Women in Ophthalmology: A Comprehensive Guide for Career and Life 3030593347, 9783030593346

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Women in Ophthalmology A Comprehensive Guide for Career and Life Christina Y. Weng Audina M. Berrocal Editors

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Women in Ophthalmology

Christina Y. Weng Audina M. Berrocal Editors

Women in Ophthalmology A Comprehensive Guide for Career and Life

Editors Christina Y. Weng Department of Ophthalmology Baylor College of Medicine Houston, TX USA

Audina M. Berrocal Bascom Palmer Eye Institute University of Miami Hospital Miami, FL USA

ISBN 978-3-030-59334-6    ISBN 978-3-030-59335-3 (eBook) https://doi.org/10.1007/978-3-030-59335-3 © Springer Nature Switzerland AG 2021 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

To my mother and father, for always believing in me. To my mentors, with whom I share every one of my successes. –Christina Y. Weng

This book is dedicated to my great grandmother Audina, a woman who in the early 1900s in the small town of Loiza, Puerto Rico, understood the importance of education. She worked as a seamstress to pay for the education of all her children, both her sons and daughters. For her vision, sacrifice, and hard work, Gracias. To all the women who have come into my life for a short time or a long time. To those who have taught me how to be and those who have taught me how not to be. To all my residents and fellows who have taught me so much about ophthalmology, retina, surgery, teaching, mentoring, and simply about myself, Gracias. To my husband Steve and my children Julia, Pablo, and Sofia who have understood the importance and value of my profession and who never once resented my not being there, Gracias. To my brother, who I miss every second of my life, my first mentor and supporter. The one who taught me to aim high, work hard, and then work harder, Gracias. To my sister, who has been the greatest example of everything a woman can be! The woman who is always there with the greatest, most logical advice about life, work, motherhood, relationships, and surgery, Gracias. To my niece and nephew, who exemplify what family is all about, Gracias. To the woman who has taken care of my children when I was not there, Aura, Gracias. To Lucy and Catherin, simply Gracias. To Marisa, Sandra, Ysa, Laura, and Bachi, amor verdadero y del bueno! Gracias. To my mom and dad, for they are the essence of it all, my forever love and gratitude. –Audina M. Berrocal

Memoriam In loving memory of our friend and colleague Mina M. Chung, MD (1968–2020)

Preface

Last week, I happened to be walking through our OR’s patient waiting room wearing my white coat and scrubs when I saw a mother sitting in the corner with her two young daughters. “Look! A lady eye surgeon!” she whispered to them, as she discreetly pointed in my direction. I smiled. Partly because I appreciated the effort this mother made to encourage her young girls that they could grow up to be anything they wanted, lady eye surgeon or otherwise. And partly because, on that Monday morning, it reminded me who I am. Until around residency, I have to admit that I never thought of gender as part of my core identity in the workplace. I was fortunate enough to be raised in a household with plenty of strong women including my mother who was the equivalent of a superhero to me when I was growing up. Watching her is how I learned that it was possible to run a family practice and run a family at the same time. Credit is also due to my father, a general surgeon, who always supported my penchant for his craft. I am grateful that he patiently answered the numerous questions I asked while flipping through his anatomy books as a child. But I am even more grateful that he never made me think, not even for a moment, that my potential as a future surgeon was any less as his daughter than what it would be as his son. It was not until after medical school when I realized how much emphasis society placed on gender as part of my professional persona. As an intern rotating on general surgery, I constantly heard the phrase “female surgeon”; interestingly, male surgeons were simply referred to as “surgeon”. I thought this might go away in a more gender-balanced field like ophthalmology, but I lost track of the number of times I was mistaken for a nurse during my residency. And perhaps the time I became most cognizant of being female was during my surgical retina fellowship as I entered a historically male-dominated subspecialty. Comments like, “It is so great to see a woman going into retina,” reminded me that even though I might not associate my gender with who I am professionally, other people do. In 2017, 41.2% of ACGME (Accreditation Council for Graduate Medical Education) ophthalmology residency positions were filled by women [1]; this percentage will likely increase in parallel with the shift in medical student demographics. In a recent historical first, female medical students outnumbered their male ix

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counterparts [2]. Despite this narrowing gap in our classrooms and training grounds, gaps in other places persist. They persist in the upper echelons of journal editorial and professional society boards [3], senior authorship of peer-reviewed publications [4, 5], full professor academic positions [6], surgical case volume in training [7], Medicare payments [8], and industry ties [9]. The reasons behind these gender-­ based disparities are most certainly multifactorial and need to be further explored. Thus, it is encouraging that recent years have brought a heightened awareness of these issues. In some areas, disparities are even starting to diminish [10]. Just remember that progress and shortfall are not mutually exclusive. While we have come a long way in terms of gender parity, there is still a ways to go. But we will get there, and we will get there even faster by supporting one another. Our overarching goal here was to put together a book written primarily from the unique viewpoint of women in ophthalmology, but with content that would benefit our male and female colleagues. When I think about how I arrived at my current point, I am truly indebted to moments of mentorship that have collectively shaped my career: the after-work phone call to review a surgical technique, the 10-minute coffee break between meeting sessions to discuss career advancement, and the encouraging text received after an important podium presentation. This book attempts to compile all of those moments of mentorship so that they can be shared widely among us. Its chapters focus on a plethora of different topics—from publishing your research to parenting during training—and are penned by some of the most well-respected and accomplished leaders in ophthalmology. I am truly grateful to all of them for contributing their invaluable insights as I am to my co-editor, Nina Berrocal, who has been a dear mentor and friend since my fellowship days in Miami. Dr. Berrocal has fostered my personal and professional growth directly, but just as much so indirectly. For me and many of my female contemporaries, she exemplifies what a powerful concept “seeing is believing” can be. When we see our role models speak on the podium, or raise families while maintaining a productive career, or voice their opinions publicly, or lead large organizations, we believe we can too. And so we present to you this collection of personal narratives—stories that embrace triumphs, struggles, wisdom, missteps, and lessons learned—told by our sisters and friends (thank you, Dr. Oetting!) in ophthalmology. The female lens being used here is special and important because while all of us in ophthalmology share commonalities, there are undeniable differences in the approaches, experiences, and perspectives between men and women. And not only is that okay, it’s a wonderful thing that brings brilliance and diversity to our field, our patients, our world. This book celebrates that; we hope you enjoy it. Oh, and to finish my story from that Monday morning—I walked over to that mother with her two young daughters, knelt down on the waiting room floor, and introduced myself to them. Because seeing is believing. Houston, TX, USA

Christina Y. Weng

Preface

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References 1. Association of American Colleges. Active physicians by sex and specialty. Accessed Apr 2020. https://www.aamc.org/data-reports/workforce/interactive-data/ acgme-residents-and-fellows-sex-and-specialty-2017. 2. Association of American Colleges. Active physicians by sex and specialty. 2019 Fall applicant, matriculant, and enrollment data tables. Accessed Apr 2020. https://www.aamc.org/system/ files/2019-12/2019%20AAMC%20Fall%20Applicant%2C%20Matriculant%2C%20and%20 Enrollment%20Data%20Tables_0.pdf. 3. Camacci ML, Lu A, Lehman EB, Scott IU, Bowie E, Pantanelli SM. Association between sex composition and publication productivity of journal editorial and professional society board members in ophthalmology. JAMA Ophthalmol. 2020;Epub ahead of print. 4. Mimouni M, Zayit-Soudry S, Segal O, et al. Trends in authorship of articles in major ophthalmology journals by gender, 2002–2014. Ophthalmology. 2016;123(8):1824–8. 5. Kramer PW, Kohnen T, Groneberg PA, Bendels MHK. Sex disparities in ophthalmic research: a descriptive bibliometric study on scientific authorships. JAMA Ophthalmol. 2019;Epub ahead of print. 6. Lopez SA, Svider PF, Misra P, Bhagat N, Langer PD, Eloy JA.  Gender differences in promotion and scholarly impact: an analysis of 1460 academic ophthalmologists. J Surg Educ. 2014;71(6):851–9. 7. Gong D, Winn BJ, Beal CJ, et al. Gender differences in case volume among ophthalmology residents. JAMA Ophthalmol. 2019;Epub ahead of print. 8. Reddy AK, Bounds GW, Bakri SJ, et al. Differences in clinical activity and medicare payments for female vs. male ophthalmologists. JAMA Ophthalmol. 2017;135(3):205–13. 9. Reddy AK, Bounds GW, Bakri SJ, et al. Representation of women with industry ties in ophthalmology. JAMA Ophthalmol. 2016;134(6):636–43. 10. Charlson ES, Tsai L, Yonkers MA, Tao JP. Diversity in the American Society of Ophthalmic Plastic and Reconstructive Surgery. Ophthalmic Plast Reconstr Surg. 2019;35(1):29–32.

Acknowledgments

First and foremost, thank you to each of our contributing authors for sharing your time and your stories. The wisdom you have provided will undoubtedly benefit our colleagues, present and future. We are incredibly grateful. We appreciate Springer Publishing and its team for providing us the opportunity to create a collective narrative in this unique way. Special thanks to Caitlin Prim for helping us transform this book from concept to reality and to Abha Krishnan for all of her efforts in this production. –Christina and Nina

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Contents

Part I Education and Training 1 The Beginning: Match and Residency ��������������������������������������������������    3 Bryn Burkholder 2 Choosing a Fellowship and How to Stand Out��������������������������������������   11 Ashley Brissette Part II Starting Your Career 3 How to Get a Great Position in Private Practice����������������������������������   19 Allison N. McCoy 4 Finding a Great Job in Academics����������������������������������������������������������   29 Bonnie An Henderson 5 As You Start a Career in Academic Medicine: Priming for Success������   35 Judy E. Kim 6 Starting Your Own Practice��������������������������������������������������������������������   43 P. Dee Stephenson 7 Building Your Clinical Practice and Reputation����������������������������������   49 Geeta Lalwani Part III Patient Care 8 Staying at the Forefront of Your Field: Embracing the New ��������������   57 María H. Berrocal 9 Improving Efficiency with EMR in Your Clinic and OR ��������������������   63 Ariane Dev Kaplan

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10 Dealing with Complications and Avoiding Medicolegal Issues������������   69 Caroline R. Baumal 11 Handling the Unexpected in Ocular Surgery����������������������������������������   77 Lisa M. Nijm Part IV Research 12 The Ins and Outs of Clinical Trials��������������������������������������������������������   87 Jennifer I. Lim 13 Becoming a Successful Clinical Trialist�������������������������������������������������   97 Diana V. Do 14 How to Successfully Publish and Present Your Research��������������������  101 Natalie A. Afshari and Rebecca R. Lian 15 Publishing and Presenting Clinical Research����������������������������������������  111 Sophie J. Bakri Part V Teaching 16 Delivering an Engaging Lecture ������������������������������������������������������������  119 Wendy W. Lee 17 Teaching in a Busy Clinical Setting��������������������������������������������������������  123 Kara M. Cavuoto 18 Teaching Surgery ������������������������������������������������������������������������������������  129 Audina M. Berrocal Part VI Dealing with Conflict 19 Sexual Harassment in Ophthalmology��������������������������������������������������  139 Laura B. Enyedi and Michelle T. Cabrera 20 Managing Conflict in the Workplace ����������������������������������������������������  149 Ruth D. Williams 21 Experiencing Health Issues as a Physician��������������������������������������������  157 Ann Ulmer Stout Part VII Family Matters 22 Romantic Relationships��������������������������������������������������������������������������  165 Lisa C. Olmos de Koo 23 Parenting During Training����������������������������������������������������������������������  173 Sara Fransen Grace

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24 Motherhood and Medicine����������������������������������������������������������������������  179 Tracy Kangas 25 Professorship and Parenthood����������������������������������������������������������������  187 Sharon D. Solomon 26 Balancing Academic Career and Parenthood: Ten Thoughts and One Bonus on Success����������������������������������������������������������������������  195 Carol L. Shields 27 Dual Professional Career Relationships������������������������������������������������  203 Jane C. Edmond Part VIII Leadership 28 Leadership for Young Ophthalmologists ����������������������������������������������  211 Purnima S. Patel 29 Preparing for Service in Whatever Comes Your Way��������������������������  221 Cynthia A. Bradford 30 How to Be an Effective Fellowship Program Director��������������������������  229 Hilda Capó 31 Keys to Public Speaking��������������������������������������������������������������������������  235 Ripple Kakkar Part IX Career Advancement 32 Getting Promoted to Associate Professor����������������������������������������������  245 Christina Y. Weng 33 A Less-Paved Road: Switching Careers and Taking an Unorthodox Path��������������������������������������������������������������������������������������  253 Anne E. Fung 34 Setbacks and Second Chances����������������������������������������������������������������  261 Tamara R. Fountain Part X Working with Industry 35 Collaborating with Industry ������������������������������������������������������������������  269 Nancy M. Holekamp 36 Why Industry Values the Female Perspective ��������������������������������������  277 J. Nicole Sheeler 37 Demystifying Pharma and BioTech: Applying Ophthalmology to Make New Tools ����������������������������������������������������������������������������������  283 Anne E. Fung and Jayashree Sahni

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Part XI Work-Life Balance 38 Work-Life Balance and Avoiding Burnout��������������������������������������������  299 Camille V. Palma 39 Making the Most Out of Academic Meetings����������������������������������������  309 Janice C. Law 40 Social Media and Privacy Issues������������������������������������������������������������  319 Maryam Nazemzadeh Part XII Personal Finances 41 Setting the Course for a Successful Future with Better Financial Planning ����������������������������������������������������������������������������������  329 Cynthia Matossian 42 Personal Finances and Career Decisions ����������������������������������������������  335 Linda M. Christmann Part XIII Mentorship and Networking 43 Effective Mentoring: A Guide for Mentors and Mentees��������������������  351 Sarwat Salim 44 Mentorship������������������������������������������������������������������������������������������������  359 Thomas A. Oetting 45 To Brand or Be Branded ������������������������������������������������������������������������  367 Alana L. Grajewski and Adriana L. Grossman 46 Promoting Yourself and Your Brand������������������������������������������������������  375 Priyanka Sood and Ghazala A. Datoo O’Keefe Organizations with Focus on Women in Ophthalmology/Medicine������������  381 Other Resources ����������������������������������������������������������������������������������������������  383 Index������������������������������������������������������������������������������������������������������������������  385

Editor Bios

Christina Y. Weng, MD, MBA  is an associate professor of ophthalmology and the Vitreoretinal Diseases & Surgery Fellowship Program Director at the Baylor College of Medicine in Houston, Texas. She has a faculty appointment at the Level 1 Trauma Center, Ben Taub General Hospital, where she is the director of Medical Student Clinical Electives and Physician Champion of the Diabetic Retinopathy Teleretinal Screening Program. She is a prior recipient of the Dan B. Jones Teaching Award. Dr. Weng graduated cum laude from Northwestern University and then went on to medical school at the University of Michigan where she was elected to the Alpha Omega Alpha (AOA) Medical Society. While in Ann Arbor, she pursued an MBA degree at the University of Michigan-Ross School of Business and graduated with high distinction. Dr. Weng completed her ophthalmology residency at the Wilmer Eye Institute, Johns Hopkins University, and surgical retina fellowship at the Bascom Palmer Eye Institute, University of Miami. Dr. Weng is involved with multiple clinical trials such as the DRCR Retina Network diabetic retinopathy trials and the AGTC Phase 1/2 subretinal gene therapy studies for congenital achromatopsia. Her other research interests include clinical/surgical outcomes, medical economics, healthcare quality metrics, and telemedicine. Dr. Weng is active in the American Academy of Ophthalmology (AAO), Retina Society, Association for Research in Vision and Ophthalmology (ARVO), xix

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and Vit-­Buckle Society. She serves on the board of directors for the American Society of Retina Specialists (ASRS), American Society of Cataract and Refractive Surgery (ASCRS), and Women in Ophthalmology. Audina  “Nina”  Berrocal, MD  received her under­ graduate education at Princeton University and her medical degree at Tufts University School of Medicine. She completed her ophthalmology residency at Tufts/ New England Eye Center and her fellowship in vitreoretinal surgery and uveitis at the Bascom Palmer Eye Institute, University of Miami Miller School of Medicine. Since completing her training, Dr. Berrocal has been a faculty member at Bascom Palmer, where she holds currently the rank of Professor of Clinical Ophthalmology. She also serves as director of the Pediatric Retina Service at Bascom Palmer Eye Institute and Jackson Memorial Hospital and as vitreoretinal fellowship director. Dr. Berrocal is internationally recognized for her approach to pediatric retinal diseases. As a pediatric retina specialist and director of the Pediatric Retina and Retinopathy of Prematurity (ROP) Service, she has extensive clinical, surgical, and research experience in the diagnosis and treatment of ROP. Dr. Berrocal has performed extensive basic science and clinical research in ROP and has co-­authored over 70 peer-reviewed papers on the topic. She received the Bernadotte Foundation Award for her work in ROP. Additionally, she maintains a robust adult vitreoretinal surgical practice. Dr. Berrocal is an active member of the Retina Society, the Macula Society, and Club Jules Gonin and holds leadership positions in many of these groups including the American Academy of Ophthalmology and the American Society of Retina Specialists. She is also a founding member of the Vit-­ Buckle Society. Dr. Berrocal is the recipient of the ASRS Crystal Apple Award for her dedication to surgical teaching and of the Bernice Z.  Brown Lecture Award for her dedication to the advancement of women.

Contributors

Natalie A. Afshari, MD  Ophthalmology, University of California San Diego, La Jolla, CA, USA Sophie J. Bakri, MD  Mayo Clinic, Rochester, MN, USA Caroline R. Baumal, MD  Tufts University School of Medicine, Boston, MA, USA New England Eye Center, Boston, MA, USA Audina  M.  Berrocal,  MD  Bascom Palmer Eye Institute, University of Miami, Miller School of Medicine, Miami, FL, USA María H. Berrocal, MD  Berrocal & Associates, San Juan, PR, USA Cynthia  A.  Bradford,  MD  Department of Ophthalmology, University of Oklahoma, College of Medicine, Oklahoma City, OK, USA Ashley  Brissette,  MD, MSc, FRCSC  Weill Cornell Medicine and New  York Presbyterian Hospital, New York, NY, USA Bryn  Burkholder,  MD  Wilmer Baltimore, MD, USA

Eye

Institute/Johns

Hopkins

Hospital,

Michelle T. Cabrera, MD  University of Washington, Seattle, WA, USA Hilda  Capó,  MD  Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA Kara M. Cavuoto, MD  Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA Linda  M.  Christmann,  MD MBA  Retired from LM Christmann Consulting, Bradenton, FL, USA Ghazala A. Datoo O’Keefe, MD  Emory University Department of Ophthalmology, Atlanta, GA, USA Diana V. Do, MD  Byers Eye Institute, Stanford University School of Medicine, Palo Alto, CA, USA xxi

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Contributors

Jane C. Edmond, MD  Department of Ophthalmology, Dell Medical School, The University of Texas at Austin, Austin, TX, USA Laura  B.  Enyedi,  MD  Departments of Ophthalmology and Pediatrics, Duke University, Durham, NC, USA Tamara  R.  Fountain,  MD  Department of Ophthalmology, Rush University Medical Center, Chicago, IL, USA Ophthalmology Partners, Ltd., Deerfield, IL, USA Anne E. Fung, MD  Genentech, South San Francisco, CA, USA California Pacific Medical Center/Pacific Eye Associates, San Francisco, CA, USA Medical Retina Consultant, Pacific Eye Associates, California Pacific Medical Center, San Francisco, CA, USA Global Development Lead – Port Delivery System, Ophthalmology Clinical Science, Genentech, Inc., San Francisco, CA, USA Sara Fransen Grace, MD  North Carolina Eye, Ear, Nose and Throat/Duke Health, Durham, NC, USA Alana L. Grajewski, MD  Bascom Palmer Eye Institute, Miami, FL, USA Adriana L. Grossman, MPH, MHA, MS  University of Miami Miller School of Medicine, Miami, FL, USA Bonnie An Henderson, MD  Tufts University School of Medicine, Boston, MA, USA Nancy M. Holekamp, MD  Pepose Vision Institute, Saint Louis, MO, USA Washington University School of Medicine, Saint Louis, MO, USA Ripple Kakkar, MHA  Retina Marketing, U.S. Commercial Eye Care, Allergan, an Abbvie Company, Irvine, CA, USA Tracy Kangas, MD, PhD  McFarland Clinic Eye Center, Ames, IA, USA Ariane  Dev  Kaplan,  MD  Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, University of Michigan, Ann Arbor, MI, USA Judy E. Kim, MD  Department of Ophthalmology and Visual Sciences, Medical College of Wisconsin, Milwaukee, WI, USA Geeta Lalwani, MD  Rocky Mountain Retina Associates, Boulder, CO, USA Janice C. Law, MD  Vanderbilt Eye Institute, Department of Ophthalmology and Visual Sciences, Vanderbilt University Medical Center, Nashville, TN, USA Wendy  W.  Lee,  MD  Oculofacial Plastic & Reconstructive Surgery, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA Rebecca  R.  Lian,  BA  Ophthalmology, University of California San Diego, La Jolla, CA, USA

Contributors

xxiii

Jennifer I. Lim, MD, FARVO  University of Illinois at Chicago, Illinois Eye and Ear Infirmary, Chicago, IL, USA Cynthia  Matossian,  MD, FACS  Matossian Eye Associates & CM Associates, LLC, Bucks County, PA, USA Allison  N.  McCoy,  MD, PhD  Sharp Rees-Stealy Medical Group, San Diego, CA, USA Maryam Nazemzadeh, MD  Sanctuary Cosmetic Center, Tysons Corner, VA, USA Rostami Oculofacial Plastic Consultants, Reston, VA, USA Lisa M. Nijm, MD, JD  Warrenville EyeCare and LASIK, Warrenville, IL, USA Department of Ophthalmology and Visual Sciences, University of Illinois Eye and Ear Infirmary, Chicago, IL, USA Thomas A. Oetting, MS, MD  University of Iowa, Iowa City, Iowa, USA Lisa C. Olmos de Koo, MD, MBA  University of Washington, Seattle, WA, USA Camille V. Palma, MD  Department of Ophthalmology, Cook County Health and Hospital System, Chicago, IL, USA Purnima  S.  Patel,  MD  Emory Unvieristy School of Medicine and Atlanta VA Medical Center, Atlanta, GA, USA Jayashree  Sahni,  MD  Roche Innovation Center Basel, F.  Hoffmann-La Roche Ltd., Basel, Switzerland Sarwat  Salim,  MD, FACS  Glaucoma Service, New England Eye Center, Tufts University School of Medicine, Boston, MA, USA J. Nicole Sheeler  RetinaLink, Fort Worth, TX, USA Carol  L.  Shields,  MD  Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, PA, USA Sharon  D.  Solomon,  MD  Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore, MD, USA Priyanka  Sood,  MD  Emory University Department of Ophthalmology, Emory University Midtown Hospital, Atlanta, GA, USA P.  Dee  Stephenson,  MD, FACS  American College of Eye Surgeons, Havertown, PA, USA Stephenson Eye Associates, Venice, FL, USA Ann Ulmer Stout, MD  Houston Eye Associates, Houston, TX, USA Christina Y. Weng, MD, MBA  Vitreoretinal Diseases & Surgery, Department of Ophthalmology, Baylor College of Medicine, Houston, TX, USA Ruth D. Williams, MD  Wheaton Eye Clinic, Wheaton, IL, USA

Part I

Education and Training

Chapter 1

The Beginning: Match and Residency Bryn Burkholder

Summary Points • Ophthalmology is a competitive subspecialty, and while there is not a single perfect formula to ensure a match, there are certain characteristics that successful applicants frequently share. • A trusted mentor can help you to navigate the application/match process, persevere through the challenges of residency, and plan for a future as a practicing ophthalmologist. • Residency is your opportunity to learn ophthalmology under the guidance of experienced teachers; being a proactive and self-motivated learner will help you make the most out of your residency experience.

Part I: Matching into an Ophthalmology Residency Program What Makes a Successful Applicant? There is not one perfect formula to ensure success of an individual applicant; each program is looking for something a little different in its future residents, and each applicant brings something unique to the table. However, there are certain characteristics that successful applicants frequently share. A survey of program directors and residency selection committee members from 2010 showed that the most important factors in evaluating an applicant are interview performance, clinical grades, letters of recommendation, and board scores [1].

B. Burkholder (*) Wilmer Eye Institute/Johns Hopkins Hospital, Baltimore, MD, USA © Springer Nature Switzerland AG 2021 C. Y. Weng, A. M. Berrocal (eds.), Women in Ophthalmology, https://doi.org/10.1007/978-3-030-59335-3_1

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While all-around academic performance—and, consequently, election to the Alpha Omega Alpha (AOA) Honor Medical Society—is important, many programs place the greatest emphasis on grades for medicine and surgery rotations. Ophthalmology electives are important for gaining exposure to the field and finding potential mentors, but keep in mind that medical school and internship are the only times you will have to explore other specialties and broaden your field of knowledge before focusing on ophthalmology. Consider doing several non-ophthalmology electives in medical school (and internship, if possible) to make you a more well-rounded physician. Electives such as neurology, otolaryngology, anesthesia, and radiology will have applications to ophthalmology that may help you in your future career. The United States Medical Licensing Examination (USMLE) Step I examination can be the source of significant anxiety for many medical students. While a poor performance on this test does not preclude you from matching in ophthalmology, it is certainly beneficial to perform well. Some programs (28.6% according to one survey) will use board score as screening tool, but if your score is not as high as you would like, keep in mind that the majority of programs view it as just one factor in the broader context of your entire application [1]. In 2020, the mean USMLE Step 1 score for matched applicants was 245, with a median of 247 [2]. Of note, the USMLE recently announced that, beginning no earlier than January 2022, the Step 1 examination will be graded on a pass/fail basis [3]. Away rotations may be helpful in a few situations—for example, if you have a strong interest in matching at a specific program. Conversely, there are reasons not to do an away rotation, and if you are a strong applicant without an interest in one particular program, doing an away rotation may be of little benefit—and may even be harmful—if you do not perform well. If you decide to do an away rotation, it would be beneficial to schedule it as early as possible, particularly if you hope to obtain a letter of recommendation from the rotation. Research experience before residency is not essential but may be extremely valuable if you hope to match at a top-tier program. Choose a project that has the potential to lead to a peer-reviewed publication. Research need not be in the field of ophthalmology; seeing a project to completion often holds more weight than the subject matter of the project. However, doing ophthalmology research increases exposure to the field and may provide material for discussion at interviews.

Finding a Mentor In medical school, as in life, a good mentor is an invaluable asset, and you should try to find one as early as possible in the application process. If your medical school has an ophthalmology department, then ideally your mentor will be an ophthalmologist, but a medical school advisor or other trusted faculty member can also serve this role. A mentor should be able to evaluate how competitive you are as applicant and, in doing so, provide some guidance on number and type of programs to which to apply. A mentor may also offer to advocate for you during the application/interview process.

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Similarly, if you decide to pursue fellowship training, you may wish to choose a mentor during residency from your chosen subspecialty field, as that person will have more specific advice and connections to help you navigate the fellowship match and your future career.

Letters of Recommendation You will need two letters from ophthalmologists and one from a non-­ophthalmologist. As someone who reviews applications, I usually have a good sense of how well the letter writer knows the applicant. I find that a letter from someone who clearly knows the applicant well is much more valuable than a letter from a more well-­ known or senior faculty member who knows the applicant only superficially. When making your request, consider asking the faculty member if they would be willing to write you a “strong letter.” Give your letter writers adequate time to produce the letter—I would recommend at least a month—and provide your curriculum vitae and personal statement to them at the time of your request.

Preparing Your Application The application is your opportunity to present your best self to potential residency programs; that being said, make sure it is your true self that is represented here. Never include false or misleading information, such as listing a publication as “in press” when it has not been accepted yet. Separate accepted/published work from ongoing projects, even if those projects are almost ready for submission. Know your publications very well; you will be asked about them on interviews. In the section about hobbies and outside interests, include only those activities which have a significant place in your life, and be prepared to talk about them in depth. Proofread your work extensively and ask a trusted person to review it as well. Above all, make sure you have spelled “ophthalmology” correctly! Finally, anticipate questions an interviewer might ask about your application and think about how you want to answer them.

Choosing Your Programs The application process can be expensive, so the goal is to apply to enough programs that you will secure an adequate number of interviews, but not so many programs that you will be wasting money. The good news is that the overall match rate has been relatively consistent at 72–78% over the past 10 years [2]. Despite this, the average number of applications/

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person has continued to steadily rise, from 50 in 2009 to 77 in 2020. A recent survey from 2013 to 2015 match data reports that 53% of applicants apply to more than 60 programs, and 27% apply to more than 80 [4]. Of note, the match rate is considerably higher for first-time US applicants than for international graduates and previously unmatched applicants. The authors conclude that US graduates who are first-time applicants with USMLE score >243 do not need apply to more than 45 programs to ensure a successful match. They also recommend that international medical graduates and previously unmatched applicants apply to more than 80 programs, especially if their USMLE score is below 236. These are, of course, general guidelines that do not apply to every applicant. Your mentor may be able to guide you in choosing an appropriate number of programs.

The Interview Day The interview day is a chance for you to really get a feel for the program. Approach each program and each interview with an open mind and allow your own experiences to shape your perception of the program. Keep in mind that outside opinions, particularly those on anonymous online forums, may be inaccurate, outdated, or misleading. Prepare for each interview day by learning about the program and formulating appropriate questions. Try to find out who will be interviewing you, so that you can personalize your conversation. During the interview day, take time to really talk with the current residents and get a sense of whether they are happy with their residency, and what they like and do not like about the program. Take notes immediately after each interview day, as you will find that programs tend to run together in your memory as the interview season progresses. Think about your personal goals and how each program might set you up to achieve them. Additionally, take time to talk with other applicants during your interview days. Ophthalmology is a small world, and your fellow applicants will become your colleagues in the future. The interview process can be long and exhausting, but it is also an opportunity to develop long-term friendships based on your shared experiences.

Creating Your Rank List A recent survey of applicants showed that the most important factors in determining their rank list included resident/faculty relationships, clinical and surgical volume, and diversity of training [5]. As might be expected, applicants planning on academic careers considered opportunities for research a more important factor than those not planning academic careers. Each applicant’s priorities are unique, and so you should really consider what is important to you in choosing a program. Size of program,

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call structure, the existence of a resident-run clinic may be important considerations. Geography may also play a big role in program choice, especially if an applicant prioritizes close proximity to family or the professional opportunities for a spouse/significant other. Finally, in considering your match list, I believe there is something to be said about your “gut feeling.” What feels like the best match for you? Can you picture yourself being happy at this program for 3 years? Do not underestimate the value of your instincts.

Part II: Succeeding in Residency You have completed medical school, successfully matched, and survived intern year; now you are finally at the place you have been working toward for years—the start of your career as an ophthalmologist. For most people, this is an exciting time but also one that is filled with some uncertainty and anxiety. You are entering into something entirely new—maybe at a new institution, in a new city—surrounded by strangers who are about to become your friends, colleagues, and mentors. Here are some tips to navigating this new world and finding your own path to success.

What Makes a Good Resident? In the competitive world of ophthalmology, you will be surrounded by bright and talented colleagues. I have found that the best and most successful residents are those who have an internal drive to continue learning and improving. They are receptive to instruction and criticism. Finally, when they fail—as everyone does at some point—they are resilient. They learn from their setbacks and grow from the experience.

Be a Team Player Perhaps the most important thing you can do to make your life as a resident easier and more enjoyable is to learn to get along with your co-residents. These are the people who will be working by your side every day as you navigate the stresses of resident life. Recognize that you are all working hard, and you are all tired, and that sometimes it is important to be selfless and go the extra mile to help a co-resident—whether that is staying late to help them wrap up a busy clinic, or agreeing to a call switch, or lending an ear when they have a rough day in the operating room—you will find that these gestures of kindness are often repaid to you when you need them most.

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Be a Problem Solver When faced with a roadblock, there are two basic responses: one response is to stop and say, “I don’t know how to do this”; the other is to say, “I don’t know how to do this, but I’m going to figure it out.” The latter response is one that will be immeasurably helpful to you—both in residency and in life. Granted, there is a time and place for asking for help, but there are also situations where taking the extra time and steps to figure it out for yourself will be a valuable learning experience for you. These situations will present themselves frequently during residency; learning to recognize them and to solve problems independently can be empowering. As you progress in residency, you will likely gain autonomy and opportunities to function without direct supervision. While on call, you will transition from primary physician to “backup,” a role in which you are advising and supporting your junior residents. Remember that the goal of residency is to prepare you to function as an independent physician, and embrace these opportunities for autonomy. At the same time, it is important to be mindful of your limitations and ask for help when the task is above your level.

Be Prepared You can improve your learning experience in any clinic or operating room by coming in to the experience prepared. Prior to the start of a new rotation, take the time to get sign-out from the resident leaving the rotation. Learn about the objectives and requirements of the rotation and the attending physicians with whom you will interact. If possible, you may want to review patient charts the day before the clinic and do some background reading. As an attending surgeon, I believe it is particularly important for any resident who is joining me in the operating room to be familiar with the patients and the procedures with which they will be assisting. If the opportunity is available, spend some time in the wet lab. Attending surgeons are generally more willing to turn over parts of cases to residents who come to the operating room prepared. Participating in postoperative care is also an invaluable part of the learning experience. In the busy rush of resident life, taking a few moments each day to stay organized may pay dividends in the long run. For example, maintaining an up-to-date calendar and to-do list may help to improve your organization and efficiency. Additionally, there are free online programs that allow you to easily share documents, spreadsheets, and calendars with your co-residents.

Make the Most of Your Learning Opportunities Most of the best residents with whom I have worked have been self-directed learners; they are excited about seeing and doing new things and continually pushing

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themselves to be better. Read something new every day; for example, commit to reading a section of the BCSC series or a journal article every night. If you see a new disease or eye finding in clinic, read about it later that night to really reinforce the learning experience. I would also advocate making time to teach your junior residents whenever you can. You will find that they challenge you to learn new things in the process. Above all, remember that residency is your opportunity to learn as much as possible under the tutelage of great mentors, and take advantage of as many opportunities as you can.

Practice Professionalism Although it is difficult to define specific factors—either academic or nonacademic— that predict success in residency [6], studies have shown that professionalism seems to correlate with clinical skills and medical knowledge, in both medical and surgical residents [7, 8]. Being a professional can mean a variety of different things, but professionalism in general rests on a foundation of ethical standards and honest work. It also means being punctual to work and treating your colleagues—from the front desk staff to your co-residents to your attending physicians—with kindness and respect. Above all, remember to prioritize good patient care. In the busy and sometimes chaotic day of a resident, it can be easy to lose focus on the reason that you are a resident physician: to treat patients. Take a moment in the chaos to re-center yourself and focus on the person you are treating.

Seek to Achieve Balance It goes without saying that residency requires hard work, especially the first year. Embrace that reality and take pride in your work. There will be days when you are tempted to cut corners; this strategy may save you time in the short term but rarely pays off in the long run. At the same time, be mindful that it is generally neither healthy nor sustainable to keep work as the sole focus of your life. The stresses of resident life can be sometimes overwhelming. To avoid burnout, take time to cultivate a life outside of the hospital—by doing things that bring you joy and by spending time with people who are important to you. In doing so, you will be a happier person and a better doctor when you are at work. If you find yourself struggling, lean on trusted friends and family, and if needed, seek help from mental health professionals. Finally, as you navigate the journey from medical school to residency and beyond, I hope you will always take time to appreciate the things about ophthalmology that initially drew you to this subspecialty. These are the things that will excite and inspire you, even when the days of residency seem long, and they will continue to fuel you as you transition into what promises to be a long and successful career as an ophthalmologist.

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References 1. Nallasamy S, Uhler T, Nallasamy N, Tapino PJ, Volpe NJ.  Ophthalmology resident selection: current trends in selection criteria and improving the process. Ophthalmology. 2010;117(5):1041–7. https://doi.org/10.1016/j.ophtha.2009.07.034. [published Online First: Epub Date]. 2. Ophthalmology residency match report. 2020. https://www.sfmatch.org/PDFFilesDisplay/ Ophthalmology_Residency_Stats_2020.pdf. 3. www.usmle.org/incus. 4. Siatkowski RM, Mian SI, Culican SM, et  al. Probability of success in the ophthalmology residency match: three-year outcomes analysis of San Francisco matching program data. J Acad Ophthalmol. 2018;10(1):e150–e57. https://doi.org/10.1055/s-0038-1673675. [published Online First: Epub Date]. 5. Yousuf SJ, Kwagyan J, Jones LS. Applicants’ choice of an ophthalmology residency program. Ophthalmology. 2013;120(2):423–7. https://doi.org/10.1016/j.ophtha.2012.07.084. [published Online First: Epub Date]. 6. Spitzer AB, Gage MJ, Looze CA, Walsh M, Zuckerman JD, Egol KA.  Factors associated with successful performance in an orthopaedic surgery residency. J Bone Joint Surg Am. 2009;91(11):2750–5. https://doi.org/10.2106/JBJS.H.01243. [published Online First: Epub Date]. 7. Reed DA, West CP, Mueller PS, Ficalora RD, Engstler GJ, Beckman TJ. Behaviors of highly professional resident physicians. JAMA. 2008;300(11):1326–33. https://doi.org/10.1001/ jama.300.11.1326. [published Online First: Epub Date]. 8. Rowley BD, Baldwin DC Jr, Bay RC, Cannula M.  Can professional values be taught? A look at residency training. Clin Orthop Relat Res. 2000;(378):110–4. https://doi. org/10.1097/00003086-200009000-00018 [published Online First: Epub Date]. Bryn Burkholder, MD  is an Assistant Professor of Ophthalmology at the Wilmer Eye Institute, Johns Hopkins University in Baltimore, Maryland. She received her undergraduate degree from Duke University and her medical degree from the University of Pennsylvania. She completed both a residency in ophthalmology and a fellowship in uveitis at Wilmer. She specializes in the medical and surgical management of ocular inflammatory diseases. She enjoys teaching residents in both the clinic and the operating room and serves on the residency education committee at Wilmer.

Chapter 2

Choosing a Fellowship and How to Stand Out Ashley Brissette

Summary Points • When deciding to pursue a fellowship, factor in time commitment and career goals. • Mentorship and sponsorship are important, especially for female ophthalmologists. • Set clear goals for your fellowship training and make them known.

To pursue fellowship or not to pursue fellowship? That is the question! You have finished college, medical school, internship, and residency. You are so close to the finish line of training that you can see it on the horizon. So after years and years of post-secondary education, why would someone decide to pursue another 1–2 years of further training? That is a question that is often asked, and that many residents will struggle with as they near completion of their education. There are many good reasons not to pursue a fellowship: the ability to start work, job opportunities that may have presented themselves, and making money. For people that want to pursue a fellowship, deciding on a subspecialty can be challenging, and there are many hurdles to overcome in terms of applications and interviewing at different programs. How does one go about approaching this complex decision? Here in this chapter, I hope to provide some insights, personal anecdotes, ways to shine as a fellow, and pass along advice that was provided to me when I was evaluating these questions myself. There are many considerations when deciding if a fellowship year (or 2!) may be right for you. First and foremost is the time commitment, which in itself may also

A. Brissette (*) Weill Cornell Medicine and New York Presbyterian Hospital, New York, NY, USA © Springer Nature Switzerland AG 2021 C. Y. Weng, A. M. Berrocal (eds.), Women in Ophthalmology, https://doi.org/10.1007/978-3-030-59335-3_2

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translate into a financial commitment. A fellowship will keep you in further training for 1–2 years (most fellowships are 1 year, but oculoplastics and surgical retina are a 2-year commitment). This will keep you out of the work force (and out of starting to earn an equitable income) for that period of time. The draw to start working earlier in order to pay off student loans, to begin or continue saving for financial goals, or to support family, may motivate some to start their career at the completion of residency training. Consider your goals and what you enjoy about ophthalmology as a specialty. Do you like the diversity of patients and their clinical problems? Do you see yourself moving from minor eyelid procedures, to cataract surgery, to glaucoma lasers all in 1  week? General ophthalmology might be the perfect fit for you. Some people do not want to give up certain aspects of the profession, which may be the case if you chose to subspecialize. Would you prefer to be considered an expert in your subspecialty and take on more involved patients and surgical presentations? Pursuing fellowship and learning complex medical and surgical management within a subspecialty may be the correct path for you. What is incredible about ophthalmology is that we are always progressing, so even if you pursue a fellowship, there may be newer surgical techniques even just a few years out of training. Continuing medical education is a part of any successful career. Whether you decide to pursue a fellowship or not, you will always be a lifelong learner and continuously refine your surgical and medical management techniques. Fellowship can also be a wonderful way to refine surgical skills. There is a diverse array of fellowships available, each with their own strengths and weaknesses. For example, consider anterior segment: some academic centers may heavily focus on corneal transplantation, while some private fellowships may offer higher volumes of cataract surgery and/or microinvasive glaucoma surgery (MIGS). If there was an element of clinical care or surgery that you felt was lacking in your residency training, you may decide to look into fellowships that could provide you these training opportunities. I would also recommend bearing in mind where you may want to live and practice. If you pursue a heavily academic fellowship or research track, this may lead to opportunities to work for a larger academic center. A private practice fellowship may be better suited for eventual independent practice, as you will also learn the ins and outs of practice management. Consider your goals or where you might want to practice and the needs for subspecialists in that area versus the need for general ophthalmologists. One tip for deciding which subspecialty might be right for you is to talk to specialists in the field that you are considering. Listen to their perspectives, their opinions on the future directions of that subspecialty, etc. Foster those relationships by attending their clinics and surgeries. Come prepared for teaching and lectures as well. You may find that your interest is piqued by reading further into subspecialties, and this may give you an idea if you might enjoy this as a career path. Fostering these relationships with your attendings will also be helpful when it is time to get letters of recommendation if and when you do apply for fellowship in their field.

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These people will be your colleagues for the rest of your career, so you want to make sure you cultivate great relationships early on. Attending ophthalmology conferences is also an excellent way to meet other young ophthalmologists. The larger meetings, such as the American Academy of Ophthalmology Annual Meeting, are extremely valuable in terms of content and education, but it can be harder to approach colleagues. I strongly recommend also attending smaller conferences because they provide the ability to really get to know others in the field as these meetings are often more relaxed, making it easier to approach others or have your mentors make introductions. Once you decide to pursue fellowship and have picked your subspecialty of interest, you will then need to start reviewing the programs that are available. The San Francisco Match (SF Match) is an online application for most fellowships available the upcoming year (note: oculoplastics fellowship applications are taken further in advance through the American Society of Ophthalmic Plastic and Reconstructive Surgery). I recommend starting with the program websites for general information about the strengths and weaknesses of each fellowship. I would also recommend talking to the current fellows of specific programs to see if they are happy (administrators will often provide you their contact information). Finding the right fit is of utmost importance in fellowship, because fellowship programs are smaller than residency programs, and you will be working more closely with your mentors. In order to stand out as an applicant, I would recommend that you do research in the field in which you wish to match. As a doctor, you will always be learning, and research is a great way to contribute to the advancement of your desired field. I would also express your interests to your residency program director and mentors, so that they may help make introductions to other faculty at programs you may be interested in attending for fellowship. So you have made the decision, you have matched to your fellowship of choice, and now you really want to stand out and shine during training. Fellowship is much more self-directed than residency, so you need to take control of your learning. Know where the gaps in your knowledge may lie and seek out opportunities to fill in these gaps. You may even be responsible for teaching residents or medical students during your fellowship, either on call or in a clinical setting, so it is important to be aware of what skills need to be strengthened. It should not need to be said, but simple things like showing up early, having a positive attitude, being prepared for the operating room, practicing in the wet lab, and consistently reading around topics in your field will really help you stand out. Consistently reading is also important if you are taking your board exams during fellowship. It can be a lot to manage when studying for the boards during fellowship, but it is also a great way to consolidate your clinical learning. To further stand out, I would recommend doing research. As a fellow, this may allow you to attend conferences where you can expand your network of colleagues, meet other people in your field, and cultivate relationships with other ophthalmologists. This networking may also help when you begin to look for jobs. Research also allows you to affect change for a greater number of people. When we interact with

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patients, it is one on one, but when you do research, you can change the way multiple people diagnose, consider, or treat a condition. It can be extremely rewarding, and fellowship is a great time to garner publications. Ask questions! Get curious, because after fellowship, you will have ultimate responsibility for your patients, treatment plans, and surgical outcomes. Make sure to take the time to ask your attendings lots of questions and learn multiple different ways to approach a problem. You can then utilize all you have learned to determine the way that you want to practice. Mentors are an integral part of fellowship. They can support you in different aspects of your career (e.g., research, clinically, surgically). Personally, I have had many mentors throughout my training, each with different strengths and insights for which I have been incredibly grateful. I have had mentors that have helped me improve clinically and surgically, and mentors that have provided personal guidance in terms of contract and salary negotiation. I do want to make an important distinction between the terms “mentorship” and “sponsorship.” Sponsorship is a newer concept to medicine, especially for the advancement of women in medicine. Most people rely on navigational support to advance their careers: this is when we ask mentors for advice or guidance. However, women are still often overlooked for speaking engagements, academic promotions, and industry involvement. Having a mentor that advises you is not enough. You also need to seek out those that can be a sponsor. A sponsor will advocate for you, and not just advise you, as would a traditional mentor. A sponsor will use their network to connect you to career advancement, whether it be in involvement in research, publications, promotions, speaking engagements, and other assignments that can advance your career trajectory. A sponsor will give you active connections and assignments to advance your career. Both mentorship and sponsorship are great, but do not just settle for a mentor, seek out a sponsor as well. These people will have a profound impact in your life. In terms of seeking out a sponsor, I think it is important to ask for what you want. Make your goals clear and people will listen. If you let others in your field know that you are keen in a certain area of expertise, they will then know to seek you out for those opportunities, should they present themselves. Mentorship can lead to career guidance, but sponsorship will lead to upward career trajectory, and this is extremely important for female ophthalmologists. Finally, remember to offer the same support to those below you in training that may be seeking engagement as well. Pay it forward, whether for residents or medical students or even colleagues, especially women and minorities. We all get better by improving the diversity in medicine. This is my last paragraph, but probably my most important one. It is critical to stay healthy during fellowship. It can be an extremely busy year (or 2) and it can be overwhelming starting at a new place after residency, learning the ins and outs of a new program, moving to a new city, and making new friends and connections. So make sure to ensure your health is a top priority. Take time for self-care and self-­ reflection. Whether it is exercise, meditation, socializing, therapy, community, or religion, you need to take care of yourself so that you can ultimately take care of your patients.

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Ashley Brissette, MD, MSc, FRCSC  was born and raised in Canada, attended McGill University (Great Distinction) and received her medical degree and ophthalmology residency from Queen’s University. Her dedication to research then lead her to pursue a master’s degree in Biomedical Sciences with a subspecialty in Medical Education. She then completed a fellowship in cornea, cataract and refractive ­surgery at Weill Cornell Medicine in New York City, where she is currently an Assistant Professor of Ophthalmology. Dr. Brissette is an active and accomplished researcher and lecturer. She has contributed extensively to the ophthalmic literature, authoring numerous peer-reviewed papers, textbook chapters, original articles, and scientific presentations. She has presented at national and international conferences, and has a passion for cataract and corneal surgery, and ocular surface disease. Dr. Brissette also has also completed many medical missions internationally, volunteering with ORBIS and the Teaching Eye Surgery Foundation.

Part II

Starting Your Career

Chapter 3

How to Get a Great Position in Private Practice Allison N. McCoy

Summary Points • A job in private practice typically provides a higher salary, more autonomy, and greater flexibility in work hours than an academic position, but in some cases may offer less intellectual simulation, prestige, and opportunities for teaching or research. • To find a job that will make you happy in the long term and identify the practice setting that is best suited to your personality and skills. • Ask residents or fellows who graduated several years before you why they chose their particular position and what they might have done differently.

Congratulations! As an ophthalmology resident or fellow, you will soon have completed 8–10 years of post-graduate education, depending on your choice of general or subspecialty training. I hope you will take some time to celebrate all that you have accomplished. Ophthalmology is an incomparably stimulating and rewarding specialty, which we are all fortunate to have chosen! The process of applying for a job can be daunting, perhaps even more so than the process of applying to medical school or residency. Your education has been preparing you for a menu of job options, and it is now time to select one job out of the many that are available. The transition from an open-ended learning environment to decisive employment, however, can be difficult. Doctors generally have little formal training in the process of finding a job or in the business side of medicine. To help you get a great position, this chapter will (1) summarize the options in non-­academic

A. N. McCoy (*) Sharp Rees-Stealy Medical Group, San Diego, CA, USA © Springer Nature Switzerland AG 2021 C. Y. Weng, A. M. Berrocal (eds.), Women in Ophthalmology, https://doi.org/10.1007/978-3-030-59335-3_3

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practice settings, (2) help you determine which type of job is best suited to your interests, and (3) explain how to find and secure such a position.

Choices in Practice Setting Now that your job search has begun, you may be surprised to discover the range of options in practice setting. Ophthalmology programs at large academic centers often emphasize academic practice and may or may not expose residents and fellows to alternative paths. Private and academic practices are qualitatively distinct paths, in ways that are critical for you to understand as you search for a job. Specifically, many people choose academics because they like the process of mentoring, writing grants, and performing research. They may also like the challenge of seeing patients with rare and unusual findings. Others may find it stressful. On the other hand, many people are drawn to private practice because the salary is higher than in academics, and it can be easier to control your work hours. However, an inquisitive person may find it to be less intellectually stimulating. The rest of this chapter will focus on how to determine which path is the right one for you and how to find a great job in a private or group practice. Academic jobs will be discussed in detail in the next chapter. Private practices generally come in two flavors: solo and group practice. A solo private practice offers the most autonomy of any practice setting, for you are your own boss. This is particularly appealing for trainees who desire the highest level of independence and control over practice management, from scheduling preferences to the decision about an electronic medical record (EMR) to the hiring of personnel. A solo private practice also requires the greatest business savvy, as the responsibility for running the business and advertising will fall completely to the private practitioner. The second flavor is the group private practice, wherein a private practitioner is joined by fellow subspecialists, general ophthalmologists, and/or optometrists. A group private practice will offer more support for the practitioner vis-a-vis the business side of practice and may also include a built-in referral source for patients as well as shared call responsibilities. Accordingly, a group private practice provides less autonomy since the members must work together to make decisions affecting the practice. Between academics and private practice lies the practice setting of a health management organization (HMO). This setting includes national multi-specialty groups such as Kaiser Permanente, as well as geographically specific multi-disciplinary groups. These medical groups provide all healthcare for patients enrolled in the HMO, and they may or may not also accept other kinds of insurance, such as Medicare or Preferred Provider Organizations. HMOs are similar to academic practices in that many of the business aspects of practice—the hiring and paying of ancillary support, for instance—are managed by the practice. This frees the physician to focus solely on his or her clinical practice without the additional responsibilities of running a business. On the other hand, such groups are more similar to

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private practices in that there is typically a higher salary than in academics, less salary going to overhead, and less involvement in teaching or research. This is ideal for a trainee who desires a hybrid setting, with a level of salary and autonomy approaching that of private practice but without many of the burdens of managing a business. In addition to these groups are hospital-based positions, where an ophthalmologist may contract with a particular hospital or medical group. For ophthalmologists who wish to use their training in less traditional ways, job opportunities can also be found in consulting, entrepreneurship, healthcare management, journal editing, and pharmaceuticals. Indeed, the options are limited only by your imagination and initiative. In summary, non-academic practice settings include solo and group private practice, large medical groups or HMOs, and hospital-based positions. A multi-specialty or HMO group practice is somewhat of a hybrid between private practice and academic medicine in terms of salary, autonomy, and opportunities for teaching or collaboration.

Finding Out Who You Are and What You Want More important than any pearl for job hunting or interviewing is the reminder that you have the ability to decide which job is right for you. What is most important to you in your future career? For many of us, the answer to that question is not clear. We have been too busy checking boxes in order to convince medical schools and residency programs of our potential value to them. Or maybe we have been pursuing a career according to what is expected of us by our parents and/or mentors. Now is the time to shift the focus internally, to identify the kind of job that will give you satisfaction in the long term. Here are some questions to consider as you conduct an inventory of yourself. What activities do you enjoy most? What is most important to you in a job: intellectual stimulation, salary, prestige, flexibility, or stability? A number of questions follow, for which there are no right answers. Please rate each category on a Likert scale from 1 to 5, with 5 indicating an aspect that is extremely important to you, 4 being pretty important, 3 being neutral, 2 being not very important, and 1 being not at all important. You will create two scores for your suitability to private practice (score A) and for academic practice (score B).

