. At this year’s vintage challenged our members, industry April. Dr. Galst was an avid sup- Vegas-themed gala, you will dine, and private philanthropists alike porter of the Academy’s Museum dance and celebrate friendships to join in this endeavor. We are of Vision (now Truhlsen-Marmor amidst the high-rolling luxury of delighted to have reached over $11 Museum of the Eye) since 1985 the Venetian Resort Hotel. Bid on million toward our goal to date! and was serving as co-chair of the one-of-a-kind auction treasures Acquisitions Subcommittee. An at this 18-karat fundraiser to sup- Your generosity allows us to avid ophthalmic historian, Dr. build a world-class Truhlsen- Former Academy deputy execu- Galst worked on the board of the Marmor Museum of the Eye™, tive vice president, David J. Cogan Ophthalmic Historical Soci- featuring the latest technol- Noonan, will be celebrated at the ety and was a past president of the ogy. Visitors will be especially 2020 Orbital Gala. Ocular Heritage Society. His book, enthralled with our virtual real- Ophthalmologia, Optica Et Visio in ity (VR) headsets. Created by the Nummis, details an extensive histo- Academy’s eLearning team for ry of ophthalmic coins and medals. U.S. ophthalmology residents, the educational VR experiences We hope you will honor Dr. demonstrate the visual pathway of Galst with a gift at this time to a human eye and show how new the museum, a project that was technology can impact medicine. so near and dear to him. To make a donation in his memory, We offer a variety of opportuni- please visit aao.org/donate. ties and ways to give. Visit aao. org/museumcampaign. Ques- We wish you the best as you tions? Contact the foundation’s keep yourselves, your loved executive director, Tina McGov- ones and our communities safe. ern, at [email protected]. Please feel free to reach out to me any time at [email protected]. 20 Senior Ophthalmologists in SCOPE The Senior Ophthalmologist the Time of COVID-19 Newsletter By John R. Stechschulte, MD

Ideas and opinions expressed in Scope are those of the authors and editor and do not necessarily reflect any position of the Ameri- t’s hard to fathom that the lives to the COVID-19 pandemic. The can Academy of Ophthalmology. Iof nearly 8 billion people on survey results show that practices the planet could be simultane- anticipate being nearly or fully ously threatened — and their daily closed for three to five months and routines and economies so dras- that a majority of practices will Scope Editorial Board tically impacted in such a short be smaller by the end of the year. Editor Emeritus time — as we witness during the The findings indicate that in the David W. Parke, MD current COVID-19 pandemic. We absence of substantive federal eco- in ophthalmology are but a tiny nomic relief and support a small Editor microcosm of what is transpiring percentage of ophthalmologists M. Bruce Shields, MD across the globe. The Academy is will consider stopping practice. Associate Editors carefully assessing the fallout to Thomas S. Harbin, MD, MBA our patients and to our profes- This information means that Alfredo A. Sadun, MD, PhD sion, and developing resources to a number of ophthalmologists, assist its members. But what has especially those older than 60, may History of Ophthalmology soon have a change in career. Will Editor become clear is that age is a sig- Daniel M. Albert, MD, MS nificant risk factor for the disease more of us retire or semi-retire and may also have specific negative in 2020? Will more doctors leave Assistant Editor personal and economic effects on smaller practices to join larger Neeshah Azam senior ophthalmologists (SOs). practices or academic institutions? Will some doctors seek medical Design Samuel Masket, MD but non-ophthalmological careers Jim Frew Chair, SO Committee such as in administration? Will 2020 Senior Ophthalmologist senior doctors who have sold Committee In April, the Academy con- their practices to private equity Samuel Masket, MD, Chair ducted a member pulse survey companies regret the decision Laurie Gray Barber, MD of U.S. practicing ophthalmolo- to sell? Is it possible that some Marcia D. Carney, MD gists in private practice to gauge of us will take on totally new Marguerite B. McDonald, MD the response of private practices careers outside of medicine? Aaron M. Miller, MD, MBA Secretary for Member Services In the April 10 issue of the Jean E. Ramsey, MD, MPH Houston Chronicle, ophthalmolo- Alfredo A. Sadun, MD, PhD Coronavirus Updates gist Belu Allam, MD, FACS, 66, M. Bruce Shields, MD for Ophthalmology said, “I would like to stay with the John R. Stechschulte, MD Read the Academy’s group but I’m at risk for catch- latest ophthalmology- ing the coronavirus and this may Academy Staff specific information on go on for several months.” She Neeshah Azam the new coronavirus at and several members of Houston Gail Schmidt aao.org/coronavirus. Eye Associates will retire soon. The Academy may address other Share Your practice changes in future pulse COVID-19 and surveys on COVID-19. Members Ophthalmology Story of the SO Committee encour- The COVID-19 pandemic age you to guide the Academy has changed how and your colleagues by sharing ophthalmologists are living your practice experiences and any their lives, running their resources that you have found P.O. Box 7424 practices and treating their San Francisco, CA helpful. Please send material to the 94120-7424 patients. The Academy SO Committee at [email protected] and wants to share your stories. we may feature your story in Scope. T: +1 415.561.8500 aao.org/senior-ophthalmologists 21