Suitability for a Private Practice Career (Score A) 1. Autonomy/control How important is it to be your own boss, to not have to answer to any particular person or organization? Do you like to design your own schedule? Do you

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like the prospect of being responsible for the hiring or firing of personnel? Do you tend to dislike rules, deadlines, and priorities imposed upon you? 2. Business of medicine How involved would you like to be in the fiscal responsibilities of running a medical practice? Would you enjoy starting a practice from the ground-up or becoming a joint owner/shareholder? Would you enjoy managing office staff, technicians, and scribes? Would you enjoy balancing the books or hiring someone to help with billing and payroll? Would you enjoy promoting your practice on social media and through your activities? 3. Salary How important is it to earn a high salary? Are you willing to see more patients or work longer hours in order to secure a maximal salary for your subspecialty? Do you like the idea of being paid by productivity, generally based on RVUs, or would you prefer the security of a regular salary? 4. Work/home balance Is it important to you to find a balance in the time that you spend at work and home? Do you have hobbies that are as important, if not more so, than your work? 5. Entrepreneurship, self-starter Do you consider yourself to be an entrepreneur, to enjoy the challenge of starting your own venture or practice? Please add up the scores you have for questions 1 through 5; this is your score A.

Suitability for an Academic Career (Score B) 6. Interest in teaching and mentoring 7. Interest in science/research 8. Academic title or prestige 9. Collaboration with other disciplines or subspecialties 10. Stimulation of an academic institution Please add up the scores you have for questions 6 through 10; this is your score B. • Score A: the closer to 25, the better your match for a solo private practice. • Score B: the closer to 25, the better your match for academic practice. In addition to this personal analysis, your ultimate choice of practice setting may also depend on practical factors, such as geography. If it is important to you to end up in a particular location, or if you and a partner are searching for two jobs in the same area, then you will have more options if you consider a range of practice settings. Part-time jobs and job-sharing have also become more common for working parents as well as for trainees who wish to pursue secondary income streams outside of medicine.

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Job Search Now that you know which practice settings are available and which kind(s) would be the best match for your interests and abilities, how do you go about finding your ideal job? The rest of this chapter will focus on how to find your desired position with a private practice or multi-specialty group. The first and most important step is to reach out to the residents or fellows who graduated 2–3 years before you. They can tell you why they chose their particular position as well as any things they wish they had known or asked in hindsight. Such advice is invaluable. You can learn from their experience and avoid making similar errors or missteps. A 2008 study by the American Academy of Ophthalmology (AAO) showed that among ophthalmologists who did not switch jobs within the first 5 years, 70% of them credited their success with having sought advice from other physicians during their job search [1, 2]. AAO and subspecialty meetings provide a good time and place to discover job openings. Consider that jobs do not only become available when a physician retires; they can also be created anew. The more that you understand your skill set and desired position, the more you can actually help to create your dream position. Positions are posted regularly on the website for AAO and subspecialty societies, such as ASOPRS, AAPOS or ASCRS, as well as their associated subspecialty journals. You can also submit your CV to the AAO Job Center website and describe the job you are seeking. PracticeLink, LinkedIn, and Doximity are other online sites where you can find job openings via your network of colleagues. A supportive mentor can also be critical in contacting colleagues and learning about job openings. Consider areas in which you wish to live, and activate your network of physician friends, colleagues, and administrators who live in this area. Fortunately, or unfortunately, there is truth to the saying that “it is all about who you know.” Some great practices in popular areas will not post job openings, but rather, will rely exclusively on the referral of candidates by existing physician members. I happened to find my first (and only) job because a person I had met during fellowship knew that I was looking for a position and let me know that one of their senior surgeons was retiring. This was a once in 20 years opening in a popular city which never formally posted. If not for the advice and recommendation of my friend, I would surely be in a different position. If you are coming up short in your independent search, you can also consider a physician recruiter, such as The Eye Group. Some job openings may only be available through a recruiter. You should understand how the recruiter is paid, since some are paid for their time and effort while others are compensated only if you end up taking the position. Be wary of the latter recruiters because they will have a vested interest in your signing with a particular practice.

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Interview and Due Diligence Once you have identified a list of positions that match your interests and qualifications, then submitted your CV and letter of interest, you will start receiving invitations to interview. The next step is to prepare for your interview by researching details of the practice and people with whom you will meet. The job interview is usually a positive and more laid-back experience than residency interviews, with a focus on convincing you to join the group rather than the other way around. However, practices will typically interview several applicants, so do your best to show your interest in the group in order to make the best possible impression. Ask your interviewer to describe a typical work week. What is the average number of patients that a physician in the practice sees during a work day? What is the surgical volume? Is there a built-in referral source for patients in your subspecialty and/or a backlog of patients, or will you be expected to grow your own practice? Will you be given the time and resources to grow your practice? Will there be a sufficient number of technicians assigned to work with you? How about scribes? Is there an electronic health system, and, if so, is it user-friendly? Ask about the equipment available to the practice and your ability to get the equipment you need to practice your subspecialty. It is important to ask about the practice’s leadership structure and how decisions are made. If it is a managed care group, is it run by physicians or non-physician administrators? Is there a Board of Directors, or does one person make decisions for the group? How are the leader(s) and Board of Directors chosen or elected? Are there multiple sites or surgery centers? Will you need to travel to different locations? Among all the things that you will be asking, try to find out whether the physicians are happy with the practice and if any physician has previously left the practice. If a physician has departed, ask whether there would be any objection to your speaking with the person. Several of my colleagues avoided problematic positions by contacting the physicians who came before them. A situation that seems too-­ good-­to-be-true may, in fact, be. Conversely, one of the most reassuring things to learn about a practice is that a person has never or rarely left the group. Presumably this is because it is a great place to work! You may also inquire about how the members of the practice are staggered in terms of their age and seniority. Ideally, the ages of group members are spaced evenly such that every 7–8 years, someone retires and a new person joins the practice. If there are too many people who are close in age, then this can lead to competition among members of the practice for shared resources and hiring challenges in the future. Call responsibilities and compensation should be discussed in detail. How frequently would you be expected to take call, and is call for general ophthalmology and/or subspecialty care? Do all physicians divide the call equally, or do senior members take less call? Do you cover call for other practices, physicians, hospitals, or surgical centers? With respect to compensation, is it determined as a salary or is it production-based (RVUs)? Is there a bonus structure? Is there an option to become

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a partner or shareholder after several years? What are the costs of becoming a partner or shareholder? What criteria determine partnership? Is the practice affiliated with an ambulatory surgical center (ASC) or an optical center? Are there options to buy-in for the ASC or optical shop? What are the benefits for health insurance, disability insurance, group life insurance, malpractice insurance, tail coverage, paid sick leave, retirement savings programs, and vacation? Does the practice invest in a pension plan or cash balance plan? Understanding all these factors about your potential future job is important for a well-informed decision [3].

Contract Negotiation and Decision-Making After completing interviews, make sure to send thank you cards to each person you met. Soon, you may receive one or more offers for employment and a contract to review! Once you receive a formal contract, do hire a contract lawyer to review it on your behalf. The legal language can be confusing, and it is important to understand fully the terms of employment. Moreover, most contracts are written to protect the employer rather than the employee. It is strongly encouraged that you ask for all the equipment you anticipate needing up front. If your practice depends on any expensive equipment, such as lasers or surgical instruments, make sure it is included in the contract. It can be difficult to procure expensive equipment later once you are already on staff, especially in a larger managed care group. If you are a retina specialist, make sure your clinic will have the high-resolution OCT machine and lasers you would like! If you are an oculoplastics specialist, now is the time to secure an Ellman radiofrequency unit and endoscope for your procedure room. Take time to understand the salary structure. In many group private practices and HMOs, there is a guaranteed salary for the first few years of employment. This is usually followed by a productivity-based salary measured in relative value units (RVUs), where the “value” units are determined by Medicare for physician reimbursement. Salary is calculated based upon a number (usually specific to ophthalmology) multiplied by the number of RVUs. Ask about the average RVUs generated by the physicians in the practice as well as the amount paid per RVU [4]. These numbers should be on par with or better than publicly available ophthalmologist salaries within the area. Some practices use a combination of a base salary and a productivity-based salary. Bonuses may be given each year based upon patient satisfaction, group participation, productivity, or other goals specific to the practice. The importance of salary structure is being highlighted by the recent COVID-19 pandemic. Physicians whose salaries are entirely productivity-based but who cannot perform elective surgeries are seeing severe reductions in their income, whereas physicians with a guaranteed base salary are more protected. Inquiring about the maternity leave policy is also important for many women during this process.

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If you have more than one offer, you can mention the competing offer(s) in negotiating your desired salary and benefits. It is important to advocate for yourself firmly but tactfully, taking care not to offend a future employer. Keep in mind that historically and presently, women have been paid less to do the same amount and type of work as men. Do not undervalue yourself. Become knowledgeable about what is a fair salary for your subspecialty, practice type, and geographical area. If it is possible to learn the salaries for other members of the practice, this knowledge can also be used to ensure the fairness of your offer and contract.

Summary Finding your first job in ophthalmology can be daunting, and a step-by-step process to determine your fit for private versus academic practice is proposed. A job in private practice or an HMO setting may provide a higher salary, more autonomy, and greater flexibility in work hours. However, teaching and research opportunities, as well as the challenge and prestige of academic medicine, are usually less prominent. The most important factor in choosing a job that will make you happy in the long term is to understand yourself and to make the decision that is right for you. Speak to former residents who are ahead of you in training about their decision-making. This stage of your life is not about pleasing anyone but yourself. Listen to the advice of your mentors, but do not choose a career to please your mentor. Consider that one in four ophthalmologists changes jobs within a few years of starting their first job [2]. Thus, a job need not be a decision for life and your course can always be redirected with additional experience [5].

References 1. Koval RC. Finding a job: answers to key questions about the search process. 2008. Reprinted from American Academy of Ophthalmology. Accessed 5 May 2020. 2. Melendez RF. Project abstract: why young ophthalmologists leave their first job. 2008. http:// goo.gl/U27x4O. Accessed 15 Jan 2020. 3. Childress K. How to evaluate a practice. 2013. http://bit.ly/1ix3pDR. Accessed 18 Apr 2020. 4. Kane L, Peckham C. Medscape physician compensation report. 2014. http://wb.md/1KQiL1f. Accessed 22 Apr 2020. 5. Foist C. What to do when the job doesn’t work out. http://bit.ly/1YBWtpS. 2013. Accessed 16 Feb 2020.

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Allison N. McCoy, MD, PhD  was born in Bethesda, Maryland. She earned her B.S. from Duke University, majoring in biology and art history. She then enrolled in Duke’s Medical Scientist Training Program, graduating in 2007 with her M.D. and Ph.D. in neurobiology. She and her family moved to Honolulu, Hawaii, for transitional internship, then back to Maryland for her ophthalmology residency at the Johns Hopkins Wilmer Eye Institute. She was awarded a Heed Fellowship and completed her neuro-ophthalmology training at Wilmer, followed by a 2-year fellowship in oculofacial plastic surgery at the University of Michigan. She now works as an oculoplastic surgeon at Sharp Rees-Stealy Medical Group in San Diego, California, where she lives with her husband, Sam, and two boys, Zev and Ezra.

Chapter 4

Finding a Great Job in Academics Bonnie An Henderson

Summary Points • Define what is your “perfect” job. • Search for a department that gives career guidance, is collegial/cooperative, and has the same philosophy toward patient care/academic pursuits. • Become an attractive candidate to land that job.

Introduction When Drs. Weng and Berrocal invited me to write a chapter about “Finding a Great Job in Academics,” I thought they must have made a mistake because I currently practice in a large private ophthalmology group. I left my full-time academic position over 10 years ago. However, when I thought about it, I realized that I might still have some useful advice. The private practice that I joined is what I would call a “hybrid” academic/private position. Although the practice is owned and run by the physician partners, the group is active in academic pursuits and educates many clinical fellows in several subspecialties. Some of the partners in my private practice participate in numerous clinical research projects (arguably more than most full-­ time academics do). Our private group has included the previous leaders of major ophthalmic organizations. Having worked in both a full-time university setting and in a private practice, I hope to share some of the lessons that I have learned in the job search process.

B. A. Henderson (*) Tufts University School of Medicine, Boston, MA, USA © Springer Nature Switzerland AG 2021 C. Y. Weng, A. M. Berrocal (eds.), Women in Ophthalmology, https://doi.org/10.1007/978-3-030-59335-3_4

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What Is a “Great” Job? Searching for a job is not that different from searching for a spouse. Contrary to the notion that there is “one true love,” I believe people can find many compatible mates who can be “true loves.” Similar to this, I do not believe in a single “right job” but instead believe that there are many jobs that could bring career fulfillment. The first step in finding a great job is to define what makes a job “great.” This is the most difficult step. If you are considering a job in an academic setting, what does that mean to you? Are you searching for a position where you can conduct basic science research or clinical research or teach? What percentage of time do you want to be taking care of patients versus teaching or doing research? Do you want to work with trainees every day? Do you need flexibility in your call schedule? What is your long-term goal for your career? Figuring out the answers to these questions is a crucial first step. Not every academic job is the same. Some academic departments are large with many basic science labs, while some are more similar to a private practice with the focus on clinical activities. Some weigh academic achievement more highly than clinical work or teaching. Some focus more on clinical activities and require the doctors to have a busy clinical practice with a demanding revenue goal. Some have large training programs and with many teaching requirements, while others may have very few. Keep in mind that the lines between academic and private practice have blurred. Clinical academic work can be done either in a traditional university setting or in a private setting. As stated above, many clinical trials for new devices and medications occur in a private practice setting. Some companies have expressed that they prefer to conduct trials in a private setting because of faster institutional review board (IRB) reviews, higher clinical volume, and less institutional red tape.

What to Look For In most industries, you often hear that the single most important factor for success is the people. This same principle holds true when searching for that great job. When comparing different job opportunities, people often focus on the wrong elements such as the starting salary, benefits, and call schedule. Instead, I believe the most important element is to work with people that you respect. The people you work with will be your partners for a long time. There will be times during your career where you may find yourself at odds with your colleagues, whether it is about finances, space allocation, research/grant access, etc. The resolution of future conflicts rests on the ability to find common ground in the philosophy of the practice/department. Search for people who share your ethics. Search for people who deliver the quality of care that you provide. Do not focus on how much income they are making. That is not a reliable indicator of the quality of care provided.

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Specifically for academic settings, select departments that have active mentoring programs for junior faculty. It can be difficult when first starting out to figure out how to build your career, especially in an academic setting. A way to assess this is inquire how often the faculty collaborate on projects and publications. If collaboration is common, that can indicate a collegial environment where the established faculty members are open to inviting young faculty. Try to assess the level of professional jealousy among the faculty. Does the chairperson encourage collaboration or competition? There are different types of academic schedules. Some departments allow faculty to have protected time to pursue research/academic work. This is important if you plan to conduct research. If your days are filled with clinic appointments and surgery, there will be less time to complete projects/write/publish. Additionally, assess the teaching requirement and how that time is valued. Is there financial support for teaching? Is the amount of teaching counted toward academic promotion? Is teaching an expectation that is weaved throughout your clinical time but not recognized or weighed significantly compared to the amount of publications in peer-reviewed journals? Another factor is the amount of clinical/surgical volume. In other words, are there sufficient patients for all faculty members to have a busy clinical practice? In departments where the volume of patients is low, there is a higher incidence of competition and lower incidence of collaboration. If there are more than enough patients, there is less reason to try to “protect” one’s own practice. For better or for worse, academic rank is often how others measure the productivity of an academic physician. This is especially true outside of the United States. Being promoted to a higher rank is paramount to career stability in certain countries. Understanding how this process occurs and what the criteria are for promotion are the first steps. Look for a department that has transparent criteria, gives opportunities for faculty to complete the requirements, and is fair in the evaluation. My recommendation is to schedule an annual meeting with your department chairperson to discuss what you have done this past year (projects, publications, teaching responsibilities, clinical achievements) and to plan what to do for the following year. No one is tracking your activities and tallying your accomplishments. I learned this the hard way. Being a naïve junior faculty member, I made the mistake of waiting for people to notice that I was working hard. I never thought to ask my chair what the criteria was for promotion, believing that someone would surely notice my productivity. You have to be your own advocate. Another aspect of a good academic job is guidance on funding sources. There are many different types of grants and funding opportunities. Most clinician scientists have heard of NIH and NEI grants; however, there are other federal/state/local/private funding sources that are available. Besides finding sources, the department should give guidance on how to apply for a grant. The department may even have staff who can help write or at least review the application. Having guidance for your first grant application will help save a lot of time and effort.

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How to Land the Job Once you have figured out what type of job you want, now you have to land it. First, be a desirable candidate. How do you accomplish this? Be industrious. Work hard. Learn as much as possible at all times about every aspect of ophthalmology. This will lead to invitations to participate in activities such as presentations, projects, publications, which all build your resume. Second, be a good team player. This pertains for all aspects of your career. Be the type of partner that you would want. Volunteer to help in the clinic, be flexible in the call schedule, and help your colleague with a deadline. Third, be honest and have integrity. Make your decisions, clinical and research decisions, with the best intentions. Finally, you need a little luck. Being in the right place at the right time when a great job opportunity opens up can lead to that dream job.

Conclusion Now that you have a great job, you may think your search is over. However, 25% of doctors change jobs in the first 3 years of their career [1]. Re-assess annually and ask yourself if this job is giving you what you need. Is it enough income? Is it enough clinical volume? Is it enough access to resources for academic pursuits? Do you have enough time to teach? Are you progressing/growing/promoted? If not, then it is okay to look elsewhere. With the baby boomers becoming senior citizens and life expectancy growing, there will be a shortage of doctors [2]. You will have the upper hand when looking for job opportunities so no need to settle for a situation that is not fulfilling. Life it too precious to waste your time in a position that does not bring satisfaction. Good luck and I wish you a long and rewarding career.

References 1. Recruiting physicians today – NEJM CareerCenter. Recruiting Physicians Today. 2015;23(1). http://employer.nejmcareercenter.org/rpt/RecruitingPhysiciansToday_JanFeb15.pdf. 2. New findings confirm predictions on physician shortage. https://news.aamc.org/ article/2019-workforce-projections-update.

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Bonnie An Henderson, MD  is a Past President of the American Society of Cataract and Refractive Surgery and a Clinical Professor at Tufts University School of Medicine. Dr. Henderson is the Associate Editor for the Journal of Refractive Surgery, has served as the associate editor of EyeWorld, and on the editorial board of EyeNet. She has authored over 175 articles, papers, book chapters, and abstracts, and has delivered over 300 invited lectures worldwide including 30 invited visiting professorships and 15 named lectures. She has published five textbooks in cataract and refractive surgery. Dr. Henderson created EnVision Summit, the international ophthalmology meeting to support and empower women leaders, and the Harvard Intensive Cataract Course for residents. Dr. Henderson has received an Achievement Award, Secretariat Award twice, and Senior Achievement Award by American Academy of Ophthalmology, “Best of” awards from American Society of Cataract and Refractive Surgery for her research and films, and “Teacher of the Year” award from Harvard Medical School. She has been inducted into the honorary International Intra-ocular Implant Club, and awarded the Lans Distinguished Award by the International Society of Refractive Surgery, the Suzanne Veronneau-Troutman Woman of the Year Award by Women in Ophthalmology, and the Visionary Award by the American-European College of Ophthalmic Surgeons. Dr. Henderson completed her ophthalmology residency at Harvard Medical School, Massachusetts Eye and Ear Infirmary. She graduated from Dartmouth College and from Dartmouth Medical School with high honors. Married with three children, her interests include culinary arts and competing in triathlons.

Chapter 5

As You Start a Career in Academic Medicine: Priming for Success Judy E. Kim

Summary Points • There are special considerations in starting a career in academic medicine. • These considerations may include passion and having skill sets for teaching, researching, and mentoring and finding an environment and mentors to be able to engage in these activities. • Know that we have options in life. Enjoy the journey!

Know Thy Self Long before searching for a job in an academic setting, I believe it is important for you to reflect on your personal and professional goals to determine whether academic medicine is the appropriate career choice for you. In most instances, you already have finished a fellowship in a subspecialty of ophthalmology, although one can be a comprehensive ophthalmologist at an academic setting. A career in academic medicine encompasses many components, such as teaching, research, publication, and administration; therefore, these activities should excite you. It helps even more, if you have an aptitude for them and you want to continue to grow and learn to do them better throughout your career. Therefore, you should be brutally honest in your introspection, reflecting on your strengths and weaknesses, considering what brings you joy, what is feasible, what are the limitations, your long-term goals, and available options you have at the moment.

J. E. Kim (*) Department of Ophthalmology and Visual Sciences, Medical College of Wisconsin, Milwaukee, WI, USA © Springer Nature Switzerland AG 2021 C. Y. Weng, A. M. Berrocal (eds.), Women in Ophthalmology, https://doi.org/10.1007/978-3-030-59335-3_5

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For example, I always desired a career in academic medicine. But my husband had some difficulties with job relocation and we ended up living apart during the 2 years of my surgical vitreoretinal fellowship, while raising two toddlers on my own with the help of a nanny and my husband commuting once a month from Miami to Milwaukee. As a result, when the time came for me to look for my first job, all I wanted was to have my family live under one roof. I was fortunate to find a position in a successful and progressive multispecialty ophthalmology group. While being in a private practice seemed the furthest thing from my life’s goal at the time, it was the best option I had under the circumstances. However, when the time came for me to commit as a partner in the practice, I had to ask whether this is what I wanted to do for the rest of my career, whether this is where I wanted to live, and whether this work would bring me personal satisfaction for the next several decades, while contributing to the society. When the answer in my heart was “no,” I began looking for an academic position in a city where my husband could also find a job, and we succeeded. While the 3 years I had spent in private practice seemed like a detour at the time, later I realized that I had gained valuable experiences in practice management and I was able to carry some of the lessons learned from the private practice to the academic setting. However, the transition to academic medicine did result in lower salary and less autonomy. Sometimes, one has to make these compromises. After all, there may not be a perfect job, but you make the job to fit your needs as much as possible. Knowing yourself and your life goals will help you to make the most optimal choice among your options, which in turn will help you to develop resilience. Resilience will help decrease the likelihood of dissatisfaction at work, which in turn will lower your chances of burnout, which plagues many physicians. It is important to remember that we have options, so choose the best option for that moment with the information you have and do not regret. Also, know that you can always alter your course in life, from academics to private practice and, less commonly, from private practice to academics, and, in some cases, be able to combine both academic and private practice.

Know to Plan Ahead If you know that you need to be at a certain location to make you happy, I suggest you start the job search early, since there are limited number of academic positions available each year compared to private practice. If you want to focus on a certain type of research, begin networking during your fellowship to connect with those who are experts in that area, such that they may have you in their mind when a position becomes available at that institution or as they plan manpower needs. Networking also may provide you with important information on the culture, dynamics, and expectations of the department to help you decide whether you would be a good “fit.” Networking that you start at this time can become your

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lifelong support as well at each stage of your career. You may consider obtaining extra training to carve out a niche for yourself, which may make you more desirable to a department, such as pediatric retina, uveitis, oncology, electrophysiology, and inherited retinal diseases. You can plan ahead and tailor your cover letter to the university to which you are applying to align with their mission and values, while highlighting the qualities and skill sets you possess, with specific examples, that they may be seeking.

Know to Ask One of the things I regret not having done during the transition to my academic job was not having negotiated for a salary. After all, I was not fresh out of fellowship but already had several years of experience under my belt. It did not even occur to me at the time that I should negotiate. After all, I am finally getting an academic position that I wanted, right? My husband found a job in the same town. My family can live together. Shouldn’t I be satisfied with that? Did you know that women are less likely to negotiate or to negotiate well when it comes to compensation? Did you know that lack of or avoidance of negotiation in the beginning of your career may result in up to $1,000,000 loss over the course of a career? You can check AAMC or other salary surveys to use as a starting point and a guide for salary at various ranks in academic medicine. Do negotiate. When negotiating, it helps to explain how your asks will benefit the department. Also, know that you can negotiate not just for salary but other things as well. These may include but not limited to protected time to do research, research start-up funds, call schedule responsibilities, clinical and administrative support staff, professional account funds, dues for organizations and societies, traveling to a satellite office, location of your office, flexible work hours, number of days allowed for attending academic meetings, block times for surgery, teaching/administrative/committee duties, and academic support such as a statistician, research coordinator, and administrative assistant. For those who are clinician-scientists, you may also want to negotiate for lab space, a start-up package, expectations for external support, protected time for how long and how much until obtaining an R01 grant, and a possibility of creating a mentorship committee for yourself. When working for large institutions such as medical schools, one may be limited by institutional rules and budget. However, you won’t know what is allowed unless you ask. You are not worse off, even if the answer comes back as “no.” More likely, you may get few of your asks. Do ask. Finally, salary parity with male peers should be maintained even after the early career phase and needs to be reevaluated continuously throughout one’s career. Learn to understand the compensation plan and be ready to approach the department chair or others, if you believe there is inequality. Do learn.

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Know the Rules Academicians are not only clinicians but also educators and researchers. In some academic institutions, there is also an emphasis on community and global engagement. While one may not be an expert at all four areas, one should excel in at least two or more of these areas to succeed in academic medicine. Therefore, it is wise to know what constitutes an expert status of each of these areas at your institution. Know the requirements for promotion and begin gathering evidence of success. Start attending seminars or seek out members of the Rank and Tenure Committee to know the requirements for assistant, associate, and professor ranks and for tenure. These may include the number of external and internal letters needed; knowing what constitutes regional, national, and international reputation; the number and types of publications necessary; types and the number of committee and leadership positions needed; and service to the hospitals and the community. There also may be different pathways for promotion, such as clinician-educator or research pathways. Most academicians prioritize teaching. Some medical schools require an educator’s portfolio that includes evidence of teaching, curriculum development, mentoring, and educational leadership and evidence of excellence such as teaching awards and student ratings. Therefore, learn to accumulate these documents. Knowing the rules for your medical school’s promotion in the beginning will help you to plan out your career better.

Know Your Mentors One of the greatest satisfactions from my academic career is being able to teach and to mentor those at my institution as well as others around the world through specialty societies, committees, and meetings. Try to cast a broad net as you seek out your mentors. Also, it is helpful to discuss with your mentors as you develop your career strategies, based on your values, personal mission, and vision. For clinician-­ scientists, having a strong group of mentors will be especially important for applying for grants and being successful in research. For most, first grants are K awards, but they can help you to identify other types of grants as well as running a successful research team and dissemination of findings. Even for academic clinicians, having mentors can help guide you with various aspects of academic medicine, such as podium presentations, getting into committees, becoming a better teacher, collaborative research, getting promoted, and learning work-life balance. It may be helpful to have multiple mentors of both genders in and outside of your institution who can address various facets of academic career. One should also try to be a good mentee, who is mindful of the mentor’s time and availability, and be active in the relationship by initiating contact with questions rather than quietly waiting for something to happen. Try to see how you can help out your mentor as well.

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While some may have an obvious group of mentors, such as in a research team, or a formal one-on-one mentorship, as during the leadership development programs, other mentor-mentee relationship may not be as clear. In many cases, it may be as simple as you try to emulate your role model who you observe from a far, such as those you meet at various conferences. No matter which type of mentor-mentee relationship you have, always look around and learn from those around you, both in and outside of your field. Networking while at specialty meetings and conferences will help you with finding mentors and role models. Doing good research and presenting at conferences or volunteering at specialty societies will also help you with networking and being noticed by potential mentors. Also know that your mentors may turn into your collaborators as well as help you to find other collaborators. Much of research now is through collaboration. Seek out those who have similar interests as you and build relationships.

Know Your Protected Time Because of various roles played by an academician in an academic career, it is important to have protected time to commit to these responsibilities. It takes time to teach, to do research, to innovate, to disseminate knowledge by preparing for lectures and presentations at medical schools and at professional meetings, write for grants, serve on committees internally and externally, write manuscripts, serve the community, serve as a journal reviewer, and mentor medical students, residents, fellows, and junior faculty. None of these activities generate revenue. But they are important for the missions of many academic centers and they take time. Therefore, to be successful in academic medicine, there should be reasonable protected time to engage in these activities. Early in the career, you may actually have more time, as the clinical and other workload such as committee involvements are light and still building. Therefore, one should use this time well. Another way is obtaining research funding which “buys” you protected time. One should consider seeking jobs in departments with sufficient number of colleagues in the section, so that one can have protected time and share calls, rather than needing to see patients all day, all week, by yourself.

Know to Balance Work and Life Studies have shown that women physicians and younger physicians are more likely to suffer burnout when compared to men and older physicians. This is despite the fact that women are about four times more likely than men to work less than full time. In our institution’s survey, this may be due to overwhelming majority of women physicians also being responsible for childcare, elder care, and household chores. A study by Starmer et  al. found that only 43% of physicians reported

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balanced work environment and women are more likely to have less balanced worklife [1]. Since a balanced work-life has been shown to be a predictor of job satisfaction, it is important that we learn to balance. It appears that electronic health records are contributing significantly to physician burnout as is the explosion of information needing to be digested in medicine. Others have shown that having trainees in the clinic and the operating rooms results in longer time needed to see patients and adds to burnout of academicians. Interestingly, those who spent less than 20% of their time on the aspect of their work they find most meaningful were more likely to burn out. Therefore, it is important for each of us to have a goal in our career and spend time working towards that goal. We should do what is meaningful and passionate for each of us, while taking time for our individual physical, emotional, and spiritual well-being to attain the work-life balance. Personally, it is one of the most difficult aspect of being in academic medicine, due to many demands on my time, but I am always striving to attain the elusive balanced state. Like others, I do not like the phrase “work-life balance.” My work life and home life are constantly intertwined, and it is difficult to completely compartmentalize in order to “balance.” Others have used the word “prioritizing” rather than balancing, to indicate that sometimes one may take priority over the other. Whichever you choose to call it, the bottom line is that we need to do both well while staying physically and emotionally healthy and grow strong in our career as well as in our relationships with family, friends, and others.

Last Words I believe being in academic medicine is one of the greatest and noblest careers for anyone. It is especially well-suited for those who desire diversity of activities at work, who want to teach, mentor, research, and innovate, and those who do not want to worry about running a practice on a day-to-day basis. However, compared to private practices in ophthalmology, academic medicine has less autonomy, less pay, more committees and bureaucracy, and more institutional rules to follow. Therefore, while academic medicine is not for everyone, it offers opportunities not possible in private practice for those with a desire to seek pursuit of knowledge, advance the field, influence the next generation of physicians and scientists, and reach out locally, nationally, and globally. For many of us, it is the greatest way to have fun and be rewarded while working. Hope you will too.

Reference 1. Starmer AJ, Frintner MO, Freed GL.  Work-life balance, burnout, and satisfaction of early career pediatricians. Pediatrics. 2016;137(4). Pii: e20153183. https://doi.org/10.1542/ peds.2015-3183.

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Judy E. Kim, MD  is an internationally well-known vitreoretinal specialist. She is a graduate of the University of Chicago, Johns Hopkins University School of Medicine, and Howard Hughes Medical Institute-National Institutes of Health Research Scholars Program. She completed her ophthalmology residency at the Bascom Palmer Eye Institute of the University of Miami and vitreoretinal fellowship at the Medical College of Wisconsin (MCW). Currently, she is a Professor of Ophthalmology with tenure at the MCW. As a Korean-American who immigrated from South Korea, she has achieved many firsts. She is the first Korean-American to become a member of the American Ophthalmological Society, first to become a member of all three US retina societies (American Society of Retina Specialists, Macula, and Retina), the first to become a Board of Trustee member for American Academy of Ophthalmology (AAO), and the second to become a Professor of Ophthalmology in the United States and the first to do so in retina. She is only the second woman to serve on the executive committee of ASRS, the largest retina organization in the world with members from 60 countries, and will be only the second woman to serve as the President of ASRS.  She is currently the chair of Women in Retina. She has held leadership positions in multiple committees of AAO, Association for Research and Vision in Ophthalmology, Macula Society, ASRS, and Retina Society. She serves on the editorial board of JAMA Ophthalmology, OSLI, and Ocular Surgery News and is part of the National Eye Health Education Group of National Institutes of Health. Dr. Kim has received numerous awards and honors, especially for her clinical excellence, leadership, and service to organizations. She has received Honor Award and Senior Honor Award from ASRS, Achievement Award and Senior Achievement Award from AAO, Heed Foundation Fellowship, and Women Pioneers Research Award. She has been named in the “Best Doctor” annually since 2003 and also has been named in the “Retina Hall of Fame.” She has published over 200 papers and given over 400 presentations, including 150 invited national and international presentations. She has mentored numerous students, residents, fellows, and international retina specialists. She has been actively involved with over 60 multicenter clinical trials and has served as a vice-chair of Diabetic Retinopathy Clinical Research network, in which she currently serves as a national study chair for Protocol AE. She leads the TeleEye Health Collaborative in Wisconsin. In addition to diabetic retinopathy and age-related macular degeneration, her research interests include surgical retina, telemedicine, ocular imaging, and community engaged research. She is married to Dr. John K. Hur and has a daughter who is an OB/GYN resident and a son who is a first lieutenant in Marine Corps, studying to become a pilot. In her spare time, she enjoys singing, playing the piano, photography, traveling, and culinary adventures.

Chapter 6

Starting Your Own Practice P. Dee Stephenson

Summary Points • Choosing the right location is a key to success. • Choosing professionals you can trust is integral to success. • Choosing the right equipment is essential to success.

Opening your own practice will be a very exciting time in your career but can also be the most stressful, limit-pushing challenge you will ever undertake. Your success will be based on being open-minded and willing to adapt to ongoing changes. You will find that the majority of your successful start-up depends on thorough preparation to ensure a smooth transition for the opening of your practice. This is not a short-term endeavor, so invest your time wisely while researching your options, associates, and employees. Sound decisions made beforehand will serve you for years to come. You are not just starting a practice, but are building your brand and a strong foundation for your future. Your first and one of the most important decisions will be where you want to live and raise your family. As your practice will be a major part of your life, you need to be happy in your environment and have an area that will accommodate your practice as well as your well-being. Choose where you want to live, but also make sure that the area is suitable to your specialty; for example, a pediatric ophthalmologist may serve better in a younger community than a predominantly retirement-aged community, and specialties such as neuro-ophthalmology may reach a greater base in a larger city. Your time is important, so consider commuting time to and from your P. D. Stephenson (*) American College of Eye Surgeons, Havertown, PA, USA Stephenson Eye Associates, Venice, FL, USA © Springer Nature Switzerland AG 2021 C. Y. Weng, A. M. Berrocal (eds.), Women in Ophthalmology, https://doi.org/10.1007/978-3-030-59335-3_6

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practice before choosing your office location. Make an appointment to speak at length with the building and zoning department if you feel you may need to make some structural changes to an existing property (e.g., adequate patient and employee parking, designated handicapped parking, wheelchair access ramps, and restrooms) to accommodate your needs, prior to committing to a property. You may find the cost for renovations exceeds the cost of a turnkey property. Consider space utilization potential, for as your practice grows you may find the need to add more equipment and allow for employee and patient accessibility to testing areas. Once you find the perfect match, make it welcoming and relaxing for your patients with pleasing décor and landscaping. There are many reputable consulting firms that can assist with identifying your financial objectives and help you with aspects of Occupational Safety and Health Administration (OSHA) compliance, insurance credentialing, securing a tax ID number, contracts and human resource requirements, as well as marketing needs, credentialing, and insurance contracting. However, if you do use a consultant, make sure you are well informed and an integral part of the decision-making process. Keep in mind that an experienced office administrator can assist with handling these tasks. It may be preferable to enlist the expertise of solo specialists in each area of need to ensure you are well informed in each area of expertise and, unlike with some consulting firms, this would not require a contract. If you prefer this approach, there are people you will need as an integral part of your many initial start-up decisions. These relationships will more than likely be long term, so choose a professional with whom you have trust, rapport, and confidence in their professional skill set. Banker  Choose a local reputable banker to first present a pro forma (ideally 3–5  years out) with documentation of your presented numbers including debts, (anticipated and current) projected revenue, and anticipated income. A banker’s expertise lies in discerning which goals are attainable and which may not be, and a detailed pro forma can give you realistic expectations for your first 3–5  years of practice. This will also serve as a factor in your decisions regarding investments to grow with your practice and your income. Obtain a realistic line of credit to cover costs, including payroll, until your income is established. Your banker will also be able to refer you, if needed, to other local professionals in the area to accommodate your needs and concerns or direct you to those who can, if they are not able. Accountant  Establish a relationship with a reputable well-established accountant to assist in setting up a corporation, tax deductions, income tax, tax ID, finances, payroll, and other monetary issues. Require detailed monthly written statements to update your pro forma, so that any changes in actual revenue can be factored into your anticipated income and be adjusted accordingly on an ongoing basis. Your accountant may also be able to recommend what coverage you should carry for disability insurance. This insurance would allow you to cover the expenses of running your office if you are unable to work for an extended period of time.

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Attorney/Compliance Officer  Choose an attorney or an experienced administrator to assist with contracts, negotiations, real estate, and medicolegal issues if necessary. It could also be beneficial to consult with a professional versed in dealing with healthcare compliance issues, OSHA, Joint Commission, accreditation, Health Insurance Portability and Accountability Act (HIPAA), medical licensing, and Drug Enforcement Administration (DEA) credentialing, National Provider Identifier (NPI) numbers, hospital privileges, and ASC surgical privileges. These are critical areas of compliance in your practice, and it is well worth your investment to consult with an expert in the field. Administrator  Hire an office administrator to oversee the day-to-day operations and requirements of your practice, including but not limited to screening and hiring personnel, payroll, maintaining records, credit card processing decisions, hiring cleaning services, bio-waste disposal, ordering supplies and equipment, meeting with sales representatives, being a patient/surgical liaison, implementing and enforcing policy and procedures, staying abreast of state employment laws and guidelines, and organizing staff meetings. Your administrator represents you in all aspects of your practice, and it is critical that many factors are considered before deciding upon an effective administrator who will be an asset to your practice. Computer Engineer/IT  Hire a computer engineer to assist with setting up and maintaining computer systems, phone systems, medical equipment integration, printers, electronic equipment and connections, VPN (virtual private networks), and security with HIPAA compliance. It may be in your best financial interest to have a yearly support “on call” contract. Involve your computer engineer with available options for your practice management system and electronic health record (EHR) system beforehand, as their existing experience and input with the current options available may be determining factor in your favor. State and Local Medical Associations  Consult with the American Academy of Ophthalmology (AAO) and your state ophthalmic society regarding your malpractice insurance. Malpractice insurance not only protects you and your assets, but also gives you peace of mind. Rates also vary state to state, so location is a factor in this decision. Some physicians relocate to areas where malpractice insurance costs are not as high, but this is a decision you alone will have to make. Many malpractice insurance companies can give you an online quote if requested; however, it may be less time-consuming and stressful to enlist the skill of an attorney in this regard. Hospital Privileges  Apply for ambulatory surgical center (ASC) and hospital/surgical privileges at a local reputable facility that is easily accessible for your patients and preferably near your office. Medical credentialing or healthcare credentialing must be complete before applying for ASC or hospital privileges. This can be a lengthy process, but if it is not done correctly, it can result in liability and be harmful to your reputation as a physician. Hospital privileges may be authorized as admit-

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ting privileges, courtesy privileges, or surgical privileges. Once granted, ensure that you uphold the facility requirements in a timely manner with regard to their stipulations, complete and signed medical records, etc. Service Organizations  Join a service organization such as the local Lions Club or the Chamber of Commerce as they will enable you to become more aware of your community. Becoming involved with your community and its needs allows others to see you as a part of the community, not just a business. Peers  Your local medical society is an excellent way to meet other physicians and share knowledge. You may also want to attend local community events, for ­example, local physician lectures, health screenings, and health fairs, to introduce yourself to your peers. Make it a point to meet your potential referral base, which may include optometrist. Establish local healthcare providers for yourself and your family (dentist, PCP, internist – whatever your needs are) and get acquainted with your new physicians. Advertising  The best advertising is word of mouth, but in the meantime you will want to advertise your practice opening. Advertise in local magazines, newspapers, and newsletters. Healthcare marketers and web design specialists can help you meet your practice needs and goals with optimal search engine placement and other ways to highlight your services. Companies also are available to offer targeted and measurable approaches to your advertising via web design, which is one of the most effective ways to grow your practice, and your investment is accountable and trackable click by click, so you can review the charted results of your advertising costs. The American Medical Association (AMA) does provide information and guidance on physician advertising, but it is important to note that a medical practice cannot be promoted in ways as other businesses can – again, refer to your attorney or the AMA for specific guidance in this area. Equipment  Having great equipment is essential. Do not skimp on things that will be acting as your workhorses, for example, slit lamp and phoropter. Buy the best you can afford, as these can be a one-time purchase for your practice. Your practice will also require diagnostic equipment and equipment for ancillary testing. Keep in mind, for example, that even if you are not a retina specialist, you may want to invest in an optical coherence tomography (OCT) machine to document findings and refer to a specialist if indicated. When purchasing equipment, also keep in mind that these costs are an investment for a limited number of years, as technology changes and equipment capabilities improve by leaps and bounds. Obtain service contracts and warranties when possible. You will, as your practice grows, add more equipment as desired. As mentioned, allow for space and accessibility to testing areas for patients and staff when initially choosing your office. EHR  One of the most important equipment decisions you will make and utilize for years to come is your choice of EHR system. There is a penalty from Centers for

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Medicare and Medicaid Services (CMS) if you choose not to utilize EHR, but that option would serve no benefit to your practice, as a good EHR system has the potential to increase the number of patients you can see daily. Do your research and, as mentioned, enlist the input of your computer engineer for help with system requirements and integration with your diagnostic devices. Most EHR systems will include with their subscription e-scribing, patient portal, e-faxing, updates, demographics, documents, training, and support. You want to choose a system that is easy to master, allowing more time for quality care by allowing you to focus on your patients, not your computer. Keep in mind it takes 30–60 days for EHR implementation, so allow yourself the necessary timeframe before you open your practice. Hiring Employees  Although the process of advertising, screening, and hiring of employees typically falls upon the office administrator, it is imperative that you are also an integral part of the hiring process. When listing a job opening in your office, be clear and specific with educational requirements and duties. This screening will save you valuable time and afford you longer interactions while interviewing potential employees. Inform applicants of the benefits to working at your practice (e.g., 401K, insurance, vacations, sick time, holiday/overtime pay, furthering education, and incentives) It is not unreasonable to require background checks, bonding, and random drug screenings as part of your personnel requirements, and these should be specified during the interview process. Provide a well-prepared policy and procedure manual for employees to read and sign before committing to employment. Provide adequate training to employees prior to opening your practice so they can become familiar with the EHR system, phone system, equipment, and office roles. The more time invested prior to opening, the more comfortable your staff will be performing tasks, and the more at ease your patients will be. Your employees are the first people your patients come in contact with: make sure they make a great first impression. Some of the positions you will need to fill prior to opening your practice are front desk reception, appointment scheduling and check-out, billing, technicians, a surgical counselor that knows you and your techniques, and perhaps a transcriptionist or in-house scribe. Keep in mind that office personnel can fulfill one or more positions in their day-to-day interactions. For example, a technician may also be capable of operating an OCT machine and alleviate the need for an ophthalmic photographer, and on your surgical day, a technician may also be able to do visual field testing. The five best things you can do before opening your practice are as follows: 1. Be well informed. Know that it will be difficult and time-consuming. As skilled as you are at your profession, your expertise may not lie in some areas that need so much attention and detail prior to opening your practice, so rely on the knowledge of professionals. 2. Be realistic. You are just starting a practice and the hours will be long. Patient schedules will be light and cash flow not yet forthcoming. Be patient. The more you invest now in each patient on an individual basis, the greater your reward will be later.

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3. Be prepared. Have your financial projections in hand and your credit line to carry you through until patient load increases and insurance payments are processed and paid. 4. Be knowledgeable. Choose an EHR system that is easy to master and affords you more time with your patients. 5. Be selective. Hire the right people. Your staff is a reflection of you and sets the tone for your office on a patient-by-patient, day-to-day basis. Now that you have invested so much time and energy into your practice, and have completed your detailed planning, research, and follow-through, it is time to open your doors and welcome your community to your practice! As with anything, most of the work lies in the preparation, but your new journey now begins. P. Dee Stephenson, MD, FACS  is the founder and director of Stephenson Eye Associates in Venice, Florida. She is a native Floridian who received her BS from the University of Florida and her Doctor of Medicine from University of South Florida; she completed her residency in Ophthalmology at the University of South Carolina. She is a Fellow of the American College of Surgeons and the American Academy of Ophthalmology, and is certified by the American College of Eye Surgeons (ACES). She has extensive expertise in micro-incisional cataract surgery, implantation of premium intraocular lenses (IOLs), custom femto cataract techniques, and intraoperative aberrometry. Dr. Stephenson has been recognized by numerous institutions and journals for her expertise and contributions to cataract surgery and premium IOLs. She was listed as one of the 250  in Premier Surgeons of Leading Innovators and more recently was named in the Ocular Surgery News Premier Surgeon 300 and Who’s Who in Ophthalmology. She is a recipient of the American Academy of Ophthalmology (AAO) achievement award along with the Castle Connolly Exceptional Women in Medicine Outstanding Female Leader in Ophthalmology recognition. She is continuously engaged in clinical research and studies to evaluate new technology and is at the forefront of research and development in the creation of specialized surgical instrumentation, techniques, as well as the development of the next generation of IOLs. Dr. Stephenson shares her knowledge with ophthalmologists worldwide and with ophthalmology residents as an Associate Professor at the Morsani College of Medicine Department of Ophthalmology at University of South Florida in Tampa. She is on the editorial board of Cataract & Refractive Surgery Today, editor of the cataract section for AAO Focal Points, a founding member of American-European Congress of Ophthalmic Surgery (AECOS), and CEDARS/ASPENS.  She presents extensively at major ophthalmic meetings. Dr. Stephenson consults for several major companies in many different roles. She is the immediate past president of the American College of Eye Surgeons and president of the American Board of Eye Surgery (ABES).

Chapter 7

Building Your Clinical Practice and Reputation Geeta Lalwani

Summary Points • Background work is needed to start a practice. • Developing a practice requires skillful relationship-building. • There are unique challenges of being a woman in solo practice.

An N of 1. That is what led me to start a practice in my hometown of Boulder, CO. For years, my father had lamented the situation of our neighbor who had a retinal detachment and had to drive an hour for his surgery and follow-up appointments; this singular fact confirmed for my dad that I should move home to Boulder, Colorado, and start a surgical retina practice. A variety of factors led me to consider this—namely my desire for control over my career and the atmosphere within it. While visiting my parents I serendipitously met a young, solo ophthalmologist. He reinforced exactly what my dad had said—there was a strong need for retina in Boulder. He was a tremendous resource and offered information on the area, referring doctors, insurances, and the overall ophthalmology landscape. It was almost as if he had known that I would knock on his door one morning. He was not the only person to help me; as I began the process of starting my own practice, I discovered generous colleagues and peers willing to help thanks to a special comradery among doctors who launch individual practices, as if by helping someone else start, it validates their own decision. Against scientific principles, an N of 1 launched the idea of starting a retina practice, and it took off from there. Having been on faculty at an academic institution, I was very comfortable with the medical aspects of retina. I knew how to address the invariable complications of

G. Lalwani (*) Rocky Mountain Retina Associates, Boulder, CO, USA © Springer Nature Switzerland AG 2021 C. Y. Weng, A. M. Berrocal (eds.), Women in Ophthalmology, https://doi.org/10.1007/978-3-030-59335-3_7

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disease, of surgery, and even patient personalities. We had just added a baby girl to our twins, and I was looking for a better career fit than where I had been, as well as some degree of balance. I knew how I wanted to care for patients, and the environment that I wanted to create for myself and my staff. It seemed natural to start my own practice. Once I made the actual decision to start my own retina practice, I never looked back. A retina friend of retina friend, to whom I am ever indebted despite never having met him, exchanged texts, emails, phone calls, helping me to begin to understand what I needed to get my vision off the ground. There were endless to-do lists that filled my computer, notes on my phone, and sticky notes everywhere. I tried to consolidate everything into broad categories: insurances, hospital credentialing, equipment needs, and pharmaceutical needs. I found that the more lists that I made, the more that I added—hospital credentialing led to malpractice coverage because credentialing cannot take place without malpractice coverage in place. Pharmaceutical ordering will require not only a business account and credit cards, but also credit verification, a process that can only happen once you have an established practice—effectively a catch 22. It is true that as a solo practitioner, you will wear many, many hats. Thankfully, I was already a good multitasker as a mom, but I have become truly exceptional through this experience. I am also lucky to have a strong network of support around me. Importantly, I had (and still have) no qualms about asking for help, something that may perhaps be easier because I am a woman. Much of this support began with my family. I come from a very strong family of entrepreneurs, though none medical. They believed in my success from the very beginning and offered time, emotional support, and more; that helped create the time and space I needed to devote myself to my endeavor. My mom and sister watched my 6-month-old baby and my 8-year-old twins so that I could physically start a practice. I cannot overstate how helpful that was; they made it possible for me to build my business without guilt or worry about who was tending the baby, as my husband worked across the country during the week, providing financial stability during an exceptionally turbulent time. My lawyer brother helped me to fill out endless reams of paperwork, and more importantly, understand what it all meant. To this day, he often offers legal advice and reads leases, contracts, employee forms, and other paperwork so I am protected, an incredible luxury. My father, who once ran his own business in computer hardware manufacturing, helped me establish “the books” to track and manage cash flow. He also became my person to bounce off ideas, as well as to do small jobs in the office as I got started. My husband, my rock, was everything else. He helped me transport equipment, set up the optical coherence tomography (OCT) machine, and network computers. He listened to me when I complained, boosted my confidence when it lagged, and gave me a shoulder to lean on. Even my practice’s graphic, the Flatiron mountain range in my hometown, was designed by a friend who understood my love for my hometown. The number of people who contributed to the formation of my practice is endless. Equally important to building my business’s foundation was picking an opening date; nothing like a deadline to ensure the job gets done. My date was January 28, 2013. In the month before, I raced around on a daily basis, ticking off items on my list. My first goal was to make my office seem, well, like an office. I bought waiting

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room chairs from another medical practice and hauled them to my office in my minivan. A friend tipped me off about a rural ophthalmology practice going out of business that was selling all kinds of ophthalmology-specific items: exam chairs, slit lamps, even instruments. My husband and I borrowed a pickup truck with a flatbed and managed to load two exam chairs. It was a brilliant plan until it started snowing on the ride home! We stopped at a gas station and bought rolls of Saran wrap to cover any electrical outlets, wiring, and openings to prevent any rogue snowflakes from undermining my quest! To personalize my office, I hired painters to repaint the interior. It looked good, but I wanted it to look better and decided the front door needed to be repainted. First impressions matter. To that end, I decided to paint it myself, but only with my left hand. Better to ensure my right hand remained untainted, so I could shake the hands of new patients without betraying the fact that in addition to being their medical provider, I was also responsible for essentially everything else about the business. Opening day came and I was ready. Lorrie, my first hire, served as my receptionist, my biller, and the grandmother figure with whom I would need to cry. The pressure of my decision to start a business manifested itself in the middle of the night, with racing thoughts about things yet to be done and to what had I committed myself. It rarely spilled over into the daytime, but Lorrie was there to hug me when it did. I delivered cookies and cards to referring doctors in the area. Not just ophthalmologists and optometrists, but endocrinologists, primary care physicians….anyone who would agree to meet me! I think that I had one patient on my first day. But on January 30, only 2 days after opening for business, one of the referring doctors called me for a macula-on retinal detachment. This felt like a major achievement and affirmed that the community of Boulder had a need for me and my services. Even though I had started seeing patients, by no means was I all set. I was still working on the insurance panels, with which Lorrie was an immense help. The billing was also chaotic, especially because I was on paper, not EMR, as is now required. I have to admit, though, that paper charts were more satisfying—like reading a book rather than a Kindle. I could literally touch the results of my endeavors—celebrating when I reached chart #100! I encourage all trainees to really concentrate on coding during their final 6  months, as a diagnosis cannot exist without the ICD-10 numbers ascribed to it! In setting up my practice, I had calculated that medical retina would be the early referrals, and that surgical retina cases would follow. In fact, I was completely wrong. Surgical retina—particularly retinal detachments and macular holes—are emergent, and a referring doctor is usually desperate to secure an urgent referral. Close proximity to the referring doctor is helpful for both patient and provider. Therefore, my surgical volume picked up quite quickly, and within 2–3 months, I was doing one to two cases a week. This may not seem like a lot, but to start from scratch and achieve a steady surgical volume in 3 months was not a milestone as much as it was a confidence booster. I also realized that taking care of retinal detachments was usually followed by less urgent, more medically related referrals. The rapid increase in surgical volume forced me to develop relationships with the hospital and the staff. I was very lucky, even though the surgical equipment was

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a little dated, that both the equipment and the staff that maintained it were excellent! As my business grew, I returned frequently to the adage about treating everyone in the room with respect, not just the higher-ups. This is how I live my life, and in my business, it was essential for building bridges with the surgical staff and management, which led to tangible results. For example, within a year and a half of opening my practice, the operating room (OR) procured a brand new Constellation (Alcon Surgical, Fort Worth, TX) and Lumenis microscope, the equivalent of Christmas presents to a retina surgeon! When you start from zero, outreach is crucial to success. In line with my willingness to meet anyone, I never turned down an opportunity to speak. I gave eye care talks in the community for assisted living facilities, nursing homes, hospitals, etc., where the audience ranged from 3 to 275 patients! Sometimes I laugh, when I realized that some patients probably could not even hear what I was saying and would benefit from ENT (otolaryngology) more than they would from me, but it made an impression on the whole community—the administrators of various care facilities and more importantly, the caregiver community at large. Many of the ancillary staff came to me as patients, even though I never considered that they were the (only!) ones listening! I often tell people that in the first few years of starting a practice, you treat every day as if it may all end the next day. It is a very vulnerable feeling to be so uncertain about your future. It also serves as enormous and continuous fire under you, which makes you constantly work harder. I started my initial office 20 minutes outside of Boulder for real estate reasons, but I knew that I wanted to be based in Boulder. I had already started seeing retina patients in Boulder in another ophthalmologist’s office, but it quickly became too busy to sustain this arrangement. As a result, I signed what I think is the single most difficult document I have ever signed: a second long-term lease, effectively expanding to a second office! I did not sleep for months after this, and not because I had a 10-month old baby at home! Again, I found myself purchasing equipment for my second office, and waiting room chairs. This time, I found brand new ones at Pier One Import and, with a coupon, was able to buy them at a reasonable price. To this day, they are one of my most favorite purchases in my office. During this time, I came into contact with an old family friend, Jim, who sold secondary market ophthalmology equipment. Jim not only helped me acquire office equipment, but he convinced my hometown paper to write an article about my practice. I credit his guidance and kindness for the ease with which we opened my second location. Once up and running two offices, I now needed to learn how to manage people. This was perhaps my biggest challenge, and initially employees took advantage of my non-confrontational nature. I recall one Friday when both my receptionist and my tech asked for the afternoon off, and I gave it to them, certain I could handle the few remaining patients by myself. It is comical to me now, but the phone rang constantly that afternoon, and three retinal detachments were sent over, in addition to my scheduled patients. At one point, one my “established” patients was helping new patients fill out paperwork so that I could actually see patients! I realized at that moment that I could no longer be nice all of the time. I had a clinic and business to

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run. I have learned the truth behind “be slow to hire, quick to fire,” even when it may seem heartless. I have also instilled in my staff the idea that they represent me; when a patient meets/speaks with them, they are the first impression of my values as a physician. I am proud to say that I receive continuous compliments from patients about my staff and the overall office culture. I have also taken on a secondary mission of pushing my employees further in their educational endeavors, with letters of recommendation and flexibility in hours for furthering their educational endeavors. Like most practices, my staff is predominantly female, and I have always supported women in the advancement of their careers. For me, there is karmic incentive when my technicians and receptionists go on to medical, physician assistant, optometry, or graduate school. I recently came across an article in the Wall Street Journal entitled How Parenting Skills Taught me to Be a Better Leader. I wished that I had written this article myself years ago when I realized that the most effective way of managing my office was to “parent” my employees—to believe in them, but also to be firm with my expectations. I was the only female ophthalmologist in my area until recently, and one of only two female surgeons at the ambulatory surgical center (ASC) out of 24. While this situation is common to many of us, the politics of being a female solo practitioner is sometimes daunting. I have had to play into the role that each referring doctor ascribes to me—I cannot be too aggressive to the older ophthalmologists, too sure of myself to those unsure about me, or too smart compared to my competition. My business depends on this. At times, I have felt like I have finally achieved equity with the community, only to be upended in business transactions, like ASC ownership. These occurrences remind me that I am still a woman. If ever I thought the field of retina was domineering, it does not compare to the mansplaining that exists in the business world. In discussions about ASC ownership with the chief financial officer of one of the hospitals with which I am affiliated, he asked me if I knew that equity ownership would involve me paying a sum of money to be a partner. I stared at him blankly, unable to believe that he was defining equity partnership to me. Similar to most physicians, the business aspect of medicine was never taught to me, and starting your own practice is essentially a crash course. Surrounding myself with solid people, my accountant, bookkeeper, and business partners, has drastically shortened the learning curve, and made me a solid business woman. Ultimately, the first 2–3 years of starting a practice are the most difficult, in the context of building patient volume, the learning curve of running a business, and honestly, getting comfortable with being uncomfortable. There is a constant pressure in knowing that my reputation is my practice, and my practice is my reputation. I have made numerous mistakes along the way, from billing to hiring to negotiating for pharmaceuticals, but I have always put the patient first. Having my own practice has allowed me to develop more unique relationships with patients, and many of them have grown my practice together with me. They have observed the expansion from a single small building, into multiple renovated offices. I am also able to nurture employees as I see fit and build relationships with referring doctors in a

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manner that fits my personality. I have created a culture around me that contributes to my career satisfaction, makes me happy, and allows me to change a small part of the world. But most crucially, it shows the most important women in my life the power of hard work—my daughters. Geeta Lalwani , MD  is the founder of Rocky Mountain Retina Associates, where she specializes in the medical and surgical treatment of retinal diseases. Prior to Rocky Mountain Retina, Dr. Lalwani was with the University of Miami’s prestigious Bascom Palmer Eye Institute as an Assistant Professor of Clinical Ophthalmology. She completed her fellowship in vitreoretinal surgery at the Bascom Palmer Eye Institute, and ophthalmology residency at Case Western Reserve, and received her M.D. from Drexel University. Dr. Lalwani is board-certified by the American Board of Ophthalmology. She is a member of the American Academy of Ophthalmology, American Society of Retina Specialists, the Vit-Buckle Society, EnVision Summit, and the esteemed Retina Society.

Part III

Patient Care

Chapter 8

Staying at the Forefront of Your Field: Embracing the New María H. Berrocal

Summary Points • Try new techniques and instruments. • Choose cases appropriately. • Make yourself visible by accepting all invitations to speak initially.

The importance of being at the forefront of innovation became prescient during my fellowship training. I was fortunate to be at the right place and time, training in the early 1990s with Stanley Chang, who is credited with some of the most important innovations of vitreoretinal surgery that we now take for granted, and with J. Donald Gass, who described many of the retinal diseases. At the time, vitrectomy was 20 gauge (20 g), some of the perfluorocarbon gases had been developed by Chang and Harvey Lincoff and were beginning to be utilized, heavy perfluorocarbon liquids were used experimentally by Dr. Chang and others, and wide-angle viewing systems such as the non-contact BIOM in Germany and the contact AVI system in New  York were being created [1–3]. Macular holes had just become a treatable pathology. The transition from extracapsular cataract extraction to phacoemulsification was also starting at this time. Being in this transition, I was able to experience first-hand the importance of innovation and how it increased our success rate in so many surgeries, from giant retinal tears, to tractional retinal detachments (TRDs), retinal detachments with proliferative vitreoretinopathy, macular holes, and diffuse unilateral subacute neuroretinitis (DUSN) to name a few [4]. I could also see how many surgeons resisted

M. H. Berrocal (*) Berrocal & Associates, San Juan, PR, USA © Springer Nature Switzerland AG 2021 C. Y. Weng, A. M. Berrocal (eds.), Women in Ophthalmology, https://doi.org/10.1007/978-3-030-59335-3_8

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change and took a long time to embrace new technologies, at a significant detriment to patients. One important lesson on integrity, and embracing advances, I learned from Dr. Gass. It was 1992, and macular holes were being operated on since the Kelly and Wendel paper of 1990 [5]. A 50-year-old woman was randomized to an observational arm on her second eye with macular hole. He told the woman that she should get out of the study and get this new surgery for macular hole, so that she would not be destined to legal blindness. Through this encounter, I learned possibly the most important lessons of my career: that the patient’s interest comes first and foremost, that change is necessary for improvement, and that complacency in our comfort zone will only lead to stagnation. The beauty and excitement of our field is how vibrant with innovation it has been, and how many developments have allowed us to successfully treat many diseases that were blindness sentences in the past. This is not only on the surgical side, but also on the medical side of retina, and it has been a privilege to practice retina during very exciting times. During my fellowships, Stanley Chang, Harvey Lincoff, and Donald Gass would practice their talks, then given in dual carousel slides. They took great pride in their presentations, even when presenting on topics in which they were the world’s authorities. That example of taking great pride in one’s work, and in the first impression that is made through a presentation was imprinted in me early on. They encouraged me to be on the podium very early on and to be visible. As a woman in a then mostly male field, I felt it was my responsibility to show that women could be on the podium and could be at the forefront of innovations. I saw this as the only way that women would begin to be more accepted in the field and seen as assets. After my fellowships, I returned to Puerto Rico to practice with my father. My father was the first vitreoretinal specialist in Puerto Rico. He trained at the time when scleral buckles, Xenon arc photocoagulation with a direct ophthalmoscope, and intracapsular cataract extractions were the surgeries of the time. He learned extracapsular cataract extraction and performed the first intraocular lens implants on the island, learned Xenon arc photocoagulation with Dr. Meyer-Schwickerath in Germany, then learned laser photocoagulation and was the principal investigator with the most enrolled patients in the Diabetic Retinopathy Study. He learned vitreous surgery and also the use of microscopes for surgery, all after his training. He also performed the first retinal detachment surgery in the Dominican Republic and taught throughout Latin America. He always wanted to try new things, a passion he instilled in me. This was not easy since Puerto Rico is economically challenged and he had to purchase most of the equipment himself just like I have had to do, but to him, being able to offer the best to his patients was paramount. When you are starting your practice, it is difficult to write papers, purchase equipment, give talks, particularly when you are beginning to have a family. I waited to have children until I finished my fellowship, so trying to manage all was a bit daunting. I was fortunate that my mentors had sent me to give talks a few times

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during my training so that some people knew of me. Because of this, I was invited to speak at a few small meetings in Latin America. I made a point of going, since I thought it was important at that point in my life to get visibility. I did get help from some great mentors; Dr. Chang asked me to author a chapter, and I was asked to make revisions on a submacular hemorrhage paper I was writing with Dr. Mary Lou Lewis and Dr. Harry Flynn. The revisions were due the week after I had delivered my first baby, who remained hospitalized for a week, and Dr. Flynn, a lovely mentor, did most of the corrections for me. After you get invited once, other people will start to invite you if you do a good job and talk about new things. I purchased things I needed such as the AVI system so that I could do wide-angle viewing surgery. A bit later, I splurged on a better camera for recording, so that I could have decent movies to present. I always wanted to try new techniques and instruments. At the time, whenever I was travelling with my family or for a meeting, I would ask to visit a vitreoretinal surgeon in the area so that I could see how they did things. This was priceless, and it is the little tricks that often make all the difference. At the time, one of the most interesting meetings was Dr. Klaus Eckardt’s. The meeting was very small, maybe 100 participants, and was totally focused on surgery with ample time reserved for discussion by the audience, which made for a great learning experience. The Association for Research in Vision and Ophthalmology (ARVO) meeting in Sarasota was marvelous too—very small, almost intimate, and always fresh. The way I approached new technology was trying everything new that came out that did not seem totally insane. I started with simple cases until I got used to the equipment, and then I would think of new ways in which the technology could be used. That is how I came up with the idea of using MIVS technology alone for the lift and shave technique. At the beginning, and particularly if you are not in an academic setting, you may need to be proactive in telling companies to bring you new instruments to try out. Whenever you are trying new technology, do it on a light day and choose simple cases. Most surgeons who get discouraged early on with new technologies do so because they choose non-ideal cases. Always keep an open mind and try things more than once. Be open to change. Surgeons become obsolete when they resist change and only stay within their comfort range. If you want to be in the forefront of things, always be eager to try new technologies. If you are surgically inclined, record your cases. Start creating a database of interesting cases, be it surgical or medical. These can be used for teaching if you are in an academic setting, or for talks if you want to be involved in lecturing. They will also be of use if you want to be involved with industry and become a lecturer or key opinion leader (KOL). When you are asked to present cases or interesting techniques, you will already have resources at hand. Often what you may think is trivial may be interesting to others. If you are interested in lecturing or working with industry, let others know. Tell your colleagues, let them know what your areas of interest or expertise are. Contact

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industry and the drug company representatives. They can always use lecturers and consultants, so let them know you are interested and available. This can be an easy way of letting yourself be known and creating a presence, particularly at the beginning of your career. Remember that initially you cannot be selective, so accept every invitation until colleagues know you. Later on, you can pick and choose. It can be difficult at first since women may often have small children or may be just starting in a practice, and free time can be scarce. Nevertheless, the initial investment in time will pay off, and once a national and or international presence is created, colleagues and industry will notice you and you can be more selective. Retina is a vibrant, dynamic, and quickly evolving field. New developments are exciting and new technologies are the norm. Jump on the train, feel the excitement, and become a part of the wave of change. Your day-to-day life will be enriched, and the diverse prospects of varied activities to complement patient care will keep you motivated and thrilled about the field. Complacency results in obsolescence and boredom. Cherish your patients, be excited about new things and techniques, and share your motivation with your colleagues. This is the difference between a life of rote activities and burnout versus a career that is vibrant, exciting, and rewarding at many different levels. Enjoy the ride!

References 1. Parver LM, Lincoff H.  Geometry of intraocular gas used in retinal surgery. Mod Probl Ophthalmol. 1977;18:338–43. 2. Parver LM, Lincoff H.  Mechanics of intraocular gas. Invest Ophthalmol Vis Sci. 1978;17(1):77–9. 3. Chang S, Lincoff H, Zimmerman NJ, Fuchs W. Giant retinal tears. Surgical techniques and results using perfluorocarbon liquids. Arch Ophthalmol. 1989;107(5):761–6. 4. Johnson MW, Gass JD.  Surgical management of the idiopathic uveal effusion syndrome. Ophthalmology. 1990;97(6):778–85. 5. Kelly NE, Wendel RT. Vitreous surgery for idiopathic macular holes. Results of a pilot study. Arch Ophthalmol. 1991;109(5):654–9.

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María H. Berrocal, MD  is Director of Berrocal and Associates in San Juan, Puerto Rico, and faculty at the University of Puerto Rico. She received her medical degree from the University of Illinois. She completed her ophthalmology training at the University of Puerto Rico where she received the Best Surgeon award. She completed her surgical and medical retina training at New  York Hospital/Cornell University. She then completed a medical retina fellowship with Dr. J Donald Gass at Bascom Palmer Eye Institute where she was a Heed Fellow Awardee. Her research interests include new techniques in vitreoretinal surgery, with a particular interest in complications of diabetic retinopathy. She has participated in numerous studies of novel treatments for the management of diabetic complications. She has held leadership positions in the Pan-American Vitreoretinal Society, Pan-American Ophthalmological Society, Retina Society, American Society of Retinal Specialists (ASRS), American Academy of Ophthalmology (AAO), and Women in Ophthalmology (WIO). She is past president of the Pan-American Vitreoretinal Society. She is on the editorial board of Retina Today, Egyptian Journal of Ophthalmology, and is a reviewer for Ophthalmology, OSLI Retina, European Journal of Ophthalmology, Retina, and American Journal of Ophthalmology journals. She has received the American Academy of Ophthalmology Senior Achievement Award, and American Society of Retinal Specialists Senior Honor Award. She has received the Doctors Choice Award yearly since 2002. Dr. Berrocal has been an invited speaker and visiting surgeon in over 20 countries. She has received the Chang Lectureship and the Founders Lectureship. She has authored and co-authored over 60 articles and book chapters. Dr. Berrocal has held numerous positions in philanthropic societies. She has established educational scholarships for cancer survivors, scholarships for the Sacred Heart University, and Our Children’s House. She has also helped establish a drug rehabilitation center in San Juan.

Chapter 9

Improving Efficiency with EMR in Your Clinic and OR Ariane Dev Kaplan

Summary Points • The rollout of EMR was intended to improve patient care by reducing medical errors, lead the way for healthcare savings, and improve physician efficiency. As of now, there is no conclusive evidence that EMR has fulfilled these goals and there is also no perfect EMR system. • Ophthalmologists spend 11.2 minutes with a patient during an encounter. Essentially, a full day of patient care entails on average 3.7 hours of EMR documentation time with 2.1  hours spent during patient encounters and 1.6 hours outside patient encounter time. This does not account for physician gender communication differences, which result in longer face-to-­ face time with patients for female physicians. Thus, female physicians may spend an additional hour in clinic in order to see the same volume of patients as compared to a male physician. • There are relatively meager scientifically proven methods to improve clinical efficiency with EMR, but many anecdotes. This chapter explores both proven methods and anecdotes to address EMR efficiency.

Electronic Medical Records The words “electronic medical records” (EMR) do not often provoke feelings of happiness and glee, but have become a part of our everyday experience in patient care. It is now estimated that 80% of all ophthalmology practices have implemented

A. D. Kaplan (*) Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, University of Michigan, Ann Arbor, MI, USA © Springer Nature Switzerland AG 2021 C. Y. Weng, A. M. Berrocal (eds.), Women in Ophthalmology, https://doi.org/10.1007/978-3-030-59335-3_9

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an EMR into their clinical practice [1]. The rollout of EMR was intended to improve patient care by reducing medical errors, lead the way for healthcare savings, and improve physician efficiency [2, 3]. Many of us have had the experience of transitioning to a new medical record system. When I was a medical student, all charting was done by hand, but there were rumors of a transition to an EMR system on the horizon. Since graduating from medical school, I have experienced six different EMR systems at three hospital systems. Unfortunately for me, that included an internship year at a hospital system that transitioned mid-year from two different EMR systems to a third system in an attempt to streamline. During the years, I have watched seasoned medical providers chose early retirement over the challenges of learning a new EMR. The purpose of this chapter is not to challenge the use of EMR. There are published papers and there will be more studies in the future to determine if successful implementation of EMR improves patient outcomes and saves our healthcare system money. As of now, there is no conclusive evidence that EMR has fulfilled these goals. There is also no perfect EMR system. Healthcare systems have implemented various EMR systems (e.g., EPIC, Cerner, Allscripts) which all have strengths and weaknesses. During implementation of a new EMR, there is an inherent learning curve. Being patient and willing to try new strategies to improve efficiency will help you in the long term.

How Does EMR Affect Charting Time for Ophthalmologists? When compared to other medical specialties, ophthalmologists see a high volume of patients in the clinical setting. And now there is even more pressure to see a higher volume of patients as increased revenue is sought, demand for care grows, patients are becoming more complex in their clinical and surgical care, and there are trends to linking physician reimbursement to patient satisfaction scores. So how are ophthalmologists spending their time during patient encounters and are we efficient with our time? On average, ophthalmologists spend 11.2  minutes with a patient during an encounter. Of that encounter, 3 minutes (27%) is spent charting on EMR, 4.7 minutes (42%) in conversation with patient, and 3.5  minutes (31%) on examination. Essentially, a full day of patient care entailed on average 3.7 hours of EMR documentation time with 2.1 hours spent during patient encounters and 1.6 hours outside patient encounter time [4]. These averages do not take into account provider gender communication differences.

Are Female Physicians at a Disadvantage with EMR? As of 2017, more women were enrolled in medical schools in the United States than men [3]. The changing demographics of our medical school student body will affect

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our practicing physician population and possibly patient care. Studies have shown that female physicians provide more patient-centered communication [5] and provide more psychosocial counseling to their patients compared to male physicians [6]. Patientcentered communication has a broad definition, but essentially, female physicians have been shown to engage in communication that involves the whole patient and not just the presenting problem. Often, there are frank discussions of emotions, and a more team-like approach to care by including patients in the decision-­making process. This different patient-centered communication style may help to explain why female physicians spend 2  minutes longer per patient (or 10% more time per appointment) compared to male physicians [6]. Therefore, in a busy clinic day, a woman physician may spend an additional hour of clinic time in order to see the same volume of patients as compared to a male physician.

 ow Can Ophthalmologists Become More Efficient H with EMR? The transition to EMR is not easy for physicians. Even after the implementation period is complete, a large percentage of physicians report EMR-related stress, which can lead to physician burnout [7]. While I wish I could pass along surefire methods to improve your efficiency using EMR, there are relatively meager scientifically proven improvement methods, but rather many anecdotes. Hopefully, you will glean some ideas that can be incorporated in your practice. It may not be surprising, but taking the time to learn the finer points of your EMR has been proven to make a more efficient user. A one-on-one EMR training session for physicians has shown that optimizing EMR use can increase confidence and improve perceived efficiency by the user [8]. Granted, not all practices can implement one-on-one training as this is a costly and a resource heavy investment, but taking advantage of these opportunities when offered can help with long-term efficiency with EMR. Gaining comfort with the EMR system will allow a user to personalize templates that will improve efficiency. Depending on the EMR vendor, there are different terms used, but easily inserted text can be created to shorten the time it takes to write notes. These phrases are created in advance and can easily be modified for a specific patient. For instance, for annual diabetic dilated examinations, I use a few quick metrics that are patient specific. Taking advantage of the EMR, I have created phrases that can quickly pull forward the last HbA1c and last three blood pressure readings from the patient to be easily inserted in the history of present illness section: HbA1c 10/11/2019 6.2% Last three blood pressure readings: 10/10/2019 130/75 10/11/2019 142/71 10/12/2019 128/63

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If the patient has no background diabetic retinopathy, then I can quickly populate the assessment section in six quick keystrokes: Diabetes mellitus without diabetic retinopathy in either eye. Discussed need for continued tight blood glucose and blood pressure control. Continue with annual dilated examinations. Then I typically personalize the note, stating when the patient was originally diagnosed and how well HbA1c is controlled. EMR systems allow users to create personalized tabs for routine orders (e.g., imaging, laboratory blood work, and surgical procedures). For cataract extraction, I just need to specify laterality and then all my pre- and intra-operative orders are instantly loaded. I can easily make specific changes if needed for a case or I can quickly sign my orders and move on. Focused training on the EMR can teach users the quick ins and outs of your specific system. Outside of clinic, I take time to update my quick phrases to optimize my clinic time. Copy and pasting is another strategy to streamline assessments and examination findings, but this must be done with caution. When pasting forward a note or examination, it takes discipline to make appropriate changes to keep the note up-to-date; otherwise, mistakes are carried forward. Another method used to improve efficiency and reduce burden of documentation for physicians is the use of medical scribes [9]. Various studies have shown that physicians benefit from less time required to document encounters and more time to listen to patients [9], improved physician satisfaction with regard to improved perceived work flow [10, 11], and improved quality of visit and patient satisfaction [11]. Despite the findings in these studies, I did not find benefit in my clinical practice with scribes. While a well-trained scribe improved my overall clinical efficiency, the high rate of scribe turnover, the time required to train a scribe, and the need to proofread scribe notes were ultimately the downfall for my practice. Having said this, there are many physicians who benefit from scribes and have positive experiences with this effort to gain efficiency and reduce documentation burden. With the transition from paper charts to EMR systems, we have endured a major shift in the way we practice medicine. In the future, there will be more studies looking at how EMR can be optimized and how physician burnout can be reduced. More innovative ideas are on the horizon, but in the meantime, try to optimize your EMR efficiency to benefit your patients and your practice.

References 1. Boland M. Electronic health records and ophthalmology. JAMA Ophthalmol. 2015;133(6):633. 2. Hillestad R, Bigelow J, Bower A, Girosi F, Meili R, Scoville R, Taylor R. Can electronic medical record systems transform health care? Potential health benefits, savings, and costs. Health Aff. 2005;24(5):1103–17.

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3. AAMC.  Women were majority of U.S. medical school applicants in 2018. [online]. 2019. Available at: https://www.aamc.org/news-insights/press-releases/women-were-majority-usmedical-school-applicants-2018. Accessed 10 Oct 2019. 4. Read-Brown S, Hribar M, Reznick L, Lombardi L, Parikh M, Chamberlain W, Bailey S, Wallace J, Yackel T, Chiang M.  Time requirements for electronic health record use in an Academic Ophthalmology Center. JAMA Ophthalmol. 2017;135(11):1250–7. 5. Roter D, Hall J. Physician gender and patient-centered communication: a critical review of empirical research. Annu Rev Public Health. 2004;25(1):497–519. 6. Roter D, Hall J, Aoki Y.  Physician gender effects in medical communication. JAMA. 2002;288(6):756. 7. Gardner R, Cooper E, Haskell J, Harris D, Poplau S, Kroth P, Linzer M.  Physician stress and burnout: the impact of health information technology. J Am Med Inform Assoc. 2019;26(2):106–14. 8. Kadish S, Mayer E, Jackman D, Pomerantz M, Brady L, Dimitriadis A, Cleveland J, Wagner A. Implementation to optimization: a tailored, data-driven approach to improve provider efficiency and confidence in use of electronic medical record. J Oncol Pract. 2018;14(7):421–8. 9. Martel M, Imdieke B, Holm K, Poplau S, Heegaard W, Pryor J, Linzer M. Developing a medical scribe program at an Academic hospital: the Hennepin counter medical center experience. Jt Comm J Qual Patient Saf. 2018;44:238–49. 10. Pozdnyakova A, Laiteerapong N, Volerman A, Feld L, Wan W, Burnet D, Lee W.  Impact of medical scribes on physician and patient satisfaction in primary care. J Gen Intern Med. 2018;33(7):1109–15. 11. Mishra P, Kiang J, Grant R. Association of medical scribes in primary care with physician workflow and patient experience. JAMA Intern Med. 2018;178(11):1467–72. Ariane Dev Kaplan,  MD  is a board-certified ophthalmologist who specializes in comprehensive eye care including the laser and surgical management of cataract. Dr. Kaplan completed medical school at the University of Louisville in 2007 where she earned the school’s top honor in membership in the Alpha Omega Alpha Honor Medical Society. She completed her transitional year internship at St. Joseph Mercy Hospital in 2008, and completed her residency in ophthalmology at the University of Michigan in 2011. After completing her residency, Dr. Kaplan joined the faculty in the Department of Ophthalmology at the University of Michigan Kellogg Eye Center. She quickly became immersed in teaching residents and medical students. In 2013, she created and directed the Residency Continuity Clinic until 2016. In 2015, she became the Director of the Medical Student Ophthalmology Clerkship, a position she continues to hold today. For her work in medical student education, she received the “Token of Appreciation from Medical Students” Award in 2018. She continues to innovate in medical student education, and created a multi-disciplinary ophthalmology residency prep course in 2019 for students interested in a career in ophthalmology. Her work gives her a deep awareness of the importance of mentoring and fostering interest in the career of ophthalmology among a diverse group of medical students to improve the diversity of the ophthalmology workforce. Her career goal is to improve the quality and diversity of medical student applicants into the field of ophthalmology.

Chapter 10

Dealing with Complications and Avoiding Medicolegal Issues Caroline R. Baumal

Summary Points • Communication skills are critical for a complication-free practice. • It is important to have knowledge and strategy for medicolegal issues. • Patients will appreciate compassionate, high-quality care.

Introduction This chapter discusses patient complications and how to approach medicolegal issues. It is not enough to be an excellent clinician and surgeon. Social and communication skills to interact with patients, staff, and colleagues; proper procedures for documentation and informed consent; and medicolegal knowledge are critical. Most ophthalmologists in the United States will be sued at least once in their career [1]. The majority of legal cases in ophthalmology are related to unfavorable outcomes rather than physician negligence [2, 3]. Poor communication can further deteriorate a complicated situation and limited documentation can reduce a physician’s ability to demonstrate competence. This chapter will consider some areas to reduce professional complications and deal with medicolegal issues with some personal anecdotes that I have learned over my career. Two tables at the end of this chapter summarize quick tips to a have a complication-free practice (Table 10.1) and common causes of medicolegal issues (Table 10.2).

C. R. Baumal (*) Tufts University School of Medicine, Boston, MA, USA New England Eye Center, Boston, MA, USA © Springer Nature Switzerland AG 2021 C. Y. Weng, A. M. Berrocal (eds.), Women in Ophthalmology, https://doi.org/10.1007/978-3-030-59335-3_10

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Table 10.1  Some quick tips to a healthy “complication-free” clinical practice [1, 2] 1. Maintain the highest standards with respect to clinical knowledge, surgical skills, and continued medical education. 2. Treat your patients like you would want your family members and yourself to be treated. Patients will recognize and appreciate this. 3. There are many different types of people, so one communication style may not work for all types of patients. Try to adapt communication styles to a wide variety of patients. Be professional and courteous to patients and staff. 4. Keep a collegial network of colleagues (in every subspecialty), peers, and mentors for questions, referrals, and second opinions. 5. Remember to take care of oneself and refresh and renew as needed. This will improve relationships with others. 6. Recognize the signs of potential litigation and call your malpractice insurer immediately for guidance. Table 10.2  Common causes of medical lawsuits Medical

Documentation

Communication

Ethical

Legal

Failure of diagnosis Failure of surgery Surgical error Inadequate or negligent patient care Lack of medical knowledge Missed pathology Highly pressured hospital system/office setting Unsafe office environment No or inadequate informed consent Absent or altered documentation Poor patient medical/surgical records Lack of communication Holding back information Poor doctor-patient relationship Failure to follow-up Failure to show empathy Patient abandonment Fraud Inappropriate patient or employee to physician relationship Altering patient records No professional liability insurance Lack of risk management guidance Lack of understanding of legal system

Modified from Mozaffarieh and Wedrich [3]

Communication, Empathy, and Intention Medical school is focused on disease state learning, with less emphasis on teaching social skills. There are student group and colleague-based interactions, but limited education on how to deal with patients of diverse backgrounds, who may be under stress from physical and/or psychological ailments. Thus, one’s style of communication may not be ideal for every patient and a degree of flexibility is necessary.

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Communication not only involves patients, but also the family members as well as nurses and office staff. One should recognize when communication is not being effective, especially before surgical planning. Specifically in the field of ophthalmology, many patients who enter the office with an acute problem are unfamiliar with the issues at hand and have an underlying fear of permanent visual loss. This may be the case even when the problem seems minor to the physician. I always teach residents and fellows to be mindful of patients’ underlying fear of vision loss, as it will enable one to be empathetic and communicate with sensitivity. The primary intention should always be that patient care is the top priority. Treat your patients like you would want a cherished family member treated. A patient will appreciate if you can sincerely state that the recommended treatment is the same as you would recommend for your mother.

 nderstand Procedural Complications and Have U an Established Plan A wise mentor once told me that the reason to learn about procedural complications is because undesirable events can happen to patients even with the best care and under ideal circumstances. Thus, it is important to be prepared, knowledgeable, and responsible to take on these issues. This was extremely useful knowledge to have early in my ophthalmology career. A clear understanding of the issues at play can improve patient outcomes in a potentially difficult situation. One should be aware of all of the potential complications related to clinical disease and surgery in ophthalmology, especially with those associated with the procedures that one performs, and have a treatment strategy on hand. It is beneficial to continue education throughout one’s career and maintain clinical and surgical excellence by attending lectures, webinars, meetings, and continuing medical education programs. Also, it is important to know one’s limitations and maintain a network of colleagues to discuss cases and have available for assistance. If a patient has a complication that you are not equipped to handle, you need to assist the patient find the best, appropriate care. Poor or lack of communication after a complication is not an uncommon cause of litigation or a report to the medical board. It is important that a patient does not feel unassisted after these unwanted events.

 o Not Avoid Dealing with Unpleasant Situations, Keep D an Open Mind, Know Your Limitations No patient is immune to potential complications. It can be hard to face the fact that your patient who had perfect surgery after you guaranteed 99% chance of success, now has a vision-threatening complication such as a suprachoroidal hemorrhage. In an understanding fashion, explain the etiology and potential outcomes including the worst and best scenarios, and offer a second opinion.

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There are multiple ways to classify complications in ophthalmology, for example, based on event severity, visual prognosis, or potential for partial or complete visual and/or globe recovery (Table 10.1). As opposed to physicians, attorneys usually view complications differently and consider the damages to sight and vision. A complication may seem minor to the treating ophthalmologist, for example a corneal epithelial defect after tonometry or eye surgery. However, something minor and self-limited from the ophthalmologist point of view can produce considerable patient discomfort and distress, leading to negative patient-physician interactions. A distraught patient told me the other day that she would not be returning to her ophthalmologist for contralateral cataract surgery because her doctor scratched her cornea during surgery. It is important to listen to patients with empathy. A more extensive explanation about this not uncommon complication may have helped to improve that patient-doctor interaction. In obtaining procedural consent, it required to explain the common complications as well as the severe and potentially sight-threatening complications, even if these are rare. Sometimes complications are new and have not been previously documented. For example, silicone bubbles in the vitreous cavity after intravitreal anti-­ VEGF injection was a relatively unknown complication until the number of injections increased in the last decade [4, 5]. With an altered, increased, or new procedure, it is important to tell patients that new unrecognized complications may arise.

Have a Safe Clinical Practice Try not to overload your practice or spread yourself too thin. This may lead one to cut corners with patients. Patients and their family members will know if you are focused on their care. Make sure that any postoperative patient who calls with an issue is appropriately screened and evaluated by trained personnel or a physician. There needs to be an extremely high index of suspicion to catch an early endophthalmitis, which may start with subtle symptoms before progressing to the full-­blown picture. I recommend clinical evaluation of patients who call with an ocular complaint in the postoperative period unless you are certain it is part of the normal postoperative course, such as a minor subconjunctival hemorrhage or dry eyes. If the patient defers their return, this should be followed-up and documented. When starting practice as a newly graduated physician, treatment protocols may not always be clear. Fortunately, well-designed, published phase 3 clinical studies can serve as guidance to provide a standard of care for patient management and procedures.

 aintain a Network of Colleagues, Utilize Continued Medical M Education, Avoid Emails It is important to have an excellent and professional working relationship with one’s staff and colleagues. In our era of email, it is critical to be aware about the rules for

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transferring patient information electronically and answering consults online. Our field is constantly changing so continue to learn about newly identified diseases and procedures. Have a network for second opinions in complicated cases.

Be Prepared and Understand the Legal System Being sued is one of the most stressful and negative lifetime experiences that most physicians will experience at least once [1]. It is important to recognize the signs of potential litigation, understand the legal system, and be ready for a potentially very long, emotional ride. One may receive a request for medical records, a letter from the plaintiff’s attorney, and/or a complaint to the board of medicine. Rather than shuffle the ominous 8 × 14 letter to the bottom of one’s to-do list, deal with it immediately! You are your own advocate and you should seek risk guidance on how to manage this situation. The first thing to do is to contact your malpractice insurer or the risk management team at your institution. You will be assigned an attorney to discuss the issue. Do not alter the medical record in any way. Usually the attorney will counsel you not to discuss the case with anyone other than your spouse because that person can be subpoenaed to testify as to the discussion. All correspondence with the patient’s attorney should be done through your attorney. It may be tempting to call the patient and discuss the situation, but this is not recommended and any contact with the patient or with anyone regarding the case should be done in consultation with your attorney. Remember your attorney is your advocate and should be there to guide you through this unfamiliar territory to prevent further complications. There will be meetings with counsel and depositions. Make it a priority to attend all of these interactions and review any documentation provided by your attorney. Also become an expert with regard to the literature as it pertains to your case, especially before your deposition. Litigation can take many years, so do not expect it to be over quickly. It is not uncommon for severe emotional stress and even depression to develop in physicians who are being sued, so it is important to recognize the signs and seek help if needed from professionals. A review from the United Kingdom found the number of legal claims in ophthalmology was low relative to the high volume of outpatient and surgical cases [6]. In this paper, cataract subspecialty had the highest number of claims while the highest payments per claim were in neuro-ophthalmology and pediatric ophthalmology. Prior studies have noted gender disparity weighted to males in past malpractice claim rates in ophthalmology [7]. Multiple factors may account for this difference including lower exposure of female ophthalmologists as females were more likely to work part-time with fewer weekly hours. Also, female ophthalmologists were younger than their male counterparts, thus earlier in their careers with lower exposure to risk [8]. Female surgeons may perform different numbers of procedures. A recent publication observed that in some residencies, despite almost equal numbers

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of female and male residents, the female residents performed fewer cataract surgeries and other procedures compared to male colleagues [9]. These findings may change with the current trend of an increasing number of female residents entering ophthalmology and vitreoretinal fellowships.

Summary In ophthalmology, litigation is usually driven by unfavorable outcomes rather than by malpractice. Maintenance of the highest medical standards with continuous training and appropriate documentation of procedures and interactions can improve professional safety in the event of litigation. Clear communication directed at patients, office staff, and colleagues can reduce the incident of complications. If you are involved in a complicated case or a legal issue, obtain experienced counsel for advice and understand the process.

References 1. Weber P. How to survive a malpractice suit. https://www.omic.com/how-to-survive-a-malpractice-suit/. OMIC Ophthalmic Mutual Insurance Company; 1997. 2. Mavroforou A, Michalodimitrakis E.  Physicians’ liability in ophthalmology practice. Acta Ophthalmol Scand. 2003;81:321–5. 3. Mozaffarieh M, Wedrich A. Malpractice in ophthalmology: guidelines for preventing pitfalls. Med Law. 2006;25(2):257–65. 4. Freund KB, Laud K, Eandi CM, Spaide RF. Silicone oil droplets following intravitreal injection. Retina. 2006;26(6):701–3. 5. Bakri SJ, Ekdawi NS. Intravitreal silicone oil droplets after intravitreal drug injections. Retina. 2008;28(7):996–1001. 6. Mathew RG, Ferguson V, Hingorani M. Clinical negligence in ophthalmology: fifteen years of national health service litigation authority data. Ophthalmology. 2013;120:859–64. 7. Fountain TR.  Ophthalmic malpractice and physician gender: a claims data analysis (an American Ophthalmological Society thesis). Trans Am Ophthalmol Soc. 2014;112:38–49. 8. Guardado JR. Medical liability claim frequency among U.S. physicians. http://www.ama-assn. org/sites/default/files/media-browser/public/government/advocacy/policy-research-perspective-medical-liability-claim-frequency.pdf. American Medical Association Policy Research Perspectives. 18 Dec 2017. 9. Gong D, Win BJ, Beal CJ, et  al. Gender differences in case volume among ophthalmology residents. JAMA Ophthalmol. 2019;137:1015–20.

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Caroline R. Baumal, MD  is a Professor of Ophthalmology and Director of the Retinopathy of Prematurity Service at New England Eye Center, Tufts Medical Center in Boston, MA. She specializes in surgery and medical disorders of the retina and vitreous. Her long-term research interests include novel retinal imaging and drug development. Her clinical interests include agerelated maculopathy, diabetic retinopathy, complex vitreoretinal surgery, and pediatric retinal disorders. Dr. Baumal completed medical school and ophthalmology residency at the University of Toronto after undergraduate studies at McGill University. She completed two fellowships: one at New England Eye Center, Boston, in Medical Retina and Lasers and another in Vitreoretinal Diseases and Surgery at Wills Eye Hospital in Philadelphia. Dr. Baumal is Board Certified by the American Board of Ophthalmology. She has received various honors including the American Academy of Ophthalmology Senior Achievement award, American Society of Retinal Surgeons Honor Award, Retinal Hall of Fame, and the Donald J. Gass Beacon of Sight Award from the Florida Ophthalmologic Society. She is on the editorial board for Retina Cases and Brief Reports and Ophthalmic Surgery, Lasers and Imaging (OSLI) Retina. Dr. Baumal has authored over 100 publications and 28 book chapters and recently edited the book Treatment of Diabetic Retinopathy. She was previously Director of Education and the Residency program at New England Eye Center and has been actively involved in teaching vitreoretinal fellows and residents for over 20 years.

Chapter 11

Handling the Unexpected in Ocular Surgery Lisa M. Nijm

Summary Points • Every surgeon experiences complications at some point in their career. • Anticipating complications preoperatively, having a plan of action should they occur, and employing thoughtful, honest communication postoperatively are primary keys to success in managing the unexpected in surgery. • Complications are an inherent aspect of surgery and while inevitable, do not need to be devastating.

Introduction: When You Can Hear a 10-0 Drop It was so quiet you could hear a 10-0 suture drop. The posterior capsule had a gaping hole just larger than the phaco probe. Pieces of nuclear material began gracefully descending, while it seemed vitreous was coming forward at the speed of light. Within a matter of seconds, every beep, hum, and sigh were a hundred times louder. Lily* (*names have been changed) was about to graduate ophthalmology residency, and was fairly certain her heart had inexplicably relocated next to her eardrum. Her throat felt constricted and her face felt warm underneath the surgical mask. Perspiration quickly followed along with what seemed to be a 20 lb. weight on her neck as she leaned over the oculars on the microscope. Does this resident’s narrative sound familiar? What if I told you Lily is

L. M. Nijm (*) Warrenville EyeCare and LASIK, Warrenville, IL, USA Department of Ophthalmology and Visual Sciences, University of Illinois Eye and Ear Infirmary, Chicago, IL, USA © Springer Nature Switzerland AG 2021 C. Y. Weng, A. M. Berrocal (eds.), Women in Ophthalmology, https://doi.org/10.1007/978-3-030-59335-3_11

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not a resident but actually a seasoned ophthalmologist with loads of experience and numerous cases under her belt? No matter how experienced you are, all surgeons experience complications. Complications occur in cases for both novice surgeons and master surgeons – men and women, in patients who are young and old; they know no boundaries. However, as the adage goes, the difference between a good surgeon and a great surgeon is how one handles these complications. During my first year of residency, I recall one of my attendings relaying the story of his co-resident, Sophie*, who managed to perform 250+ cataract surgeries during her training without having a single complication. Amazing! All of her co-residents were envious. Her attendings bestowed many compliments regarding her marvelous surgical skills. Sophie graduated her residency program with the utmost confidence in her abilities as a surgeon and landed a job at a well-established practice nearby. She was flying on top of the world until 2 months later when she experienced her first complication. A ruptured posterior capsule with nuclear loss. She froze. Her heart raced as she realized she was paralyzed and did not know what to do. All eyes were on her and she found herself entirely unprepared. What could she have done differently? How can one best handle the unexpected in the operating room (OR)? This chapter will discuss three main areas of focus for effectively managing the unexpected during surgery: (1) preoperative preparation, (2) intraoperative action, and (3) postoperative management.

Preoperative Preparation Preoperative preparation is the first step in preventing and managing complications in surgery. Despite not having any complications during her residency training, Sophie could have prepared for that inevitable situation by anticipating complications as much as possible and having a plan for how she would handle it. The appropriate question for the surgeon should not be “if” but rather “when.” You must have a plan in place for that uncommon occasion when these complications occur. Logically, this preparation begins with the examination of the patient, identifying potential risk factors that may make a routine case more difficult (e.g., in cataracts, noting features such as zonular weakness, poor dilation, and history of tamsulosin use). As an MD/ JD, one of the risk management pearls I emphasize in my lectures is to not only identify those risk factors, but also to follow through with a thorough discussion with the patient prior to surgery and document that discussion in the chart along with all other associated risks, benefits, and alternatives of the procedure (Fig. 11.1). In addition, having clear and effective education has been found to be imperative in reducing preoperative anxiety in patients about to undergo surgical procedures [1]. Preoperative preparation extends beyond the clinic visit. If you have a case that may be more complex or something you do not routinely encounter, review surgical videos ahead of time. A wealth of rich information for handling complex cases is available on many websites: American Academy of Ophthalmology (AAO), American Society of Cataract and Refractive Surgery (ASCRS), European Society of Cataract and Refractive Surgery (ESCRS), YouTube, Eyetube, and Video Journal of Cataract and Refractive Surgery to name a few [2–6]. I would also recommend

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Fig. 11.1 Explaining potential intraoperative complications of cataract surgery using an eye model can help patients visualize the procedure more readily

discussing the case with a colleague or a mentor. Over time, you will develop a network of trusted subspecialists that you can turn to for helpful thoughts and suggestions as you build your own repertoire of techniques to utilize. Further, make sure any special equipment that is needed will be available in the OR that day. You do not want to be caught in the middle of the case without the necessary tools to carry out your plan. Moreover, I would highly recommend that you review these instruments in person with your staff. Several years ago, I had a patient referred to me who needed an intraocular lens (IOL) exchange. This was the first IOL exchange I had performed at this new surgery center, so after scheduling the case, I meticulously reviewed each instrument on my preference card over the phone with the scrub nurse the week prior. After our discussion, I was confident that they had all the instruments I needed, and we were “good to go.” When I arrived at the ASC that day, much to my surprise, I learned that what had been labeled “intraocular lens cutters” were actually Westcott scissors. Since that case, I make a point to look over each instrument needed in “non-routine” cases with my surgical staff in person. One of the most helpful things I have found is to have a “success kit” present in the OR at all times [7]. This kit is filled with supplies and tools you may need if that routine case does not go as planned (e.g., Malyugin ring, iris hooks, trypan blue, and capsular tension ring). My preference card also requests to have an extra viscoelastic unopened but present in the room (which I typically verify when I walk into the OR that day). Having equipment and supplies readily available will help keep you and your OR staff calm in tense situations.

Intraoperative Action There are two primary components to the next step in managing challenging cases: (1) being mindful of your body’s natural reaction to stressful situations and (2)

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taking action to counteract this response while addressing the surgical complication at hand. First things first. How can you effectively manage a complication intraoperatively while you are experiencing anxiety-related symptoms as Lily felt in our case example above? Dr. Bob Osher, one of the foremost experts on cataract surgery and managing challenging cases, offers this advice: “Take a deep breath, carefully consider how you will manage the situation, and then put into motion the steps necessary to resolve the situation as you have prepared for this to occur all along.” Being mindful of the human stress response helps us understand how best to master this step in management. In brief, when we are exposed to stress, our body naturally releases a cascade of hormones that produces a near-instantaneous physiological “fight or flight” reaction [8]. The amygdala (which interprets images and sounds) sends a distress signal to the hypothalamus (the command center) which then activates the sympathetic nervous system by sending signals through the autonomic nerves to the adrenal glands [8]. The adrenal glands respond by releasing epinephrine into the bloodstream which in turn causes the heart to beat faster (sending blood to the muscles, heart, and other vital organs) and the lungs to breathe more rapidly and open up the alveoli to take in as much oxygen as possible with each breath. Extra oxygen is then diverted to the brain to increase alertness and sharpen all other senses. Epinephrine also triggers the release of glucose and fat from temporary storage sites to supply additional energy to all parts of the body [8]. Everything that Lily experienced – from the tachycardia to the perspiration to the tightening of her muscles – are all a natural result of the normal physiologic response to stress. If the stress becomes overwhelming, hormone levels rise and the mind starts to panic which may result in racing thoughts, paralysis, and an inability to make a decision as Sophie experienced in our second example. So how does one restore homeostasis when a stressful complication occurs? Dr. Osher already gave you the first clue. To activate the parasympathetic response and “pump the brakes” on the sympathetic system, start by taking slow, deep breaths to stimulate the vagus nerve [9]. The vagus nerve is the key regulator in the parasympathetic response. In general, when we breathe in, the lung stretch receptors send information through the vagus nerve to the brain, and when we breathe out, the brain sends information back through the vagus nerve to the heart. Therefore, when we breathe slowly, the brain senses this and slows the heart, allowing us to tamponade the sympathetic response [9]. Vagal activity is highest, and therefore heart rate lowest, when you are exhaling. In fact, studies show the ideal, most calming way to breathe is six times a minute: 5 seconds in, 5 seconds out [10]. You can count it out while breathing if it helps you. Interestingly enough, studies have shown that this is the same breathing pattern that practitioners naturally lapse into during meditation with mantras, and during the Ave Maria prayer with rosaries [10]. Physiologically, you can actually reduce the production of adrenaline and cortisol in stressful situations by taking deep breaths in a rhythmic fashion and repeating a prayer or mantra for a minute or two. This will allow you to re-establish equilibrium and regain your ability to think, assess, and respond. Just like anything else, this requires practice, but with careful focus, you can direct your body to respond rather than react. The second half of mastering this intraoperative skill involves moving forward with the right mindset to take action. Much like a professional athlete, you must train yourself for these moments when you will need to rely on your ability to

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efficiently analyze the situation, form a plan, and execute the necessary steps. Olympic athletes are often trained in visualization techniques to accomplish this feat [11]. Visualization involves going through every step that would need to be performed for an action to be successful, including engaging all of your senses. Amazingly, when peak performers master visualization of their sport, the muscles involved in the activity will fire in the same sequence and at the same rate as if the activity was actually being performed, creating in essence muscle memory [11]. Just as athletes utilize these techniques, ophthalmic surgeons can practice how to handle complications and imagine successful outcomes in their minds before the procedure even begins. Visualize each step you would need to perform should a complication such as a capsular rupture occur (e.g., identifying the opening in the bag), sensing what it would feel like (e.g., the rush of adrenaline when you realize the capsular bag has torn), and what a successful operation would look like at its completion (e.g., set-up and utilize anterior vitrectomy, assess lens support, and place the IOL in the sulcus). You will benefit from this exercise a great deal intraoperatively, and much like an athlete, your instincts will take over and you will do what needs to be done to remedy the complication efficiently and effectively. While doing this, you must also remember to stay positive and manage your thoughts to focus on the task at hand. The internal dialogue we have with ourselves (self-talk) is a powerful influence in self-efficacy and successful performance [12]. The techniques described here are not easy to master and require careful thought and practice. Certainly, some individuals possess these skills inherently to a greater extent than others, but research has shown that they can be cultivated as well. Studies of highly regarded music students showed that superior students were the ones who devoted themselves to the most hours of practice [13], but not just routine, mundane practice. The greatest amount of improvement occurred in those who were in engaged in “intense, solitary and deliberate practice” [13]. Further, the most accomplished performers focused on not just repeating the same thing over and over again, but rather “achieving higher levels of control over every aspect of their performance” [13]. Indeed, this is exactly what we do as ophthalmic surgeons. No two cases are the same. Each time we are successful in being mindful of our body’s reaction in these situations and handling complications, we develop a greater capacity for honing these important skills and maximizing surgical outcomes.

Postoperative Management There is a reason your mother told you honesty is the best policy. When a complication occurs, you should inform the patient of the occurrence immediately after surgery. Further, this explanation should be communicated again the following day to ensure the patient comprehends the situation fully after the sedation has worn off. Dr. Osher notes when counseling patients postoperatively, one must have “an honest discussion with the patient and their family and provide proper reassurance without alarming the patient.” A majority of patients simply want to understand what is going on, what they can expect postoperatively, and be reassured that you will be by their side to help them on their road to recovery.

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A complication during surgery does not equate to malpractice. Nonetheless, it is prudent to recognize that communication issues underlie most malpractice suits, especially when complications have occurred [14]. A research analysis of 4000 pages of depositions revealed communication shortcomings to be the primary basis behind malpractice litigation [15]. Litigation was “associated with a perceived lack of caring and/or collaboration in the delivery of health care.” Issues identified included “perceived unavailability, discounting patient and/or family concerns, poor delivery of information, and lack of understanding the patient and/or family perspective” [15]. Setting appropriate expectations about risk factors and potential complications preoperatively helps a great deal in explaining complications postoperatively [16]. It is also important to place yourself in the patient’s shoes and convey the information you would want to hear if the complication occurred to you or to your loved ones. Dr. Tamara Fountain, President-Elect of the American Academy of Ophthalmology (AAO) and the former chair of Ophthalmic Mutual Insurance Company (OMIC), shares these words of advice in managing complex cases postoperatively: “Telegraph to the patient your genuine concern – make a connection with them, ease tensions with a laugh when appropriate, place your hand on their shoulder. Let them feel how much you truly care.” Consider scheduling the patient a little more often than usual when you have a complication so that you can maintain that bond and soothe any concerns that might come up. Even if you do not have to see them medically for 3 weeks, better to check on them in 1 week when a complication has occurred. Complications are rare and in most cases can be managed effectively. However, if you need outside expertise in managing a complex case, do not hesitate to ask. Your malpractice carrier undoubtedly has a dedicated team of risk management specialists who can help navigate these unchartered waters. An entire book can be devoted to this topic alone but in short, your mom is right – honesty is the best policy (at least my mom is right, on almost everything, as I have learned repeatedly throughout the years).

Conclusion Performing ophthalmic surgery is a privilege and one that should be undertaken with the utmost care and diligence. While complications are an inherent aspect of surgery and therefore inevitable, they do not need to be devastating. Most complications can be effectively managed with proper preoperative preparation, timely intraoperative action, and appropriate postoperative management.

References 1. Ayyadhah A.  Reducing anxiety in preoperative patients: a systematic review. Br J Nurs. 2014;23:387–93. 2. https://www.aao.org. 3. https://www.ascrs.org.

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4. https://www.youtube.com. 5. https://www.eyetube.net. 6. https://vjcrgs.com. 7. https://www.healio.com/ophthalmology/cataract-surgery/news/online/%7B512967d3c10c-425f-a96f-ec21e61dc71f%7D/video-pearls-for-mastering-complicated-cataract-surgery. 8. Tsigos C, Kyrou I, Kassi E, et al. Stress, endocrine physiology and pathophysiology. Updated 10 Mar 2016. In: Feingold KR, Anawalt B, Boyce A, et al., editors. Endotext [Internet]. South Dartmouth: MDText.com, Inc.; 2000. Available from: https://www.ncbi.nlm.nih.gov/books/ NBK278995/. 9. Wang S, Li S, Xu X, Lin G, Shao L, Zhao Y, et al. Effect of slow abdominal breathing combined with biofeedback on blood pressure and heart rate variability in prehypertension. J Altern Complement Med. 2010;16(10):1039–45. 10. Bernardi L, Sleight P, Bandinelli G, et al. Effect of rosary prayer and yoga mantras on autonomic cardiovascular rhythms: comparative study. BMJ. 2001;323(7327):1446–9. 11. https://theconversation.com/how-olympians-train-their-brains-to-become-mentallytough-92110. 12. Meggs J, Ditzfeld C, Golby J.  Self-concept organisation and mental toughness in sport. J Sports Sci. 2014;32(2):101–9. 13. The new brain: how the modern age is rewiring your mind paperback. By Richard Restak. 6 Oct 2004, p. 60–1. 14. What patients say, what doctors hear. Danielle Ofri, MD. 2017, p. 134–5. 15. Beckman HB, Markakis KM, Suchman AL, Frankel RM. The doctor-patient relationship and malpractice: lessons from plaintiff depositions. Arch Intern Med. 1994;154(12):1365–70. 16. https://www.omic.com/disclosure-of-risks-complications-and-adverse-outcomes/. Lisa M.  Nijm,  MD, JD  is a board-certified corneal, cataract, and refractive surgeon and the founder and medical director of Warrenville EyeCare & LASIK.  After graduating from Benedictine University, Dr. Nijm pursued a post-graduate education that uniquely combined her interests in patient care and health care policy advocacy. She completed a 6-year dual M.D., J.D. degree at Southern Illinois University School of Medicine and School of Law, a program designed to train physicians who believe a legal education will augment their primary career goals in medicine. After completing residency at the renowned University of Illinois Eye and Ear Infirmary and a top-ranked corneal and refractive fellowship at University of California at Davis, Dr. Nijm then established her cornea clinic in an underserved region of Illinois and became the first surgeon in central Illinois to perform femtosecond LASIK.  Subsequently, she ventured to open her own practice to provide compassionate, expert eye care to patients in her hometown. Dr. Nijm serves as a Clinical Assistant Professor of Ophthalmology at University of Illinois at Chicago and Director of the Osler Ophthalmology Board Review course, where she has become the most frequently requested instructor, having taught over 2500 ophthalmologists. She has been an invited lecturer internationally and is a published author. Dr. Nijm has received numerous honors, including the top 50 most influential o­ phthalmologists globally on The Ophthalmologist’s Power List 2019, Rising Star Alumni Award Benedictine University 2019, AMA-WPS Inspirational Physician, and Northwestern-CDH 50th Anniversary Heroes in Medicine. In 2020, Dr. Nijm was selected to be the first Chief Executive Officer (CEO) of Women in Ophthalmology.

Part IV

Research

Chapter 12

The Ins and Outs of Clinical Trials Jennifer I. Lim

Summary Points • A successful investigator is ethical, organized, meticulous, and compliant with all regulations/study protocols. • Successful enrollment requires selection of eligible and patients who are likely to be compliant, as well as participation of the team (co-­investigators, coordinators, photographers). • Successful clinical trials address an unmet need and have a well-planned trial design and plan for data analysis.

Designing a Successful Clinical Trial Knowledge of the Disease Process Knowledge of the disease and its treatment options are crucial in designing a clinical trial. The unmet needs must be identified in order to identify areas in which opportunity exists to improve outcomes of that disease. This can include an investigation to evaluate effectiveness of a new drug that addresses a disease process, for which there is no treatment or for which there is room for improvement. In the case of prevention of progression of non-neovascular AMD to center-involving atrophy or to neovascular AMD, knowledge of high risk factors for progression of the disease is crucial in order to be able to conduct a study in a reasonable time frame (i.e., include patients that are most likely to progress within a few years). This was done in the Spectri and Chroma Trials [1, 2]. New treatments to address unmet needs

J. I. Lim (*) University of Illinois at Chicago, Illinois Eye and Ear Infirmary, Chicago, IL, USA © Springer Nature Switzerland AG 2021 C. Y. Weng, A. M. Berrocal (eds.), Women in Ophthalmology, https://doi.org/10.1007/978-3-030-59335-3_12

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have the highest potential impact, as opposed to treatments that are similar in effect and duration to existing drugs.

Knowledge of Regulations Surrounding Human Research Compliance with Good Clinical Practice (GCP) and the Health Insurance Portability and Accountability Act of 1996 (HIPPA) can be achieved with Collaborative Institutional Training Initiative (CITI) training [3]. This online program, whose design and implementation was funded by the Health & Human Services (HHS) Office of Research Integrity, includes educational courses on research, ethics, regulatory oversight, responsible conduct of research as well as research administration. Certification by CITI is required before an individual may participate in clinical studies. Investigator maintenance of certification and compliance is an absolute requirement; certification should never be allowed to lapse. I typically bookmark the dates when CITI and other certifications are nearing expiration and work well ahead of the deadlines to ensure the training/recertification processes are completed on time. In order to be successful at clinical trials, it is important to also know the specific regulations of the Institutional Review Board (IRB), applicable Food and Drug Administration (FDA) regulations, and sponsor regulations. The study protocol should be reviewed in detail. If an investigator is part of a larger organization, such as a university, additional regulations may be necessary. For instance, at my university, the contract with the study sponsor must be reviewed and approved by the university lawyers and other officials. Even before this stage, a confidentiality agreement (CDA) must be first reviewed by the university officials. In some cases, a centralized IRB can be used by investigators. Some organizations do not allow the use of a centralized IRB and require that the local IRB be used. It is useful in these situations to know names of key personnel in charge of “moving” the process along. In my university, my lead coordinator is on a first-name basis with the administrative personnel in the contracts office as well as the IRB.

Securing Funding Funding for clinical trials arise from two main sources, private or public. Public sources of funding include the National Institutes of Health (NIH) and other governmental agencies. Private sources of funding include local departmental funds, philanthropic organizations (Research to Prevent Blindness (RPB), state ophthalmology societies, Knights Templar Foundation, Pew Foundation), private donors, and pharmaceutical companies. Universities and private sources of funding are more likely to fund a phase 1 study. If the drug or product was developed or acquired by a pharmaceutical company, then that company will typically fund and conduct its own clinical trials in conjunction with selected investigators.

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Companies, however, are also interested in funding investigator-sponsored trials (ISTs) in which the investigator has total control of the clinical trial. These projects focus on clinical trials studying additional indications of an approved drug or a novel treatment protocol for one of their approved drugs or devices. These ISTs require much work, as the investigator must obtain an IND from the FDA, create a protocol, investigator brochure, oversee the conduct of the study (including multiple sites if present), and, of course, comply with all other regulations. Each company has information on how to submit an IST.  Paramount for successful application is a clearly defined hypothesis and a protocol that addresses the question to be answered in addition to access to the study population to ensure adequate enrollment. Phase 3 multicenter studies are usually funded through the National Institutes of Health (e.g., the National Eye Institute (NEI)) or through pharmaceutical companies. One may be selected to participate in a study through the recommendation of the organizers of the study or by submitting a request to the funding agency. If one is a new investigator, it is helpful to introduce yourself to individuals in charge of a study and let them know you are interested in becoming an investigator. Prior experience in clinical trials is helpful, and one can also ask established investigators for help and advice. Studies run by the NEI use a formal process of application to be a study site. In both instances, a feasibility questionnaire is completed. Information about the investigator (training, experience) and the site (personnel, equipment, patient population) are sought. The budget of the study is also an important aspect of the study. If you are creating your own trial, you must carefully plan out the details of how much the study will cost. These costs include salaries, equipment and necessary supplies, data analysis (statistical consultation), IRB costs, meeting-related costs for the study, patient travel costs (sometimes), and possibly publication costs. If you are participating in a study with a prepared budget, make sure to review each line item (or ask someone in your financial department) to ensure that the study budget will be enough to cover the costs to conduct the study. You should be aware of how much money your site will have to contribute to the success of the study if the budget is not sufficient. You should ask for more funding at this stage. For example, at my institution, the indirect costs for clinical trials can approach 50%. Therefore, I typically ask companies for additional funding. Keep in mind that payments for studies are prorated based upon the number of patients enrolled into the study (e.g., you are paid per patient). The full budget is not received upfront and may never be received if recruitment is not achieved.

Becoming a Clinical Trial Site It is crucial, when asked to complete a feasibility questionnaire for possible inclusion into a clinical study, that the potential investigator provide accurate and realistic information. The study requires realistic estimates of how many patients a site

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can enroll into a study. The availability of a minimum number of investigators and coordinators must be truly stated. This is important to enable cross-coverage for study patients. It is also required if there are both masked and unmasked investigator and/or coordinator roles. At this point, the main investigator at the site is identified and is in charge of the administration of the study. This person is given the title of principal investigator (PI). The PI must ensure that these personnel are available prior to the start of a study. The names of the study participants will be listed on a “1572” form to comply with regulations. Once selected to be a participant in a clinical trial, the PI must complete the contract and regulatory requirements. Other investigators must sign forms as needed, but they are typically not involved in the contract and IRB process for the specific study at this point. The contract between the investigator and the study sponsor (agency funding the project) should be reviewed by the institution or private practice. Institutions typically use lawyers to review and negotiate the contract. Be aware that this can take some time depending on your institution. Approval by an IRB is needed. The IRB is mandated by the Office for Human Research Protections (OHRP) within the Department of Health and Human Services (HHS) of the US government [4]. The OHRP maintains the Code of Federal Regulations that IRBs must follow. This is available as an Electronic Code of Federal Regulations (e-CFR) [5]. The Belmont Report states the ethical principles and guidelines for the protection of human subjects. All investigators should be acquainted with these reports [6]. Some studies use centralized IRBs, which will take care of most of the paperwork required for getting IRB approval for a site. In general, it is much easier if there is a centralized IRB.  However, some institutions do not allow the use of centralized IRBs, although this is evolving. Local IRBs have detailed information on how to submit the IRB application. The informed consent form is a crucial part of the IRB application. The language used on the consent is typically stated to be at the level of a 6th to 8th grader. The informed consent and application for approval will be reviewed by the IRB. The IRB committee is comprised of individuals with expertise and training in scientific backgrounds, individuals with expertise and training in non-scientific areas, and members of the community who may represent people who would participate as subjects in research studies [7]. Once the contract and IRB are completed, a site initiation visit must be held before the study can open at a site. The PI must be available for that visit and all personnel certifications should be completed. It is incumbent upon the PI to communicate with the study sponsor and to be compliant with all regulations. Responsibility for the proper conduct of the study falls ultimately upon the shoulders of the PI. Sometimes, multi-centered clinical trials will have a national meeting held at the beginning of the study. It is ideal for the PI and coordinators to attend. The protocol will be extensively reviewed at that meeting, and it is an opportunity for the PIs and co-investigators to meet key study personnel.

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Conduct of the Study Personnel Responsibilities The PI must allot time to conduct the study. This includes time to meet with the sponsor and with the independent certified research organization (CRO), which helps the sponsor oversee and monitor sites (initiation, periodic site, and close-out visits) for the study sponsor. The periodic site visits should be scheduled when requested by the CRO. The PI must be available to meet as needed with the monitor at these visits. A successful investigator is aware of the inclusion and exclusion criteria of the clinical trials open for enrollment at his or her site. I find that having my clinical trials coordinators prepare a listing of open studies with the inclusion and exclusion criteria listed is very helpful. This can be sent to one’s co-investigators periodically in order to keep them aware of open studies. When I identify a potential study patient during their office visit, I introduce the study as a treatment option. I give a broad overview of the study goals and study design and answer any questions of the patient and any present family members. Next, I introduce my study coordinator, whom I have asked to bring the informed consent document to the patient. The patient, if interested in the study, is asked to read the document and then to return for a screening visit. When the patient returns for the screening visit, an opportunity to enroll into the study is given. The consent form is signed once I verify the subject remains eligible for the study. Only after the consent form is signed should any of the study protocols be performed. This includes the standardized visual acuity test using the Early Treatment Diabetic Retinopathy (ETDRS) charts, imaging protocols, and data entry. It is imperative to adhere to the study protocol and to avoid protocol deviations. The patient should not be unmasked as to their study assignment. All members of the study team should work to ensure masking be continued as required. The investigator should facilitate the appointment in order to promote future compliance with the study visits. The investigator must complete all study visit forms in a timely fashion. I typically fill out these forms while I am seeing the patient. This requires completion of the source document (clinic note) and the forms specific to the study during the clinic visit. I then sign-off on the final forms either immediately or within 24 hours. There are other forms that the investigator will need to certify, and these should be completed in a timely manner. A good clinical trials coordinator is key to being successful in clinical trials. The coordinator is the primary contact person for the study patient. During the study visit, the coordinator will “move” the patient through all of the required testing procedures and also set up the room for the study treatment. The coordinator is the person who sets future appointment dates. The coordinator acts as an intermediary and interfaces with the sponsor/investigators to resolve queries about data on study forms. The coordinator will enter data electronically or on paper forms as needed during the visit.

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Study Documents All forms for the study are placed into various study binders. Study binders must be kept up to date at all times. All study documents should be filed immediately and acknowledged with a signature (as needed). More often, studies now utilize electronic forms and these are electronically “on file.” Any deviation from the protocol must be reported and a detailed “note to file” created as per study requirements. Copies of correspondence showing adherence to procedures and notification of the IRB about these deviations must be filed. Keeping the study binders up to date will facilitate a smooth site visit. The study documents must be kept for a duration of a specified number of years (usually 10–15 years) at the close of a study. These files must be kept in a locked drawer/file in open areas or in a locked office. Documentation is key to any study, and all forms should be completed during the examination itself. Electronic charts require a “sign-off” which should be completed usually within 1–2 days of the study visit, if not completed during the visit itself. The investigator should periodically meet with the coordinators and inquire about completion of forms and protocols. I meet with my coordinator each day I am in clinic and also keep in close touch via email. My coordinators always know where I can be reached and that I am available to manage study-related issues. They know that protocol deviations and out-of-window visits are frowned upon. In order to limit these occurrences, they are instructed to book study visits at the beginning of the visit window. This way, if cancellations occur, the visit can hopefully be rescheduled within the visit window.

Recruitment The clinical protocol should be strictly followed. The investigator should carefully evaluate the inclusion and exclusion criteria for enrollment. A checklist is usually provided by the sponsor; these are very useful. Once a patient is identified as eligible, careful consent should be obtained. Patients should never feel rushed or coerced into a study. A witness to the consent should be present. Recruitment of patients into a study should not be the overarching goal of an investigator. Rather, the investigator should aim to recruit eligible patients who would be most likely to successfully complete a study. Reminders should be sent to investigators to remind them of the open studies for recruitment.

Supervision of Staff The PI is ultimately responsible for the conduct of the study at his or her site. The PI should closely supervise all members of the clinical trials team: coordinators, visual acuity examiners, photographers, and co-investigators. In turn, co-­ investigators

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should assist the principal investigator in identifying, screening, recruiting, examining, and treating patients for the study. All investigators should complete documentation and sign-off on study forms as soon as possible. Meticulous documentation within the source document, the examination clinic note, is an absolute must. If one notes a co-investigator is non-compliant with required certifications for clinical trials, it is incumbent upon the PI to notify the individual investigator, IRB, and sponsor that the individual may not participate until compliance is once again achieved. Although it may be uncomfortable situation, one must enforce the rules. I have had to remove a colleague from a study because he was not be able to complete the certification process. A successful clinical trial investigator works well and motivates his/her team. Delegation of responsibilities and trust is needed. Hence, the initial choice of whom to place in the study roles must be thought out carefully. Ideally, I choose coordinators who are attentive to details at almost an “obsessive compulsive” level, punctual, reliable, and honest. I cannot overemphasize how important it is to have truthful and forthright personnel. Mistakes happen but cover-ups should never happen. The ethical standards for conducting a clinical trial must be known and adhered to at all times. The patient’s rights and best interests must be foremost in the clinician’s mind. If harm is suspected during a drug study, one should notify the sponsor and IRB and do what is needed to protect the patient. Sometimes a patient may want to withdraw from a drug trial. As a clinical investigator, it is your responsibility to honor the patient’s wishes. This has happened in my career. A study patient complained of subjectively worsened near visual acuity. After examining the patient and not finding an objective change, I discussed my findings with the patient. The patient however, still wished to be exited from the study and I complied. Despite my best efforts up front to enroll only patients who would be compliant, this still occurred.

Successful Participation Which Studies? The investigator should seek studies in which he or she has an expertise and in which it is likely that patients will be able to be recruited for the study. In addition, competing studies with the same inclusion and exclusion criteria should be avoided as this would dilute the number of patients able to be recruited. In contrast, one can participate in clinical studies with dissimilar criteria, provided there are enough key personnel to perform the study.

Which Patients? Patients with better overall general health are ideal candidates for a study. These patients are less likely to miss appointments because of other clinic appointments,

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diagnostic testing, or hospitalizations. Patients with job flexibility, good transportation options, and a supportive social network are more likely to return for study visits [8]. One should select patients who understand the protocol and the treatment options. In cases where the patient is non-English speaking, the consent should be available in that patient’s primary language. If not, one should not recruit such patients. A patient who is not willing to enroll, should never be coerced into a study. Patients should be thanked for their participation in studies.

Summary Successful clinical trial investigators remain engaged, active, and available throughout a study. They actively participate in the daily conduct of the study, attempt to recruit patients, and complete data forms in a timely fashion. They are honest, forthright, meticulous, and principled. They comply with certification requirements, attend study meetings, and fulfill duties diligently. In return, study sponsors invite such investigators to participate in clinical trials, present study outcomes at national meetings, and participate in the writing of study manuscripts.

References 1. ClinicalTrials.gov. Spectri lampalizumab study page. https://clinicaltrials.gov/ct2/show/ NCT02247531. 2. ClinicalTrials.gov. Chroma lampalizumab study page. https://clinicaltrials.gov/ct2/show/ NCT02247479. 3. https://about.citiprogram.org/en/homepage. 4. www.hhs.gov/ohrp/regulations. 5. www.ecfr.gov/cgi-bin/retrieveECFR. 6. Protection of human subjects; Belmont report: notice of report for public comment. Fed Regist. 1979;44(76):23191–7. 7. Byerly WG.  Working with the institutional review board. Am J Health Syst Pharm. 2009;66(2):176–84. 8. Zhou B, Mitchell TC, Rusakevich AM, Brown DM, Wykoff CC. Noncompliance in prospective retina clinical trials: analysis of factors predicting loss to follow up. Am J Ophthalmol. 2020;210:86–96.

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Jennifer I.  Lim,  MD, FARVO  holds the Marion H.  Schenk Esq., Chair in Ophthalmology for Research in the Aging Eye as Professor of Ophthalmology, is Vice-Chair for Diversity & Inclusion, and Director of the Retina Service at University of Illinois at Chicago (UIC). She received her MD with Distinction from Northwestern University (6-Years Honors Program in Medical Education), where she was AOA and received the Dean’s AOA Student Research Award and Julius Conn Memorial Award. She completed residency at UIC, receiving the Resident Research Award and American College of Surgeons Resident Competition Chicago Chapter Keeshin Prize. She completed medical and surgical retina fellowships at Wilmer Eye Institute of Johns Hopkins Hospital as a Heed Fellow and Heed Knapp Fellow. She joined the faculty of Emory University as an Assistant Professor of Ophthalmology and was recruited to Doheny Eye Institute of University of Southern California (USC) as an Associate Professor with tenure and promoted to Professor. In 2007, she was recruited to UIC.  Her research interests include clinical trials, translational research, and retinal imaging. Current leadership positions include Deputy Associate Editor for JAMA Ophthalmology, EyeWiki Retina Lead Section Editor, Treasurer of The Retina Society, Vice President of COS, AOA Coucilor for UIC Medical School, IOVS Editorial Board member, and UIC Faculty Senator. She has received the AAO Lifetime Achievement Award, AAO Secretariat Award, Macula Society Paul Henkind Memorial Award, ASRS Senior Honor Award, SuzanneVeronneau Troutman Award, ARVO Silver & Gold Fellow Awards, Chinese American Ophthalmology Service awards, USC teaching awards, ASRS Retina Hall of Fame, UIC Departmental Faculty of the Year Award, Mother McAuley Liberal Arts HS Hall of Honor Award, inaugural UIC Distinguished Sweeney Lecturer, Chicago Super Docs, Best Doctors, and Top Doctors. She has authored over 300 articles and 30 book chapters, and edited several books including ­Age-­Related Macular Degeneration (now in the Third Edition).

Chapter 13

Becoming a Successful Clinical Trialist Diana V. Do

Summary Points • Pursue research that you are passionate about. • Identify research mentors to guide your career development. • Be ethical, collaborate, and work hard at developing your skills as a clinical trialist.

Identify a Mentor Finding a mentor who can guide you during your early career development is absolutely essential and its importance cannot be overstated. Even though you have successfully graduated from ophthalmology residency and fellowship, becoming an independent ophthalmologist (or retina surgeon in my case), is a big career step that still requires guidance from someone who is smarter and more experienced than you. I was extremely fortunate to have had several terrific mentors during my training and early career development at the Wilmer Eye Institute, Johns Hopkins University School of Medicine. I do not think I would have gained such detailed insight into conducting clinical trials without their guidance and generosity. A generous mentor will show you how to become a well-respected clinical researcher. You will learn by watching your mentor and she/he will impart their knowledge onto you. Carefully observing your mentor-led clinical trials will help you develop the key skills necessary to be a leader yourself. Ideally, your mentor can first get you involved as a co-investigator on clinical trials, and then after you have acquired the skill set to lead, you can transition into becoming the principal

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investigator on future studies. In addition, mentors will introduce you to new collaborators that can expand your research possibilities. A terrific mentor will be with you forever, guiding you in your early, mid, and even late career.

Establish the Research Infrastructure Clinical research involves a dedicated team and space to conduct human subject research. Integrating clinical research into your busy ophthalmology/retina practice takes proper planning. Practically, it is easier to join an academic institution or a community practice that is already engaged in clinical research and has all the necessary infrastructure than to start from scratch. Aligning yourself with a mentor who already has developed this infrastructure will save you a lot of time and effort from developing it from scratch. If you are building your clinical research center, ensure that your clinical site has sufficient space for personnel, equipment, and storage. The key components include the following: • Clinical research coordinator (CRC): an individual who is trained to handle the management and documentation of a trial. • Study personnel (e.g., photographers and imaging technicians): individuals in your practice who are certified to work on the clinical trial. • Co-investigators: ophthalmology colleagues who are in your practice that can collaborate and be co-investigators on trials which involve the participation of more than one ophthalmologist (for masking purposes). • Four-meter lane room for best-corrected visual acuity testing. • Office space for the CRCs to work, space for drug storage, equipment, and clinical research files.

Join a Clinical Trial Once you are in clinical practice, you can ask your mentor and colleagues about finding clinical trials that would be appropriate for your area of interest. It can be helpful to start by being a co-investigator on your first clinical trial, gaining knowledge and experience, and then graduating to become the principal investigator of a future trial. A mentor is a great resource to aid you in networking with colleagues and the pharmaceutical industry who sponsor many clinical trials. Showing interest in research will help them select you and your site for these trials. Once you have been selected an investigator, you will be required to complete documentation prior to enrolling subjects. Often a clinical research organization (CRO) hired by the study sponsor will work with you to complete all the necessary

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paperwork. Examples of key documents required for an investigational new drug include the following: • • • • •

Curriculum vitae for principal investigator and co-investigators. Investigational review board (IRB) approval of the study protocol. Investigational drug brochure. Financial disclosures. Contract between your site and the study sponsor: provides you and your site with financial compensation for enrolling subjects.

There will be numerous documents to complete before you and your site are ready to enroll eligible patients. Once everything is in order, the sponsor and CRO will arrange a site initiation visit to ensure all the requirements are met. After successful completion of the site initiation visit, you may start enrolling participants.

Enrolling Subjects It is very important to recruit eligible subjects into your clinical trials. Do not join a trial unless you can recruit for it. Fortunately, your busy retina clinical practice is the source for your clinical trials participants. If you remember the inclusion and exclusion criteria (or have a laminated information sheet with this information in each of your exam rooms) for the protocols you are involved with, you can use this as a guide for finding potential study subjects in your daily clinic. Strategically having your study coordinator nearby during clinic can help introduce clinic patients to the research staff and applicable clinical trial, and potentially schedule a screening visit for the study. If you and your research site follow good clinical practice, enroll and retain study subjects, you and your team will be successful in conducting clinical research. If you are successful in enrolling subjects and ethical in your conduct of the trial, additional clinical research opportunities will naturally evolve and grow overtime. Study sponsors prefer going back to investigators and sites with proven track records.

Knowledge and Success Once you have successfully participated as a principal investigator, you will have gained a vast amount of knowledge on clinical trials, which can be applied to future clinical research. Past success predicts future success; if you continue to work hard, have a strong clinical trials team working with you, enroll appropriate participants, and follow the study protocol, you will have discovered the recipe for success. As you develop your reputation as a clinical trialist, you will have opportunities to contribute to the design of the study protocol, serve on the steering committee,

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use your leadership skills to analyze and interpret data, and publish manuscripts. You will not only be involved in developing new medicines and therapies for your patients, but you will have opportunities to lead. Enhancing your professional recognition will lead to promotion within your practice or academic institution. Hopefully in 10 years when you will look back at your successes, please remember to share your knowledge with other young investigators who are following in your footsteps. Disclaimer  There are many paths to becoming a successful leader in clinical trials so do not feel you have to follow a specific formula. That being said, there are key steps that can make your journey more streamlined and efficient. Having been involved in clinical research for over 13 years, I have learned from the best and gained knowledge that I hope to share with you. This chapter is designed to provide an overview of the key steps needed to become a clinical investigator. Diana V.  Do,  MD  is a Vice Chair for Clinical Affairs and Professor of Ophthalmology at the Byers Eye Institute, Stanford University School of Medicine. She is an internationally recognized clinician-scientist whose research focuses on developing novel treatments for retinal vascular diseases such as age-related macular degeneration, diabetic macular edema, diabetic retinopathy, and retinal vein occlusion. She has been the principal investigator and co-investigator on more than 45 clinical trials. In addition, she has authored over 150 publications in the medical literature and has contributed to over 25 book chapters. Before joining Stanford, Dr. Do was Associate Professor of Ophthalmology at the Wilmer Eye Institute, the Johns Hopkins University School of Medicine in Baltimore, Maryland. At Hopkins, she was Head of the Retina Fellowship Training Program. After her tenure at Johns Hopkins, she was recruited to serve as Vice Chair of Education and Professor of Ophthalmology at the University of Nebraska College of Medicine. Dr. Do was educated at the University of California at Berkeley where she graduated summa cum laude with a Bachelor of Arts in Molecular and Cellular Biology. She received her medical degree (Alpha Omega Alpha) and was a Regents Scholar at the University of California San Francisco School of Medicine. After completing her medicine internship at Massachusetts General Hospital/Harvard Medical School, she pursued both her ophthalmology training and retina fellowship at the Wilmer Eye Institute, the Johns Hopkins University School of Medicine.

Chapter 14

How to Successfully Publish and Present Your Research Natalie A. Afshari and Rebecca R. Lian

Summary Points • Much of what will help you to be successful in publishing is the work that you do in advance. This includes finding what motivates you to pursue research, cultivating a relationship with a research mentor, and picking a research topic that interests you. • Writing, submitting, and revising are integral to the research process. When writing a manuscript, it is important to adhere to the guidelines for writing a scientific paper and to critically review the paper prior to submission. If your paper requires revisions, learning to do this clearly and methodically will increase the chances of success. • Careful practice beforehand, on-site preparation, and being ready to answer questions can help you to present your work effectively.

Reasons to Publish Nothing in life is to be feared, it is only to be understood. Now is the time to understand more, so that we may fear less. – Marie Curie (First woman to win a Nobel Prize)

As physicians, we lead very busy lives. Between academic, clinical, and family responsibilities, it can often be difficult to find time to take on an interesting project. And once the research project is done, the publication process certainly demands time and energy. So why do many ophthalmologists, and physicians in general, choose to pursue research publications?

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Many physicians publishing today feel the same intrinsic motivations that have compelled scientists for hundreds of years. The desire to add to the body of knowledge about a particular topic is one driving factor for many physicians. Others may want to encourage discussion and collaboration within a particular community or to influence health policy. Still others may be most motivated by scientific curiosity [1–3]. For me, both the desire to explore the unknown and the excitement of pursuing new discoveries led me to become involved with research. Undoubtedly, there are also other reasons that physicians dedicate time to research. Publications can increase physician and institution academic standing. Additionally, a strong track research track record is helpful when seeking promotions and leadership positions within academic medicine [3–5], an area where women are still largely underrepresented [1]. Whatever constellation of reasons has led you to conduct research, you will inevitably have to navigate the process of publication and presentation. In this chapter, we will walk through what I see as some of the most important considerations when undertaking the goal of publishing and presenting your research.

Mentorship Opens Doors I believe that fortitude is key. More than anything, be consistent. Go at it. Go at it. Go at it. When you succeed, don’t forget the responsibility of making someone else succeed with you. – Antonia Novello (Former Surgeon General of the United States)

The process of successfully publishing often begins with finding a research mentor. Throughout a career in medicine, each physician will have many mentors for different aspects of his or her professional life. Guidance from a strong research mentor can open doors for a novice researcher and leave a lasting positive impact on his or her career. Of course, the role of a research mentor will change depending on the stage of your career. Regardless, when seeking out a research mentor there are a few factors to consider: 1. Mentorship Track Record: When seeking out a research mentor it is important to consider his or her history of mentorship. Has this physician mentored others in the past? How successful were these mentees at accomplishing their career goals regarding research? A mentor who has invested significant time and energy into his or her past mentees is likely to do the same for you. 2. Research Interests: Evaluate whether your prospective mentor’s research interests align with your own. Research is hard work and it is important to pursue projects you are truly interested in. 3. Availability: Look for a mentor who is able to dedicate time to helping others succeed [6]. Some very productive researchers may be extremely busy, difficult to get a hold of, or constantly traveling. A mentor who has time to meet regularly with you and who gives timely feedback may be easier to learn from. In contrast, it is certainly very possible for busy physicians to be wonderful research men-

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tors. Although they may not have an abundance of time, the nuggets of wisdom they are able to impart as a result of their experience can be extremely valuable. 4. Personality: A mentor is someone who you will work closely with and with whom you should expect to spend considerable time. It is important to find a mentor who you feel comfortable working alongside [5, 6]. 5 . Publication Track Record: It is helpful to look at your prospective mentor’s track record of research productivity. Physicians who have a strong research background are more likely to have the experience and expertise needed to help you navigate the process of publication [5]. One final piece of advice regarding mentorship in research is to remember to pay it forward. Whatever level of training you are in, there are always smart and motivated people earlier in their careers who can benefit from your guidance. This can mean giving a pre-medical student a tour of your workplace to spark their curiosity, or including a medical student rotating through your clinic on a small project. As you successfully find mentors who open doors for you, remember to leave those doors open for those who follow.

Picking the Right Project Science and everyday life cannot and should not be separated. – Rosalind Franklin (Chemist and X-ray crystallographer, first person to capture images of DNA structure)

Carefully considering the research projects you spend time pursuing can significantly increase the likelihood of successfully publishing your work. Picking a topic to research can feel like a daunting task especially when simultaneously working long hours [7]. But in reality, the time spent in clinic and the operating room can be a rich source of inspiration for research projects. Rare or unusual cases, clinical observations that strike you as odd, or an idea about how to improve the quality or safety of patient care can all translate into meaningful projects [5]. Several of my own research projects have been inspired by questions I was asked by patients during clinic. After some time, I was able to return to clinic and answer those questions. It was very satisfying be able to bring the answers to these clinical questions from the lab bench back to the bedside. However, before jumping into any project, it is worthwhile to take a step back and ask yourself a few questions: 1. What specific question am I trying to answer? At the onset, it is essential to make clear the specific goals of your project. Think critically about your study design, methods, and how you will measure your outcome. It is much better to realize that a project is infeasible at this stage rather than have the paper rejected after significant time and effort has been invested. 2. What has already been written about this topic? Make sure you know what has been previously written about the topic that you are interested in. Will your paper

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be the first to answer a certain question? Is the topic timely? Picking a project for which you can answer yes to these questions will help you to produce results that add to the current literature and significantly increases the likelihood that you will be able to get your manuscript published [7]. 3 . What type of manuscript do I plan to publish as a result of this project? With that in mind, how long will it realistically take to complete? Not everything you publish has to be an experiment. For physicians at the onset of their research careers, projects such as case series, case reports, and editorials provide an opportunity to learn about the publication process and practice academic writing. These types of papers can also be completed quickly and with relatively few resources. Other study designs include cross-sectional studies, retrospective and prospective cohort studies, and randomized controlled studies. These types of projects are suitable choices for physicians with more research experience and time to commit to data collection and analysis. Prospective studies, the gold standard in research, are ideal ways to contribute to your field, but they require a large budget and many years of persistent effort to complete [5].

Strategic Writing For a research worker, the unforgotten moments of his life are those rare ones which come after years of plodding work, when the veil over nature’s secret seems suddenly to lift & when what was dark and chaotic appears in a clear and beautiful light and pattern. – Gerty Cori (First woman to be awarded the Nobel Prize in Physiology or Medicine)

Writing is a skill. Academic papers require a writing style and structure that is unfamiliar to many. There are several writing strategies to keep in mind in order to maximize your chances of successfully publishing your work. Before starting to write your paper, there are preparatory steps that may be helpful. First, create an outline. Second, familiarize yourself with the structure of an academic paper and adhere to that structure in your writing. Table 14.1, taken from a series by Gilhotra and McGhee, succinctly describes some basic elements that should be covered in several sections of the manuscript [8]. Additionally, it is important to note that most journals have specific instructions about structure and length of submitted articles. Make sure your manuscript fits these criteria before submitting. Finally, keep your writing style in mind. Try to vary sentence structure and length. Reading your work aloud to yourself is a good way to identify awkward phrasing and run-on sentences [2]. Once the manuscript is written, careful revision should be undertaken before submitting. Read the paper critically and consider the questions reviewers will be asking when evaluating each section of your paper (Table 14.2) [8, 9]. Your mentor is a valuable source for editing and providing input prior to submitting your article. Also, remember most papers will go through a number of drafts before submission. At the end of the day, it is extremely rewarding to see a project you have worked so hard on come together as a polished manuscript.

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Table 14.1  Guidelines for refining an academic paper [8] Section Introduction Materials/subjects/ methods Results

Discussion/conclusion

Writing guidelines This is not a review, be brief. Use only to set study in context. Provide sufficient data for study to be repeated by readership. Always insert a brief section on statistics. Be succinct. Present positive and negative results. Tabulate data if appropriate. Do not repeat tables/graphs in text. Clearly present statistics, not simply P values. This is not a review – be succinct and focused Concentrate on study results Compare results with those in relevant published studies. Tabulate is necessary to summarize the study in context of other published data. Reference key material only; seldom fewer than 10 or more than 40 references are required.

Table from paper by Gilhotra and McGhee [8] and used with permission

Acceptance, Revision, and Rejection I was taught that the way of progress was neither swift nor easy. – Marie Curie (First woman to win a Nobel Prize)

As others discussing this topic have written, no research is complete unless it is published [10]. By the time a paper has been submitted, you will have already spent many hours designing, conducting, writing, and editing. Following submission, there are several possibilities. A relatively uncommon but exciting possibility is that the article can be accepted without any conditions. It is more common, however, that your submission will be sent back for revisions or rejected [10, 11]. The scope of revisions required can range from minor changes to a major rewrite. If the paper requires only minor changes, it is likely to be printed following those changes. If a major revision is required, your chances of success are higher than at initial submission, but there is still a chance that the article will eventually be rejected. While revising your article be sure to address every point made by the reviewers, highlight the changes you have made, and if you disagree with a reviewer, politely explain why [10]. Unfortunately, rejection is also very common. Any physician conducting research as part of his or her career will have articles rejected from publication. The reasons for manuscript rejection vary [12]. A 2009 study looking at submissions to Clinical and Experimental Ophthalmology found that the most common reason for original manuscript rejection was “Does not add to current literature.” Other common causes of rejection cited in this study include “Poor methodology,” “Problematic control groups,” “Poor English and grammar/poorly organized,” “Needs further work/clarification,” and “Simultaneous submission to another journal/plagiarized” [11]. It is disheartening

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Table 14.2  Think like a reviewer. Questions a reviewer will ask [8], based on McKenzie [9] Reviewer questions (Based on McKenzie [9]) Are the title and abstract an accurate reflection of the paper? Does the abstract define the study and its importance in a clear and concise manner? Introduction Is the question raised relevant? Is the link between the background and the hypothesis clear? Is the literature reviewed appropriately? Materials/ Are the definitions unambiguous? Is it clear what data are to be collected, as subjects/methods well as how and why? Is the sample representative? Was the selection of the controls correct, was the randomization proper, etc.? Are the inclusion and exclusion criteria clearly defined? Is the statistical method used for data analysis appropriate? Results Can the raw data be presented graphically? Do points and figures correspond to numbers in the text? Are the data presented correctly? Discussion: Is the discussion of results in relation to the question raised in Discussion/ conclusion the study? Are comparisons with previous studies valid? Conclusion: Is there any over interpretation or inappropriate extrapolation of the results? Does the paper give any new information, and will the reader learn anything from it? References Are references more or fewer than necessary? Are references complete and accurate? Are there any secondary references? Is the latest literature reviewed and referenced? Presentation Is it in accordance with the instructions for authors? Is it a good presentation with clear, concise, and proper scientific English? Tables and figures Are they of good quality; can they be simplified? Have they all been referenced in the text? Are the legends complete? Do they repeat the material in the text? Section Title and abstract

Table from paper by Gilhotra and McGhee [8], based on a paper McKenzie [9], and used with permission

to be rejected after so much hard work. However, it is important not to take the decision personally. Instead, use the critiques you have received to learn and move forward. After manuscript rejection, you have three options. Likely the best option will be to resubmit to a different journal. When resubmitting your paper, carefully consider the relevance of the paper’s research topic to the interest of the journal. I once had a paper rejected from two journals before being accepted to a much more selective journal to which my research topic was more relevant. Also, remember that you should still be revising your article based on all the comments you received from the original submission [12]. This is important for a couple reasons. First, it will improve your paper, thereby increasing the chances of success during your second submission. Second, there is a possibility that you will get one of the same reviewers at your second submission. The reviewer may be annoyed if he or she sees that you did not address any of the problems he or she had already noted. Additional options after receiving a rejection letter include writing an appeal to the editor or abandoning the paper all together [10]. Abandoning the paper is deflating. However, if upon reading your reviews, you realize that there is a critical error in your methodology or study design, abandoning the project may be most appropriate [10]. Even if a particular manuscript must be abandoned, the insight you have gained may

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help you to formulate ideas for a new project. Perhaps you will need to go back to collect additional data, enroll more participants, or look at your research question from a different angle. Remember that, at the end of the day, it is much better to not publish a manuscript than to publish something misleading or poor quality.

Presenting Your Work Courage is like—it’s a habitus, a habit, a virtue: you get it by courageous acts. It’s like you learn to swim by swimming. You learn courage by couraging. – Marie Daly (First African-­ American woman to earn a PhD in the United States, successful researcher, activist)

Presenting is an exciting but often nerve-wracking experience. It is certainly an accomplishment to be selected to present your research, but standing up in front a room full of colleagues to discuss your work can feel like a lot of pressure. This section will cover the elements of a successful academic presentation. • Prepare Beforehand: When it comes to presenting, preparation is key. The first component of this is outlining your talk. Your speech should be organized, use simple language, and include relevant sections. Make sure your slides are simple, with minimal words or illustrations [13]. The presentation should also have a confident introduction, transition statements between sections, summaries at the end of key segments, and a clear conclusion. Speaking with enthusiasm and practicing your talk are also important. Be sure to allot time for questions at the end of your talk [14]. Before the day of your talk, practice in front of a friend or in front of the mirror. Make sure you adhere to time limits given by the conference. Also, remember to practice speaking much more slowly than you would in a conversation to make yourself understood by a larger audience. • Presentation Day: On the day of the presentation, be sure to arrive early and be professionally dressed. Arriving early will allow you to get acquainted with the moderator and projection system. You will also have the opportunity to work out any logistical or technological issues that may arise [14]. As the American Academy of Physicians has pointed out, it is also helpful to have a back-up plan in case something goes wrong at a presentation [14]. For example, what will you do if the slide projector of laser pointer does not work? You may decide to bring an extra laser pointer or handouts—just in case. • Questions: Answering questions after your talk is another exciting, yet often anxiety-producing, part of presenting research [13–15]. When approaching questions, start out by repeating the question you were asked. Then, answer as succinctly as possible. If a question is confusing, ask for clarification. If someone asks a question you do not know the answer to, admit that you do not know and offer to take the questioner’s contact information after the presentation, so that you can get them the answer at a later date. • Practice Makes Perfect: Finally, remember that great presenters have learned from their past mistakes. The more you present, the more adept and confident a speaker you will become. Try to always learn from your missteps and stay excited about presenting your work to others.

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References 1. Gender and leadership [Internet]. Am Acad Ophthalmol. 2017. Cited 4 Sept 2019. Available from: https://www.aao.org/eyenet/article/gender-and-leadership. 2. McGhee CN, Gilhotra AK. Ophthalmology and vision science research: part 3: avoiding writer’s block—understanding the ABCs of a good research paper. J Cataract Refract Surg. 2005;31(12):2413–9. 3. Van Teijlingen E, Hundley V. Getting your paper to the right journal: a case study of an academic paper. J Adv Nurs. 2002;37(6):506–11. 4. Rexrode KM. The gender gap in first authorship of research papers. BMJ. 2016;352:i1130. 5. McGhee CN, Gilhotra AK.  Ophthalmology and vision science research: part 2: how to commence research—Eureka or that’s a little unusual? J Cataract Refract Surg. 2005;31(11):2205–11. 6. Yeung M, Nuth J, Stiell IG. Mentoring in emergency medicine: the art and the evidence. Can J Emerg Med. 2010;12(2):143–9. 7. Kahn CR.  Picking a research problem--the critical decision. N Engl J Med. 1994;330(21):1530–3. 8. Gilhotra AK, McGhee CN. Ophthalmology and vision science research: part 4: avoiding rejection—structuring a research paper from introduction to references. J Cataract Refract Surg. 2006;32(1):151–7. 9. McKenzie S. Reviewing scientific papers. Arch Dis Child. 1995;72(6):539–40. 10. Shah J.  An author’s guide to submission, revision and rejection. Ann R Coll Surg Engl. 2015;97(8):546–8. 11. Wyness T, McGhee CN, Patel DV.  Manuscript rejection in ophthalmology and visual science journals: identifying and avoiding the common pitfalls. Clin Exp Ophthalmol. 2009;37(9):864–7. 12. Chernick V. How to get your paper rejected. Pediatr Pulmonol. 2008;43(3):220–3. 13. 11. Guide to preparing for the abstract competition. ACP national abstract competition. ACP [Internet]. Acponline.org. Cited 4 Sept 2019. Available from: https://www.acponline.org/membership/residents/competitions-awards/acp-national-abstract-competitions/ guide-to-preparing-for-the-abstract-competition. 14. Bavdekar SB, Anand V, Vyas S.  Presenting research paper: learning the steps. J Assoc Physicians India. 2017;65:72. 15. 12. Giving the podium presentation. Guide to preparing for the abstract competition. ACP [Internet]. Acponline.org. Cited 4 Sept 2019. Available from: https://www.acponline.org/membership/residents/competitions-awards/acp-national-abstract-competitions/ guide-to-preparing-for-the-abstract-competition/giving-the-podium-presentation. Natalie A.  Afshari, MD  is the Stuart I.  Brown MD Chair in Ophthalmology in Memory of Donald P. Shiley, Chief of Cornea and Refractive Surgery, Vice Chair and Professor of Ophthalmology at the Shiley Eye Institute, University of California, San Diego. Prior to this, she was Professor of Ophthalmology and Director of Centers of Excellence at the Duke University Eye Center. She received her medical degree from Stanford University and did her residency and fellowship training at Harvard University, Massachusetts Eye and Ear Infirmary. Dr. Afshari is the recipient of the Senior Achievement Award and the Secretariat Award by the American Academy of Ophthalmology and has been named a Gold Fellow of the Association for Research in Vision and Ophthalmology. She has received the inaugural Top Ten Women in Medicine award by

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Triangle News, Women Who Mean Business award by San Diego Business Journal, and the Teacher of the Year award at the Duke University Eye Center. She has also been recognized in the Best Doctors in America in each listing for the past decade, and was named in the U.S.  News & World Report’s Top Doctors List. Most recently, she has been recognized by the American Medical Women’s Association as the 2019 recipient of its Women in Science award. Dr. Afshari is the co-editor of a two-volume cornea book entitled Principles and Practice of Cornea. She is on the editorial boards of six journals: Investigative Ophthalmology and Visual Science, American Journal of Ophthalmology, Survey of Ophthalmology, Eye and Contact Lens, Topics in Ocular Antiinfectives, and Journal of Ocular Pharmacology and Therapeutics. She has previously served on the EyeNet editorial board and BCSC Cornea textbook committee. Currently, Dr. Afshari is on the BCSC Lens and Cataract textbook committee and the chair of the American Society of Cataract and Refractive Surgery FDA Committee. Her NIH research grant is on the study of Fuchs dystrophy, and she investigates the intricacies of endothelial keratoplasty and regeneration of cornea. Rebecca R.  Lian,  BA  is a senior medical student at the University of Hawaii at Manoa John A. Burns School of Medicine. She received her undergraduate degree in Public Health at the University of California Berkeley. Rebecca completed a year as a visiting research scholar at the University of California San Diego and plans to apply for a position in an Ophthalmology residency program. She has been the recipient of several academic awards and scholarships including Alpha Omega Alpha, Medical Student Training in Research Scholarship, Phi Beta Kappa, Regents and Chancellors Scholarship at UC Berkeley, and Regents and Chancellors Research Fellowship at UC Berkeley.

Chapter 15

Publishing and Presenting Clinical Research Sophie J. Bakri

Summary Points • Communication of research findings via presentation and publication is important. • Target an appropriate meeting and presentation format, conform to the guidelines, and practice. • Publishing in peer-reviewed journals is the gold standard; revisions are commonly requested, but it is important to follow through.

Great news! You have labored hard and finished your research project. The hypothesis is novel, the methods sound, and you have come up with some results to share. Now, we have to remember the initial goals of the project: to contribute new knowledge and ultimately improve patient care. With this in mind, it is time to share and communicate what you have just found. But it is not that easy. The process is rigorous. The questions from the audience can be challenging, and the peer review process is tough. However, it will make the research better and the message stronger. The first thing you have to consider is where you will present your research. Who is the target audience? Ideally, you should disseminate your findings to a large audience, and preferably in a format where you can get some feedback as to how to improve your work. For a subspecialist, meetings like the American Society of Retina Specialists, American Glaucoma Society, American Society of Cataract and Refractive Surgeons, American Society of Ophthalmic Plastic and Reconstructive Surgery, and North American Neuro-Ophthalmology Society typically accept abstracts in the form of a podium presentation, either full-length or rapid-fire,

S. J. Bakri (*) Mayo Clinic, Rochester, MN, USA © Springer Nature Switzerland AG 2021 C. Y. Weng, A. M. Berrocal (eds.), Women in Ophthalmology, https://doi.org/10.1007/978-3-030-59335-3_15

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traditional poster, or e-poster. I typically check the paper/poster option when submitting the abstract, as it gives the greatest chance of being accepted. In preparing the abstract, it is important to follow the guidelines. Having served on program committees, I have seen a quick way to get rejected: no data! “Data will be forthcoming”; or “Patients are being recruited for the study” often results in a quick rejection. Each society has guidelines for abstract submission, including subheadings and word count, so it is important to be in compliance. Remember also to list your co-authors, and importantly get permission from them to present the work! Sending the abstract to them the night before the abstract guideline for approval, or letting them know after the presentation, are not good habits. Also, remember to list any financial disclosures you have, and again, follow the guidelines for disclosure (e.g., timeline for reporting). Smaller meetings are also good venues for presenting research. The advantage of a smaller meeting is that there is usually more discussion. More discussion opportunity may give you more ideas for future direction of the research. The disadvantage is that the reach of your presentation will be less. Often, you can present in both types of venues, sometimes putting a different twist on one of the presentations. Once your abstract gets accepted for presentation, it is time to prepare. Again, please follow the guidelines. In the case of a podium presentation, it is imperative that you stay within the allotted time. If you do not, you will likely be cut off by a moderator, or the screen may go blank. Not a good thing to have happen just before the punch line. And, yes, some of us have learned this the hard way. I will never forget my first podium presentation, as a resident at a major meeting, when I was cut off just before my conclusion slide. I remember it well, but the moderator I am sure does not, as he was just doing his job. There are many resources available to help you with presentation skills. Books, online videos, and articles are all valuable. To sum it up, the presentation should be well organized, starting with your title and affiliation, financial disclosures, then moving on to methods, results, conclusion, and discussion. You should not have too many words on one slide; three lines of bullets is ideal. The goal is to provide a visual stimulus, yet have people hear what you have to say. If you write it all on the slide, then the audience will skim read your slide, faster than you speak. Figures and illustrations are also useful, and you can speak over them and engage the audience. I would recommend sharing your presentation with your co-authors and soliciting their comments, as this can be very helpful, not only to your presentation on the day, but also in soliciting further ideas for writing the manuscript. Now comes the time to practice. As you start out practicing, the first thing you have to do is know the content very well. Think: if there is an audiovisual problem, and the screen blacks out, can you talk without slides? Believe it or not, this happens, and there are speakers who stand and wait for the screen to come back, and there are those who seamlessly continue, as if nothing happened. Once you know your content, it is time to practice your presentation skills and timing. There are workshops you can attend and courses or videos you can view online. After practicing yourself, it is time to find a trusted colleague or mentor who is experienced at presentations, and will give you candid and honest feedback. The most common

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feedback I give mentees on presentation skills, is to look at the audience, not speak too quickly, speak clearly and into the microphone, and to not use fillers like mm, ur, and ah. Not using fillers takes practice and knowing the content really well helps boost confidence and make the presentation flow better. On the day of the presentation, I would recommend wearing comfortable professional business clothes that are not distracting. The focus of the audience should be on what you are saying, not on what you look like. Shoes should also be comfortable, as you will be walking up to the podium in full view of everyone. Then, show up early and run through the presentation in the speaker-ready room. Many presenters have had surprises due to MAC-PC incompatibility, or different versions of Powerpoint. Sometimes on the screen, only part of the slide appears. Make sure videos run properly from within your Powerpoint. When there is a break in the program, or even the day before, you should check out the podium. Make sure you know how to work the slide advancer, and that you can reach the microphone. I have on occasion made sure there is a step stool there, after discovering that otherwise, only the top of my head is visible to the audience through the podium! We are all different heights, yet some podiums are not adjustable. Hopefully, the audience, moderator, or panelists will find your talk stimulating enough to pose questions or make suggestions. Being prepared for questions ultimately means not only knowing your content well, but also understanding others’ work in this area. You should also be able to explain and defend your methodology – for example: why you chose to do a retrospective design instead of a case-control, why one statistical test versus another, why certain exclusion/inclusion criteria. Understanding the limitations of your work, explaining the significance of your findings, and knowing what future work in this area is needed, is also very important. Hopefully, you will gain knowledge from this, meet new people, and maybe even develop some collaborations, so your future work can be even stronger.

Publishing Your Work Now that you have discussed your work with your co-authors, and had some feedback from presenting it, you are ready to prepare the final manuscript. Again, it is important to evaluate the reach of the manuscript and decide on the target audience. You need to consider if this is relevant to general ophthalmologists, or subspecialists, or another audience. There are also highly specific journals that focus on areas such as basic science, translational science, technology, education, quality, or telemedicine. Beware of “predatory journals.” There are hundreds of them around, masquerading as real journals, and with similar names to bona fide journals. They will typically send you an email at 5 am every morning inviting you to be on the editorial board, or to submit a paper, and will sometimes waive the fee to entice you. Go for a reputable peer-reviewed journal; if in doubt, look at who the publisher is, and do ask more experienced colleagues for their opinion. Peer-reviewed journals usually

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do not have a publishing fee; but exceptions exist. It is common, however, for journals to charge a fee for you to publish photographs in color. I encourage mentees to prepare a draft of the paper just after finishing the work, parallel to abstract submission and preparing the presentation. This is when the work if freshest, and when momentum is highest. You can always tweak the manuscript, or do another statistical analysis, prior to the final submission. You may want to look at a similar format paper in the journal you are planning on submitting to. This will give you an idea of format, subheadings, and style. Although the Instructions for Authors section can be overwhelming, it is important to follow them. The introduction should discuss the reason for the study, as well as some background information as to what has been done in this area before, if relevant. Methods should be concise, yet comprehensive. If it is an alreadyestablished lab technique that is done routinely, you may just want to reference that, instead of reciting it. In a clinical project, you should discuss inclusion/exclusion criteria, statistical methods, and software used. If you had help from a statistician, it is important to acknowledge them, either as a co-author or in an acknowledgment, depending on their level of involvement. In the results section, consider what should be put as prose, and what is best described in a figure or graph with a footnote. In most cases, it is superfluous to describe the results in a paragraph and also in a figure with a caption. You do not want too many figures either. It is a skill to be able to organize the information succinctly. The discussion should discuss the results, what has been learned from the study, limitations of the study, and offer some suggestion for how this may impact clinical care, or for further work that needs to be done. After submission, that is not all. You should expect to hear back from the reviewers with either a rejection, or an acceptance, usually pending revision. It is rare for a manuscript to be accepted as is, with no revisions. With a revision, you should address each and every point the reviewer has made, regardless of whether you agree with it. You do not have to make the changes requested, but you should address why you are not going to make that change. I hope this chapter has given you a snapshot of the journey through which you can share your research. In this process, collaboration and mentorship are keys to success, so do not be afraid to ask. You may be surprised at some of the collaborations and friendships you will form along the way!

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Sophie J. Bakri, MD  is Professor of Ophthalmology at Mayo Clinic, Rochester, MN. Dr. Bakri is a specialist in diseases and surgery of the retina and vitreous, in particular, age-related macular degeneration, diabetic retinopathy, and repair of complex retinal detachments. She undertakes both clinical and translational research in the pathogenesis and treatment of retinal diseases. She is active in teaching residents and fellows and has served as Director of the Medical and Surgical Retina Fellowships at Mayo Clinic. Dr. Bakri completed a vitreoretinal fellowship at the Cleveland Clinic Foundation and her residency at Albany Medical College, New  York. She graduated from the University of Nottingham Medical School, England. She has authored over 180 peerreviewed papers and 17 book chapters on retinal diseases. She is a principal investigator on numerous multicenter clinical trials on novel drugs for retinal disease. She is the Editor-in-Chief of the book Mayo Clinic on Vision and Eye Health, and is on the Editorial Board of the American Journal of Ophthalmology, Retina, Seminars in Ophthalmology, and OSLI Retina. She is an active participant in several ophthalmic societies. She has served the Macula Society as Meeting Planning Chair and as an Executive Committee member and the American Society of Retina Specialists as a Board member and member of the Program Committee. She is a member of the Retina Society, serving on the Nominating Committee. She has received numerous awards, including the Ophthalmologist Top 40 under 40 award, a Senior Achievement Award from the American Academy of Ophthalmology, a Senior Honor Award from the American Society of Retina Specialists and was inducted into the Retina Hall of Fame. She recently received the Young Investigator Award from the American Society of Retina Specialists.

Part V

Teaching

Chapter 16

Delivering an Engaging Lecture Wendy W. Lee

Summary Points • Choose a topic that you know well. • Prepare a well-designed presentation that is concise. • Present with confidence and humility at the same time while engaging the audience.

Getting up on stage behind a podium can be unnerving to say the least, no matter what size the audience or who you are speaking to. It takes practice. It takes courage. There are many ways to prepare and learn to give an engaging lecture. Some start at a young age with public speaking. Some join groups such as Toastmasters, which help build skills to be a successful speaker. Some learn by watching others and observing what works for the crowd and what does not. No matter when you begin public speaking, it is never too late to develop talent to engage your audience. And if you have been speaking in front of crowds for years, it is important to continue learning and improving. With every experience comes a new lesson. This chapter is designed to give tips learned from years of both being on the podium and being in the audience. It is an honor to be invited to give a talk or deliver an accepted abstract. When given this opportunity to get up on stage or even stand next to a poster or be videotaped, realize that you have been given the gift of spreading knowledge. All eyes in the room will be on you to listen to what you have to say. It will be important to make your message meaningful and capture the attention of those around you.

W. W. Lee (*) Oculofacial Plastic & Reconstructive Surgery, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA © Springer Nature Switzerland AG 2021 C. Y. Weng, A. M. Berrocal (eds.), Women in Ophthalmology, https://doi.org/10.1007/978-3-030-59335-3_16

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First of all, choose a topic that you are comfortable with and know to the core. This will help build the confidence you need to deliver a great talk. Research the topic from inside and out. Think about your own experiences and then find out about others’ so you can present from different angles. Realize with your topic that there are likely multiple ways to accomplish the same goal and that your method and opinions may not be the final answer, but emphasize that your own experiences have given you chances to learn and build your recommendations. There will be times when you do not necessarily have a choice of topics, but rather are assigned a title. And it may not be what you feel is an interesting topic. But it is absolutely possible to make it exciting. Research fun facts about the disease. Throw in trivia for the crowd. With a small audience, you can even incorporate a game show type of atmosphere where the attendees participate and can win small prizes or candy. Constructing the talk is the first battle. First start by gathering the facts, then add the bells and whistles. Refer to reputable journals and textbooks. Make sure the data presented is up to date. Do not use wordy slides. Your audience is not there to read. They are also not there to be read to, so do not read lengthy slides word for word. The words on a slide should be there to guide you as you speak but should not be the main method of delivering the message. Rather, use main key point bullets and know the material so you can talk to each of the points. Use animations in an appropriate manner without too much distraction. Incorporate high-quality pictures and videos in your presentation; if you are showing before and after pictures, try to have the same background and exposure. Zoom and crop to the same level. If the photos are externals of patients, make sure they are as similar as possible by pulling hair back and removing makeup. Make sure you have consent to show pictures or black out recognizable features. Do not include slides that you do not have time to discuss. It is distracting to the audience when slides are advanced over quickly because they automatically start to read what is on the screen. So, if they are midway through a sentence, it becomes annoying if the slide is advanced. Make sure the layout conforms to the meeting guidelines (16x9 widescreen vs 4x3). Choose a slide design that does not have too many distracting ornaments and colors. Font is also important. Choose one that is easy to read rather than a fancy cursive that can present a challenge. If you choose a dark slide background, make sure you choose a light letter color. White is sometimes the best in these situations. If your slide background is light, choose a dark letter color. Finally, proofread your slides for grammatical errors. In the Slideshow tab on PowerPoint, check to make sure “Use Timings” is not checked. When creating a new presentation, PowerPoint will default into this mode, so you must uncheck the box. If not, your slides will advance on their own after a certain number of seconds, many times before you are done talking through the slide. And from the stage you cannot fix this issue so you will end up hitting the reverse button every time it happens—frustrating for the presenter and the audience. When you are finished preparing your talk, practice. This can be done in front of a mirror or someone who you trust to give honest feedback, or you can simply film yourself. Make sure you respect the time given to you for your talk by using the “Rehearse Timing” tool in the Slideshow tab on Powerpoint. Plan for your talk to

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be 2 minutes shorter than the allotted time so you can get through the material without speaking too fast or feeling rushed. Seeing the timer in front turn red and start blinking can provoke anxiety and distract the presenter. Some moderators may even cut off the microphone or interrupt a speaker so that the session runs on time. The goal is to get the necessary information out in an effective and timely manner. If speaking to an international audience, speak extra slowly and leave more time so that every sentence is understood. Make sure there is no content that will offend others. It is easy to miss the slightest comment that was not intended to offend, but does. When rehearsing your talk, listen to it also and put yourself in the audience seat. Hear what you are saying and ensure that your message is coming across in a manner you wish. Well before your assigned time, go to the Speaker Ready room to upload your slides and run through them, making sure the content was not altered and that any videos play correctly. Embed videos if needed. Mute the audio unless you wish to include a narration. It is now time to deliver your masterpiece. Enter the stage poised, with good posture, confidence, and appropriately dressed and groomed. Smile at your audience and engage them by asking questions. Project your voice without yelling into the microphone and do not be monotone. Speak slowly and advance through your slides in a fluid manner. If possible, move around the stage. If the audio-visual team has a lavalier or free microphone for you to use, this is useful for mobility. Use your hands, but refrain from being too theatrical. Eliminate “um, like, uh” and other filler words from your presentation. Do not make people dizzy with excessive movement of the pointer. Look at the entire audience so they know you are interested. Rather than continuous scanning of the room, look at one section or one person. When you come to a pause in your talk, move your gaze to another area of the room and cover the entire crowd during the course of your talk. Tell a story. Use a personal experience and incorporate this into a lesson that you are trying to convey. Be humble. Give experiences of your own, but also do not be afraid to tell about mistakes you have made and what you have learned from them. People learn from their own and other’s mistakes. Sharing one of your own faults takes guts, but it is also one of the most effective tools for teaching by allowing others to avoid them in their own practices. Use humor in your talk. Everyone loves a good laugh. Many times, you will be giving a talk at a conference where the attendees will sit for hours listening to dozens of speakers. It can get mundane after a while. You do not have to make it a standup comedy skit, but if you can get a few chuckles from the room, you hit a jackpot. Be prepared, though, for the “tough crowd” and do not get offended if the room is silent. End your talk with a useful summary, or better yet, an impactful closure that will drive your message home. Takeaway points tell your audience the most important items that you want them to remember. Finally, before leaving the stage, thank your attendees and anyone who inspired you to give the talk. Go back to that honor you have been given to present on stage and the privilege of having such a great opportunity to spread knowledge and teach others. It is a powerful feeling that should be appreciated and respected.

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W. W. Lee Wendy W.  Lee, MD  is Professor of Clinical Ophthalmo­logy and Dermatology, specializes in ophthalmic plastic and reconstructive surgery with a special interest in aesthetic medicine. Dr. Lee earned her medical degree from Tulane University School of Medicine. She holds a Bachelor of Arts degree from the University of California at Santa Barbara and a Master of Science degree in physiology from Georgetown University. She completed both her residency and internship at Tulane and a fellowship in ophthalmic plastic and reconstructive surgery at the Bascom Palmer Eye Institute at the University of Miami (UM). Dr. Lee treats a broad spectrum of oculoplastic disorders, including eyelid cancers, orbital and eyelid trauma, tearing, eyelid malpositions, orbital tumors, and infection and inflammation of the lids and orbit. Dr. Lee has a special interest in aesthetic medicine and performs blepharoptosis surgery, blepharoplasty of the upper and lower lids, brow and forehead lifts, and non-surgical cosmetic enhancements including botulinum toxin treatments, dermal fillers, and photorejuvenation. She also performs laser skin resurfacing to rejuvenate the face, neck, hands, and eyelids. Dr. Lee dedicates time to teaching residents, fellows, and medical students on a daily basis. She is also co-director of UM Cosmetic Medicine, a multidisciplinary cosmetic group involving the departments of ophthalmology, dermatology, ENT, and plastic surgery. Together with her colleagues, she organizes multispecialty trainings in cosmetic aesthetic injectables, lasers, light therapy, and topical treatments of the eyelid, face, and body. Dr. Lee conducts research at the Bascom Palmer Eye Institute with special interests in eyelid reconstruction, aging of the eyelid skin, and aesthetic lasers. She also lectures around the world on oculoplastic disorders and aesthetic treatments related to the eye. She has been featured on CNN for her charitable work on patients from other nations. She has also been featured on local news channels such as NBC and WSFL and is often quoted in women’s interest magazines such as Allure, Marie Claire, and Women’s Health regarding aesthetic treatments around the eyes.

Chapter 17

Teaching in a Busy Clinical Setting Kara M. Cavuoto

Summary Points • Teaching in a clinical setting requires a careful balance between the educational needs of the learner and patient care. • Successful teachers demonstrate organization, accessibility, enthusiasm, and relatability, as well as outstanding clinical skills and rapport with patients. • Employing techniques such as knowing your audience, focusing on one skill at a time, and encouraging active involvement in learning will improve the educational experience for the teacher and the learner.

What Are the Challenges of Teaching in a Clinical Setting? Whereas teaching in a traditional classroom has clear roles and definitions, teaching in a clinical setting is much more complex. There are simultaneous demands placed on the teacher, as he or she must balance patient care with education. These challenges can be classified into three general groups: challenges related to patient care, challenges related to the learner, and challenges related to the teacher. Challenges Related to Patient Care  Taking care of patients is the first and foremost priority. Particularly in a busy clinic, the schedule does not build in time for teaching. Teaching must occur during the patient interaction via observation of clinical skills, analysis of images/testing results, and discussion with the patient or

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family. The patient may not be amenable to multiple repetitions of the exam components, particularly if the patient is a child. In addition, patients and parents may feel uncomfortable when they or their children are examined multiple times, particularly when it is not “necessary” for medical care. Finally, patients may value a shorter wait time over the opportunity to participate in education. Challenges Related to Learners  Learners have different levels of background knowledge and vary in their levels of clinical training. The learners may consist of medical students, residents, fellows, or a mix of all of the above. This presents a challenge when trying to engage all the learners present, particularly simultaneously. Some learners will find concepts too basic, while others will miss important details if they do not have the background knowledge. To complicate it further, assessing the learner’s fund of knowledge can be quite difficult during a brief introduction at the beginning of clinic. This causes the teacher to have quickly assess and recalibrate to the learner’s level. One such example of this exists in recognizing patterns of strabismus. While a resident or fellow may pick up on the clinical inference from the sensorimotor examination revealing an incomitant hypertropia worse in contralateral gaze and ipsilateral head tilt, a medical student may miss the importance of these findings. Challenges Related to the Teacher  The teacher is often tasked with competing clinical, research, and administrative responsibilities. He or she manages the clinic staff, addressing issues such as patient flow, technician work product, and clinic equipment. Meanwhile, there are abstracts for conferences to prepare, manuscripts to submit, and deadlines for grants. Additionally, if the teacher is a clinician-­ scientist, he or she may lead a laboratory and have responsibility for graduate students and administrative staff. Also, there is often a lack of a direct or tangible incentive for teaching, which decreases its relative priority and therefore the amount of energy put into this effort. Finally, the teacher may have stressors in his or her personal life, such as an illness in the family, which may influence the time available for teaching.

What Makes a Good Teacher in a Busy Clinical Setting? First and foremost, a teacher who is enthusiastic about sharing their specialty with others is an important foundation. Characteristics such as organization and the ability to multi-task are imperative, as he or she must balance teaching with clinical care. Additionally, someone who is accessible, supportive, and compassionate will inspire others to follow in their footsteps. This person must also be engaging and relatable in order to quickly establishing rapport with the learner. Finally, someone who is genuine with his or her interest in the future success of the learner can have an impact that goes far beyond the time spent shadowing in clinic.

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What Are Some Tips for Teaching in a Busy Clinical Setting? 1. Know Your Audience One important technique is for the teacher to clarify the learner’s level of training at the very beginning of the introduction. There are different expectations for fund of knowledge based on the stage of training. For example, a high school student shadowing in clinic during summer vacation would be expected to have a very different fund of knowledge compared to a fellow in the subspecialty. To this point, it is crucial to identify the personal motivation for the learner’s presence in clinic. Is their participation voluntary or required for a course/ residency? Are they trying out the field to see if it is a possible career path or seeking to further knowledge in the specialty? Is the learner requesting a letter of recommendation from you at the end of the experience? If so, how will you gauge their performance? Next, try to identify an objective for the learner that is appropriate for the level of training and goals. For example, a pediatrics resident does not need to recognize the specific subtype of esotropia (e.g., accommodative esotropia with a high AC/A ratio), but he or she does need to know how to correctly identify signs associated with strabismus that could be associated with a vision and/or life-threatening condition. This differs dramatically from an ophthalmology resident who should be able to identify and measure the strabismus or a pediatric ophthalmology fellow who needs to develop a management plan that includes if/ when surgery is indicated. We must also remember that today’s medical students, residents, and fellows have had different educational experiences in their progression toward a career in medicine. This particularly relates to emergence of technology as well as different classroom styles such as flipped classrooms and problem-based learning. We must adapt our teaching style to align with the changes in medical education in order to keep the learner engaged in the process. Examples of this can include creating a case presentation on an interesting/rare diagnosis or leading a journal club on management guidelines for a particular condition. 2. Focus on One Skill/Teaching Point at a Time Clinic patients can present with a wide variety of conditions, depending on the focus and subspecialty of a given provider. It is extremely difficult for a learner to understand all of these conditions simultaneously, even as a resident in that field. Therefore, it is important to establish a clear learning objective at the beginning of the interaction. You can accomplish this by asking the learner to focus on one topic, such as esotropia. For the initial patients, he or she would work on identifying esotropia clinically. For example, are they able to use the Hirschberg test to visualize the temporally displaced light reflex? If so, can they estimate the size of the esotropia by the amount of displacement of the light reflex? How is the prism held (i.e., base in or base out) to objectively measure the alignment? Next, have the learner repeat the Hirschberg test for every patient

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(even ones you know do not have esotropia) in order to reinforce the learning point. With focus on one specific diagnosis/element, the learner can fully master that skill prior to moving on to the next skill. Depending on the learner’s background knowledge and skill, this process may be as quick as a few patients or may be the entire clinical session. 3. Encourage Active Involvement in Learning The ability to recite numbers or statistics is much less relevant in a world where the answer to the question is a few seconds away with an internet search. Instead, focus on questions that require analysis of facts and synthesis of ideas. One such example of this would be to avoid questions like “How common is esotropia?” Instead, consider questions such as “What would be the important clinical signs in a child with an acute onset of esotropia?” This could be done prior to entering the patient’s room, which primes the learner to think about the clinical information about to be gathered during the visit. After the visit is complete and the patient has left the room, return to the learner and gauge whether they noted the pertinent clinical findings. For example, did they note the fullness of the ductions or that the cycloplegic refraction revealed more hyperopia than expected for the child’s age? Following up with questions such as, “Why might we have chosen glasses instead of surgery in this patient?” may be helpful for the learner to understand the logic for your selected management plan. 4. Provide Constructive Criticism Feedback is a critical part of the teaching and learning process. One technique is the “feedback sandwich” which consists of layering constructive criticism between statements of positive feedback. Focus on something the learner has done well and then provide an area where they can strengthen their skills or knowledge. For example, “You did a great job identifying esotropia during clinic today. Reading more about the clinical findings that distinguish congenital esotropia, accommodative esotropia, and Duane syndrome in the Basic and Clinical Science Course book will help you diagnose these conditions in the future. Given how well you did today, I have no doubts you will be able to do this the next time you are in clinic.” Addressing only one improvement at a time will allow the learner to direct his/her attention to one area and truly master those facts. Also providing specific examples of how to improve will help guide them toward a corrective action that will be productive in achieving the goal. 5. Follow-Up If the learner did not seem to grasp a particular condition or clinical finding, then make sure to follow-up. Be specific and set a deadline. For example, “We will talk about the difference between congenital esotropia and Duane syndrome before clinic on Friday. I would like you to be able to discuss how to differentiate the conditions clinically and how their management differs.” This can be done informally via a discussion in a one-on-one setting so that the learner does not feel intimidated. Importantly, you must follow through – if you don’t, they won’t.

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How Do I Put This in Practice? My goal in teaching in a busy clinical practice is to put all of the tips to use with every student. Teaching throughout clinic provides the benefit of goal-oriented learning with immediate reinforcement of new clinical skills and data interpretation. Typically, I start the conversation with the student outside the exam room to get to know his or her background, clarifying what he or she hopes to achieve during the clinic. Based on the level of training and interest, I will pick one element of the clinical exam on which to focus (e.g., red reflex). The student will perform that element during the patient interaction and I will ask them to summarize the findings at the end of the encounter after the patient has left the room. This provides an opportunity for me to give feedback regarding technique and interpretation. I will then follow-up with a question to gauge if the learner understood how that information was important in the patient’s management. When a knowledge gap is identified, I will ask the student to focus on reading the appropriate section in a textbook and set a timeframe for follow-up, whether that be as soon as the next patient or the next clinic day. When these techniques are used together, I have found this to be useful as a guide to teaching in a busy clinical practice. Kara M.  Cavuoto, MD  is an Associate Professor of Clinical Ophthalmology and Clinical Pediatrics at the Bascom Palmer Eye Institute at the University of Miami Miller School of Medicine. Kara attended both college and medical school at the University of Miami as part of the Honors Program in Medicine combined BS-MD degree program. She completed an internship in internal medicine at Jackson Memorial Hospital followed by ophthalmology residency and a pediatric ophthalmology and strabismus fellowship at Bascom Palmer Eye Institute. She is boardcertified in ophthalmology and currently practices at both the Miami and Palm Beach Gardens offices of Bascom Palmer Eye Institute. She evaluates and treats patients with pediatric eye disorders, including amblyopia and strabismus, as well as adults with strabismus. As the Medical Director of Emergency Services at Anne Bates Leach Eye Center, Kara leads the team of physicians, optometrists, and nurses, providing eye care to patients in the unique 24-hour ocular emergency room. She also serves as Director of Medical Student Education in Ophthalmology at the University of Miami, overseeing all ophthalmology clerkships and pre-clinical graduate coursework and advising University of Miami medical students applying for ophthalmology residency. In addition, she has played active roles in national committees for the American Association for Pediatric Ophthalmology and Strabismus and the Association for Research in Vision and Ophthalmology. Her efforts have been recognized with honors such as the American Academy of Ophthalmology’s Achievement Award, the Women in Ophthalmology’s Emerging Leader Award, and the American Medical Women’s Association’s Exceptional Mentor Award.

Chapter 18

Teaching Surgery Audina M. Berrocal

Summary Points • Doing surgery is a privilege that comes with great responsibility. • There is nothing more valuable than a surgical trainee who asks, how could I have done that better? • Surgical teaching does not end in the operating room, but in clinic.

I have taught vitreoretinal fellows since I started as an attending. In the beginning, operating with a fellow was a learning experience for us both. I still remember my first fellow, Dr. Elias Mavrofrides, and the cases we did together. We learned a lot from each other, and I was surprised how much I grew as a surgeon from teaching him. As time went by, and experience set in, my true role as a surgical teacher congealed. Teaching surgery, whether it is cataracts or retinal detachment repairs, is one of the most gratifying jobs for me. It is important to remember, and never forget, that from every fellow, every case, every complication, and every success, one continues to learn. For the surgical teacher, the key is to clearly understand the surgical steps. This often requires significant introspection for the teaching surgeon. Rarely, do we think of surgery as a step-by-step algorithm, but this is exactly what the trainee surgeon needs to understand before even beginning the first case. It is important for the teaching surgeon (TS) to understand his/her own abilities and surgical approach. This is the basis of surgical training. The TS needs a mental map of what she is going to do, how she is approaching the case, and an understanding of the possible complications at each surgical step. One cannot teach a surgery

A. M. Berrocal (*) Bascom Palmer Eye Institute, University of Miami, Miller School of Medicine, Miami, FL, USA © Springer Nature Switzerland AG 2021 C. Y. Weng, A. M. Berrocal (eds.), Women in Ophthalmology, https://doi.org/10.1007/978-3-030-59335-3_18

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if one does not fully understand surgical steps and possible complications. A good TS can preempt most complications with knowledge and experience. The first thing surgical trainees (ST) should do is come early to the operating room. Introduce themselves to the surgical desk personnel, pre-op or holding room nurses, surgical and circulator nurses, and the anesthesia attending in the room. This is true, especially if the surgical trainee is starting at a new program, new hospital, or with a different attending. It is always a great habit to check with the surgical desk and the pre-op nurses to see if there is anything that is needed to get the patient in the room. If you are starting with a new attending, ask the scrub nurse what instruments the attending likes. The OR team usually knows the TS surgical preferences better than anyone else. Remember, scrub nurses have seen more cases than the ST. Listen to them and ask them for suggestions. They know their instruments and different ways of doing things because they work with many different surgeons. Before the surgical day starts, the ST should be sure she knows how to work the microscope, the pedals, and the machines and instruments being used that day. Remember to take time to arrange the position of the table, the chair, the hand rest, and the pedals. A major component of surgical success is to be physically comfortable and confident at the head of the table. If you are not familiar with the pedals or the microscope, ask. You might ask the nurses in the room or your attending. Never start your surgical day without having reviewed the cases for the day. There is nothing more reassuring than a ST who has reviewed all the cases for the day. Know the age, diagnosis, surgical plan, and review the images or tests that have been done. What makes a ST differentiate himself/herself is that extra work. Be the ST you would want to train! It is important for the TS to be able to evaluate the level of ability of the surgical trainee. Starting with a new ST every year is a new challenge. Understanding his/her level of ability and experience is difficult especially in vitreoretinal surgery. Starting with the basic steps of surgery and letting the ST progress through the case is a good way to gauge his/her level of ability. Many times, the first time she operates with a new attending, nerves get in the way. That is why it is important to give the ST more than one surgical opportunity to allow her to feel more comfortable with the individual attending and the surgical procedure. The first surgical case of the rotation or the day is always nerve-wracking for the ST (and the TS!). It is a good idea to let her start the case and delve into the beginning of the case. This will allow her to be aware of her nervousness, understand if she gets a tremor with anxiety, get familiar with the TS teaching style, and get comfortable at the head of the surgical table. Switching early in the first case allows the ST to relax and develop some insight into her surgical performance. It is important to have insight into when a ST is most receptive to constructive criticism. Not every ST can handle criticism during the case (many times patients are awake), and it is better to wait to a time where you know that the ST is most receptive. Knowledge is power. This is true for everything in life including surgery. The ST must acquire didactic knowledge prior to surgery. There is nothing better than a ST who has a good fund of knowledge, especially if that includes an understanding of surgical techniques that could be employed in the cases at hand. A ST whose

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knowledge is vast will grow more in the operating room. If you do not have the knowledge because of gaps in your education, ask your attending for recommended reading. Remember it is important to combine the acquisition of surgical knowledge by both reading and watching surgical videos online. The combination of these two forms of didactics is best. It is always very valuable for the TS to have in place presurgical training options such as wet lab, surgical modeling, and interactive presurgical discussion and planning. Many times, surgical planning occurs at the time the patient is evaluated in clinic or at the time the TS and the ST scrub outside the surgical suite. There is nothing better for both the TS and the ST than to discuss different surgical techniques and approaches right before the surgery, and then to review the dynamics of the case. Once surgery starts, it is important for the TS to personally show the trainee how to perform the surgical procedure. Many times, observing a case is important. In my opinion, alternating between doing and observing is ideal. Of course, this prolongs the case, but a committed TS will take time to do this. Many times, the ST gets very frustrated with individual aspects of the case and there is nothing better than giving her a moment to take a mental and physical break by allowing her to observe the TS do the case. Never underestimate the mental toll of frustration and uncertainty. I have seen ST tighten her fingers around the instruments so much that the tension goes all the way to the shoulders and neck. Sometimes during the case, I will have her remove the instruments from the eye, just to have her relax her body and her mind. Remember that tightening the fingers, arms, shoulders, and neck may induce tremor. The TS should focus the surgical trainee on individual aspects of surgical procedures. As the ability of the ST improves, there will always be parts of the surgery that will be a particular challenge for that ST. It is important for the TS to understand what the surgical challenges are for the ST, so that as the year progresses, more focus should be directed to these areas. A ST has to understand that every time she comes to the OR, she gets better, especially when things do not go perfectly. It is when a ST is challenged that the ST grows the most. That said, I have seen STs who are oblivious to their inabilities and this, in my mind, is a sign of concern. It is the responsibility of the TS to make the ST aware of this. In time, the TS allows a trainee to perform increasingly complex surgical procedures. A ST should understand that the more of a case she is allowed to perform, the more comfortable the TS is with her performance. It is important for the ST to never compare her experience in the OR with those she has had with other STs. Surgical training is a very personal, individual, and unique path. No two trainees have the same abilities or needs; therefore, they cannot have the same path. The teaching surgeon should have a surgical discussion with the ST that includes a positive and negative assessment of each surgical case. It is important for the trainee to ask for criticism and receive it. There is nothing that I value more than the ST who asks, how could I have done that better? Or the ST who evaluates her surgical performance with humility and honesty either by reviewing the surgical video or discussing the case with the TS. There is great humility to ask how one can do better. Remember, there is nothing as humbling as surgery.

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If the TS utilizes video capture of all aspects of each surgical case as major teaching tool, then it would be ideal for the trainee to review surgical videos. This allows the trainee to be more objective about her performance. There is a focus at the time of surgery that does not allow the ST to see the entire complexities of the case. I have STs who have made mistakes and not realized it. It is by reviewing the surgery that the ST will see her mistakes and improve. The TS should participate in ongoing surgical complication conferences. If these are not available, then the trainee should ask to review surgical cases with TS. As a surgeon myself, I remember all my complications since the first day I started ­operating. It is through the mental review of these, that I believe I have become a better surgeon. It is through reliving the difficult cases that one strives for perfection, even though we all know that in surgery perfection does not exist. The TS should show the ST how to dictate cases, but be sure that she reviews and discusses them with the ST. Teaching trainees how to compose the operative note is crucial and often overlooked. Major points for the teaching surgeon: (a) Do not have the ST perform a case that you are not comfortable with. This can only lead to a disaster. (b) Never leave the OR; stay until case is completely done. I have learned this the hard way. No matter how much you like and trust the ST, people get careless at the end of cases. This is when avoidable, careless mistakes happen. (c) Remember, once you are in the OR, take your time. Never rush, never cut corners. Never schedule things to do after the OR and if you do, do not let that affect your decision-making in the operating room. Surgical days and OR rooms are “sacred” and they deserve your complete devotion. (d) Each surgical teaching case starts in the clinic. One of the hardest things to learn and teach is when to take a patient to the operating room. It takes years to fully understand this. Furthermore, it is even harder to learn and teach why not to operate. This takes time and experience. If as a TS you can start teaching the way you think about this matter, then the ST will benefit from starting to think about what cases should be operated on and which should not. Always remember that many of these decisions are not simply made on pathology alone. (e) It is important to teach how to discuss surgery and expectations. In my mind, we need to teach STs how to address patients’ anxieties and demands. I believe that we do not spend enough time teaching STs surgeon-patient relations. Patients place their entire trust in you. You need to address their fears and anxieties which means you have to spend time addressing their questions. You have to understand who the patient is, his/her job, and living situation; at the end of the day, all these things will come into play for the success of your surgery. If you do a complex case and the patient cannot buy the eyedrops, does not have someone to help at home, does not understand positioning, needs to go to work the next day, cannot travel to see you….the chances that your surgery fails are higher and you may end up with a very unhappy patient. (f) As each surgical teaching case starts in the clinic, it also ends in the clinic. The post-operative period is a critical one. It is important to teach that what happens

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after the operating room is many times the key to success. Doing well in the operating room is one thing, but being able to recognize changes in the postoperative period that will hinder or enhance your outcomes is very, very critical. (g) Surgical teaching is not only about the operating room. ST sometimes lose track of this. It is not the number of cases that you do in the operating room; it is understanding the post-surgical issues that will ultimately lead to surgical success. I see so many STs that never spend time really studying the retina ­during the post-operative period. They have not realized that this is critical. There are subtle changes that can be addressed that will avoid having to go back to the operating room. Recognizing these changes early is imperative. (h) The TS must be comfortable in handling every potential complication. The patients that have complications have to be spoken to with honesty, and they have to be seen more often. Treat those patients exactly as you would want to be treated after a complication. Complications happen and it is how we manage the patient that is most important. Patients want honesty and they want to know that you are trying your best given the complication. Acknowledge the issues at hand, look the patient in the eye, spend more time with them (schedule them either early or late in the day), and see them more often. Many times, we feel so bad about the complication that we would prefer to see them less since it reminds us of our “failures,” but these are the patients that we need to see more! In my experience, I have learned a lot about myself while dealing with my surgical complications. If you were that patient, remember how you would want to be treated. (i) The TS must target her style of teaching to adapt to the trainee’s learning abilities. It is important that the TS understands what the trainee needs to learn. It is important to know your trainee, her personality, and her mental and intellectual strengths and weaknesses. Spend time learning about your trainee. If you really want to enhance her learning, you need to understand who she is. (j) The ST must understand her responsibility to the patient both in and out of the OR. Doing surgery is a privilege that comes with great responsibility. Honor that. Develop some responsibility for the cases you do in the operating room. I have STs who have had complications and not once have they followed the patient, or asked about the patient’s outcome. This to me shows a lack of true understanding of themselves, the impact surgery has on a patient’s life, on your life as a TS and of surgery itself. (k) Trainees must understand that surgical training is a unique opportunity. STs must be respectful to the patient, the staff, and the attending surgeon. The trainee should be conscious of what is spoken during the operating room. A patient puts his/her trust in our hands, and we should be respectful of the OR space. (l) Trainees must understand that they are being scrutinized by every member of the pre-op, op, and recovery teams. Be aware of what you say and how you say it. Everyone is listening! Treat your team with respect, say “please” and “thank you.” A trainee must behave appropriately and with respect.

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(m) Remember that your TS is paying attention to everything. Do not sit in the side scope and yawn. Be engaged, asks questions. The ST needs to be thinking about each step and about the surgical decision-making. For me, it is important to ask the opinion of the ST during difficult surgical decision points, and there is nothing more disappointing than a ST who has no opinion. (n) Trainees must understand that surgical training is truly a unique relationship that apprentices the trainee to the training surgeon. (o) When dealing with children, do not forget that the discussions with the parents are most important. Parents need to understand a timeline. Remember that family lives are complicated and the impact of a child’s disease is immeasurable. Families need to understand what to expect over the next few weeks, months, or years ahead. This allows them to comply with the post-operative management. Give them realistic expectations. During the discussions with the family, address the kids with respect. Be certain that you not only address the parents but the kids too. They want to feel part of the conversation. Kids need to be empowered and you need them on board. Ask them about what they think about surgery. Are they scared, do they have any questions? Sometimes they are afraid of things we can control such as needles. If they are afraid of needles, we can reassure them that we will put them to sleep before we use any needles. Things like this are easy; we just need to have an open conversation with them. Gaining the trust of kids is essential for a good doctor-patient relation. Remember that when you are a pediatric doctor, many of those patients will see you for many, many years. Surgical training will always be one of my passions, and it started when I was a trainee myself. Early on, I realized what I like about each one of my TSs and I decided that those where the things that I wanted to incorporate into my own practice. I believe everyone has something to teach, even when they teach you how not to be. I had some wonderful teachers that made me want to teach surgery, and, I still hear them in my head during critical parts of the case: “less is more, less is more!” A real TS will always be with you. Be grateful to those who spend their time teaching you and remember, “When a person doesn’t have gratitude, something is missing in his or her humanity. A person can almost be defined by his or her attitude towards gratitude” (Elie Wiesel). Be grateful to those who spent time teaching you how to become a well-rounded, outstanding surgeon!

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135 Audina “Nina” Berrocal, MD  received her undergraduate education at Princeton University and her medical degree at Tufts University School of Medicine. She completed her ophthalmology residency at Tufts/New England Eye Center and her fellowship in vitreoretinal surgery and uveitis at the Bascom Palmer Eye Institute, University of Miami Miller School of Medicine. Since completing her training, Dr. Berrocal has been a faculty member at Bascom Palmer, where she holds currently the rank of Professor of Clinical Ophthalmology. She also serves as Director of the Pediatric Retina service at Bascom Palmer Eye Institute and Jackson Memorial Hospital and Vitreoretinal fellowship director. Dr. Berrocal is internationally recognized for her approach to pediatric retinal diseases. As a pediatric retina specialist and Director of the Pediatric Retina and Retinopathy of Prematurity (ROP) Service, she has extensive clinical, surgical, and research experience in the diagnosis and treatment of ROP. She has performed extensive basic science and clinical research in ROP and has co-authored over 70 peer-reviewed papers on the topic. She received the Bernadotte Foundation Award for her work in ROP. Additionally, she maintains a robust adult vitreoretinal surgical practice. Dr. Berrocal is an active member of the Retina Society, the Macula Society, Club Jules Gonin, and holds leadership ­positions in many of these groups including the American Academy of Ophthalmology and the American Society of Retina Specialists. She is also a founding member of the Vit-Buckle Society. She is the recipient of the ASRS Crystal Apple Award for her dedication to surgical teaching and of the Bernice Z. Brown Lecture Award for her dedication to the advancement of women.

Part VI

Dealing with Conflict

Chapter 19

Sexual Harassment in Ophthalmology Laura B. Enyedi and Michelle T. Cabrera

Summary Points • Sexual harassment is highly prevalent and impactful in ophthalmology. • Bystander interventions include the 5 D’s: Direct, Distract, Debrief, Document, and Delegate. • Both men and women can play powerful roles in preventing harassment and supporting gender equity through bystander interventions and mentorship of women.

The Scope of the Problem The #MeToo movement has brought attention to the egregious behavior of high-­ profile celebrities, executives, and politicians. Sexual harassment (SH) is not only common in Hollywood; a recent ABC news poll found that over half of women in the USA have experienced “unwanted and inappropriate sexual advances,” often at work [1]. SH is known to occur with similar frequency in academic medicine [2] with higher prevalence among trainees in medicine [3, 4]. The authors conducted and reported the first national SH survey of ophthalmologists, published in Ophthalmology [5], which found that 59% of mostly female ophthalmologists had experienced SH at work. Inappropriate behaviors were experienced by trainees and practicing ophthalmologists. Perpetrators included trainees, faculty including departmental chairs and residency program directors, and patients.

L. B. Enyedi (*) Departments of Ophthalmology and Pediatrics, Duke University, Durham, NC, USA M. T. Cabrera University of Washington, Seattle, WA, USA

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Victims experienced significant impacts on their professional lives, with almost one quarter experiencing impairment in their ability to work. A significant number (15%) changed jobs or even careers. Women in ophthalmology are known to have lower earnings compared to men [6], fewer industry ties [7], and fewer editorial positions [8], all of which may be exacerbated by SH. SH in ophthalmology also distracts from the important work we do in clinical care, research, and education. Our findings are in line with the National Academies of Sciences Engineering and Medicine (NASEM) 2018 report [9], which finds that harassment of women in medicine interferes with education, decreases job satisfaction, and is associated with increased rates of mental illness and constrained opportunities for professional advancement. Shame and silence are central reasons for the pervasiveness of harassment. A personal example from one of the authors illustrates this problem: As an ophthalmology resident, my attending repeatedly touched my buttocks in the patient clinic rooms with the patients present. I spoke to other residents and discovered that many of them had the same experience. A first-year medical student whom he was mentoring accused him of caressing her buttocks and thighs. He confessed and therefore was only given a warning. Nonetheless, over the subsequent 10 years, roughly 50% of the female graduates experienced his inappropriate touching. He even sexually assaulted an international research fellow. The medical student developed clinical depression and suicidal ideation. Rather than reporting his behavior, residents included his harassment in the rotation sign out as recently as 2018. During his subsequent investigation confirming the allegations, he stepped down to join private practice.

Silence, acceptance, and normalization of SH sustain the problem [9]. For this reason, the authors strongly believe in a global effort to change workplace climate and culture which allow SH to continue. Keys to culture change include education that is authentic and relevant (e.g., results from a recent SH survey of ophthalmologists is impactful for ophthalmologists), a focus on positive behaviors, implicit bias training, diversity and gender equity, encouragement of reporting in order to build an “information escrow,” bystander training, and measurement of objective data [9]. Some of these solutions are the responsibility of our institutions. This chapter focuses on what ophthalmologists can personally do to promote a climate and culture of respect and inclusion in the workplace.

Potential Solutions Traditional workplace SH policy and procedure training is often ineffective because it makes people uncomfortable and defensive without encouraging preventive strategies [9]. In addition, traditional SH training can backfire because of “identity threat reaction,” i.e., people do not want to identify as either the harasser or the victim, so they feel the information is not applicable to themselves. Current policy and training focus on severe forms of SH, such as promotions in exchange for sexual relations, sexual assault, and rape. These behaviors have significant institutional and legal consequences. Nonetheless, the NASEM report

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[9] finds that subtle forms of SH and gender discrimination such as sexual gestures (e.g., staring at the breasts), relentless pressure for dates, rude images at work (e.g., inappropriate slides), and offensive comments (e.g., sexual jokes, gender slurs, insults to working mothers), contribute to a climate that allows even more atrocious behaviors to flourish. Furthermore, chronic exposure to these “microaggressions” has been shown to increase perceived stress, depressive symptoms, hypertension, and poor sleep [10, 11]. For these milder behaviors, the victim may not be interested in punishment for the harasser; they often just want the behavior to stop. Bystander interventions and victim response are successful strategies to consider.

Bystander Interventions and Victim Response Bystander interventions have been well studied in college campus and military settings as an effective strategy to combat SH and sexual assault [12]. Bystander intervention can prevent SH and escalation of behavior, while bystander inaction allows SH to continue and sends a message to the offender that the behavior is accepted. In addition, bystander interventions are specifically meant to diminish shame associated with victimhood and to make all accountable to change behavior and culture, removing some of the burden from the victim. Witnesses to harassment can call out or stop the inappropriate behavior and/or support the victim. One way to organize bystander interventions is the “5 D’s,” including Directly intervening, Distracting, Debriefing, Documenting, and Delegating. Finally, the victim can use some of these techniques to respond to SH by directly giving feedback to the harasser in the moment, documenting the behaviors, and reporting to an authority when appropriate.

Bystander Intervention and Victim Response: Direct Speaking up about the inappropriate comment or behavior is direct and powerful and can be the best way to deal with harassment by colleagues, patients, and their families. Among ophthalmologists who responded to our national survey, 45% had been harassed by patients [5]. Often, doctors and trainees feel unsure of how to manage SH from their patients and families. Patient behaviors usually do not reach the level of severity to warrant reporting or legal action, but they create an unprofessional climate and, for some, a hostile work environment. Why don’t you just leave the pretty girl here until you get back? I’m sure I could find plenty of things to do with her all day [13]

Olivia Killeen, an ophthalmology resident, included this quote from a patient in her commentary published in JAMA called “Solving the Silence” [13]. When trainees or staff are harassed, senior physicians have an obligation to protect them and model bystander action [13]. Confrontation can feel uncomfortable, but the person who made the inappropriate comment has already created an awkward situation, so there

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is little to lose and much to gain by sending a clear message to everyone in the room that the behavior is unacceptable. As the victim, you may feel you can “handle it” or are not bothered, but recognize that the next victim, a trainee or technician, is likely going to be harassed by the same person with escalating severity [9]. Responding directly sets a professional and safe expectation for your workplace. Exactly what to say is less important than saying something in the moment, and brief, clear language with no arguments or apologies is recommended [14]. Criticize the behavior, not the person. Potential responses are presented in Table 19.1, and the University of Iowa “EyeRounds.org” has published a useful toolkit for responding to patient-initiated harassment [15]. Making a direct intervention induces anxiety, but it often gets easier with practice. To prepare, visualize yourself in control with a response that is swift, calm, and without emotion. Repeating the comment back can buy time in the moment. Practice 1 or 2 follow-up phrases that seem comfortable for you. Then quickly return to providing clinical care as usual.

Table 19.1  Example verbiage for bystander intervention and victim response Directa “I’d like to keep this conversation professional.” “We don’t allow those kinds of comments here.” “She is a doctor and should be respected; It is not ok for you to speak that way to her.” “Please do not do/say that. That is considered harassment.” “I think you are funny, but that comment was not.” Distractb “Let’s step out to review those OCT images.” “I heard you are inviting Susan (medical student) out for dinner. Can I join you?—I’m really interested in your research.” “Can you help me find the ladies’ room?” Debriefc “It’s not your fault.” “That comment was not cool.” “You are not alone.” “I believe you.” “It took a lot of courage to tell me about this.” “I’m sorry this happened. / This shouldn’t have happened to you.” “This must be really tough for you.” “I’m so glad you are sharing this with me.” Responses for a bystander or victim to make directly to the perpetrator in the moment Neutral, non-confrontational interventions for a bystander to make in the moment c Supportive comments that you can make to a victim in the aftermath of an event or if the victim chooses to share an experience with you a

b

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Bystander Intervention: Distract When you witness an inappropriate behavior, removing the victim or joining the victim can be a good non-confrontational intervention. One real-life example illustrates this approach: At a work-related social event, an attending was drinking heavily and encouraging trainees to do the same. He proceeded to dance inappropriately with a drunk trainee. Another ophthalmologist inserted herself between the pair and asked the resident to dance with her.

By distracting from the current behavior and/or preventing isolation of the victim, you can often prevent escalation. Other examples are presented in Table 19.1.

Bystander Intervention: Debrief Providing the victim of harassment support can occur in the aftermath of an incident (Table 19.1). This intervention can work for an eyewitness bystander or if you are told about an experience. If you are required to report any SH, it is critical to address confidentiality at the outset. Victims may blame themselves, worry that they are misinterpreting a situation, or wonder if they are being too sensitive [16]. Comments such as “That was not your fault” or “That was a really rude comment” can provide powerful support and validation to the victim. Victims may feel ashamed or worry that they will not be believed. Phrases such as “This must be really tough for you,” and, “I’m so glad you are sharing this with me,” help to communicate empathy. Avoid probing questions. Try to be non-judgmental. Avoid suggesting what the victim should have done differently and do not recommend simply ignoring or avoiding the situation. You can offer suggestions for formal reporting (discussed below) or professional counseling, if warranted.

Bystander Intervention and Victim Response: Documentation Often harassers commit inappropriate behaviors repeatedly and with many people. One incident may not rise to the level of formal reporting, but a pattern of behavior may emerge, and documentation can be critical to build an information escrow. As a bystander or victim, you can write an email to document what you witnessed or experienced. A bystander can ask the victim if they would like you to submit this to a supervisor or if they prefer to keep it for future use.

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Bystander Intervention and Victim Response: Delegation A victim or bystander may choose to report an incident to allow for a formal investigation or to build a record for a particular harasser. Title IX of the Education Amendments of 1972 is a federal law that protects from discrimination based on sex and applies to most universities (receiving federal assistance). For private practice, Title VII of the Civil Rights Act of 1964 prohibits employers with 15 or more employees to discriminate based on race, color, sex, religion, or national origin. Many states have much lower employee thresholds for these policies. Local harassment and discrimination policies may differ, but in most instances, supervisors are required to report incidents of policy violations to the Title IX or human resources office and are not confidential sources. Confidential resources include university ombudsperson, clergy, and counseling services. The victim can also remain confidential if they discuss their case as a theoretical situation or something that happened to a friend. The Title IX investigation is formal, legal, and discreet, and the punishment is typically proportional to the offense (e.g., firing for sexual assault vs. a warning for an inappropriate comment). The identity of the complainant may be revealed to the respondent, but the victim may decide not to participate in the investigation. Some experiences are reportable, but do not meet guidelines to prompt an investigation. Examples include insensitive comments or suggestive gestures. Because harassment is often serial, targeted at multiple victims, and escalating, reporting both mild and severe behaviors helps build the information escrow. Finally, federal policy protects complainants from retaliation during these investigations.

Unintended Consequences of #MeToo No discussion of SH can ignore the widespread fear of false accusations, a fear that distracts from the real issue of SH. In reality, men are more likely to be sexually harassed than to face an accusation of SH [17]. In our study, only 15% of victims reported the incident [5]. Barriers to reporting included fear of retaliation (45%), fear of being labeled (48%), no known reporting option (42%), and an assumption that reporting would have no impact (53%). The concern that the reporting would have no impact was likely justified, as among those reported, 55% of harassers faced no known punishment. The fear of false accusation is often rooted in the worry that an innocent gesture (compliment on a new haircut or hug at a meeting) will be misinterpreted, and that the “victim” will seek to punish the “perpetrator.” These concerns conflate small misunderstandings and/or unintended microaggressions with more serious allegations, presuming that both would result in job loss and/or legal battles for the perpetrator. Of course, these assumptions are false. Less commonly, men worry that women may lie about SH for their own gain. Most women would not inappropriately malign or entrap a colleague. Nonetheless, if a supervisor has a concern that a

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supervisee or colleague might lie about a sexual situation, they should immediately document and report their concerns to a human resource and/or Title IX office, for their own protection. Ironically, the attention on SH false accusations has created an unintended consequence of gender-based neglect of women because men fear mentoring women, interacting with women informally, or even having closed-door conversations with women [18]. This neglect occurs at a time when female doctors are increasing in numbers and need mentorship from men more than ever. Women are underrepresented in leadership positions, less likely than men to have active mentors, and leave academic medicine at higher rates than men [18]. Women can reassure male colleagues that the focus on SH is to change behavior and to address harm to victims, not to persecute or malign men. Women can encourage men to continue to actively mentor women and to address their fears head-on with mentees. For example, ask “Do you mind if I close the door?” or “Are you comfortable discussing our research over dinner or would you prefer to meet in the conference room?” Men can also be powerful bystanders. Finally, men also want to work in professional and collegial environments and can often appreciate the benefits of a better work culture for everyone. In conclusion, SH in ophthalmology is a widespread and impactful problem. We live in a unique time in history whereby shifting cultural perceptions of SH are increasing awareness, lowering victim stigma, and increasing trust in the victim. Fortunately, there are many solutions within reach to prevent SH and counteract some of the harm that results from SH. We all can improve workplace climate and culture by addressing SH head on through bystander interventions and victim response. We can encourage open conversations. Through these steps, we all can play a powerful role in shifting the tide of SH in ophthalmology. The future of our profession depends on it. Acknowledgements  The authors acknowledge that this chapter does not directly address other critical forms of harassment or intersectionality. In addition, the authors acknowledge that men and especially LGBTQ and non-binary individuals are also frequently the targets of SH. Many of the bystander strategies discussed are directly applicable to other forms of harassment (e.g. harassment based on race or religion). We also acknowledge the power of language and will use the term “victim” for simplicity, despite the fact that many who experience SH do not want to be considered victims.

References 1. Langer G. Unwanted sexual advances not just a hollywood, Weinstein story, poll finds. ABC News. 17 Oct 2017. 2. Jagsi R, Griffith KA, Jones R, Perumalswami CR, Ubel P, Stewart A. Sexual harassment and discrimination experiences of academic medical faculty. JAMA. 2016;315(19):2120–1. 3. Komaromy M, Bindman AB, Haber RJ, Sande MA. Sexual harassment in medical training. N Engl J Med. 1993;328(5):322–6. 4. Fnais N, Soobiah C, Chen MH, et al. Harassment and discrimination in medical training: a systematic review and meta-analysis. Acad Med. 2014;89(5):817–27.

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5. Cabrera MT, Enyedi LB, Ding L, MacDonald SM. Sexual harassment in ophthalmology: a survey study. Ophthalmology. 2019;126(1):172–4. 6. Reddy AK, Bounds GW, Bakri SJ, et al. Differences in clinical activity and medicare payments for female vs male ophthalmologists. JAMA Ophthalmol. 2017;135(3):205–13. 7. Reddy AK, Bounds GW, Bakri SJ, et al. Representation of women with industry ties in ophthalmology. JAMA Ophthalmol. 2016;134(6):636–43. 8. Mansour AM, Shields CL, Maalouf FC, et al. Five-decade profile of women in leadership positions at ophthalmic publications. Arch Ophthalmol. 2012;130(11):1441–6. 9. Benya FF, Widnall SE, Johnson PA, editors. Sexual harassment of women: climate, culture, and consequences in academic sciences, engineering, and medicine. Washington (DC): National Academies Press (US); 2018 Jun 12. 2018. 10. Lui PP, Quezada L. Associations between microaggression and adjustment outcomes: a meta-­ analytic and narrative review. Psychol Bull. 2019;145(1):45–78. 11. Thurston RC, Chang Y, Matthews KA, von Kanel R, Koenen K. Association of sexual harassment and sexual assault with midlife women’s mental and physical health. JAMA Intern Med. 2019;179(1):48–53. 12. Potter SJ, Stapleton JG.  Translating sexual assault prevention from a college campus to a United States military installation: piloting the know-your-power bystander social marketing campaign. J Interpers Violence. 2012;27(8):1593–621. 13. Killeen OJ, Bridges L. Solving the silence. JAMA. 2018;320(19):1979–80. 14. Cowan AN.  Inappropriate behavior by patients and their families-call it out. JAMA Intern Med. 2018;178(11):1441. 15. Hock L, Scruggs B, Oetting T, Abramoff M, Shriver E.  Tools for responding to patient-­ initiated verbal sexual harassment. 2019. http://webeye.ophth.uiowa.edu/eyeforum/tutorials/ sexual-harassment-toolkit/index.htm. Accessed 3 Nov 2019. 16. Hinze SW. ‘Am I being over-sensitive?’ Women’s experience of sexual harassment during medical training. Health (London). 2004;8(1):101–27. 17. Kearl H. The facts behind the #metoo movement: a national study on sexual harassment and assault. Stop Street Harassment. 2018. 18. Soklaridis S, Zahn C, Kuper A, Gillis D, Taylor VH, Whitehead C. Men’s fear of mentoring in the #metoo era – what’s at stake for academic medicine? N Engl J Med. 2018;379(23):2270–4.

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Laura B.  Enyedi, MD  is a Professor of Ophthalmology and Pediatrics at Duke University. She serves on the Duke School of Medicine Sexual Harassment Task Force and on the departmental Diversity and Inclusion Committee. She co-authored the first national survey on sexual harassment in ophthalmology, published in Ophthalmology. She has served numerous volunteer positions in the American Academy of Ophthalmology and is the current Pediatric Ophthalmology and Strabismus Section Editor for the AAO ONE Network. She has trained over 50 clinical fellows and hundreds of ophthalmology residents in her career and has been awarded the Duke University Golden Globe award for excellence in teaching and the Women in Ophthalmology 2019 Mentorship award.

Michelle T. Cabrera, MD  is an Associate Professor of Ophthalmology and Chair of the Dean’s Standing Committee for Women in Medicine and Science at the University of Washington as well as Chief of Ophthalmology at Seattle Children’s Hospital. She is the recipient of the Women in Ophthalmology Champions for Change award. She authored the first national survey on sexual harassment in ophthalmology published in Ophthalmology. She also spearheaded a council advisory recommendation for the American Academy of Ophthalmology that resulted in the first sexual harassment comprehensive policy for the organization.

Chapter 20

Managing Conflict in the Workplace Ruth D. Williams

Summary Points • Managing conflict is a requisite for effective leadership. • Women sometimes have particular difficulty getting comfortable with the inevitable tension arising from leadership. • Harnessing conflict requires a set of skills that can be developed through conscious effort, coaching, and practice.

The word conflict elicits a feeling of tension. Often used to describe unresolved geopolitical tensions and even war, conflict occurs on a smaller stage as well, in all types of human interaction—and especially in the workplace. Managing conflict is a requisite for effective leadership and an essential skill that ophthalmologists must acquire for professional success. While all leaders must learn to develop strategies to manage and resolve conflict, women sometimes have particular difficulty getting comfortable with the inevitable tension it produces. Many of us have internalized cultural messages that we should be agreeable, cheerful, supportive, and compassionate. Learning the companion set of characteristics—serious, tough, direct, insistent, and competitive—can require conscious effort, coaching, and practice. When I experience the tension of conflict in the workplace, I often think of a 10-year-old girl on the soccer field. She is there because of Title IX of the Education Amendments Act of 1972, a law that mandates equal opportunities for girls and boys in public school and has vastly increased girls’ participation in sports. Today, our girls and our boys learn to aggressively pursue the ball, compete fiercely, and focus intensely on the goal. They also learn teamwork and leadership, and they discover that even more is learned through a loss than through a win. This new era

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that celebrates competitive and ambitious young girls is highlighted in the 2019 Nike ad featuring the 10-year-old California soccer player Makena Cooke alongside soccer phenomes, namely, Lieke Martens (Netherlands midfielder), Crystal Dunn (US forward), and Sam Kerr (Australia midfielder). When I am feeling anxious about a rising conflict, I sometimes imagine Makena Cooke driving the ball down a soccer field full of other dedicated, determined, and well-trained athletes. Conflict is the struggle required to move a team forward. It is our friend. Here are a few specific strategies that I have found helpful in learning to manage—and even harness—conflict for the best result.

Face Up to the Conflict Attempting to avoid tension inevitably leads to a less desirable outcome—the issue causing that tension will not just go away. A conflict-avoidant leader is often a supercompetent person who “picks up the pieces” on a team project. Rather than engaging with her team members to hold them responsible for doing their part, she simply handles the neglected or subpar work herself. The consequences? The final product does not have the richness of input from other perspectives, and the super-­leader is stressed, overworked, and not using her skills well. Beyond that, this cycle will repeat itself, since underperforming team members have no incentive to improve. It takes self-awareness and practice to transform conflict-avoidance behaviors. A first step is to consciously acknowledge that tension is good and necessary.

Observe from the Outside When I am sitting at a table and my colleagues have strong opinions—and even stronger emotions—I imagine a big blob in the middle of the table. The blob contains the tension, so it is outside of me. If I start feeling the pressure build, I envision a transfer of the energy from my brain to the blob, where it is a separate entity and can be observed. You can come up with your own favorite image for this. Remember the Pensieve in the Harry Potter movies? It is a magical stone bowl that can store memories extracted from the brain. While thoughts are highly personalized, putting them outside, perhaps in a stone bowl, allows them to be analyzed without (or with less) emotion.

Gather the Information The old saying “information is power” applies to the skill of managing conflict. When a seemingly unsolvable conflict arises, every person on the team needs to learn as much as possible about the issue. This accomplishes two immediate goals. First, data and background information are neutral; doing the necessary research

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engages the curious mind—and helps to deflect emotional involvement. Often, this process gives colleagues time to reflect and discover that a problem is more complex than they had assumed. Second, digging deeper into the information provides perspective and just might open up new ideas about possible solutions.

Communicate in Person Another challenge is that team members or colleagues might not communicate well. Sound bites, texts, or emails too often become the default mode, but they can be poor mechanisms for communication, leading to misunderstandings and partial truths. The leader might be in the dark about what is said in side conversations, and that can be disruptive to good teamwork. A significant conflict is best worked out in person. Even though it can be challenging and time-consuming in the short run, it is usually worth the investment for the long-term health of the organization and the relationships.

Understand the Other Perspective It is tempting to congratulate ourselves for listening politely before jumping in to make our own points. Not interrupting and giving the other person room to talk is a good leadership habit, but it is only the first step. The next step is to actively explore the other person’s perspective. Ask a few more curious questions. Ask for a little more explanation. Most ophthalmologists are visual people, so an image can be helpful. Sometimes I visualize myself in a white coat staring through a microscope with all the curiosity and imagination of a scientist. What would that scientist notice about the other person? What phrase or seemingly unrelated sentence was dropped into the narrative? When did the other person start chewing his lip? What data point did not make sense? We cannot collect accurate and detailed information while we are crafting a rebuttal. Careful listening conveys deep respect for another person. Though it requires time and discipline, our colleagues can tell when we truly care about their perspective and their arguments. Listening and asking curious question builds trust in the workplace.

Cultivate Quiet The leader does not always have to respond or share her opinion. She does not need to convince the other person that she has got the answer. Instead, she should strive to deeply understand the other person’s argument; doing so promotes better-­ informed decision-making that incorporates a range of viewpoints. And, just as

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important, it can help her anticipate some of the possible outcomes of the decision and how others might respond to her guidance. Usually, being quiet is more effective than talking. Leadership is not a debate stage.

Seek “The Third Way” One of my favorite statements is “There’s always a solution.” It is my way of reminding colleagues that although a conflict appears intractable, I am confident that, working together, we will find the optimal path to resolution. If a leader takes the time to get good data, communicate well, and listen carefully, the way to solve the problem usually emerges—often a “third way” that encompasses the perspectives of both sides.

Get Comfortable with Discomfort Leaders need to become comfortable with discomfort. A key element of leadership is making tough decisions—and accepting that some team members or colleagues will be deeply unhappy with the outcome. While this is never pleasant, we need to remember that our job is not to make everyone satisfied; it is to do what is best for the organization. Inevitably, there will be some decisions our colleagues disagree with and might even be vocal about. And that is actually okay, as long as they feel that they were heard and respected in the process. Then, following the chosen course of action will go more smoothly when the leader consistently displays fairness, equanimity, and good processes.

Wait for Emotions to Cool Emotion is more powerful than reason. Any of us can be overpowered by emotion, and it is usually rooted in an unconscious and unresolved place. But, as a colleague once told me, “No one can hear a thing you are saying once their heart rate is over 100 bpm.” When emotions are high, it is best to postpone the conversation, as long as follow-up is assured. Wait, but set up the next meeting. Once a colleague was angry at me and accused me of breaking a promise of which I had no recollection. There was a rational and straightforward explanation for the misunderstanding, but his perception had triggered an intense emotional reaction. Realizing this, I suggested that we meet again in 1 week. At that next meeting, he was still angry and accusatory. I told him that his perspective was extremely important, but that we really could not talk yet and suggested that we meet in another week. Finally, 2 weeks after our initial conversation, my colleague was calm and we talked through the situation. I was able to listen to him, and then he was open to hearing my explanation. He apologized for his previous comments, and we worked

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out a compromise. We continue to be great colleagues, and our mutual respect was increased by this incident. A common misperception is that women are more emotional than men, but I have found this to be the opposite of reality. Our culture tends to allow men to be very emotional, though it is often expressed as anger or disguised as intensity. Women, on the other hand, are discredited for displaying emotion, especially crying or showing anger. The truth is that some people—our great leaders—are thoughtful, curious, and usually rational, whereas our less mature team members are reactive and insecure.

Recognize Your Role in the Conflict Sometimes the person with the emotion is me. Recognizing this in ourselves is essential to leadership. Learning to pause before responding is a terrific skill and a sign of hard-earned maturity. A famous quotation expresses this concept powerfully: “Between stimulus and response there is a space. In that space is our power to choose our response. In our response lies our growth and our freedom.” Although this wise saying is often attributed to Viktor Frankl, author of Man’s Search for Meaning, it is more likely derived from psychologist Rollo May’s 1963 article “Freedom and Responsibility Re-examined” [1]. Regardless of authorship, the quote describes a leader who refrains from being immediately reactive and cultivates that tiny space required to craft a thoughtful and rationale response.

Establish Ground Rules for Behavior It is normal for colleagues to have strong opinions, emotions, and intensity. However, it is mandatory to be clear when behaviors cross the line into abuse or intimidation. One strategy is to open the door if a discussion gets intense or to request that another person join in the conversation. And it is always okay to postpone a conversation to another, but clearly defined, time. It also helps to request that a colleague stop using swear words, provocative language, exaggerations, or name-calling and to end the meeting if it continues. If this request is made without drama, the behaviors will extinguish. A calm, quiet voice is almost always more effective than a loud one.

Pick Your Battles Some personalities derive energy from conflict, and these people can be taxing on an organization. Some conflicts are not for the leader to solve. It takes experience and wisdom to know when to engage a problem and when to ignore it, since some

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problems dissolve easily. It is helpful to step back and ponder how a particular conflict might affect the organization and whether it needs addressing.

Commit to Learning and Keep Going Ophthalmologists are great leaders. We direct our medical and surgical teams every day. We assess our patients, give wise advice, and make clinical decisions. We are very comfortable having difficult conversations with our patients and their families. Learning to manage conflict is one more skill to acquire. Finding a mentor for guidance is terrific. Some of the best mentoring happens through observation of a skilled leader in action—and the mentor might not even realize she is teaching. As with all experiences that promote our growth, it is helpful to be thoughtful about the process and to reflect on times when we could have done better. Such reflection increases our self-awareness and hones our ability to manage conflict. With continuing practice, we can become comfortable with being uncomfortable. The successful leader recognizes that conflict is unavoidable but—when resolved with tact and skill— helps to make the team stronger. When I think of leaders I most admire—for example, Sacajawea, Earnest Shackleton, and Nelson Mandela—each of them faced seemingly impossible challenges. Sacajawea was the Shoshone woman who guided Lewis and Clark’s Corps of Discovery across the uncharted West. She negotiated agreements between the Euro-American explorers and the leaders of the Indian nations that resulted in a mostly peaceful journey. Undoubtedly, she managed tension, differing agendas, and misunderstandings. Ernest Shackleton, a British Antarctic explorer, rescued every single man on his ship—The Endurance—after it was crushed between ice floes and sank. He quelled a rebellion led by the ship’s carpenter Harry McNish, but later selected McNish to join a team of five to attempt the most dangerous part of the rescue. Nelson Mandela, the anti-apartheid leader and South Africa’s first democratically elected president, confronted conflict that was rooted in centuries of racism, slavery, and segregation. Each of these remarkable leaders embraced the conflict of their situation and, in doing so, protected the team and ushered new ways of thinking. Conflict is inevitable. Embracing the tension is the process that leads to exceptional outcomes.

References 1. 1963, Behavioral Science and Guidance: Proposals and Perspectives, edited by Esther LloydJones and Esther M. Westervelt, Article: Freedoma and Responsibility Re-Examined by Rollo May, p. 101-102, Bureau of Publications, Teachers College, Columbia University, New York.

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Ruth D. Williams, MD  is a glaucoma consultant at the Wheaton Eye Clinic. She was managing partner of this 77-year-old ophthalmology practice for nearly a decade. Wheaton Eye Clinic provides subspecialty eye care to more than 175,000 patients each year and employs 33 ophthalmologists and 14 optometrists in six locations. One of the few large, independent single specialty practices in the region, Wheaton Eye Clinic provides ophthalmic care to the patients of several integrated health systems in the Midwest. Dr. Williams is a past president of the American Academy of Ophthalmology. Before serving on the Academy’s Board of Trustees, she represented ophthalmology at the American Medical Association, also chairing its specialty section. She has served on the board of several ophthalmic organizations and is currently vice-chair of Glaucoma Research Foundation. Dr. Williams is the Chief Medical Editor of EyeNet Magazine. A dynamic speaker, Dr. Williams has given numerous named lectures, nationally and internationally. She has appeared on a dozen major television networks and talk shows and provided interviews to numerous magazines including Health, Women’s Health, Shape, and Good Housekeeping. After attending Rush Medical College, Dr. Williams completed an ophthalmology residency at California Pacific Medical Center in San Francisco and a glaucoma fellowship at Shaffer Associates and the University of California San Francisco.

Chapter 21

Experiencing Health Issues as a Physician Ann Ulmer Stout

Summary Points • Doctors can become patients, and eye surgeons are not immune to eye problems. • Do not underestimate the importance of disability insurance, or overestimate your own disability. • Health issues can be another opportunity to continue lifelong learning, especially in areas that cannot be gleaned from books.

We have all heard stories of the gynecologist battling metastatic breast cancer, or the neurologist left impaired after a serious stroke. Physicians are no more prone to developing a medical problem in their own field than in another, but it is a cruel coincidence when they succumb to conditions they have dedicated their life to treating. We wonder if their insider knowledge could have somehow changed the course of events. Did denial lead them to ignore early signs? Did they see the best doctors and get the best care? Did they follow their advice? I can answer those questions for myself, after being afflicted with two eye issues that impacted my life and work. There was no denial or delay on my part, I had excellent care, and did everything I was told to do, but I still had a life-changing outcome. Here is my story and what I learned. One night when lying in bed I noted the overhead ceiling light splitting into two images. I could easily merge them back into one with a little focusing effort, and I wrote it off to being tired. As an experienced pediatric ophthalmologist who treats adults with double vision, I was not too concerned. Over the next

A. U. Stout (*) Houston Eye Associates, Houston, TX, USA © Springer Nature Switzerland AG 2021 C. Y. Weng, A. M. Berrocal (eds.), Women in Ophthalmology, https://doi.org/10.1007/978-3-030-59335-3_21

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2  years, this progressed to the typical divergence insufficiency esotropia of a middle-aged woman, causing doubling of my vision at times. Initially it was minimally annoying and easily controlled and I found it academically interesting to get a taste of what my patients have to put up with. As it slowly progressed, I experienced persistent diplopia in certain situations such as when viewing a performance in a darkened theater, or after a second glass of wine. Depending on which direction I looked or how I turned my head, the diplopia would come and go. Looking over my reading glasses to talk to people helped align my eyes. Other times I found myself involuntarily winking one eye closed to block the second image. I had to close one eye coming down the stairs to see only one set of feet in the morning, and when looking to either side at traffic intersections to keep the cars single. All of this I could live with, frustrating as it was. It gave me more insight into what my patients with diplopia were dealing with, and empathy based on my own experience. My double vision never happened at close range, so I could still work, with excellent stereovision in clinic, both at the slit lamp and in the operating room. What I could not live comfortably with was anyone else knowing what I was going through outside of my immediate family. I absolutely did not want my colleagues or patients to know. I worried my colleagues would pity me and talk behind my back, and that if I ever needed surgery, I would have to pick one of them over another to do it, which would be another topic of speculation. My patients would surely be anxious about having a surgeon with double vision operating on their eyes even if it did not affect my surgical skills. Ultimately, it became persistent enough that I underwent surgery to fix it. Once I chose the surgeon, I tried to assume the role of a patient and put my faith in her judgment, surgical approach, and skill. As she marked my forehead in the pre-­ operative area, I realized I would much rather be in my position than hers, as she held the responsibility for another physician’s livelihood in her hands. This was the first of many times I would need to learn to trust another ophthalmologist’s skill set instead of my own. Being vulnerable gets easier with practice. Recovery was another learning experience. I discovered that a bag of ice works almost as well as ibuprofen for local pain control, and that “dissolving sutures” make your eyes red until the last bit of foreign material is gone 8 weeks later. I found that having gone through the process, I could share my experience with patients who were very anxious about what strabismus surgery would be like, offering them some personal reality-tested reassurance. I enjoyed my restored single vision and got on with my life. Spoiler alert – my husband is a retinal surgeon, so that leads me to the second medical issue. Several months after my eyes had healed, I noticed the onset of some floaters and flashing lights in my right eye. As a myopic patient, I knew that my risk of retinal detachment was higher than average, and I immediately saw a retina specialist. I had suffered a posterior vitreous detachment (PVD), but there was no tear in the retina. The floaters clouded my vision and were hard to ignore in my

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dominant right eye. They sometimes blocked my view just when I got my retinoscope lined up with the pupil of a squirming toddler. My exams took a little longer and tested both my and the parents’ patience. Several weeks went by without any change, and I grumbled inwardly at this new intrusion on my vision. Eventually I did develop a tear in the retina which was treated with a laser barricade to prevent a retinal detachment. Despite this, the exposed underlying pigment cells triggered an exuberant inflammatory process called proliferative vitreoretinopathy (PVR), which started to detach the retina. I noticed the change in my peripheral vision after a busy morning of surgery. I was tempted to ignore it, being worried about getting behind on my own clinic and surgery line-up. If I went to the retina doctor and needed surgery, who would see my post-operative patients the next day? We are often held in thrall by our patient schedules and may pay a price for putting our own needs last. I reluctantly headed to the retina doctor, knowing this turn of events would likely necessitate an operation, time out for my recovery, and an unknown length of time before I could operate again. I was right about the disruption in my routine, as my retina required several trips to the operating room to try and get it to stay attached. When it finally settled down 7 months later under a blanket of silicone oil, there were retinal battle wounds and an intraocular lens to show how extensive the fight had been.

Aftermath All odds being equal, I had the same chance as anyone of having a good or bad outcome. A good outcome is when both the patient and surgeon, in that order, are pleased with the results. As a surgeon you may critique your results, striving for perfection in every case, while the patient is perfectly happy and does not need to hear your disappointment. A bad outcome is when the patient and surgeon, in that same order, are dissatisfied with the outcome. A bad outcome for the patient may be the fault of processes beyond your control, despite the best you can do as a surgeon. You may want to explain this to the patient to make them feel better, which it will not. The outcome lies beyond any explanation of how you and the patient got there, and how your patient lives with that bad outcome will determine their future, despite how you try to spin it. As a patient, a bad outcome may change your life forever and you have to decide how to live with it, how to work with it, and how to accept it in order to keep moving forward. Acknowledging disability is hard for anyone, especially physicians. Hopefully, you already have a long-term disability plan in place. If not, put this book aside and make one. Have conversations with your family, meet with a financial planner, buy an insurance policy, or better yet, do all three. You have invested too much in your career at this point not to be covered for life’s medical surprises.

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As a physician, you know they happen with alarming frequency. When I underwent LASIK refractive surgery 20  years ago, my surgeon asked me a very important question before I signed the consent: “How good is your disability insurance?” I was happy to report that it was very good, and even happier when that surgery went off without a hitch. The emotional rollercoaster of dealing with your own complicated medical issue should not prevent you from attending to important logistics. I was surprised at how resistant I was to even contact my disability insurance company to apply for long-­ term benefits. It felt like another admission of failure, and I was worried that my case would not qualify. Colleagues who had gone through similar issues encouraged me to apply early and open every letter as soon as it came. Sage advice, as the ostrich in me wanted to stick my head in the sand and hope things would just work out. It is another frustrating and humbling experience to have to fill out forms that are not “one size fits all,” to trouble your treating doctors to fill out these forms, knowing the burden it creates for them, and to have to do it over and over though nothing really changes. Having to answer how many hours per day you spend sitting, standing, bending, and lifting as though you are a construction worker instead of a physician is another de-personalizing experience. And each time, there is the fear that they may take it away on the next review. I had a bad outcome, defined by me as a re-attached retina but one that only provides a distorted fun-house image, which is also tilted and displaced. My double vision has returned. I had gotten good at winking my left eye closed to block the double previously, but I am not a good right eye-winker. I lost all stereoscopic vision, and the ability to do fine motor tasks with ease, including surgery. In losing the ability to call myself “surgeon,” I realized how much I had come to value that title and felt I had lost a part of myself. There is now no denying my vulnerability and imperfection to patients, as I explain to those who need surgery why I am sending them elsewhere for their procedure. At first I did not notify referring doctors, hoping things would improve, but this inconvenienced both the doctors and the surgical patients they referred. I found I still had a useful role to play. I had more openings in my clinic schedule without the surgical visits and operating room time. I could get the patients in more quickly to start the surgical evaluation process and then guide the patient to the best surgeon for them, while factoring in their personalities, choices, and limitations around insurance or scheduling. Some patients could not be helped with surgery, or had to wait, and struggled with their double vision as I do. I now have test-driven and discarded many of the suggested ways to block double vision, such as the cheap pharmacy patches that are too irritatingly tight. I find it just as emotionally rewarding to offer to share a patient’s grief over the insolubility of the problem, and let her know she is not alone, as it is to have a successful diplopiafree post-operative patient throw her arms around me, weeping with joy. I have more time to spend with patients, and smoother days, without the adrenalinecharged surgical hours.

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Disability may interrupt your work and life plans at any time, but if the condition is not immediately fatal, life will go on. To a physician, this will at first feel like a loss of control, and this powerlessness may be frightening. You can still find meaningful work in your new life whether it is refiguring your medical career into a different area, or putting your energy and intellect into other things, remunerated or not. Take the time to use your prior life experiences to guide your next steps. Navigating a medical condition, involving doctor visits, tests and treatments, surgeries and recoveries, is a disruptive experience that can actually create some space to reimagine your priorities. Physicians have often not stopped to take a breath since medical school, diving straight into postgraduate training followed by a job. As long as the bills can be paid, this may be a time to reassess how you want to spend the years ahead of you. Discuss options with a trusted loved one, friend, or counselor and explore what has made your heart sing thus far. If you have loved your work and can somehow continue in your chosen field, I suggest you do so, at least for a while. Most disabled physicians can continue to work in the medical field [1]. Initially your ego may try to tell you that you are underperforming, or overqualified for the things you still can do. It took me a few months to appreciate that the experience I bring to doing a difficult refraction and providing a good pair of glasses can mean as much to a patient as diagnosing and treating a more complicated problem. I have more time to spend talking to patients, since I am not racing off to the operating room. Hopefully you will be working with colleagues who value what you can continue to bring to the practice more than maximizing revenue. If not, practice self-­advocacy in this situation and ask for help in getting what you need to continue your work [2]. You may enjoy mentoring other younger physicians, getting involved with teaching through your state or national organization, taking on advocacy in your field, or providing pro bono services locally or internationally. You may want to spend more time with family, or explore other areas that have interested you, such as business or painting, yoga or kayaking. There might be a tendency to think your training has been “wasted” if you are not able to continue in your profession. Even before finishing medical school you have been of service to countless patients, spending time with them after rounds when the attending physician moved on, listening to their stories, evoking giggles in a frightened child, and bearing witness to their sufferings. No illness can take that away from you and, more importantly, from the people you have served. But now you have been given the wisdom to see how much your service has meant, as you too are now a patient.

References 1. Wainapel SF. Physical disability among physicians: an analysis of 259 cases. Int Disabil Stud. 1987;9(3):138–40. 2. Gautam M and MacDonald R. Helping physicians cope with their own chronic illnesses. West J Med. 2001;175(5):336–8.

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A. U. Stout Ann Ulmer Stout, MD  was raised in Houston, attended Wellesley College and Baylor College of Medicine where she was elected to the Alpha Omega Alpha Honor Society. She did her Ophthalmology Residency and was Chief Resident at Baylor. She moved to Los Angeles to do a 2-year pediatric ophthalmology fellowship at Children’s Hospital Los Angeles and the University of Southern California Medical School, where she stayed on as faculty for 10 years. In 2000, she moved to Portland Oregon to join Oregon Health and Science University as an associate professor. While there, she was active in teaching residents and fellows, starting a strabismus clinic at the Veterans Hospital, as well as taking part in clinical trials. In 2014, she returned to Houston and joined Houston Eye Associates to focus on clinical care. She still teaches residents at the VA strabismus clinic and continues clinical research. She goes on annual eye care mission trips to South America with Medical Ministry International. She is on the Executive Committee of Houston Eye Associates and the board of Prevent Blindness Texas and has done advocacy work in Texas around health care policies and procedures. Her full life includes raising three children to adulthood, spending time with her family, biking, running, and travel. She has been involved in community service through various nonprofit organizations including Galveston Bay Foundation and MS150 bike rides. Currently, she is doing a lot of writing about her experiences.

Part VII

Family Matters

Chapter 22

Romantic Relationships Lisa C. Olmos de Koo

Summary Points • There are many issues facing female ophthalmologists in their personal lives. • Some of the topics covered in this chapter include dating, being single, online dating/social media considerations, marriage (including the decision of whether and how to change one’s name), the impact of children, and navigating relationship problems or the end of a relationship. • Awareness of these issues and topics as well as open discussion of any challenges can help us achieve the best possible outcomes.

Introduction This is an exciting time to be a woman in ophthalmology. It is a time when we can forge our own paths as women, and we no longer have to fit in as “one of the guys” in order to function professionally. This opens up many more opportunities in our personal lives as well. The inspiration for this chapter on the delicate issue of romantic relationships has been the amazing network of female friends, family, and colleagues I have been fortunate to develop over the years. These remarkable ophthalmologists hail from around the country and the globe, from different backgrounds, and from career stages spanning from residency through retirement. Some of the anecdotes and commentary included in this chapter come from my own life experiences, but most of the material has been gleaned from conversations and informal interviews I have conducted with these women and their partners. My goal is that this chapter not include advice, per se, but rather that it encourage frank

L. C. Olmos de Koo (*) University of Washington, Seattle, WA, USA © Springer Nature Switzerland AG 2021 C. Y. Weng, A. M. Berrocal (eds.), Women in Ophthalmology, https://doi.org/10.1007/978-3-030-59335-3_22

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discussion about different approaches to the challenges that face us in our personal lives. Read on for a multifaceted perspective on romance as a woman in ophthalmology.

Relationships and Dating While in residency and fellowship training, you face many constraints that may hamper you developing or maintaining a romantic relationship. To mention just a few: long work hours, lack of control over your own schedule, a relatively lower salary, and uncertainty about the future. Where will you match for residency and fellowship? Where will you land a job after training is over? These issues can be a “test of fire” for your significant other. In order for things to work out, it is important that your partner be willing to accept these temporary constraints, while understanding that there is (often) hope for an improved schedule when training is done. A partner who is not in medicine can sometimes have difficulty understanding how demanding this time in your life is or seeing the light at the end of the tunnel, which may be why there are so many double doctor relationships for women. A recent study out of Harvard Medical School found that 31% of female doctors were married to male doctors, which is a remarkably high percentage [1]. Nevertheless, no matter who you are with, it is important that he or she respect and support you in all the things you care about, including your career. Dating (and even marrying) within your training program – does it ever work out? To be sure, there can be complicating factors, but we have all seen the success stories. Especially for those whose training programs are demanding with busy on call and overnight duties, there is no better test of marital success than working closely with someone under the stress of training. The pros: you get to see them a lot at work, you can have a “built in” second opinion on the patients you see, and your partner truly understands what you are going through. Medicine and ophthalmology have their own lexicon, and when you are tired or stressed there is something comforting about not having to define every acronym. The cons: other trainees may feel you have a unfair bias towards your significant other (particularly in small training programs), you may never get to take vacations together until you graduate, and if things go south for the relationship, it can make your work situation excruciating. The perils are even greater for romantic relationships with those senior or junior to you in the training hierarchy, namely perceived and/or real favoritism, which can harm your relationship with colleagues and your reputation, and possible retaliation against you if things do not work out. It is important to mention here that coercion to enter a relationship by a superior or retaliation for rejection of romantic advances is a situation that is not acceptable in any workplace. How to proceed is covered elsewhere in this book in the chapter on sexual harassment. The bottom line seems to be to consider romantic relationships within your training program very carefully before proceeding, but do not rule them out completely. As a fully fledged, fully trained female ophthalmologist, you face yet another set of relationship quandaries. Experience has shown that some potential mates can be

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intimidated or “scared off” by a professional woman who may have attained a higher educational level or who may earn more than her partner. Some advice heard on the street: “hurry up and get married before you finish training and become un-­ datable.” Fortunately, those attitudes seem to be changing, and different family arrangements have become more socially acceptable, such as the spouses of female physicians taking on more of the work responsibility within the home. This may serve as yet another litmus test for a relationship, because our partners must accept and value us for who we are: professional women.

The Single Life So, what if you are single? In the past, when being a woman in medicine was a rarity, there was social pressure not to get married and not to have children. Female doctors in the past were perceived as “taking up a spot” that could have gone to a male without the potential for maternity. Attitudes have thankfully also changed here, but these days it seems that as a woman, you face social pressures to be in a relationship of a particular kind. A woman dating various people can be viewed as scandalous, whereas the practice is more socially acceptable for men. And what seem like constant prying questions regarding your relationship status can be irksome, even more so when they are posed by well-meaning colleagues, mentors, or patients. You might ignore and not comment, you might respond directly, or, as I used to do, you might choose to deflect the question with a funny one-liner and enjoy a good laugh. How to handle unwanted romantic advances when they made by your patients? This is something that comes up much more often when you are (or are perceived to be) single – with no visible ring on your left fourth finger. How to proceed is covered elsewhere in this book, in the chapter on sexual harassment. Remember that as the physician, you have a responsibility to set professional boundaries for the patient-doctor relationship, and that if a patient is making you feel uncomfortable, often one of your colleagues can and will assume their care upon request. In most cases, you are not the only one who can provide that patient with great care. If you are single and that is how you like it, more power to you! If you are single and you are trying to change that situation, remember to be cautious of the potential pitfalls related to online dating and social media, outlined in the next section.

Online Dating and Social Media Considerations In today’s world, online dating and social media connections are the rule rather than the exception. Even if you and your significant other did not first “meet” online, chances are social media will play a big role in how your relationship is framed in the eyes of your friends and colleagues. Going public with a post together on Facebook or Instagram is the modern-day equivalent of wearing your boyfriend’s class ring – announcing to the world that you are dating. Remember to be cautious of what you reveal in your online dating profile (most female doctors I know do not

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include too many details about their occupation). And, to the extent that you can, try to verify the identity of those you are connecting with. It is important to bear in mind that as a physician, you are somewhat of a public figure. You are (or will be) easily “searchable,” with your name, biography, and picture often readily available both on your practice website and professional ratings websites. To the extent that information about you exists online, expect that your patients, colleagues, and potential employers will have access to it, where they may use it form opinions about you even before meeting you. Patients may even specifically search for you on social media or dating sites. So, if you would prefer to keep your privacy, you must do some work to safeguard it. One practice, often used by celebrities, is using a pseudonym or scrambled name on social media accounts that you would like to keep private or that you only share with your close friends. Some of us have stopped using social media altogether, which may be a decision based on concerns for both privacy and time management. For others, managing an online persona is not only a part of being social; it is a valuable career tool. Whichever route you go, remember to think about what you have shared in the context of your patients and potential future employers.

Making It Official: What Is in a Name? Getting married is certainly a big step. But for a woman in the United States, it has traditionally come with an even bigger change in identity: your name. Deciding whether or not to switch, append, or otherwise modify your last name after marriage can be tough, especially as societal practices change and more options are available. In the United States, it is becoming more and more common not to change your name. According to a Google consumer survey, roughly 20% of women married to men in recent years have kept their names [2]. There are many options. Some of these include changing your last name to that of your husband or wife (with the added option to make your maiden name into your middle name), making no changes to your name, hyphenating your maiden name with the last name of your partner, or both partners changing their names together to create a new family name. Modifying your name can be an especially difficult decision if your degrees and diplomas all feature your maiden name and you have already racked up a number of publications and citations. If you change your name completely, you might be seen as “starting over” in terms of developing your professional reputation. The fear is that in a google or PubMed search, the body of work related to your maiden name would be lost. But remember that your maiden name can also be included in CVs, National Institutes of Health (NIH) biosketches, applications, and official publication lists. When I decided to get married, I was already an attending ophthalmologist, and I had never really considered changing my name after marriage. This was mostly because my mother, who was also an ophthalmologist, chose not alter her maiden name when she got married in the 1960s, so it seemed “normal” to me not to.

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However, I quickly learned that my husband-to-be felt strongly that there should be a name change (not necessarily just mine) for the sake of family uniformity, especially considering that we both wanted to have children. And in turn, I realized that I felt strongly that I should retain the identity and link to my father’s Mexican ethnic heritage that my maiden name provided. So, as is the case in most successful marriages, we compromised. I left the first word of my maiden name (my father’s last name) intact and I added my husband’s name. However, I did not use the hyphen customary in the United States. I chose to follow the Mexican custom of adding the word “de,” meaning “of,” as a link to my husband’s last name. This resulted in quite a mouthful of a last name: Olmos de Koo. The result is that no one ever knows what to call me. Dr. Olmos, Dr. Koo, Dr. de Koo, Dr. Olmos de Koo; it does not really matter to me. However, I usually go by Dr. Olmos, as it is less of a mouthful, my Spanish-speaking patients can identify with me, and I am used to it. After all, that is what I was called for the first 7 years of my doctor-hood. However, after we had children (who followed tradition and took their father’s last name), I became much more appreciative of my new crazy mixed up name, and now I am glad I changed it. My kids just love our identity as the Koo family and the fact that my name in particular has Koo in it, too. I never would have expected that it would be so important to them because as a kid I was never bothered by the lack of uniformity in my family, but now I love it too. These days, I am known as Dr. Olmos in professional circles and as Lisa Koo in social circles. I enjoy the variety, but understandably there is a cultural factor for me that does not work for everyone! While no one gets married thinking of divorce, the reality is that some marriages do end in divorce. As a professional woman, if you have changed your name this can be an additional complication as changing your name back to your maiden one can be time-consuming and costly due to legal fees. If you have children, you may have a reason to keep your married name, but if you do not, you are faced with another set of decisions regarding whether to change back. How does that impact your publications, grants, the body of work you have accumulated, and your professional presence? For these reasons, even those individuals who choose to change their name may wait to do so until after they become parents.

The Impact of Children No doubt about it, having kids can both strengthen and strain your relationship to various degrees and in various ways. Other chapters in this book will cover the topic of transition to motherhood in a more general sense. The question I will address here is how to give your significant other enough attention when your career and your patient’s needs as well as your children’s needs are all vying for attention. It is not a trivial one. Everyone will tell you that relationships take time and attention to maintain, even strong ones that have been going for years. Most of the women ophthalmologists I know who are happy in their relationships have told me how important it is to set

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aside time for you and your partner to enjoy one another. Different people have different needs. For some, this could be a date night or a weekend away; for others, checking in with text messages and phone calls during the day may meet those needs. I, for one, have a rule to always answer my cell phone when my husband calls or texts me, no matter what I am doing. He has a unique ring and text tone, so I can always tell that it is him. I will pretty much always pick up unless I am scrubbed into surgery, in which case I will ask the circulator to pick up. I should note here that he does not contact me that often during the work day – this practice might be unsustainable if he did. Sometimes having children will cause a couple to reevaluate their careers. One or both partners may cut back their hours, sometimes going to part-time or choosing to become a full-time parent. The most successful transitions come when both partners are on the same page and agree to a plan. If one person feels that the other has not respected his or her career or parenting needs, it can lead to resentment that may become chronic and toxic. This leads us to the next section, dealing with the unfortunate reality that not all relationships last.

When Relationships Falter or End How can you avoid a breakup when things with your partner seem to be on the rocks? Most of those I spoke with recommend taking a step back and looking at your interactions with your loved one. Dr. John Gottman, professor emeritus of psychology at the University of Washington, has identified “the four horsemen,” which are behaviors that, when they become pervasive, very accurately predict a couples’ early divorce (average 5.6 years after the wedding) [3]. 1. 2. 3. 4.

Criticism Contempt Defensiveness Stonewalling

The good news is that Dr. Gottman and his collaborators have found that there are effective “antidotes” to each of these behaviors. Instead of criticism, which is a verbal attack of personality or character, you can try a “gentle start up,” talking about your feelings using “I” statements to express a positive need. Instead of contempt, which is demonstrated by destructive statements that come from a position of moral superiority, work to build a culture of appreciation and try to bring out your partner’s positive qualities. Instead of defensiveness, which is when you victimize yourself to ward off a perceived attack and try to reverse the blame, take responsibility (when you can) and offer apology for any wrongdoing. And instead of stonewalling, which is withdrawing to avoid conflict and convey disapproval and separation, try taking a break from the conversation and spending that time doing something

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soothing and distracting that you both enjoy, only later coming back to the conversation. It is best to have these conversations when you are both receptive, alone, and are free to focus on the issue at hand. Breaking up or losing a spouse or partner after an accident or illness is never easy, no matter if it was a short-lived romance or a years-long relationship. Weathering the end of a relationship while maintaining a productive career is a skill few have managed to perfect, but one that can be learned. One person’s advice on getting through her divorce: compartmentalize to the best of your ability. If things are not going well at home, make sure they go extra well at work. “Throw yourself” into your work and/or your hobbies. Some examples: write on that manuscript you have been meaning to submit, launch that blog you have been wanting to start, apply for that grant you have never had time to gather the data for, learn or re-learn a musical instrument, or shadow a colleague in the operating room to learn that new surgical skill you have been meaning to pick up. When my mother suddenly became a widow after having retired from ophthalmology to care for my father during his long illness, she applied to become a voluntary faculty member at the institution where I trained. Reentering the professional world of ophthalmology has been a tremendous source of joy and comfort for her. As ophthalmologists, we are so fortunate to have a rewarding career, a sense of purpose in our work, and a wonderful network of professional colleagues to support us in our times of personal grief and loss.

Conclusion As hard-working and dedicated ophthalmic professionals, we all deserve to find happiness, and for many of us, it is with a romantic partner. Getting together, staying together, and navigating relationship transitions and pitfalls are not trivial considerations. Awareness of the issues facing female ophthalmologists in their personal lives as well as open discussion of any challenges can help us achieve the best possible outcomes. I offer my sincere thanks to all the inspiring ophthalmologists who have influenced my own career and personal life, and especially to those who have contributed their valuable perspectives to this chapter.

References 1. Ly DP, et al. Ann Intern Med. 2018;168(5):375–6. 2. https://www.people-press.org/2012/11/07/a-comparison-of-results-from-surveys-by-thepew-research-center-and-google-consumer-surveys/. 3. Gottman J, Levenson RW.  A two-factor model for predicting when a couple will divorceexploratory analyses using 14-year longitudinal data. Fam Process. 2002;41(1):83–96.

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L. C. Olmos de Koo Lisa C. Olmos de Koo, MD, MBA  is an Associate Professor of Ophthalmology at the University of Washington in Seattle, WA, where she is the Director of the UW Retina Fellowship Program. Dr. Olmos earned her medical degree from Baylor College of Medicine in Houston, TX, along with an MBA from Rice University. Following the completion of her ophthalmology residency and vitreoretinal fellowship at Bascom Palmer Eye Institute in Miami, FL, she was selected to serve a 1-year term as Chief Resident and Co-Director of Ocular Trauma at BPEI. From 2011 to 2016 she was an Assistant Professor of Ophthalmology at the Doheny Eye Institute and at the USC Roski Eye Institute of the University of Southern California in Los Angeles, CA. While at USC, Dr. Olmos served as Primary Investigator for the Argus II retinal prosthesis device clinical trials and became one of the few implanting surgeons worldwide. At UW, she maintains a busy clinical and surgical practice. Her research interests include vision restoration for retinal degenerations and all aspects of diabetic retinopathy.

Chapter 23

Parenting During Training Sara Fransen Grace

Summary Points • Becoming a parent during residency presents unique challenges for the female ophthalmology resident. • There is no standardized maternity leave across residency programs and policies vary widely. • The return to training can be associated with a variety of stressors such as planning childcare, breastfeeding, completing training requirements, and psychosocial factors. I did not enter residency as a mother, but became one at the beginning of my third year of training. The idea of being pregnant, giving birth, and returning to work in a demanding and busy program was daunting, but so was the idea of delaying the start of our family. I despise the proverbial “ticking biological clock” analogy that women seem to be constantly reminded of, but I cannot say I did not hear it. At my program, no female resident had been pregnant during the past 15  years of my ­program director’s tenure. There was no current precedent or existing culture for maternity leave, and I felt anxious about how my pregnancy and maternity leave would affect my residency training and ability to graduate on time for fellowship, as well as my co-residents’ and attendings’ opinion of me as a “good resident.” Thankfully, I was fortunate to have one of the kindest, most open-minded program directors in existence. Though he was essentially stunned into silence by my revelation, he was supportive and encouraging of the plan I had made. I asked to take maternity leave during my six-week, third-year elective so I could graduate on time and maintain similar surgery numbers to my colleagues since our elective was

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mostly composed of research time and an optional international rotation. My six co-residents were gracious in giving me the first pick of the rotation schedule so that I could put my elective near my due date, and together we devised a call schedule to distribute the amount of call shifts equally. The options for financial compensation during the six weeks of maternity leave were full pay if I used all my sick days and most of my vacation time, or file for Family Medical Leave Act (FMLA) and receive a reduced disability rate. I worked a full shift in our eye emergency room on my due date, then gave birth to my beautiful baby girl, Ruby, four days later. At this time, the Accreditation Council for Graduate Medical Education (ACGME) has no standard approach to maternity leave [1]. This is concerning in the era when there are larger numbers of women than men entering medical school [2]. That medical school, residency, and fellowship training fall during the peak of a woman’s fertility creates a challening scenario for female physicians; women that delay parenthood may encounter fertility and pregnancy complications, and women that do become mothers during training face a myriad of obstacles, the first of which may be negotiating their maternity leave. Without a standard approach at the GME level, for better or for worse, your program director is the main determinant of your maternity leave. The American Board of Ophthalmology requires 36  months in an ACGME-accredited residency to be board-eligible, and states that “If you have taken time off or extended leave for any reason during the course of your training, you will need to make up the missed time in consultation with your Residency Program Chair or Director” [3]. These guidelines obviously leave much room for variability among programs. In a 2009 survey of 27 ophthalmology residency training programs, 40% of females had taken maternity leave during residency. The majority of programs (42.3%) permitted 6 weeks (range 3–13 weeks) before residents were required to make up missed time [4]. If you are unaware of your program’s maternity leave policy or if one does not exist, speak with co-residents in your program or in other programs. Their experience may differ from yours, but it will help you formulate a plan to discuss with your program director. FMLA entitles you to 12 weeks of unpaid leave [5] and will protect your position in the program, but there are only a few states that require employers to give at least partial pay during that time. Additionally, FMLA cannot be taken until the employee has worked a full year so it does not apply to first-year residents. Another option is to use some or all of your vacation and sick days to receive full pay. Preserving some vacation and sick days for when you return to work is desirable and usually necessary with a young child at home. The American College of Obstetricians and Gynecologists (ACOG) describes the standard postpartum maternity leave as six weeks [6], and I believe this is a logical time period to base your discussion around. Everyone feels differently about the right time to return to work after the birth of their child, and there are many factors that influence that choice. The demands and requirements of residency introduce a particularly difficult dynamic into this decision. With no precedent at my program, I asked for six weeks since that coincided with my elective rotation. I took FMLA and received a reduced disability rate offered by

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my university, and my program director generously allowed me to keep my vacation and sick time. The transition from being home with my daughter all day to 12-hour stretches without her was hard. I vividly remember how lonely I felt for her when I cinched up scrub pants around my newly flattened waist, so different now without her in my belly kicking me during cataract surgery. I chose to breastfeed, and pumping enough during clinic, ER shifts or between surgeries was a challenge, increased by the fact that my “designated pumping room,” which your employer is required to provide, was on the seventh floor of the building while I spent most of the day working on the second floor. To get a quick pumping session in, I would sneak into the second floor minor OR room with my back to the non-locking door, rapidly consuming a granola bar while yelling out “just a minute” when someone would try to enter. Without frequent enough pumping, my supply dropped and I started supplementing breastmilk with formula when she was 3 months old and it took awhile for that not to feel like defeat. For me, six  weeks was a reasonable though difficult compromise between my dueling selves: the driven ophthalmology resident that wanted to continue to develop her surgical skills, be a conscientious co-resident as well as graduate and start fellowship on time, and the new mother who felt despair at the thought of leaving her infant child. My co-residents welcomed me back without any resentment for the extra “buddy in-house call” they had covered for me during the first few weeks of July, and I made up my call shifts throughout the year. Coming back after six weeks, I did not feel “rusty,” though I was sleep-deprived, and I graduated with similar numbers of surgery cases and clinical volume as my co-residents. I presented research projects at the American Academy of Ophthalmology (AAO) meeting as well as the American Association for Pediatric Ophthalmology and Strabismus ­conference, and brought my daughter and husband with me to both. One of my favorite photos is of me holding my 3-month-old daughter in front of my scientific poster at AAO in Chicago. I am grateful that I had a supportive program director and co-residents that helped make a difficult journey an overall positive one. I was thrilled when two female residents in our program also had children in the subsequent years after I graduated. They are strong women that charted their own difficult route of motherhood during residency, but I felt that in some small way I had changed the culture in our program to be more open and supportive in this regard. An ACGME-standardized maternity leave policy is needed to normalize motherhood during training, create equal treatment of resident leave across different programs, and ensure completion of residency requirements. Female residents should be permitted six weeks of designated maternity leave without using sick time. The ACGME is clear about clinical and surgical minimum requirements in its mandate for residents to log their case volume each year of residency. When a resident informs her program director of her pregnancy, interval meetings are needed to review these requirements and identify potential areas of deficiency with a plan to address them both pre- and post-maternity leave. If a resident intends to pursue fellowship, there is great impetus to graduate on the traditional academic schedule as to not delay fellowship start, and these residents may feel increased pressure to return early from maternity leave to stay on track. Greater flexibility in fellowship start date and graduation timelines are needed, such as staggered fellow start and

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completion dates. Along with their position in the program, full resident salary needs to be protected during the six-week maternity leave period. Many residents are already under great financial strain from educational debt, and reducing or eliminating salary during maternity leave creates stress and limits resources for the childcare that will allow the resident to return back to training. While pregnant, my husband and I visited a few preschool daycares in our area and decided on one at his university campus. It was close to his office so he could easily pick her up and drop her off, and they offered a great discount to university employees. We placed our names on the absurdly long waiting list, but planned to keep our daughter at home with my mother for the first several months of her life. My mother was semi-retired and lived out of state, but generously came to live in Miami for several months to care for her first grandchild. It is an absolute luxury to be able to have someone care for your baby in your home, be it a family member or nanny. Your child is sick less, there is minimal stress due to transportation, and it lets your child be on their own schedule which allowed things like shifting my daughter’s bedtime so that she was awake later in the evening when I got home and we could spend time together. We transitioned her to daycare at 9 months old, and her teachers there became family to whom we tearfully bade goodbye when we left Miami when she turned age 2. Now being the mother of two young children who attend daycare and elementary school, I am thankful for the socialization and early introduction to learning they have received at preschool. The things I have found important in determining our satisfaction with their daycare is of course compassionate and loving teachers that promote a positive leaerning environment, but also a low teacher turnover rate, administration that treats the teachers well and communicates often with parents, proximity of the daycare to either our home or work, and a small class size. On a resident salary, the cost of daycare is significant but cheaper than a nanny, and many university-affiliated daycares offer reduced rates to resident physicians. There are other creative ways to cobble together childcare, and it may evolve as your child grows. As an attending, I applauded an intelligent solution that a female resident employed after her maternity leave. Her daughter was cared for by the wife of one of her co-residents. It benefited both parties – the wife who was currently a stay-athome mother and happy to add to their family’s income, and the female resident who was assured her child was being cared for by a trusted person that understood the unpredictable and demanding schedule of residency. During training, I frequently questioned if I was actually fulfilling any of my roles: a mother, an ophthalmology resident, a wife. A casual comment by a senior male attending that “it was interesting that I had chosen residency as the right time to have a kid” emphasized my anxiety that colleagues doubted my competence or dedication, and the weekdays and call weekends when I rarely saw my daughter planted seeds of doubt that I was a good mother. I started sharing tidbits of these thoughts with my female attendings who were mothers, and was met with a flood of reassurance and support from strong women I respected professionally and also viewed as “good mothers.” As my daughter grew, I focused on setting aside time to do things alone together. We went on long walks on weekend mornings and did a

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Saturday Gymboree class that we kept up throughout our time in Miami. I initially equated not being constantly present as depriving my daughter of attention and love, but I soon realized that she was getting great amounts of both from wonderful people – my husband, my mother, and later her daycare teachers – and that was okay, that all of it could not and should not come from me. “It takes a village” is an especially appropriate saying that applies to parenting in residency. For me, balancing career and parenthood does not mean that everything is simultaneously in balance. There are weeks or months when one will dominate the other, and you will feel guilt about the one you perceive as being neglected. In residency, you unfortunately have minimal control over your schedule and hours, but the intense time spent learning on the job is finite and invaluable. As an attending, you have more responsibility that carries its own stress, but also the ability to negotiate and dictate your own schedule. For maternity leave with my second child during my first year as a new attending, I took two months off and then worked two days per week for an additional month which made the transition less abrupt than what I had done in residency. There were many times in residency when I assuaged my guilt as a mother by reminding myself that I only had a few years to build the knowledge and skills I would need for the rest of my career, and that my daughter and I had a lifetime ahead of us. I hoped that she would be proud of me and understand the choices I made in pursuing a career that I am passionate about and find deeply fulfilling. My “residency baby” recently turned six, and though she cannot quite yet grasp how much I strive to maintain my feeling of balance between work and my family, I feel affirmation about my choices through the success I’ve had in my chosen profession, the incredible bond I have with both of my children, and my daughter’s most recent career declaration of becoming a ballerina eye doctor.

References 1. Vassallo P, et al. Parental leave in graduate medical education: recommendations for reform. Am J Med. 2015;132:385–9. 2. Glicksman E.  A first: women outnumber men in 2017 entering medical school class. AAMC News. 2017. Retrieved from: https://www.aamc.org/news-insights/ first-women-outnumber-men-2017-entering-medical-school-class. 3. American Board of Ophthalmology. Requirements: medical education and residency training. Retrieved from: https://abop.org/become-certified/requirements/. 4. Perry LJ, Loewenstein J, Loek CE. Resident maternity leave in U.S. ophthalmology resident training programs. Invest Ophthalmol Vis Sci. 2009;50(13):5063. 5. U.S. Department of Labor. Family and medical leave (FMLA). Retrieved from: https://www. dol.gov/general/topic/benefits-leave/fmla. 6. The American College of Obstetricians and Gynecologists. Employment considerations during pregnancy and the postpartum period. ACOG committee opinion. 2018; number 733. Retrieved from: https://www.acog.org/ Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/ Employment-Considerations-During-Pregnancy-and-the-Postpartum-Period.

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S. F. Grace Sara Fransen Grace, MD  grew up in Oklahoma City and attended the University of Missouri-Columbia intent on applying to their prestigious journalism school. Along the way, she discovered a passion for medicine and international volunteer work. After graduating with honors with a Bachelor of Arts in Psychology and minor in Spanish, she attended the University of Oklahoma College of Medicine where she graduated with Alpha Omega Alpha honors. During medical school, she was a leader in the local community health service and volunteered abroad in Nicaragua, Ecuador, and India. She completed ophthalmology residency at the Bascom Palmer Eye Institute in Miami, Florida, and a subsequent fellowship in Pediatric Ophthalmology and Adult Strabismus at the same institution. After fellowship, she became an assistant professor at the University of North Carolina at Chapel Hill for two and a half years prior to joining North Carolina Eye, Ear, Nose and Throat/Duke Health. Dr. Grace is board-certified by the American Board of Ophthalmology. She is a member of the American Association for Pediatric Ophthalmology and Strabismus and the American Academy of Ophthalmology. Dr. Grace is interested in global health and expanding pediatric vision screening and ophthalmic care to areas without existing programs. After volunteering in Nicaragua in college, she established long-term relationships with physicians there and participates in clinical research, teaching, and medical volunteering in the country. Dr. Grace lives in Cary, North Carolina, with her husband, a professor of engineering at NC State, as well as her son and daughter. She reads a lot of fiction novels (and is trying to write one of her own) and enjoys running and exploring new places (especially abroad) with her family.

Chapter 24

Motherhood and Medicine Tracy Kangas

Summary Points • Examine your goals and choose a job with good benefits and flexibility; run your clinic and your household as efficiently as possible. • Choose dependable childcare, let family help, and communicate and coordinate frequently with your spouse. • Set up consistent routines with children and involve them with household chores as soon as they are able; foster independence.

Introduction Integrating profession and family life is a never-ending dance. We each need to find our own balance between career and parenting, but we must be ready to adapt to constant change. We expect ourselves to perform flawlessly at the clinic and take care of everything at home. We have two full-time jobs. Parenthood is a demanding journey and so is medicine. We are on “the border of order and chaos,” as Jordan Peterson would say. We have 1 foot in the known and predictable (order), and 1 foot in the unexplored (chaos), but this is where we can find the most meaning.

T. Kangas (*) McFarland Clinic Eye Center, Ames, IA, USA © Springer Nature Switzerland AG 2021 C. Y. Weng, A. M. Berrocal (eds.), Women in Ophthalmology, https://doi.org/10.1007/978-3-030-59335-3_24

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Goals, Role Models, and Organizing Chaos Let me share my journey with you. Our family moved nine times when I was a kid. My mother packed up six kids and our shepherd and moved us to wherever Dad was teaching next. I went to first grade in three different cities. I was very lucky to graduate from college with a full scholarship in the MD/PhD program at the Medical College of Wisconsin. Mom, my role model, graduated later and became CEO of 600 employees at Genesys Home Health. Mom thought work was easy compared to organizing our family. When we become parents or physicians, we are projected into an ever-changing future. We must keep abreast of it. Our ability to deal calmly with change provides security and reassurance to those around us, both our family and our patients. My college beau and I started medical school in Milwaukee, but he quit during the first year. We were engaged. He asked me to give up my scholarship and return with him to his hometown. I sent him home alone. I could not afford to relinquish my scholarship. Change comes. Adhere to your goals.

Choosing a Mentor Fine mentors are jewels. Treasure them. I chose my PhD mentor by asking grad students about their experiences. Joan Macdonald beamed when she described Dr. Henry Edelhauser. He developed the BSS Plus solution used in cataract surgery. He was a powerful communicator, well respected by both clinicians and scientists, and a great connector between them. He directed lab research to solve clinical problems. He became my role model. Search for a mentor with values that correlate with your own. Dr. Edelhauser had integrity, humility, and an energetic work ethic. He managed time well, including time with his family. I have been blessed with many other fine mentors. The book Tribe of Mentors at my bedside is a collection of writings by inspirational people.

Training and Starting a Family I had no intention of falling in love during a busy internship. Christian Ledet was a tall, capable flight surgeon. He asked me to fly with him over the Mississippi River. I told myself, “Don’t even consider getting serious about this man.” Christian transported all my furniture from Wisconsin to Atlanta, then hauled it up three flights of stairs in the July heat. My heart melted along with my candles. During my ophthalmology residency at Emory, I was the only female out of 15 residents. When Christian came to my graduation, my roommates asked him for identification. “We thought Tracy just made up a boyfriend since we never saw you.” Vitreoretinal surgery fellowship at Bascom Palmer Eye Institute was pure delight. The enthusiastic, positive attitude towards learning was infectious. I contemplated

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staying there to do research, but Christian was doing anesthesia residency in Iowa. I joined a busy retina practice in nearby Chicago. After 6  years of a long-distance relationship, I married Christian in 1997. He secured a pain fellowship in Chicago and moved into my apartment downtown. I loved the city; he hated it. He was offered a job at a large clinic near his parents’ home in Iowa. McFarland Clinic in Ames, Iowa, needed a retina specialist too. The clinic had great health insurance, life insurance, disability insurance, and an excellent retirement plan. Scrutinize these benefits. They matter. After we moved to Iowa in 1998, I had a miscarriage. I was devastated, childless at 36 years old. By 2000, my biological clock was ticking loudly. I inquired about fertility treatments. One day I walked into Christian’s office with an ultrasound of three tiny babies, and his face went white. “Triplets!” I was placed on strict bed rest. Three 5-pound healthy baby boys were born on April 3, 2001. The clinic insurance paid for everything, including 11 days in the neonatal intensive care unit. I was also paid short-term disability while I was on bedrest.

Choosing Childcare Let family help with childcare when they can. Our capable mothers anticipated our needs and those of the babies. We recorded feeding times as I breastfed babies and supplemented with formula. We worried that one son would get fed twice, and another not at all, so we painted babies’ toenails distinctive colors to identify them. We found nannies through online services and friends. I hired two, one for weekdays and one for weekends. I also hired a corporation to file nanny taxes. When hiring a nanny, or any employee, look for integrity and values first. We wanted reliable, punctual nannies that loved our children, and they did. In 2002, I miscarried again and got the “baby blues.” My mother-in-law suggested I go back to work.

Pay Attention to Benefits I joined outstanding colleagues at Iowa Retina in 2002. However, since I was not full-time, I was not able to participate in their health insurance or retirement plan. I did not think I needed to discuss maternity leave with them. Silly me! Christianne was born on September 24, 2004, just before my 42nd birthday. I returned to work 3 weeks later, using vacation time for maternity leave. I lugged my cumbersome breast pump to Iowa Retina and pumped breastmilk in a stall in the communal ladies’ restroom. Look for a pleasant nursing room in your clinic. In 2005, Dr. Phil Rosenfeld presented his outstanding work on treatment of exudative age-related macular degeneration with bevacizumab. We were awed: an untreatable disease had become treatable. Soon retina specialists became very busy doing intravitreal injections. I made the difficult decision to give up retinal surgery

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and focus on intravitreal injections in the clinic. My ego wrestled with my practical desire to make life simpler. The latter won.

Building a Home In 2005, we built a home near Christian’s parents. Building a house is time-­ consuming, and it costs 20% more than buying one. The multiple decisions involved likely lead to marital discord. Nonetheless, residing next door to Christian’s parents and their acreage enabled us to roam woods, swim in their pond, and appreciate nature. Christian’s father had planted 40,000 trees on his land. Our children grew up next door to wise and loving grandparents. As our kids outgrew the nannies, Grandma Jo and Papa Arlo made them supper on nights when we worked late. If you can live close to family and nature, do it.

If It Does Not Work, Fix It By 2010, Christian was unhappy with his job. Two busy physicians with four small children have little time to communicate. We started marriage counseling; it was a good decision. During counseling, we could converse uninterrupted, which we could not do at home. We understood and appreciated each other again. Do not avoid counseling if you need it. We did not learn to negotiate in medical school. Do not assume your spouse is a mind-reader, or that you are. In 2013, Christian quit his job at a large orthopedic clinic. He spent a year at home with our children as he laid plans to create a Pain Center of Excellence. He would have no salary or benefits for a while. I had no benefits either. I was driving 35 miles each way to Iowa Retina, and unable to attend the kids’ dance, band, and sports activities. I quit Iowa Retina and returned to McFarland Clinic. I had health, life, and disability insurance, and a great retirement plan again. I had autonomy to design my schedule and my practice. In between jobs, I visited with my 39-year-old Brazilian friend Christianne who was dying of breast cancer. She left behind three small boys. She gave me an unforgettable appreciation for our own good health and future. Time is our most precious gift. Do not waste it.

Managing a Business and a Household Before you undertake the overwhelming tasks of organizing your business and your household, set long- and short-term goals. What is most important to you and your family? How does every event on your calendar help you achieve your goals? Eliminate unnecessary activities that are not congruent or supportive of your goals.

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We review goals on New Year’s. A large wall calendar helps us synchronize events. We interface call and school schedules first and add reminders to our phones. Getting and staying organized is imperative to both your business and your household. At work, others may, “Manage cash, manage time, manage people.” Be proactive about managing your time, though. We found Six Sigma and Lean concepts were useful for improving process efficiency in the clinic. Map patient flow through your clinic. Maximize patient outcomes and patient satisfaction. Maximize profit so you can stay in business. Minimize things that waste time, footsteps, or resources. Work at your highest level, and delegate other tasks. Maximizing efficiency in the clinic helps you get home to your family. Additionally, improving process efficiency helps organize work at home, including meal planning and preparation and family schedules. Delegate tasks you detest to outside services. Encourage children to participate in laundry, cleaning, and meal preparation as soon as possible. Let kids help clean floors and bathrooms, and mow lawns. They also had daily chores raising chickens and sheep. We paid children after jobs were performed rather than a regular allowance. Cleaning will be easier if you minimize your belongings. Get rid of clothes, shoes, and toys that kids have outgrown. Sort mail and toss it daily. Buy less stuff. Cluttered spaces beget cluttered minds. They distract. Each object should have a “home,” so kids know where to put it away. Both parents and children should have a designated quiet “homework” space without clutter.

Raising Toddlers Children are more capable than we assume. Our 1-year-old boys colluded to push an ottoman up to the baby gate, then climbed it and escaped. At 2 years old, Tom climbed a 6-foot fence and let his brothers out of a porch that I thought was Alcatraz. Horns honked as three naked boys ran into the street, and I sprinted to collect them. We need to supervise children and keep them safe. But, as kids get older, interfere less. Kids learn self-esteem by solving problems. They build confidence from achievement through hard work. Do not take that from them. Praise their efforts. Maria Montessori proposed that children do not “play”; they “work” like adults do. Play time and role-modeling prepare children to work. Humans are most fulfilled when they are absorbed working on a meaningful task. We are busy professionals and want quality time with our kids. However, we cannot use this as an excuse to withhold discipline. Children need boundaries. You are the cultural ambassador entrusted with teaching your kids socially acceptable norms. If you do not, children are deprived of their ability to function successfully in society. If a child does not learn how to share, make friends, and be socially acceptable by age 4, he will have a hard time maintaining friendships in adulthood. Set up consistent routines for meals, chores, and bedtime. Children learn better with predictable routines. Tantrums occur most often when they are hungry or tired. Be gentle, firm, and consistent. Use positive rewards for good behavior. Withdraw privileges for bad behavior. Praise in public and admonish in private. Catch them doing something good and acknowledge it.

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Getting Along Watch children unobserved. One hot summer day, Ryan was taunting his brothers mercilessly. Next, I saw Erik holding down Ryan while Tom sprayed the hose on him. Ryan laughed as he got his just punishment. I did not have to interfere. One February day, Ryan and Erik fought constantly. I vowed to separate them. Instead, Christian put them into the wilderness together for the night by themselves. He dropped them off with one tent, sleeping bags, and food. I was horrified. They were 12. It was cold. The next morning, they were so proud that they had exhibited their survival skills together. Fighting was forgotten. Siblings often behave differently for parents than they do with each other. Do not assume you know what happened. Listen to children first. When the boys were 6, I found the words, “My name is Ryan” carved into our new bamboo floor. Ryan was not the guilty one. His brother had done that to get Ryan in trouble. A well-meaning friend gave the boys an X-box. I noticed more fighting and tension among them. I threw away the X-box. (I actually smashed it in the garage.) Our kids played outside again.

Raising Teenagers Sleep is incredibly important for children and parents. The book, Why We Sleep, changed the way we parent. Sleep is essential to the developing brain for learning, memory, and emotional balance. Sleep deprivation invites chaos. Do not try to discuss issues with a sleep-deprived teen (or spouse.) Wait until they are rested and fed. All our kids ran cross country, and they slept better after physical activity. Teens need to work and manage money. When our teens wanted non-essential clothing, they paid 50% of the cost. This ensured that they searched for the best deals. I watched them return several online purchases, because they realized the item was not worth their money. We were happy to let teens host parties at our house so we could meet their friends. We knew where they were, and what they were doing. The boys were exceptionally motivated to clean the house before girlfriends arrived. I met each new friend at the door, made eye contact, and shook their hand. Let teens take responsibility for themselves and learn from consequences. One son flipped the Toyota into a ditch on an icy road. He bought car panels off the internet to fix the car himself. He replaced the steering mechanism by watching You Tube. It worked. Discover where and when teens need guidance before you speak. Mentors are supposed to spend 80% of time listening to the mentee and 20% of time talking. This is also applicable to teens. Listen first, then talk. Children are amazingly resilient. They need to know you love them, but they also need discipline and guidance. Teach by example. They may not listen to you, but they will watch and imitate you perfectly. You are always onstage.

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Conclusion There is no one recipe for balancing parenting and career. Choose a job where you want to live with good benefits and a flexible schedule. Communicate and coordinate with your spouse. Pay for reliable childcare and let family help. Organize your household and your schedule as efficiently as possible, so you can spend meaningful time with your family. Set predictable schedules for children, especially for meals and sleep. Encourage hard work. Discipline them. Let consequences of their actions drive them to improve. Stay calm with teenagers. Encourage healthy diets, exercise, and sleeping habits and protect your own. Prepare children to be independent and self-reliant, and you will be amazed at the adults that emerge.

References 1. 2. 3. 4. 5. 6.

Crouch, Chris. Getting Organized (Memphis: Dawson Publishing, 2005). Ferris, Timothy. Tribe of Mentors (New York: Houghton Mifflin Harcourt Publishing, 2017). Gygi, D., Williams, B. Six Sigma for Dummies (Indianapolis: Wiley and Sons, 2005). Morganstern, Julie. Organizing from the Inside Out (New York: Henry Holt and Company, 2004). Peterson, Jordan. Twelve Rules for Life (Canada: Penguin Random House Books, 2017). Walker, Matthew. Why We Sleep (United Kingdom: Penguin Books, 2018). Tracy Kangas, MD, PhD  is a retina specialist practicing at McFarland Clinic in Ames, Iowa. She is married to Dr. Christian Ledet and has triplet sons in college and a 15-year-old daughter at home. She completed her MD and PhD at the Medical College of Wisconsin, and her ophthalmology residency at Emory University. She received a Heed Fellowship to train in vitreoretinal surgery at Bascom Palmer Eye Institute. Prior to moving to Iowa, she was employed at Retina Consultants in Chicago and Retina Center of Illinois. She worked at Iowa Retina Consultants then at McFarland Clinic. In 2018, she completed a CTI Physician Leadership Fellowship. She is Director of the Mentorship Program of Women in Ophthalmology. She enjoys gardening, planting trees, and learning new things from her four teenagers.

Chapter 25

Professorship and Parenthood Sharon D. Solomon

Summary Points • There is no other job that trumps being a mother to one’s children. • It takes a village: The resident, fellow, technician, scribe, study coordinator at work; the nanny, relative, supportive spouse at home. • Enjoy all stages of the journey. Being a parent is a privilege. Being a physician is a privilege.

The two most important days in your life are the day you are born and the day you find out why. — Mark Twain

If, like me, you are a first-generation American of West Indian ancestry whose core family value was education above all, then, of course, you knew that you wanted to be a doctor before you started kindergarten. In reality, the dream of becoming a doctor is one that is shared cross-culturally by the offspring of many immigrant families coming to America. However, a career in medicine is not a good fit for everyone. While there is no other profession that enables an individual to improve the quality of life for her fellow man more than the practice of medicine, the sacrifices along the way are many. Gratification, in terms of a sense of accomplishment from finishing one’s education and starting a career, settling down and starting a family, and achieving financial independence, is definitely delayed. Even more challenging than becoming a physician is achieving the work-life balance that feeds the mind while sustaining the soul, ensuring a productive career and a happy home life.

S. D. Solomon (*) Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore, MD, USA © Springer Nature Switzerland AG 2021 C. Y. Weng, A. M. Berrocal (eds.), Women in Ophthalmology, https://doi.org/10.1007/978-3-030-59335-3_25

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As Mark Twain once said, “The two most important days in your life are the day you are born and the day you find out why.” For many of us, the “why” gradually revealed itself during our years of medical training when we chose ophthalmology as our field, perhaps focusing on a particular sub-specialty. For me, the day I assisted my vitreoretinal attending and caught my first three-dimensional glimpse of the retina while stabilizing an AVI lens on the cornea, it was love at first sight! The “why” was completely apparent when I embarked, as an assistant professor, on the tripartite mission of research, teaching, and patient care – the challenge of academic medicine. In any moment of decision, the best thing you can do is the right thing, the next best thing is the wrong thing, and the worst thing you can do is nothing. — Theodore Roosevelt

So, the years of training are behind you. The university website shows your impressive credentials. To the public and to your private practice colleagues, you are now the world’s expert in your specialty. Meanwhile, you are trying to figure out transportation for your kids from school to their pediatrician appointment, finish clinic, head to surgery, and reschedule your research meetings- all while you really just want to meet up with them to assume the role of mom. Did I forget to mention that both your grant, the Holy Grail for protected time and academic promotion, and your child’s history project are due tomorrow? There will definitely be days when you ask, “Why, oh why, did I go into academic medicine?” Relax. Take a deep breath, and realize that first things are first. No matter how biased, sexist, and inappropriate it may seem in the twenty-first century to say that your kids only have one mother and that being a mother is really your most important job, I will say it because it is true. Being on bedrest with my twin boys for 3 months so that I could give them the best chance of a healthy arrival into the world, followed by a 3-month maternity leave, seemed, at the time,  like a huge set back to the momentum I had built early in  my academic career. However, there were a dozen other qualified faculty members in the retina division who, for better or worse, absorbed my clinical and surgical practice, leaving me in a position, post-­maternity leave, of having to not only get my research projects back on track but of having to simultaneously start from ground zero in again building a clinical practice that would generate surgery and serve as a source of recruitment for my clinical trials. The reality was that Wilmer survived without me. I was not the cornerstone. As a faculty member, I was dispensable. However, I was then and remain now indispensable in the lives of my sons. At a seemingly critical time in my career, while still overcoming the gravitational drag of making the transition from trainee to world expert, I made the right decision to do what was best for my children and for my family. That decision has made all the difference. Now, let us get back to the current challenge at hand – the struggle to balance the competing interests of meeting the real deadlines that affect your children’s well-­ being and the ones that affect the viability and ultimate success of your career in academic medicine. Here, I would remind you that your medical training did not only prepare you to be an excellent physician and ophthalmologist, it trained you to

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be a proficient multi-tasker who can prioritize, delegate, and, if necessary, forgo sleep for the short term to get the job done. So for the 3 months that I was on strict bed rest, not only did I delegate the work that had to be done in terms of preparing the boys’ nursery, researching pediatric practices, and getting them on the interview list for competitive pre-schools (remember– West Indian core value of education), but I also kept my laptop on my belly and wrote review articles for publication, feasting on “low-hanging” fruit for academic promotion. Once my boys, Ian and Aidan, arrived – full-term and healthy – I wasted no time in getting a loving nanny onto the home team. There was ample overlap between the nanny starting and my returning to work so that she could see what my expectations were on a daily basis with respect to caring and interacting with the boys. I could also monitor her behavior and make sure that she was a good fit for my family prior to my returning to a hectic work schedule, avoiding having to change nannies because of mismatched expectations. I was fortunate that I also had a mother who was willing and able to spend time with the nanny during the day for a few weeks even after I returned to work to make sure that everything remained on-track. While we are on the subject, you may wonder why we chose a nanny as opposed to an au pair or placing our children in day care. Like anything in life, there are pros and cons. As a busy retina specialist with long clinic days and an unpredictable surgery schedule, I did not want the added pressure of having to be concerned about drop-off and pick-up times each day. My husband is incredibly supportive – a huge bonus – but also has a very demanding career with late meetings and travel. Knowing that the boys did not have to be awakened and dressed in the winter for early drop off before a 7:30 AM surgery was almost as comforting as knowing that I could allow the retina fellow to appropriately participate in a complex retinal detachment without having to consider that I needed to be done in the OR to pick-up the kids at a certain time. I did have a number of colleagues who went the au pair route; however, the quality of care for their children, by their own accounts, varied widely. A good au pair could only stay with the family for 2  years, and it sometimes took weeks to replace a suboptimal au pair – not ideal when work is in full swing. Managing and surviving the transition from maternity leave back to a busy clinical practice and academic career is not easy, but I think it is the most challenging part of the entire journey. Again, I believe the key to a successful transition is having a reliable team in place that you can envision keeping on board for the long haul, as the children grow and as their needs evolve. You, as the mother, are the head of that team. Between you, your hopefully supportive partner, and the attentive caretaker, the children should be enveloped by an environment of love and attention (Fig. 25.1). As my boys have grown and have developed schedules of their own, I make it a point to be involved in all facets of their weekly routines. For instance, on days that I have to work late, I arrange my schedule so that I can spend time with them in the morning and take them to school. If there is an occasional administrative or research day when I finish early, I pick them up from school and shuttle them to their after-­ school activities  – perhaps, stopping at a café for a treat and to spend some time together. Fortunately, the school they attend is really good about providing a very

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Fig. 25.1  Ian (left, age 3) and Aidan (right, age 3) on a merry-go-round with me

detailed calendar during the summer for the subsequent academic year. I go through the schedule meticulously, adjusting my clinic and surgery schedule in such a way that I am able to attend every concert, every recital, every parent-teacher conference, every Halloween parade, and to even volunteer for classroom events. My kids see that I am involved in their lives, despite my demanding career. They know they are my top priority. We all do our “homework” together in the evenings. I show them the slides that I am preparing for my next meeting or the stack of applications that I have to review for a committee. They often come to my office and read or do their homework if I have to be at the hospital over part of the weekend. At an early age, my boys seem to understand that I am supportive of their work and activities, and they are supportive of mine. Rather than feeling excluded because of the demands of my academic career, my boys are very much involved in the activities that would otherwise “take me away” from them when I am home. So, finally, let us get back to your grant and to your child’s history project that are both due tomorrow. Well, with the support structures that have been put in place, there really should not be a problem. You may get less sleep that particular week, but everything should get done. From the time you navigated your way from maternity leave back into the academic arena, you should have been relying on your support team and delegating tasks when appropriate. If you did not have the time to personally shop for project supplies at least two weekends in advance, then your supportive spouse or loving nanny should have already struck those items off the “to do” list for you. (If you did not know about the project in the first place, then you might want to encourage your child’s school to increase communication directly with parents.) While your child was working on his project in the evening and on weekends, you should have been available for assistance but primarily working on putting the finishing touches on your grant. He would be used to a paradigm where you are both doing your homework near each other. In a nutshell, proper planning, with mom at the helm, prevents poor performance. “When the going gets tough, the tough get going.” -A mother in academic medicine, of course!

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Succeeding in academic medicine requires the same skillset that you used to achieve success at every stage of your training and career to this point. In addition, you need to identify pretty early on in your field what niche or research focus is so appealing to you that you want to build an entire career around it. Then, you just pace your productivity. There will be times when you have to ramp up your productivity to meet your academic goals and deadlines, and there will be times when you have to ramp down in order to meet your familial obligations and to be there for your children. The following is a list of tips and tricks that I have found helpful in achieving balance over the years: • Lights out: When the boys were little, my husband and I would read to them at bedtime and then sometimes all go to sleep in the same room. Fortunately, we were able to configure their room to accommodate this. It lent time to cuddle, decompress, and just spend time together as a family. I, quite frankly, often found the early bedtime a welcome charge to the system that then  enabled me to ­wake-­up in the very early morning hours and get a tremendous amount of work done in a completely peaceful environment. • Less is more: During the first few weeks following maternity leave, I found that my least stressful days were my OR days because I would wake-up and know that I was slipping into a clean pair of scrubs – very simple. I did not have to think about accessories, dry cleaning, ironing, etc. I finally asked myself, “Why should I have this feeling of relief only one day each week?” Since then, I have worn scrubs to work every day – for clinic, for surgery, for research meetings, for committee meetings, all the time. I have different colors and different styles. They are comfortable but still professional and keep me warm in the winter and cool in the summer – the perfect clothing. • Are we there yet?: I am not a fan of having the boys miss school; however, whenever there is an academic meeting I plan to attend that coincides with their vacation schedule, I make the meeting a family affair. Again, I am fortunate to have a very capable and supportive spouse who can handle the kids on his own. Exposing the kids to new surroundings and cultures is educational for them – school away from school. In addition, they get a first-hand sense of the other facets of my job as an academic physician (Fig.  25.2). My boys have a better appreciation for what I am doing during the times that I am abroad for a meeting and not able to take them with me. • It takes a village: I cannot emphasize enough how fortunate I am to have a supportive spouse. My husband is not only a great father, but he is also a great listener and sounding board for the challenges that inevitably arise during an academic career. He sincerely wants to see me succeed. It is important for children to see that their parents not only support each other with issues at home but that they also respect and support each other’s careers (Fig. 25.3). I hope in this way that my husband and I are modeling behavior that will help our boys have healthy and fulfilling partnerships later in life. As you publish the papers, do not neglect to put out the pumpkins. — Sharon Solomon, MD

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Fig. 25.2  Ian (left, age 7) and Aidan (right, age 7) playing at the podium the day before I gave an inaugural named lecture at the University of California, San Francisco (UCSF)

Fig. 25.3  Aidan (left, age 10) and Ian (right, age 10) joining me in front of the Maryland General Assembly where I received citations for becoming the first person of African descent to be promoted to full professor in the history of Wilmer. Also in the photograph, from left to right, are Dr. Peter McDonnell  (current  chairman of Wilmer), Senator Shirley Nathan-Pulliam, Dr. Morton Goldberg (emeritus chairman of Wilmer), Dr. Basil Morgan, Monica Solomon (my mother), and Li-Wen Kang (my supportive husband)

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Sharon D. Solomon, MD  is the Katharine M. Graham Professor of Ophthalmology at the Wilmer Eye Institute. A retina specialist and board-certified ophthalmologist, Dr. Solomon’s clinical expertise includes medical and surgical treatment of age-related macular degeneration, diabetic retinopathy, epiretinal membranes, macular holes, and retinal tears and detachment. Dr. Solomon has a large national and international referral practice at Wilmer. Dr. Solomon is a member of the prestigious MillerCoulson Academy of Clinical Excellence at Johns Hopkins. Dr. Solomon has served as principal investigator at Wilmer on a number of NIH-sponsored clinical trials. She has numerous publications from her clinical trials involvement. She serves on the editorial board for the journals Ophthalmology and Ophthalmology Retina. Dr. Solomon is a recipient of the American Academy of Ophthalmology (AAO) Secretariat Award for her service to this organization. She currently serves as the chair of the Retina Subcommittee on the AAO’s Annual Meeting Program Committee. Dr. Solomon received her bachelor’s degree in Biochemistry from Harvard University and her medical degree from the University of California, San Francisco. After her internship at Stanford, she returned to UCSF for her residency in ophthalmology. Dr. Solomon completed her surgical retina fellowship at the Wilmer Eye Institute prior to joining the faculty.

Chapter 26

Balancing Academic Career and Parenthood: Ten Thoughts and One Bonus on Success Carol L. Shields

Summary Statement • The balance of academic career and parenthood begins with you. • Be a supporter at work and a Mom at home. • Family comes first – always – and having a little humor can help.

In medicine, we are fortunate to have a remarkably challenging, yet satisfying, career, and, at the same time, some of us are blessed with a family. How do we balance this? When to favor academics and when to “chill out” with family? Every day, every minute, we make this choice, as tiring and confusing as it might be. Each of us has a different approach to balancing a high-level career of academic medicine with the duties of familyhood. In this balance, we seek to find a peaceful combination of the two with as little deficit from either. We seek the perfect balance. Over the years, I have watched, read, and audio-listened to advice from a variety of authorities on this topic. Now it is my time to share with you my secrets in this precious, sometimes fragile and more times stoic balance. I must admit, most of my scientific writings are crisp and calculated, with p values, Kaplan-Meier estimates, and survival outcomes emanating from my brain. Now, in this free-thought essay, my writing is personal, thoughtful, “warm and fuzzy,” coming straight from my heart. You can hear my heartbeat in this prose – and you do not need a stethoscope. Below are some of my philosophies on balancing academia with parenthood. This is my recipe and it requires a cup of organization, a dash of confidence, a teaspoon of belief in self (self-esteem), a tablespoon of belief in others (collaboration), and a gallon of love for family. And a pinch of humor.

C. L. Shields (*) Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, PA, USA © Springer Nature Switzerland AG 2021 C. Y. Weng, A. M. Berrocal (eds.), Women in Ophthalmology, https://doi.org/10.1007/978-3-030-59335-3_26

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Thought #1. Follow your heart. Things happen for a reason. It seems like I have been balancing my life forever, even as a child, as I enjoyed school, sports, art, music, and friends. So over the years, I have felt pretty comfortable multi-tasking my endeavors. As an adult, my balance of career and home officially began in 1984 when I arrived at Wills Eye Hospital, four decades ago. My intention during residency was to gain the best possible skills for the practice of ophthalmology. I was focused and determined. Then, I learned my first lesson and this arrived unnoticed when I met my future husband, Jerry A. Shields. We fell in love, I followed my heart, and we were married. Then my world unfolded. Soon I was a doctor in the field of ophthalmology and subspecialty-trained in ocular oncology and pathology with the intention to care for patients clinically and surgically and explore major scientific research topics, but this was all balanced with our soon-to-be growing family of seven children. None of this was planned. This just happened. As I look back, this was the best direction I could have taken. Follow your heart. Thought #2. It begins with you. The delicate balance of career and parenthood begins with you knowing and wanting to develop these two major aspects of your life. Each is different, with the former more focused on scientific aspects, and the latter more directed to humanitarian concerns, but there is overlap. While at work, focus on academics to the fullest. Avoid distractions, complaints, or negative advice. Be strong, positive, and believe in yourself – after all, look at what you have accomplished. Find a similar colleague at work and ally your careers. While at home, be mom. Try to arrive home in time for homework, a quick dog walk with the children, and preparing the family dinner together. We always lit a candle at dinnertime to signify “family time” and the entire family took a seat at the table. For me, dinnertime was a time to talk, show interest in each other, and make decisions and plans. This gave our children time to inquire and simply spend valuable moments with the parents. At dinner, I was Mom, despite the fact that I had worked a heavy-duty day at the office or in surgery. In fact, being Mom was relaxing, most of the time. Balancing these two aspects requires two hats – the doctor hat and the Mom hat. Thought #3. Be a supporter at work. While at work, get involved, but do not let work duties traipse into evening hours. That time is reserved for family. I kept my career day fully busy, volunteering to help during my work hours, but never after – as that infringed on my family time. I was a “12 hour” worker while at work, and then a “12 hour” Mom while at home. At work, it is important to be a team player and support coworkers. Avoid the traps of never-ending complaints, planning your “easy way out,” or passive-­ aggressive moves. These are losing ways to run a business. Be confident, strong, pleasant, agreeable, helpful, and roll up your sleeves during the work hours to get the job done (Fig. 26.1). You will be appreciated and rewarded with good salary or bonuses and potentially time off when you need it. Contribute, participate, and carry the corporation forward, for a common goal. Work is not about you, work is about

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Fig. 26.1  The surgical team at Wills Eye Hospital Ocular Oncology Service including two staff physicians, Sara E. Lally M.D. (SEL) and Carol L. Shields, M.D. (CLS)

your team succeeding in patient care, so know your role and make it happen. You will be much appreciated. And then, when you need the afternoon off to watch your daughter’s lacrosse match (which you should always do), your colleagues will graciously give you the time due to your dedication. It is that simple. Thought #4. Be a Mom at home. I have always loved being “Mom.” From the conception to the exciting birth of a child, I was overwhelmed with pride and happiness. From kindergarten graduation to college matriculation, I would shed tears of joy. Each step in child-rearing has been interesting, sometimes challenging, occasionally exciting, and filled-to-the-­ brim with satisfaction and happiness (Fig. 26.2). When at home, put the cell phone and computer away. Emails can wait until your child duties are done. And actually, office email can wait until you are back in the office. Each moment spent with your child impresses on him/her a sense of self-­ importance and security. Review his/her homework or project. Avoid stress or interruptions as every twinkle of anxiety in a parent is magnified in the child. Be calm, enthusiastic, happy, supportive, and even add some humor to the scene. My workday is busy. However, I crunched the schedule so that I could make most of our children’s afternoon/evening sporting events, high school plays, after-­ school science presentations, and other relevant items. In fact, I would incorporate this into my office schedule so that the technicians understood that I must be heading out by 3:00 to make the 3:30 game. I weighted my schedule towards early morning, starting at 6:00 am in clinic so that most of my patients were done by 2:00 pm and I could make afternoon school events if necessary. “The early bird catches the worm” way-of-thinking was my driving force. Having a parent show up at an event

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Fig. 26.2  The Shields family at Christmas 2018

shouts support to your child and instills reams of self-confidence. And do not forget to bring a tele-photo camera lens to record the events in real time. Thought #5. Be happy. During life, we make choices that generally are intended to provide happiness. The word “happy” is derived from middle English from the root noun “hap” which means “lucky.” By definition, “happy” means “contentment, satisfaction, and sense of confidence.” In the book, The How of Happiness, it is written that happiness is 50% genetically determined (based on twin studies), 10% affected by life events, and 40% dependent on self-control [1]. Humans are happiest when they have pleasure, satisfying interpersonal interaction, social relationships, life meaning, and accomplishments. So, knowing this, we are partly in control of our happiness, and this rests on several points regarding ourselves, our friends and family, and our career. Thought #6. Organize your day: Take hold of the steering wheel and make your own turns. Early on, I was confident in knowing my direction and goals as a doctor and steering my life. I sought a challenging career and a satisfying family life. As a doctor, I have tried to achieve the “5 As” of doctor success, including availability, affability, ability, and my own two personal business-related traits of affordability and accountability. These traits allow for a friendly and accomplished physician who, at the same time, is responsible to the business. Our office opens early so that all patients are seen by 2:00 pm, in time for us to finish our mail, email, and other communications at a reasonable hour, so that all gets done in a single day. Then we head to home to join our children for dinner. Our patient hours begin at 6:00  am, often

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seeing up to 50 new patients on a “new patient day” and over 80 patients on a “follow-­up patient day.” Our technicians appreciate it too as it allows them to start early and get home in time for their children. Some patients even arrive for examination in early morning, and then go to their own employment (dilated) – same day. There is a cool book on What the Most Successful People Do Before Breakfast [2]. This book focuses on making mornings the highest level of meaningfulness. Morning duties often open up afternoon trenches and allow us to better control each day. Thought #7. Heal thy patient. Our primary goal as a doctor is to heal our patient. There are seven skills that make a doctor successful in his/her practice including (1) Think about the patient’s health before you enter the office, (2) Develop comfortable rapport with the patient, (3) Assess the patient response to illness, (4) Communicate effectively with the patient, (5) Use the power of touch, (6) Insert humor if possible, and (7) Show empathy and sincerity [3]. These points build confidence with the doctor-patient relationship and can help with patient healing. I would like to emphasize point #5 – the power of touch. There is a general medical reservation to shake a patient’s hand upon entry into a room for fear of passage of germs, but I tend to wash hands prior to entry into the room so that I can shake hands. Also, on exit of the room, I typically tap the patient’s knee with a nod that all is or will be fine. This is a neutral tap and I believe this transfers the human, caring side of the doctor to the patient. Thought #8. In an academic career, organization, efficiency, commitment … and a good mentor helps. In academics, you must be the ultimate doctor and researcher. Find a reliable mentor and learn from him/her the “ropes.” It is not always easy, but I guarantee you that it is rewarding. When young, put in time to organize all the interesting cases you experience, keep a log or coding system so you can review your series and find trends. As you gain experience, this database becomes immensely valuable in your research. Take good notes, make detailed observations, and record, record, record on the chart. Knowing how to construct a reasonable research question, then create a useful flowsheet, work with students to assist in entering data, create tables with statistical relevance, and then build a publishable report is a magnificent work of art. This is learned only by experience with a reliable mentor. A mentor will share his/her knowledge with you, but you must provide reliability and loyalty back. Thought #9. In an academic career, you must be honest. Honesty is everything in academics. A publication with no complications is not believable. A report with 100% control is hardly fathomable. Be honest and list your outcomes with true values. “Touching up” numbers or outcomes will be easily detected. Your reputation depends on each and every patient you care for and report that you publish. Keep it clean – always. Thought #10. Family comes first – always. And Erma Bombeck humor helps. As Mom, the duties, worries, achievements, frustrations, and happiness multiply as your children grow. Mom and Dad should always be a united team, with the same goals. Family traditions and rules are essential. We enjoy dinner by candlelight every night with all family members present – this builds camaraderie. Additional

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family time with bike riding, skiing, tennis, frisbee, gardening, painting classes, and “you-name-it” has been done in our family and downright enjoyed. Even watching an evening movie together is time well spent. I have learned some humorous things over the years that have carried my husband and me with levity. Here I relay a few to you and these include some concepts that I believe are true including the following: (1) nothing is perfect, (2) it is ok if socks or even shoes do not match – no one will notice, (3) the house will never be as clean or organized as you want it, until the kids grow up and leave, (4) if Mom is too busy to hem your dress, then staple it, you might set a fashion trend, (5) provide a good personal example, and (6) always give thanks. Beyond me, far beyond me, is the comedian/writer Erma Bombeck from the 1970s. I have read and enjoyed her numerous newspaper columns and published books. She offers a glimpse of the comical side of life and does not take life too seriously. Bombeck provides light-hearted tips for parenting including: do not lose your sense of humor, follow your dreams, worry is fruitless, guilt comes with the territory, and eat dessert – that is, just sit down and enjoy it. Her happy-go-lucky attitude is a great lesson in life values. Her often-ridiculous advice causes me to smile and occasionally chuckle out loud. Her writing is therapeutic. She believes that laughter is the greatest revenge. Bonus thought #11. If I had my life to live over… Erma Bombeck was asked late in her life what she would do differently if she had her life to live over again [4]. Initially she did not respond. After some thought she initiated “I would have invited friends over to dinner even if the carpet was stained and the sofa faded,” “I would never had insisted the car windows be rolled up on a summer day because my hair had been teased and sprayed,” “I would have listened more to my grandfather ramble about his youth,” and “When my child kissed me, I would never have said, ‘Later. Now, go get washed up for dinner’.” She added that there would have been more “I love yous … more I’m sorrys … more I’m listenings” and most importantly she indicated that she would look at life and really see it, try it on fully, live it, and exhaust it. I live the Erma Bombeck philosophy. Live life to the utmost, be happy and proud, and enjoy every day. You are in charge of your life, so take that steering wheel and cut your path. How lucky we are to be gifted the distinction to experience life with career and family.

References 1. Lyubomirsky S. The how of happiness. A new approach to getting the life you want. New York: The Penguin Press; 2008. 2. Vanderkam L.  What the most successful people do before breakfast. New  York: Penguin Publishing Group; 2012. 3. Egnew TR.  The art of medicine: seven skills that promote mastery. Fam Pract Manag. 2014;21:25–30. 4. Bombeck E. Eat less cottage cheese and more ice cream: thoughts on life from Erma Bombeck. Kansas City: Andrews McMeel Publishing; 2003.

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Carol L. Shields, MD  completed her ophthalmology training at Wills Eye Hospital in Philadelphia in 1987 and subsequently did fellowship training in ocular oncology, oculoplastic surgery, and ophthalmic pathology. She is currently Director of the Oncology Service, Wills Eye Hospital, and Professor of Ophthalmology at Thomas Jefferson University in Philadelphia. She has authored or coauthored 11 textbooks, 330 chapters in edited textbooks, nearly 1800 articles in major peer-reviewed journals, and given over 850 lectureships. The five most prestigious awards that have honored her include the following: • The Donders Award (2003) given by the Netherlands Ophthalmological Society every 5 years to an ophthalmologist worldwide who has contributed to the field of ophthalmology. She was the first woman to receive this award. • The American Academy of Ophthalmology Life Achievement Honor Award (2011) for contributions to the field of ophthalmology. • Induction into the Academic All-American Hall of Fame (2011) for lifetime success in athletics and career. • President of the International Society of Ocular Oncology (2013–2015), the largest international society of doctors and basic scientists interested in ocular tumors. • Ophthalmology Power List 2014, 2016, and 2018 to which she was nominated by peers as one of the top 100 leaders in the field of ophthalmology. Dr. Carol Shields is a member of numerous ocular oncology, pathology, and retina societies. She serves on the editorial or advisory board of 31 journals, including JAMA Ophthalmology and RETINA. She practices Ocular Oncology on a full-time basis with her husband, Dr. Jerry Shields, and associates on the Oncology Service at Wills Eye Hospital. Each year, the Oncology Service manages approximately 500 patients with uveal melanoma, 120 patients with retinoblastoma, and hundreds of other intraocular, orbital, and conjunctival tumors from the United States and abroad. She and her husband Jerry are the parents of seven children, ranging in age from 19 to 31 years.

Chapter 27

Dual Professional Career Relationships Jane C. Edmond

Summary Points • The successful dual professional couple relationship requires a partnership with a shared destiny. • The universally shared destiny for dual professional couples is the pursuit of their careers. • The success of a dual professional career relationship requires support and respect, possible separation, personal compromise, and possible re-­ contracting the terms of the partnership.

Whether you are married to a physician or another professional, a successful relationship requires partnership. Like in the business world, this partnership means that both parties should have a shared destiny. As for the shared destiny, it is very likely the reason couples commit to a partnership in the first place! Frequent components of this shared destiny are purchasing a home, having children, religious beliefs, mutual hobbies, saving for higher education for the children, and retirement. A universally shared destiny for dual professional couples is their pursuit of careers. Personally, I found this to be the greatest challenge in my own professional couple partnership. Given my experiences, I would predict this to be the supreme challenge for hard-driving, successful, motivated professionals who are also partners. I volunteered to write this chapter because I feel my husband, an academic cancer surgeon, and myself, a department chair, have had a relatively successful partnership in terms of our professions. The success of our dual professional career

J. C. Edmond (*) Department of Ophthalmology, Dell Medical School, The University of Texas at Austin, Austin, TX, USA © Springer Nature Switzerland AG 2021 C. Y. Weng, A. M. Berrocal (eds.), Women in Ophthalmology, https://doi.org/10.1007/978-3-030-59335-3_27

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relationship has required lots of support and respect, some separation, personal compromise, and re-contracting the terms of our partnership.

Support and Respect If one’s partner is not supportive, attainment of professional success will be much more difficult and the journey much less enjoyable. The work of professional people is often mentally and physically exhausting, especially for physicians. Face it, we physicians might be in a partnership with a professional person, but we also have a relationship with our patients. We work long hours, work often spilling over into the evenings and weekends, and for many of us, we chronically live with varying degrees of stress. Early in my career, I was anxious about achieving the best surgical outcomes, while my husband stressed about establishing his academic career. During the middle of my career, I felt daunted by juggling a career and raising a family, while my husband stressed about never being at home. Now, in the senior portion of my career, I wake at 3  AM worrying about whether I can recruit and retain top faculty, provide value-based care to my region’s safety net population, and remember how to be a pediatric neuro-ophthalmologist! My husband is concerned about life after his soon-to-be retirement. These experiences have led me to appreciate the vital importance of mutual support for the success of any dual professional relationship, and ours is no exception. In my opinion, deep respect for each partner’s career is an absolute must for a successful partnership. Resentment will result if partners do not honor and respect each other’s professional efforts and what each brings to their family, community, industry – and certainly our patients.

Some Separation My husband and I were fortunate to both live in Houston during our training. When nearing the completion of my residency at Baylor, I wanted to pursue fellowship training in pediatric ophthalmology – but not at Baylor. It was time to get a different perspective! My husband understandably wanted to remain at his institution as he was completing his third year as a clinician-scientist. He could clearly understand my desire to pursue a best-in-class fellowship, but in spite of the overwhelming benefits to me professionally, the year away would hold very few immediate benefits for my husband. After having been married just a few years, we were justifiably anxious about how this would impact our relationship so I began to plan for ways to ease the stress of living apart for a year. I investigated the flight options to and from the cities of my top choice programs. I spoke with our mutual friends and enthusiastically suggested the idea of regularly inviting my husband to dinner. I suggested a weekly exercise schedule with his pals.

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In the end, my husband became a popular dinner guest, established a weekly jog (now walks!) with his former residency mates, and was academically productive. I, in turn, completed one of the most enriching and satisfying years of my ophthalmology training as a pediatric ophthalmology fellow at the University of Iowa. I was able to fully devote myself to the study of my subspecialty, and prepared for (and passed!) both the written and oral ophthalmology boards. In the end, and in spite of our separation, the year was resoundingly successful from a professional and personal standpoint for each of us.

Personal Compromise When my children were young, I wanted to spend more time with them. Therefore, I scaled back my clinic schedule at the Children’s Hospital of Philadelphia and Wills Eye Hospital. During this period, I was not very academically productive, and my salary was embarrassingly low. However, I was continuing to develop my clinical and surgical skills in fantastic institutions alongside brilliant faculty. On the flip side, my husband’s career at Penn was like a bonfire doused in kerosene – it was ablaze! His career was burning bright, but it was all-consuming, leaving him with no time for his personal life. Although I admit I was occasionally (OK… often) resentful about raising our children solo, and felt guilty about my lack of academic progress, my heart longed to spend more time with my kids when they were still kids. I felt the compromises I made were better for me personally and took precedence over my desires for professional advancement. In the end, this short hiatus from full-time work had no impact on my career path, and gave me renewed professional vigor.

Re-contracting Terms of the Partnership After returning to my career with renewed energy, I felt a second fellowship in neuro-ophthalmology would help further my career objectives. For this fellowship I did not leave town, having returned to Houston. I completed a year of training with Rod Foroozan at my parent institutions, Baylor College of Medicine and Texas Children’s Hospital. It was then when my career truly began to flourish. As one of fewer than 30 US pediatric neuro-ophthalmologists, I began to publish and lecture in my new sub-subspecialty. I also was also passionate about my service to the American Academy of Ophthalmology and the American Association for Pediatric Ophthalmology and Strabismus, eventually attaining important leadership positions in both. I felt my fire was burning. Three years ago, I was asked to apply for the position as chair of a new department of ophthalmology at a brand-new medical school, Dell Medical School, UT Austin. I certainly had never envisioned myself as a department chair, and was

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reluctant after having witnessed the travails of my husband’s chairmanship. However, the more I researched and interviewed, I found that the dean and the faculty had the same dreams and aspirations as I did – to change and improve the way we deliver health care, to put patients at the center, to expand access to care to an under- or uninsured safety net population. Never before in my career had I felt so culturally aligned with an institution’s mission and goals. The recruitment process was swift; within 6 months, I had signed a term sheet, and 3 months later, I moved from Houston to Austin, Texas, leaving behind my husband, son, friends, my job, my nail lady, and my hair stylist! Successfully navigating this professional and personal seismic shift in our lives would require a complete reorganization of our partnership contract. I live in Austin, driving back to Houston on weekends. My husband became the main manager of our home, a task that had been mine. My new position meant that I would not retire on his planned timeline. It would mean that in the future, I would be the primary income generator. To re-establish a successful relationship, my husband would need to make the majority of the compromises. He would feel resentment. The whole situation was nearly identical to the one I wrestled with so many years ago. Now, after 2 years as a department chair, I feel we have, for the most part, successfully both made compromises and re-contracted our partnership. It is still a work in progress! We sold my beloved beautiful home, my compromise which released him from his solo home manager job. I head back to Houston on the majority of weekends. Upon his retirement he will move to Austin, a city he is increasingly visiting and enjoying. Over time, my husband has become less annoyed and more supportive of my important work – begin a new ophthalmology department, recruit faculty, build a clinic, establish a residency, utilized value-based models of care, and improve access to ophthalmic care for the under- and uninsured of Central Texas. Jane C. Edmond, MD  is Professor and Inaugural Chair of the Department of Ophthalmology at the Dell Medical School at the University of Texas at Austin, the Director of the Mitchel and Shannon Wong Eye Institute, and Wong Family Distinguished University Chair. She is also an Adjunct Professor in the Department of Ophthalmology at Baylor College of Medicine in Houston, TX. Dr. Edmond’s alma mater is the University of Texas at Austin where she graduated with honors in 1981. She is a member of Phi Beta Kappa, the nation’s oldest and most prestigious honor society. She went on to get her medical degree from Baylor College of Medicine and graduated in 1985. While she attended medical school, she was elected to Alpha Omega Alpha, the national medical honor society. Dr. Edmond started her residency in Ophthalmology at the Cullen Eye Institute at Baylor College of Medicine in Houston, TX in 1989. Furthermore, she completed two fellowships: one in Pediatric Ophthalmology and Strabismus at the University of

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Iowa Hospital and Clinics (1990) and one in NeuroOphthalmology at Baylor College of Medicine (2006). She was faculty at Baylor College of Medicine and Texas Children’s Hospital in Houston, TX from 1991 to 1997. From 1997 to 2003 she was faculty at the Children’s Hospital of Philadelphia, Scheie Eye Institute, and Wills Eye Institute, all in Philadelphia, Pennsylvania. Texas called her and her family back though and in 2003 she resumed her faculty appointment again at Baylor and Texas Children’s. In 2018 she returned to The University of Texas at Austin. Dr. Edmond is a nationally known expert and educator and she serves on many professional committees. She has served the American Academy of Ophthalmology (AAO) as a Trustee at Large, she has been on their Board of Trustees, Chair for the Lifelong Education for the Ophthalmologist/MOCEC Committee, Chair for the Awards Committee, and as a Chair for the Membership Advisory Committee. Additionally, Dr. Edmond is a Consultant for AAO’s Basic and Clinical Science Course Committee (Pediatric Ophthalmology and Strabismus). For the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) she served as the Vice President-Elect, Director at Large of the Board of Directors, Councilor to the AAO, sits on the Journal Editorial Board, and is currently the President. She is also an active member of the North American NeuroOphthalmology Society and the Austin Society of Ophthalmology. She has been invited to speak at many national and international professional conferences and she takes enjoyment in educating the medical community. Dr. Edmond is a native of El Paso, Texas. She and her husband, Randal S. Weber, MD, have two adult children. She is enjoying living in downtown Austin and exploring the abundance Austin has to offer!

Part VIII

Leadership

Chapter 28

Leadership for Young Ophthalmologists Purnima S. Patel

Summary Points • Leadership skills are necessary for all physicians no matter what role you have. • Build a mentorship team to navigate and enhance your leadership journey. • Get coaching to help you with key leadership skills such as communication, time and people management, negotiation, and networking.

Women need to shift from thinking ‘I’m not ready to do that’ to thinking I want to do that – and I’ll learn by doing it. — Sheryl Sanberg

As physicians, we are all inherently leaders. We all must lead our eye care teams in our clinics, operating rooms, and/or research labs. How high we climb up the leadership ladder is our own choice based on our career goals and interests. Whatever the level, solid leadership skills are necessary for effective outcomes. In addition, it is especially important for women to have a seat at the table where decisions are made. We bring different perspectives that are important for our patients and the advancement of our profession. We are the best advocates for other women in our profession as well. This is important especially for young ophthalmologists, our future leaders, to know and accept. Their voice is important and needs to be heard. Envisioning themselves as a leader can be especially daunting for young ophthalmologists. Being a good leader is a process. Young leaders can build their leadership skills by starting to model good leaders, practicing leadership skills, and having patience in the process. Developing strong leadership skills will help a young ophthalmologist gain confidence in his/her own ability to be a leader.

P. S. Patel (*) Emory Unvieristy School of Medicine and Atlanta VA Medical Center, Atlanta, GA, USA © Springer Nature Switzerland AG 2021 C. Y. Weng, A. M. Berrocal (eds.), Women in Ophthalmology, https://doi.org/10.1007/978-3-030-59335-3_28

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Finding Your “Why” Simon Sinek, an author, motivational speaker, and organizational consultant, is a big proponent of understanding your “why” in order to inspire you and your team. He proposes that great leaders inspire action by understanding and sharing their “why.” [1] Your “why” aligns closely with your values and your goals. Your “why”(s) may not be clear to you and may even change over time. Several of my mentors have given me this same exercise to help me elucidate my “why.” First, make a list of 50 one-word values. You may find coming up with just 50 words is challenging. Then narrow the list down to 25, 10, and finally 5. What you are left with are your key drivers. You work from the foundation of these values to build your vision for your future. This exercise should be repeated every few years, when you are deciding about a major change, or embarking on a new project or role. Your why is your north star. Your why provides the confidence to choose opportunities and ignite passion for them.

Getting Started on Your Leadership Journey Write Down Your Goals Writing down your goals forces you to think about what you value now (1 month, 3  months, 6  months), in the near future (1–2  years), and the distant future (5–15 years). There will be discomforts from the uncertainty of the now. But know, you will be moving toward your long-term goals as you go through the exercise of choosing a few goals to start. Devise ideas on how you plan to achieve your goals. Set a timeline. Check in with your goals periodically to monitor your progress and determine if some goals have shifted.

Finding Your Opportunity Step 1. Show Up It may be cliché, but showing up is key. This means going to meetings and taking the sometimes uncomfortable step of simply introducing yourself. Developing meaningful relationships at large meetings can be harder but larger meetings offer larger networking opportunities. For example, the American Academy of Ophthalmology Annual Meetings has over 20,000 attendees with trainees, earlyand mid-career ophthalmologists, and leaders from around the world. However, there are lots of smaller meetings happening during the AAO Annual Meeting as well. These smaller meetings are a great way to meet people and become aware of

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available opportunities. Your state ophthalmology and medical society meetings are typically smaller meetings and a great place to start building your local network. At first, you say yes to a lot of opportunities to uncover what you really enjoy and naturally gravitate toward. Saying yes to almost everything in the beginning gave me leadership opportunities earlier than I would have expected. I got involved with the Academy’s Young Ophthalmologist (YO) Committee my first year as an attending. Through this role, I met ophthalmologists from across the world, both YOs and senior leaders. I learned that I enjoyed organizing meetings, especially developing new ways to bring people together to share ideas. Along the way, I became passionate about advocating for more women and diversity in leadership. Through the networks I built from my Academy work, I found collaborators for my passion projects. For you, these early leadership opportunities may be in new areas (e.g., social media or resident education), where needs lie (developing a new streamlined process, standardizing clinic protocols, technician education, etc.), or areas that are not as desirable for the more selective, experienced ophthalmologists in your practice. If you know you are not going to love a needed role, you can provide a time limit for the task (i.e., “I will commit to leading this effort for 2 years.”) or identify someone else who you can train and transition to the role. As you gain more experience, you can start being selective. When you don’t yet have the experience, it’s important to take most of the opportunities that come your way. Step 2. Build a Mentorship Team Mentors function like agents who help introduce you to opportunities and help you vet them. It is important to have a team of mentors instead of a single mentor. Different mentors will help you with different aspects of your career: speaking, organization, leadership, work-life balance, practice-building, etc. Choose mentors with diversity in experience, gender, race, and practice type so you can leverage a broad range of experience. These mentors do not all have to be physicians. Diversity in your mentorship team will broaden your depth and breadth of knowledge and experience. This diversity will make you more resilient, adaptable, and nimble. As you advance in your career, commit to mentoring others. Having young, fresh ideas from young ophthalmologists, residents, and medical students strengthens your network. They also help you with research and presentations, nominate you for awards, and refer you patients. Step 3: Find an Unmet Need Look around your environment to see what’s missing. Is there a new idea you can bring that others can learn and benefit from? For example, my previously male dominated institution had many young women joining faculty who needed mentorship to grow their professional careers as well as balance their work-life demands. I

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identified this gap and started a Women in Ophthalmology Group at our academic center early in my career. We continue to meet monthly to discuss professional development topics such as leadership skills, negotiation, communication, financial planning, and network building. This meeting also allows us to develop strong relationships among ourselves and learn more about our work environment. Most importantly, we are able to leverage the combined talent and experience in the room to help each other grow. Not only did I gain significant personal and professional growth through this group but this effort led to additional opportunities outside of my department. I helped establish a women in medicine group for the school of medicine, I participated in a leadership development program, and I became involved with the Women in Ophthalmology organization where I have met several incredible women from across the country who have become part of my growing network of mentors and collaborators.

How to Be a Better Leader Leadership Styles Leadership is the ability to make sound decisions, inspire others to perform well, and build ideas for growth. Everyone has their own individual leadership style which often changes with experience and situation. Observe others to determine which styles resonate with you and complement your attributes. No one style is best all of the time. We all aim to be effective leaders. Effective leaders are able to set and achieve challenging and aspirational goals, take swift and decisive action in difficult and/or stressful situations, outperform their competition, take calculated risks, and persevere in the face of failure. Strong communication skills, self-confidence, openness to change, and ability to have others follow are essential. These skills separate leaders from managers. Managers are deployed whereas leaders deploy themselves. Some common leadership styles include transformational, democratic, authoritarian or autocratic, laissez-faire, transactional, and servant. They all share common traits of vision, effective communication, consistency, honesty, and conviction. Different environments may benefit from different leadership types. Transformational  These leaders are the visionaries. They are change-oriented. They aim to align goals of their followers with those of the organization. This leader must talk the talk and walk the walk. They place a high priority on inspiring and motivating their followers. These types of leaders constantly challenge followers to reach raise their potential [2]. Democratic  In this type of leadership model, each member gets a vote, but the leader has the final say. Members are more empowered in the decision-making process. This system is rooted in mutual respect for each member. Success is dependent

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on each member being highly productive and meeting expectations. This style requires leaders to be very familiar with the followers’ capabilities and potential. This style can be challenging when urgent decisions are needed [2]. Authoritarian/Autocratic  In this system, the leader dictates all policies and procedures, decides the goals, and directs all actions without input from the subordinates. These leaders rarely seek or accept advice from followers. The style does not involve a great deal of trust between the leaders and their subjects. This style tends to stifle creativity and disengages active involvement from subjects. This style can be effective when high-urgency, dangerous circumstances arise [2]. Laissez-faire  This is a very hands-off leadership approach with a reliance on self-­ management by followers. This style provides the least amount of guidance to the followers. It relies on the principle that people excel when they are left alone to address their responsibilities. These leaders remain open and available when needed. This style works for highly skilled, self-motivated, and capable workers. Among physicians, this can work in certain circumstances. This leadership style is not effective when the group lacks skill or experience [2]. Transactional  This is a managerial style with a behavioral approach driven by the ability of leaders to appeal to their followers’ self-interest. These leaders develop a relationship based on an exchange with successes being rewarded and failures being reprimanded. Clear goals and standards are required from the outset. This style is very task-oriented without an emphasis on creativity or innovation. This can be effective when a specific goal is to be achieved [2]. Servant  This approach to leadership is rooted in a desire to serve first. Strong altruistic and ethical overtones guide these leaders to be attentive to the needs and goals of their followers and empathize with them. The power of leadership does not overshadow the desire to serve. They display listening, empathy, and awareness as well as a commitment to the growth of people and building community. These leaders tend to be inspiring. Servant leaders prioritize their followers’ professional growth and wellness. They aim to empower autonomy such that their followers become servant leaders as well. This is a bottom-up leadership approach ensuring that the voices and ideas of followers are heard and their priorities are met. This style requires a high-level of constant engagement to allow leaders to achieve the best fit for an individual follower’s strengths. This extra time spent can lead to greater employee retention, increased productivity, and a more positive work experience overall – with a better patient experience as the ultimate outcome. Because of the values of our profession, this leadership style tends to be effective in medicine. This is an essential style of leadership for volunteer organizations. However, because of the silos of care in which we work, this style can be challenging to implement [2, 3]. The different leadership styles may seem contrary but in actuality can be symbiotic with an emphasis on service first. Those who you are leading feel their own personal growth, learning, advancement, and achievement while performing their

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duties for you as their leader. This goes past treating your team as cogs in a machine and fosters more teamwork, community, and exchange of ideas. While transformational leaders and servant leaders both show concern for their followers, the overriding focus of the servant leader is upon service to followers. The transformational leader has a greater concern for getting followers to engage in and support organizational objectives. The leadership styles above can be grouped into leader-centered (authoritarian and transactional) and follower-centered (transformational, democratic, laissez-faire, and servant) styles. Follower-centered treat the employees as the most valuable organizational assets. Leadership styles can also be considered as task-oriented vs. people-oriented. Task-oriented leaders create clear, easy-to-follow work schedules with specific tasks, and deadlines. The leaders focus on the task at hand and are less concerned with catering to employees and more concerned with finding technical, step-by-step solutions for meeting specific goals. This leadership style maintains high standards with optimal efficiency to get tasks accomplished; downside to this leadership style is that it can lead to a lack of employee autonomy, creativity, and flexibility which can result in low morale in the office. People-oriented leaders focus more on employee relationships which tend to energize employees to make them feel valued for skills and work ethic. As a result, employees work harder and have higher morale because they feel they are part of the company’s success. The challenge to this style can occur when employees may feel their responsibilities are overwhelming and they may need clearer, more specific direction.

High-Yield Leadership Pearls 1. Get more comfortable with failure I haven’t failed – I’ve just found 10,000 ways that won’t work. – Thomas Edison

Failure is a part of the learning process. Success is not the absence of failure but the resilience to deal with failures. If you haven’t failed because of lack of trying or staying within your comfort zone, then you have robbed yourself of the opportunity for something new, challenging, and/or difficult. The failures are where the steep slope of high-yield learning lies. We must all forgive ourselves when we fail, learn from the mistakes, and move forward. We must learn to redefine failure like Edison. Failures are opportunities to learn what didn’t work with the given circumstances. Other permutations may just be a winning solution, but we won’t know unless we try. The pursuit of perfection will have us stuck in indecision. We then allow others to define who we are. Furthermore, we must share our failures with each other. The act of sharing shows other women that being vulnerable isn’t wrong, failures happen to everyone, and we will get past them with the support of our sisterhood.

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When we focus on growing ourselves and those around us, we remain curious, open, and true contributors. 2. Leadership development courses Take advantage of leadership development or communication courses early in your career. When your clinical and administration duties are lighter, you have more flexibility in participating in leadership development programs. These courses can be found at your institution or local medical society. Find out about them early and figure out what is required to be selected. Not only will you learn important leadership skills, but these courses are a great way to expand your network and meet other colleagues. Often times, these courses are taught by generous, experience leaders who are committed to mentoring the next generation of leaders. They are an excellent resource. 3. Get a professional coach Leadership coaching provides the extra finesse to the foundation of skills you have gained from your experience. Mentors can provide some coaching, but for enhanced performance, you need a professional coach. Get references for good coaches from mentors and colleagues. There are coaches for communication, negotiation, leadership, professional appearance and style, time-management, burnout, etc. Some coaches do all of the above. 4. Video-tape all of your talks in the beginning I know it’s painful to watch yourself. Just like watching your surgical videos, you will learn from watching yourself talk. You will observe your posture, speech pattern, eye contact, and use of slides/pointers. Review these with your friends (especially those who are not in medicine because they will just focus on you and not your material), colleagues, mentors, and coaches. 5. Learn how to run a good meeting Have an agenda and distribute it in advance. Have clear goals for what you hope to accomplish at the meeting. When meeting in groups of more than five, pre-wiring is necessary. This means reaching out to key opinion leaders and participants of the meeting in advance to discuss ideas. This allows you to take the temperature of each person on new ideas or initiatives before the meeting. You are better able to prepare for questions or concerns. Pre-wiring is also an opportunity to engage with attendees prior to the meeting and gain their input in forming the agenda. In order to leverage the experience and expertise of each attendee, it’s important to employ strategies to increase engagement level. For smaller groups, ensure that each person has a line item on the agenda. For both small and large groups, allow time for discussion so you can leverage the experience and expertise of attendees to brainstorm and vet ideas. The presence of discussion adds justification to having a meeting versus just sending an email. Discussion is especially important when attendees do not have frequently face-to-face interaction. You want to take advantage of everyone being in the same room together. Especially for volunteer groups, make the meetings fun with a good ice breaker or other fun activity. Most people have an inherent aversion to meetings, but you

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can create a meeting environment that is energizing and empowering. Try to take advantage of everyone’s presence, especially in smaller groups. If you find that a particular attendee is shy or new and does not speak up much, hopefully, you have already identified a potential solution for this in your pre-wiring. If not, reach out to the person during a break and see if you can find a topic for which they can provide input. “That’s a great idea. Why don’t you mention that when we discuss ideas for next year after the break?” You could also say “I’d like to hear from Jane next.” This gives Jane a heads up to gather her thoughts before providing a comment. Timing is incredibly important for an effective meeting. Set a specific time and start and stop at the given times. Build in flexibility to help ensure you don’t get delayed. You can designate someone as a time-keeper so you don’t come off as cutting someone off. Set the expectation from the outset of the meeting the importance of timeliness. If you have someone who tends to dominate the discussions, provide a time limit on comments. Let the group know that in order to stay on time and not take away from someone else’s time on the agenda that you will continue the discussion at the break, over e-mail, or in a smaller group later. All of this can be anticipated in your pre-wiring discussions. At the end of your meeting, provide a wrap-up of key takeaways from the discussions, post-meeting goals, and the date of the next meeting. In a follow-up e-mail, provide meeting minutes and a timeline for action items. Get feedback on how things went with the meeting from the participants directly and indirectly (via anonymous surveys) and from senior attendees/mentors. The feedback is essential to improve your skills. 6. Find your successor Succession planning is key in servant leadership. Succession planning also preserves the legacy for your work. Lead your organization in such a way that goals continue to be acheived after your have left. Start planning early because good succession planning takes time. Succession planning gives you a dignified exit out of an opportunity and a graceful entry for your successor. 7. Don’t listen to voices that say you can’t do it. You can be a successful leader. Find the team that will help you get there. There is a strong sisterhood of women in ophthalmology that wants to see you succeed and will raise you up! Remember to lift as you climb. 8. Learn to delegate As your experience and expertise increase, you will find yourself with more and more opportunities. Delegating responsibilities will allow you to do more and have more balance in your life work and personal life. The future is bright and ready to benefit from the leadership of a new generation of young, talented women in ophthalmology. As you climb, remember to pull up others along with you. And so, lifting as we climb, onward and upward we go, struggling and striving, and hoping that the buds and blossoms of our desires will burst into glorious fruition ‘ere long. With courage, born of success achieved in the past, with a keen sense of the responsibility which

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we shall continue to assume, we look forward to a future large with promise and hope. Seeking no favors because of our color, nor patronage because of our needs, we knock at the bar of justice, asking an equal chance. – Mary Church Terrell

References 1. Sinek S.  How great leaders inspire action. 2011. https://www.youtube.com/ watch?v=7zFeuSagktM. 2. Kim N.  Servant leadership style: what is it and what are the benefits and contrasts to other leadership styles. 2016. https://cdr.lib.unc.edu/concern/parent/f1881q662/file_sets/4q77fv914. 3. Savel RH, Munro CL.  Servant leadership: the primacy of service. Am J Crit Care. 2017;26(2):97–9. https://doi.org/10.4037/ajcc2017356. Purnima S. Patel, MD  is a medical retina, uveitis, and cataract surgery specialist in Atlanta. She is currently Associate Professor of Ophthalmology at Emory University School of Medicine and staff physician at the Atlanta VA Medical Center. She has held numerous leadership positions including chair of the American Academy of Ophthalmology’s and Georgia Society of Ophthalmology’s Young Ophthalmologist committees and chair of the Georgia Society of Ophthalmology’s Continuing Medical Education Committee. She currently serves on the board of Women in Ophthalmology and as Deputy Editor-in-Chief of the Academy’s Online Education (ONE) Network.

Chapter 29

Preparing for Service in Whatever Comes Your Way Cynthia A. Bradford

Summary Points • Prepare for leadership and know yourself. • Master areas of weakness, communicate, and collaborate. • Be decisive and take action.

Know Yourself If I asked who you are, you would be able to tell your story—adversity in life that has made you stronger, opportunities you have been fortunate to have, family and friends who have shaped who you are. Perhaps you are at a point in your life where you would like to become more involved, perhaps hold a leadership role, but are wondering what you should be doing next. The first step is to know and accept yourself and be comfortable in your own skin. Do not try to be someone else. As a child I realized that I tended to pick the job no one else seemed to want, or picked the job that seemed hardest for me. As an introvert, public speaking was not my strength and in junior high, I picked Speech as my elective and had to speak in front of the class two to three times a week. Was I great? No, but it was a beginning. I am an eclectic reader, now listener, and jump genres. That is how I learn about the world, others, and myself. A book by Susan Cain entitled, Quiet: The Power of Introverts in a World That Can’t Stop Talking, gave me new insights and is a good read for both introverts and extroverts. Knowing you begins with doing an inventory of your strengths and weaknesses. Get a journal and start a list of each and your first

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work is to improve your areas of weakness, one at a time. Your weakest skills will limit use of your abilities. My primary service to the American Academy of Ophthalmology (AAO) was in advocacy, which involved speaking to state and subspecialty societies as well as at legislative hearings. I will never forget my first state society meeting where I gave the advocacy update. My PowerPoint presentation was a compilation by several individuals. I think the best description of my presentation that day was that I made it through the talk. With time, I learned I had to create and personalize my talks and practice, practice, practice the delivery and timing. It takes self-discipline to learn to improve our weak skills and not pursue what we already do well. It is also very important to take care of yourself. Exercise, eat healthy, and get plenty of sleep. Without a healthy body, it is hard to excel and have a good attitude. For the AAO State Affairs team, the legislative session can be brutal. Conference calls every night, emergency legislative hearings—it can be stressful! In anticipation of the legislature beginning, I started working out with a personal trainer, meeting him 3 days a week at 5:15 AM. I had to go to bed earlier, but it gave me the strength, endurance, and mental toughness (trainer was nice guy, but pushed me) to do my day job as well as legislative advocacy. The reward was that I felt like I was making a difference. Leo Rosten (not Ralph Waldo Emerson, as sometimes credited) said, “The purpose of life is not to be happy-but to matter, to be productive, to be useful, to have it make some difference that you lived at all”. Make yourself useful.

Preparation You cannot sit around and wait for a leadership role; you must prepare and be ready. I describe myself as an accidental leader. Early in my practice, my state of Oklahoma was in an unrelenting scope battle. As I listened year after year to comments from ophthalmologists at the AAO annual meeting about Oklahoma losses in the legislature, I knew I needed to review what happened. I wanted to understand every nuance of the scope expansion, so I could explain it to others and perhaps understand how to help other states. I reviewed all the primary documents and actually created a poster for the annual meeting (Fig. 29.1). At the poster, I met some interesting physicians and, comically, the Dean of the optometry school in Oklahoma. He had turned his nametag over to hide his name, as if I did not know who he was! I also met Mike Brennan, the AAO Secretary for State Affairs. He called me later and said he wanted to stop through Oklahoma on the way home from the AUPO and meet members of our state society and get them engaged. What followed was an invitation to join the AAO State Affairs Secretariat. This was an opportunity and a mentor that I could never have imagined when I created my poster. Most people have a mindset of status quo and when faced with change will weigh the potential losses more heavily than the potential gains. When you are preparing yourself for future opportunities, you have to think outside the box and maintain a

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Fig. 29.1  Poster created and presented at AAO annual meeting

positive attitude. Smile from the heart. Remember that life is not always fair and you need to expect some failure. At those crucial times of decision-making, push yourself to action, which will separate you from those standing indecisively on the sidelines. You must have a passion to solve the problem before you. For every opportunity that is presented to you, do your best. Good effort is not a waste. Keep moving forward, for if you stop, it is hard to restart. If you are perceived as risk-­ averse, it can be perceived as weakness. A quote from Louis Pasteur is, “Chance favors the prepared.” Luck comes from taking more chances, being more active, and sometimes it is simply showing up. As AAO Secretary for State Affairs, I remember a last-minute need for me to testify in the South Carolina legislature. I packed a bag and carried a note pad with me. On the plane I studied what I knew about the bill and what was being claimed by optometry. I did not know how long I had to talk but knew I had to make three solid statements and expand as time allowed. I focused and wrote down my three points and sketched other ideas. The plane landed and it was off to the tense, overflowing legislative hearing. The state society had everything in place and we won. I have loved South Carolina peaches ever since that trip. We never get a guarantee of success. Emotions that hold us back from trying are uncertainty, fear, and doubt. Douglas McArthur said, “There is no security on the earth; there is only opportunity.” As you prepare for opportunities, there are some personal traits one must possess—but remember that no one is perfect. These personal traits are important to be able to work well with others. You must be honest and authentic. You cannot fake preparation and get away with it. Be kind to others and value their input. Learn to apologize and not argue. Pay attention to other’s emotions and mindset. Hold yourself accountable for your responsibilities, but do not be too hard on yourself if there is failure. Learn from the experience. I teach the residents early in their surgical career. I encourage them to use positive words with surgery patients and have a cheerful countenance. But they must also be mentally prepared, knowing the patient and important details about the surgery. Preparing ourselves also should involve positive thoughts and sweeping negative thoughts away. When there is fear or anxiety weighing us down, it is important

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to stop and ask why the feeling exists, address the issue, and create a plan to resolve it. Do not let the feelings defeat you or overshadow your day. If there is conflict, you must pick your battles; sometimes, it is better to give in and try to achieve your objective at a later time. Just as in teaching surgery, there are some skills that need to be learned that are boring and it requires a stick to it attitude to repeat until the skill is mastered. These skills are not acquired by accident. The result of the boring practice is what we celebrate. Master the skill that you need to be a leader. There are those that live in Someday Isle. “Someday I’ll do something when everything is just right.” Confucius said, “A journey of a thousand leagues begins with a single step.” The simple rule is that you have to take action to accomplish things. You have to take the action even when you do not feel like doing it, which takes self-discipline. If you want more success, try more things, take more actions, and get busier. Make that phone call. Send that e-mail. Write that paper. All actions, which once initiated, seem so simple and actually bring joy. Why wait? Act.

Communication Communication may be the most critical skill to lead and motivate others. You need to effectively and clearly communicate in spoken and written word. To be clear in communications requires careful thought. It is not a tweet. Criticism destroys creativity. In 2009, Warren Buffet’s advice to a Columbia business class was to improve communication skills, which Buffet believes can improve your value by 50%! Read online about Buffet’s pride in taking the Dale Carnegie Course, which leads to another classic, the Dale Carnegie book, How to Win Friends and Influence People. When you speak, the audience should have insight into your character and you must be perceived as credible. Actions must back your words. Your words must express logical and reasonable ideas. Distilling complex ideas into simple messages is very powerful. And perhaps most importantly, your words must impact emotions. Storytelling is a great way to get your message across. On this subject, another good read/listen is Never Split the Difference/Negotiating as if Your Life Depended on It by Chris Voss. In this book, the author discusses how we think we make decisions rationally, but how decision-making is an emotional decision. I won’t say more and give away the ending. When giving talks, brevity is key, and truly less is more. In journalism and e-mails, “you lead with the lead.” Know what your hook with the audience is and use that idea to start, or simply start with a relevant story. Be clear and succinct. Slides should be simple and not busy. You want the audience to listen to you and not be reading the slides. If you have an 8 min talk, have your slides and talk at 7 min 30 s using a slow pace. Do not go over your allotted time and start rushing. Use the stopwatch on your phone to get the timing perfect. Know your slides well enough to look at your audience. Everyone is nervous at the beginning of a talk. Have your

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opening line down pat and speak slowly and with a lower voice. As you do this, your heart rate will follow and slow down! Try this little trick. It always works. As a leader it is important to clearly communicate your expectations and your words should match your actions. Your expectations of yourself should be high. Clear expectations provide direction for your team and prevent uncertainty and anxiety, which can derail progress. There will be failures and problems, but as a leader, you must be able to admit your mistakes, ask for help, and let people know you feel they are important.

Goals and Collaboration As a leader, you need the mindset of doing something useful. Not concentrating on what you will get, but what you will give. Leaders make decisions and not all of them are right. Once a decision is made, a plan is created, with input from all involved parties, and action started. Any involved parties that you leave out could cause the plan to fail. Two AAO Leadership Development Program (LDP) participants decided to work on a project together and that program was ultimately implemented and became the very successful AAO Advocacy Ambassador Program (AAP). But it could have failed. It was dependent on collaboration of the AAO with state societies and academic ophthalmology departments. AAO waived registration and provided meals. The state societies sponsored residents to come (flight and room). Academic departments allowed the residents to attend without using vacation time. Although we thought we communicated well, the money for some state societies was prohibitive. Smaller states with several programs had problems. Through collaboration, some of the academic departments had funds to help send residents. Another thing we overlooked was the date of OKAPs! Be sure you know all the involved or impacted groups. When you have an idea, bounce it off your mentor or another knowledgeable person. Sometimes we can be terrible judges of our ideas and work. Input from others can help develop your idea or prevent you from spending wasted time on a dead-­ end idea. When you are in a leadership position that will last a year or two, you need to focus on only one or two goals to accomplish during that time. It must align with the society or group’s needs. Once the goals are set, create a timeline and do the most important task first so that you are always accomplishing important steps. You will have to continuously keep your team and collaborators on track. It is like herding cats, they will run off in all directions. You must bring them back to the mission. Having a mentor or a colleague who is an enthusiastic champion is very empowering. Everyone wants positive feedback, but honest feedback is critical. When you know someone believes and trusts you, it motivates you to do a better job. In return, you can empower someone else. Reggie Jackson said “A great manager has a knack

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for making ballplayers think they are better than they think they are. It makes players never settle for playing less than your very best.” As ophthalmologists, we are very detail-oriented and realize the importance of quality. In leadership, quality is not the top goal. Prioritize to guarantee work is done at a level of quality that has the most impact on what you are trying to accomplish.

Final Thoughts I would never want to discourage anyone from leadership, but you must be willing to allow time to assume that role. Fortunately, you do not head to the highest position first! It is often an incremental increase in activity and responsibility. My early years in service were at the state society level. After our legislative losses, no one wanted to be state society president, and as I said before, I took jobs no one else accepted. My greatest challenge was finding successors, but I did and they accepted the challenge. We all have different pathways; some are lucky they have challenging pathways that allow them to develop their skills. If the road is easy, you must challenge yourself by creating greater tasks. We do not have choices of where we start. Life is what we make it. Hopefully I have given you ideas and incentives to do whatever you want to accomplish. Know who you are. Prepare and recognize opportunities, and step forward to take action and make a difference. Be useful. Cynthia Bradford, MD  is a Professor of Ophthalmology in the Department of Ophthalmology at the University of Oklahoma Health Sciences Center in Oklahoma City and the Dean McGee Eye Institute. She is a Presbyterian Health Foundation Presidential Professor. A native of Texas, she received her undergraduate degree at Texas A&M University (magna cum laude) and medical degree with high honors from the University of Texas Medical Branch in Galveston. She moved to Oklahoma and completed her ophthalmology training at the University of Oklahoma Health Sciences Center. Dr. Bradford has authored modules and books to teach ophthalmology to medical students and primary care physicians. She is the Executive Editor for the American Academy of Ophthalmology text, Basic Ophthalmology, Editions 8 and 9 which has been translated into Spanish, Chinese, and Russian languages. She was a member of the AAO Section 11 Basic and Clinical Science Committee responsible for the teaching text on cataract and lens. For over 25 years, she has taught the University of Oklahoma ophthalmology residents to perform cataract surgery. Dr. Bradford is a comprehensive ophthalmologist with a clinical focus in routine and complex cataract surgery, with extensive experience performing cataract surgery on patients with prior reti-

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nal and glaucoma surgeries, or after refractive surgeries such as RK, PRK, or LASIK. She was the 2017 President of the American Academy of Ophthalmology, having previously served on the board of trustees as Senior Secretary of Advocacy. She has been faculty of the AAO Leadership Development Program for close to 20 years. She has been an Associate Examiner of the American Board of Ophthalmology and also serves on the Oklahoma Medicare Carrier Advisory Committee for Medicare. Dr. Bradford participated as a surgeon in the clinic trial for the implantable miniature telescope for age-related macular degeneration. She is a member of Alpha Omega Alpha Honor Medical Society, as well as Alpha Lambda Delta and Phi Kappa Phi honor societies. She received the Edward and Thelma Gaylord Faculty Honor Award for Teaching Excellence and the Veteran’s Hospital Excellence in Attending Award. She has been listed in the Best Doctors in America for many years. She has received the AAO Honor Award and the AAO Secretariat Award from the Secretary for Quality Care and the AAO Lifetime Achievement award. From OU College of Medicine she received the Dewayne Andrews, MD Excellence in Teaching Award, 2019. She is married to a retinal surgeon and they raised three sons, and now have five grandchildren.

Chapter 30

How to Be an Effective Fellowship Program Director Hilda Capó

Summary Points • The role of a fellowship director is both challenging and gratifying. • It is key that the right motives drive the decision to become a fellowship director. • Certain traits are advantageous to have in succeeding as a fellowship director.

Introduction The definition of effective is to be successful in producing a desired or intended result, so possessing the required abilities is advantageous, but most importantly, having the correct motives is critical in order to be an effective fellowship director. You should carefully evaluate your career goals and ponder upon the reasons for your decision to pursue a fellowship director position. Then, you should assess whether you believe you have what it takes to do it well. We will first explore reasons for becoming a fellowship director and then expand on the qualities that will make you an effective director.

Why Should You Become a Fellowship Director? There are good reasons for becoming a fellowship director, and not so good ones. Assuming a leadership position has its challenges and its rewards; therefore, the right motives should drive the decision. The desire to effect change and have a H. Capó (*) Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA © Springer Nature Switzerland AG 2021 C. Y. Weng, A. M. Berrocal (eds.), Women in Ophthalmology, https://doi.org/10.1007/978-3-030-59335-3_30

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positive influence on others appear to be two top reasons why women pursue leadership positions and these should be the reasons for becoming a fellowship director. Financial compensation should not be the main motivator, as frequently there is minimal to no economic incentive to be a fellowship director. The rewards as a fellowship director stem from the significant impact that you will have on your trainees, not only professionally but also personally. I have repeatedly seen how a one-year training program can transform the lives of fellows by allowing them to develop new skills, build personal and professional relationships, enhance confidence, and expand employment opportunities. My own fellowship training opened doors and provided opportunities that would have not been otherwise available to me, so I appreciate how gratifying it is to participate in the fellow’s growth and to create long-lasting bonds.

 aluable Traits That Will Allow You to Be a Successful V Fellowship Director If you aspire to be a fellowship director, then you are most likely aware of how much work and experience is required. In addition there are certain traits that can help determine your success. We’ll take a look at some traits that fellowship directors tend to possess. Be Excellent  Be excellent in your field of expertise. Excel at your job. Instead of just doing enough to get the job done, strive for more and push yourself that extra mile. It will gain you recognition from your seniors, your staff, your co-workers, and your learners. Having achieved a level of respect from your peers enables you to pursue a leadership position. Be Collegial  You cannot run a fellowship program by yourself. Build professional relationships. Appreciate your associates and how they enrich the fellowship training program, as they frequently have diverse areas of interest and different educational methods. Make them feel that they are part of the fellowship program. Include them in decision-making concerning potential fellowship candidates, weekly schedules, didactic lectures, and evaluations. Millennials are now entering fellowships and they prefer the chance to work with multiple mentors, as this collaborative generation wants to gain knowledge from every resource possible. Recognize that you need your peers in order to have a successful fellowship training program. Be Organized  Understand and comply with the fellowship program certification requirements. Submit all the mandatory reports. Meet all the deadlines. At the beginning of the training program, review with the fellows the duration of the fellowship, vacation and sick time policies, and stipends. Go over the expectations and duties, including learning objectives, clinical work, and on-call schedule. On a regular basis, evaluate the fellow’s performance and maintain proper documentation.

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Make certain that the fellow meets all the requisites for fellowship certification and is competent and ready to practice independently at the completion of training. Be Enthusiastic  Enjoy your work on a daily basis, and do it with dedication and enthusiasm. Keep moving forward, even when facing difficult situations. Be aware that as a leader you set the tone for those around you. Nobody wants to train with a preceptor who is unsatisfied with their job or in a program with an uninviting environment. Be Aware of Generational Differences  It takes more than just a desire to become a fellowship director. As fellows are typically a younger age bracket, it is important to have an understanding of the general characteristics of different generations as this may have a significant impact on how the diverse generations interact [1]. Baby boomers, born between 1946 and 1964, are generally senior faculty and are often the leaders in academic institutions. They tend to be workaholics, extremely dedicated, ambitious, and competitive. Their careers often define them, and they have limited understanding of work-life balance. The Gen-Xers, born between 1965 and 1979, are usually midlevel. They have a better understanding of work-life balance and rely more on technology than the boomers. Millennials or Gen Y, born between 1980 and 2000, grew up in a prosperous economy with close parental involvement, so they are accustomed to constant praise. They require immediate access to technology and value work-life balance. They also are team players, civic-minded, and wish to make the world a better place. Understanding these generational differences will maximize the fellowship experience for both the trainee and the mentor. Be a Great Teacher  Encourage the fellows to learn and develop their maximal potential. Promote scholarly activity. Inspire them to be educated in multiple ways. Recognize that younger generations have grown up with digital technology, learning new skills from online resources and watching YouTube videos. Ask them frequent questions about specific conditions including their differential diagnosis and therapy options in order to challenge them and assess their level of knowledge. Involve them in research. Encourage them to teach residents and medical students. Be Generous with Your Time  Teaching can be time-consuming. It is usually faster to evaluate patients in the clinic and perform surgery without a fellow. Studies have shown that presence of trainees is associated with longer appointment times, even for patients not seen by a trainee [2]. In addition, surgical trainees’ participation in common surgical procedures is associated with an increase in total operative time [3]. With this information in mind, embrace the extra time you spend teaching and giving feedback to your fellows. Be a Motivator  Motivate, demonstrate, let the fellow try, acknowledge the efforts, and work together to improve the developing skills. Inspire them to think and process information when evaluating a patient and formulating a treatment plan. In

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surgery, give encouragement with each step. Reinforce the positives and give credit for the strengths. Concentrate on improvement, not necessarily perfection. Be a Good Communicator  You have to communicate with your fellows on a regular basis. Evaluate their performance, give them constructive criticism, be honest with them, and provide timely feedback. You would do them a disservice if you did not point out their errors and weaknesses. Millennials crave feedback and candid, practical advice. Mentors should not “sugar coat.” It is important to give honest feedback in real time. If delivering bad news makes you uncomfortable, consider setting up a warning word for difficult feedback, such as a “let’s fix this” moment. When you alert your fellow that a “let’s fix this” moment is coming, they can be prepared. Face-to-face communication is ideal, but be ready to connect via text when necessary, as younger generations prefer texting over the phone or e-mail. Be Open to Learning New Things  The landscape is constantly changing. Be agreeable to adapt. Few old dogs want to learn new tricks, but be one who is eager to do so. Be willing to learn from your fellows (reverse mentoring). Millennial mentees have a lot to offer. They are creative and energetic and experts on technology and social media. Make them feel valued. Some young fellows do not appreciate the traditional hierarchy and want their mentors to treat them as equals. They frequently prefer to feel like two peers, where each has valuable input, rather than one older, more experienced person, telling the other what to do. Recognize their strengths and acquire new skills from them as you teach them what you have learned from years of experience. Be Caring  Do not be afraid to get personal with your fellows and talk about things outside of work. Fellows want to care for and be cared for by their mentors. Many millennials are looking for a second family at work and want their workplace to be social. Tell your fellows a story, listen to their stories, inquire about their families. They will appreciate it. Be Courageous  Build balance between education and workload, independence and supervision. Be brave and allow your fellows autonomy. You want to allow increased responsibility for the care of patients by providing the opportunity to work independently. Autonomy with adequate supervision will result in increased fellow’s competencies and confidence. Be Patient  The reality is that some fellows can be exasperating. In spite of careful selection, not every fellow will meet your expectations. Remember that fellows come from different residency programs and have diverse knowledge base and skillsets. Additionally, not all fellows are fast learners. Be patient with those who are slower and require more guidance. They may be the most grateful ones for their training. Be Respectful  Fellows come in different shapes and forms. They have different upbringings and personalities. Be sensitive to the variety of cultural, ethnic, social, and religious backgrounds. This is particularly important when dealing with international fellows. Take advantage of the opportunity, learn from them and acquire an appreciation of their cultures. Also, be aware and accepting of different sexual pref-

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erences. Embrace what they bring to the fellowship program and to your own personal development. Be Fair  Foster a spirit of cooperation. Treat the fellows fairly and equally. Engage them in your projects. Acknowledge when fellows come up with good ideas. Value their contributions and give them full credit for their efforts. Allow them equal access to opportunities in your program. Be a Sponsor  Connect your fellows with leaders in the field, encourage them to participate in professional societies, and recommend them for positions within these organizations. Provide letters of recommendation and reach out to your contacts to help them advance in their careers. Be a Role Model  We all learn by example, so be the best role model you can be. You will know you have done your job when your fellow becomes a better version of you—more successful and more skilled than you.

Summary As a mentor to almost 30 clinical fellows and a mother of three, I frequently equate the role of an educator and fellowship director to that of a parent [4]. When performing either function, you need to be tough but loving, provide guidance but allow autonomy, motivate but not impose, and give feedback but not lessen confidence. As a fellowship director, it gives me great satisfaction to see my fellows become successful ophthalmologists proud of their accomplishments. It is fulfilling to meet with fellows at scientific meetings, dinners, and other social occasions and share updates regarding their professional and personal life events. If you are an effective fellowship director, your fellows not only will be well trained and ready to join the workforce, but also will become your extended family and the best supporters and ambassadors for your fellowship program.

References 1. Aaron M, Levenberg P. The millennials in medicine: tips for teaching the next generation of physicians. J Acad Ophthalmol. 2014;7:e17–9. 2. Goldstein IH, Hribar MR, Read-Brown S, Chiang MF. Association of the presence of trainees with outpatient appointment times in an ophthalmology clinic. JAMA Ophthalmol. 2018;136(1):20–6. https://doi.org/10.1001/jamaophthalmol.2017.4816. J Surg Educ. 2012;69(2):149–55. https://doi.org/10.1016/j.jsurg.2011.08.003. Epub 2011 Oct. 3. Papandria D, Rhee D, Ortega G, Zhang Y, Gorgy A, Makary MA, Abdullah F. Assessing trainee impact on operative time for common general surgical procedures in ACS-NSQIP. J Surg Educ. 2012;69(2):149–55. https://doi.org/10.1016/j.jsurg.2011.08.003. 4. Blomquist PH.  Educator as parent: the 2019 Straatsma lecture. Ophthalmology. 2019;126(8):1073–4.

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H. Capó Hilda Capó, MD  is a Professor of Clinical Ophthalmology at the Bascom Palmer Eye Institute, University of Miami Miller School of Medicine in Miami, Florida, where she holds the John T. Flynn Professor of Ophthalmology Chair. She has worked as a clinician and educator for almost 30 years. Dr. Capó completed her medical studies, internship, and residency at the University of Puerto Rico, followed by fellowship training in pediatric ophthalmology and strabismus at the Wilmer Eye Institute, Johns Hopkins University, and in neuro-ophthalmology at New  York University. She is passionate about pediatric ophthalmology and adult strabismus, and enjoys providing medical and surgical care to her patients and sharing her knowledge and expertise with her residents and fellows. As a dedicated teacher, throughout the years she has participated in the training of over 200 residents and almost 30 fellows, and has been the Division Chief and Fellowship Director of pediatric ophthalmology and strabismus at the Bascom Palmer Eye Institute for the last 15 years. She has over 50 publications in peer-reviewed journals and an extensive list of national and international presentations, including named lectureships. She has participated with the American Academy of Ophthalmology as Chair of the Pediatric Section of the Program Committee and with the American Board of Ophthalmology as an examiner for the oral boards, most recently as a mentor examiner. As a Hispanic female born, raised, and trained in Puerto Rico, Dr. Capó understands the challenges that women and minorities face in career development and advocates for professional equality.

Chapter 31

Keys to Public Speaking Ripple Kakkar

Summary Points • Strong public speaking skills can make you a more effective communicator and accelerate your career trajectory. • Knowing your audience and rehearsing content are important components in preparing for a speech. • Incorporating deep breathing techniques and visualizing success are techniques that can help you overcome anxiety about public speaking.

Background Growing up, my family was very interested in current events and law. At an early age I learned the art of persuasion through effective communication and debate. My father, an engineer and immigrant from India, would frequently attend Toastmasters International events to work on perfecting his English. My father always believed that eloquent and confident presentation ensured success, regardless of the field. My older sister practiced speech and debate throughout high school, always working on her craft. I was able to watch and learn. In my house, we regularly discussed perspectives on current events and frequently challenged each other on our core assumptions underlying those perspectives. This created an opportunity for me to fully understand how individuals think

R. Kakkar (*) Retina Marketing, U.S. Commercial Eye Care, Allergan, an Abbvie Company, Irvine, CA, USA © Springer Nature Switzerland AG 2021 C. Y. Weng, A. M. Berrocal (eds.), Women in Ophthalmology, https://doi.org/10.1007/978-3-030-59335-3_31

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and make decisions, and how to see an idea from different points of view. Moreover, I learned to build critical listening skills, organize my thoughts, and verbalize my position. My siblings followed their passion for law and pursued careers as attorneys. I followed the finance and marketing route, having a background in public speaking from high school and a passion for the medical field. My career path has connected me with inspiring people from around the world largely because I have been able to overcome the anxiety of public speaking and conduct myself with the confidence needed to captivate an audience. Of course, this took years of practice, workshops and application. Few people have public speaking skills naturally, as these skills have to be honed or mastered through experience. However, anyone can develop these skills by building confidence through practice.

Overcoming Fear Decades of studies have shown that speaking in front of an audience is one of the most common fears among people around the world. This may increase with the rapid growth of and exposure to technology and screen time which requires limited face-to-face time or interaction with large groups. Regardless, even the most seasoned speakers can find themselves with a case of the butterflies before taking the stage. Knowing your content well, incorporating effective warm-up and deep breathing techniques, and visualizing success will all help address different levels of fear. • There are several warm-up techniques you can use to try to calm your nerves before speaking. These include arriving early, attending other speeches to understand the vibe in the room before your section, meeting with a few members in the audience to get a few quotes or inspiration, and taking a quick walk right before speaking. • Taking a few deep breaths will help get oxygen to your brain and relax your body during the actual speech. I now use the pauses to remember to breathe and speak slowly during the exhale. Remember in speaking, the power is contained in the silences between key messages. • Many of the top speakers will take time to visualize success and therefore focus their energy on how it will look and feel to achieve their goal. The power of positive visualization can be incredibly effective. Sometimes I think about progress toward that goal while pausing. This further allows time for a powerful silence during the speech. Relaxation is the key point. Everyone gets nervous—that is just human nature. When I think in context about real challenges in life, then how bad can speaking in front of an audience really be? As long as you are prepared, well rehearsed, and know your facts, nothing can stop you from overcoming your fears and delivering an effective presentation—even if you are a little nervous.

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Your Presentation Style Everyone has a natural presentation style. However, some styles are more effective than others. Fortunately, presenting effectively is a skill that can be developed. Successful politicians, actors, physicians, and business professionals have honed this skill over the course of their careers. Although you can develop your presentation skillset through trial and error, a more effective strategy may be to study the presentation styles of successful people. There is a wealth of content available online for review. TED Talks is a good source, and there are many others. While reviewing the presentations of others, concentrate on their delivery and the content. Consider these questions as you determine the effectiveness of their presentation: 1. Do I like the speaker? Given the opportunity, would I want to interact with the speaker further? 2. Do I trust the speaker? Do I think that the speaker honestly believes and stands behind the content of the presentation? 3. Do I feel an emotional or personal connection with the speaker? Would I consider supporting the cause presented? If you answer “yes” to all three questions while viewing a presentation, then consider the body language and style of delivery of the presenter. It may be valuable to incorporate some of these elements into your personal presentation style. As a parent of a child on the spectrum, I have learned to adapt my communication approach. This includes ensuring eye contact, asking targeted questions, providing a pause for response, and paying attention to visual signals. Ironically, these also apply to interactions with a large audience. Public speaking is never a monologue. Regardless of your unique style, you need feedback from your audience to ensure that they are following you along the journey as your speech unfolds. Some questions that you can ask yourself to gain confidence and clarity about your unique abilities include the following: • What challenge have I overcome or am overcoming that now defines me? • What are the common themes when I link a few wins, failures, or moments of truth over the last 10 years? • What are some observations from others about myself that have surprised me? Lastly, recall what it was like being the medical or business professional in the audience that is hungry for success. Use your unique abilities to tailor your message in a way that will resonate with this audience member.

Preparation and Delivery Rehearsing is just the beginning when it comes to preparing for an important speech or presentation. There is no such thing as being too prepared for a public speaking engagement. However, knowing your content is only one part of being prepared.

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• Frame your story. Think about how you will take your audience on a journey with you, to explore a collective issue or problem, “humans are wired to listen to stories, and metaphors abound for the narrative structures that work best to engage people. When I think about compelling presentations, I think about ­taking an audience on a journey. A successful talk is a little miracle—people see the world differently afterward”1 [1]. • Aim to shift perspective about your topic. As you develop your talking points, provide a framework as “many of the best talks have a narrative structure that loosely follows a detective story. The speaker starts out by presenting a problem and then describes the search for a solution. There’s an “aha” moment, and the audience’s perspective shifts in a meaningful way”1 [1]. • Know your audience. This is the most important part of preparation. Public speaking is not only an opportunity to provide information, but it is also an opportunity to persuade your audience and build your personal brand. From this perspective, every speech is a marketing effort which requires some segmentation to deliver the appropriate messages to each segment. “One size” never fits all. Ensure that your presentation is tailored to the interests of each audience to whom you deliver. This may only require small changes for each venue, but these small changes will help ensure audience engagement and message retention. • Practice your speech with distractions. The audience and venue environment are out of your control, and these elements do not have to control you. After you are very familiar with the content, rehearse your speech with the television or radio playing in the background, or while you are at home doing your daily routine. Allow the words to become second nature and flow freely in spite of various distractions. • Practice in front of a mirror and work on your gestures and body language. Most of the messages that your audience perceives are non-verbal. Body language that promotes confidence increases the engagement of your audience so that they are more likely to concentrate on the content of your presentation. • Slow down and take longer pauses. When we are nervous in front of an audience, we tend to speak rapidly to reduce our own anxiety. This makes our audience work harder to understand what we are trying to say. Most listeners view rapid speaking as a lack of self-confidence. Moreover, rapid delivery may also make them feel as though you are “force feeding” them information without giving them to opportunity to contemplate it. Make a conscious effort to deliver your presentation slightly slower than normal conversation. Use pauses to emphasize key points which will provide your audience time to process and remember the most important messages after your presentation. Allow your message to really sink in and resonate with your audience. • Use humor and emotion to personally connect with your audience. Many experts agree that emotional events are easier to remember and recalled with more detail. Providing content or an anecdote that your audience can relate to on an emotional level will make you and your speech more memorable. Humor can also be 1  Reprinted by permission of Harvard Business Review (Excerpt). From “How to Give a Killer Presentation” by Chris Anderson, June 2013. Copyright ©2013 by Harvard Business Publishing; all rights reserved.

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used to “break the ice” and connect with your audience. However, not everyone is a natural comedian. That does not mean you cannot slide in a joke or two, a humorous observation, or a personal story for good measure. Care should be used to ensure that the humor is appropriate for your audience and supports the message in your speech. “With one appropriate quip, you have told everyone within earshot that you know what you are doing” [2]. The ‘checkpoints’ for if humor is appropriate include [2] the following: –– –– –– ––

“Do you think it’s funny?” “Can you say it confidently and with comfort?” “Is there any danger of offending anyone?” “Will they understand and appreciate it?”

• Project confidence during your delivery. It has been said that the art of the selling process is the transference of enthusiasm from the seller to the buyer. Your goal when delivering a speech should be to have your audience walk away with your same level of enthusiasm about your content. The crucial component of this transference is your audience’s perception that you are confident in your subject matter and that you are the best person to deliver it. More people will respond to what you have to say when you convey your message confidently on a personal level and show them that you sincerely believe in your content.

On Becoming a Leader It is not always easy to be a leader as a woman. This can be especially true when standing at a podium in front of an audience that can be largely made up of men. Leadership expert Cari Haught Coats shared her thoughts in an article recently published in Forbes [3]: Harvard Business Review recently published an article on research showing that women score higher than men in most leadership skills. Yet we continue to have a dearth of women in senior positions of power and authority. Many women seem to stall in middle management. It is a problem that many are trying to solve. I believe the answer can be found in just two words: grit and grace. More specifically, it is the synthesis of the two that can be the rocket fuel that accelerates women to the top. According to Merriam-Webster, grit can be defined as ‘firmness of mind or spirit: unyielding courage in the face of hardship or danger.’ The definitions of grace include ease of bearing and ‘disposition to or an act or instance of kindness, courtesy, or clemency.’ Within the context of these definitions, think of a woman you respect as a leader. Does she have these traits? My guess is that the answer is a resounding ‘yes’. Grit and grace, together, can be formidable for women in the leadership game. They provide women with their own road map to success that allows for bold leadership combined with warmth. If you think of the combination of grit and grace as a recipe, grit would be the cake. Grace would be the icing.

Statistics show that when a woman speaks up early in a business conversation, it is more likely that additional women will speak up during that conversation as well.

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This is just one example of how successful women can support each other with the understanding that all of our leadership roles are hard-fought and no two people have the same journey. I have a tremendous amount of respect for other women in leadership roles and I am reminded of the importance of listening and seeking feedback from others, rather than competing with them. The higher that one climbs in any organization, the less available are the sources of immediate feedback. In spite of this, it is important to seek out ideas from others to remain in tune with your team, peers, and customers. Many of us are averse to asking for feedback, especially if it may include constructive criticism. However, this feedback is essential to ensuring that our growth as a leader is relevant to the people with whom we interact. Glenn Llopis provides this perspective in her Forbes article: “Leadership is about seamlessly being able to reinvent yourself, your organization and the people who serve it—all at the same time. If you or your organization’s leaders lack this a­ bility— it’s time for a refresh”2 [4]. I have lived and worked on both coasts and in the Midwest of America, with many career changes and job responsibilities. Through these events, I have learned the art of survival and confidence to reinvent myself on several occasions. I have accepted unpaid internships to gain the critical experience and skills that I needed to attain my next goal. Also, I have made lateral moves to build new skills, learn new markets, and expand my network. Of course, I failed on multiple occasions—sometimes spectacularly. All of these events were opportunities to learn, grow, and refine the path toward my goals, and every new challenging role was an opportunity to stretch myself and to test my potential. No one can reach their full potential alone. Teams with diverse backgrounds, skills and viewpoints are much more effective than the most capable individual. As a leader, it is up to you to recognize other people’s unique strengths and bring them together for maximum impact. Just like a conductor blends the instruments of an orchestra into a beautiful symphony, you must blend the strengths of your team to succeed at the highest level.

References 1. Anderson C. How to give a killer presentation. Harvard Business Review [Internet]. 2013 Jun [cited 2019 Dec 31]. Available from: https://hbr.org/2013/06/how-to-give-a-killer-presentation. 2. Monkhouse B. Just say a few words: the complete speakers handbook. New York: M Evans & Co; 1991. 3. Coats CH. Grit and grace: a power combination for women leaders. Forbes [Internet]. 2019 [cited 2019 Oct 14]. Available from: https://www.forbes.com/sites/forbescoachescouncil/2019/08/12/ grit-and-grace-a-power-combination-for-women-leaders/#6eaa1d50404a. 4. Llopis G.  Eight clear signs it’s time to make a leadership change. Forbes [Internet]. 2013 [cited 2019 Oct 14]. Available from: https://www.forbes.com/sites/ glennllopis/2013/11/25/8-clear-signs-its-time-to-make-a-leadership-change/#1f59a6f610ef.

 From Forbes.com. [https://www.forbes.com/sites/glennllopis/2013/11/25/8-clear-signs-its-timeto-make-a-leadership-change/#1f59a6f610ef] © 2013 Forbes. All rights reserved. Used under license.

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241 Ripple Kakkar, MHA  is a results driven and accomplished medical devices and pharmaceutical leader with a proven and award-winning track record across brand strategy, sales, marketing, and financial analysis, as well as an inspirational public speaker. She leads Retina marketing at Allergan, an Abbvie Company, in Irvine, CA. Growing up in Southern California, her family had a major influence on her love of public speaking and debate. After completing her Bachelor’s degree in Neurobiology at the University of California, Berkeley, Ripple went on to earn a Master’s degree at the University of Michigan, and completed Exective Education at the Kellogg School of Management at Northwestern University. She has driven strategy across multiple companies to successfully transform brands to meet market demand and create value. She brings a diligent and fast-paced level of innovation to address complex issues, overcome hurdles, and create lasting compelling solutions.

Part IX

Career Advancement

Chapter 32

Getting Promoted to Associate Professor Christina Y. Weng

Summary Points • Academic promotion to Associate Professor is an important step in one’s academic career and requires preparation, planning, persistence, and patience. • Treat your curriculum vitae like a living document and update it frequently. • The academic dossier often consists of your curriculum vitae, letters of support, a portfolio of your work, a personal statement, a departmental and chairperson endorsement, and institutional forms.

Introduction So you’ve landed your dream academic position and are starting to settle into your multiple professional roles as a clinician, surgeon, teacher, mentor, researcher, and peer. Before you know it, a few years have gone by, and you may find yourself wondering about the direction of your career and next steps. For every academic ophthalmologist, one of those “next steps” is rank advancement, a process that, until recently, seemed ambiguous and mysterious to me. I hope that by sharing my own experience in this chapter, it will help demystify the academic promotions process for others. Why bother to pursue this arduous process in the first place, you ask? Academic promotion is important for several reasons. It is a way that your institution formally acknowledges your academic contributions and value; it can affect your salary or

C. Y. Weng (*) Vitreoretinal Diseases & Surgery, Department of Ophthalmology, Baylor College of Medicine, Houston, TX, USA © Springer Nature Switzerland AG 2021 C. Y. Weng, A. M. Berrocal (eds.), Women in Ophthalmology, https://doi.org/10.1007/978-3-030-59335-3_32

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financial benefits; there may be a stipulation on how long you are able to remain in a certain rank as a faculty member; it serves as an external signal of your achievements and career position; and it might affect opportunities made available to you. Interestingly, while females represent 42% of all medical school full-time faculty members in the United States, they hold nearly half (49%) of the lower rank positions (Instructor and Assistant Professor), but only 32% of the upper rank positions (Associate Professor and full Professor) (Table  32.1). There are many potential explanations for this disparity, and while these are beyond the scope of this section, this gender gap in academic rankings can have downstream effects on financial compensation, industry opportunities, and leadership positions. Thus, I would argue that an important part of achieving gender parity in our specialty involves achieving gender parity in our titles. I was promoted from Assistant Professor to Associate Professor with tenure last year. While every person’s promotions process will vary depending on the institution, focus, and individual, there are some general actions one can take to increase the likelihood of success. Reflecting on my personal experience, I will highlight what went well in addition to where I stumbled along the way.

Get an Early Start It is never too early to start thinking about promotion. We often get wrapped up in establishing our clinical practice and research during those first few years and tell ourselves that we will focus on things like promotion later on “when we have more time.” Lesson learned: We will never have more time! So start thinking about this from day one. In fact, before you even sign your contract, clarify what your entry rank will be. Many institutions will start faculty off as an Assistant Professor, but some may start you off as an Instructor which would mean an additional step in the rank ladder. Here are some other things to focus on during your first few years on faculty: • Get involved, but stay focused Work with your ophthalmology or subspecialty societies. Accept leadership roles that interest you. Make yourself available for lectures (invited lectures, Table 32.1  US medical school full-time faculty by sex and rank, as of December 31, 2019 Rank Professor Associate Professor Assistant Professor Instructor Total (including unreported ranks)

Male 28,595 22,481 43,628 6,503 103,404

Female 9,874 14,216 39,489 9,396 75,771

Total (including unreported) 38,478 36,712 83,150 15,903 179,238

Source: Association of American Medical Colleges. https://www.aamc.org/data-reports/facultyinstitutions/interactive-data/2019-us-medical-school-faculty

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especially at the national level, are particularly important for promotion). Get your research off the ground and say yes to writing opportunities (publications are arguably even more important). All of these things will give your dossier the substance it needs. However, it is important to remember that you need both breadth and depth. The academic “stool” traditionally has three legs: patient care, research, and teaching. A professional development advisor told me that one of the biggest mistakes people make is doing good work in all three legs, but not excelling in any particular area. Many institutions will ask you to select a primary (often denoted as a “track” as discussed below) and secondary area of focus; those are the areas where they will want to see evidence of excellence. If you have some accomplishments in the third area, it’s a bonus. One caveat to this is that some institutions only offer a single track to promotion: research; however, this is changing as universities are recognizing that faculty may have different interests that still support the mission of the institution. Along these lines, start thinking about your academic niche; I was told that this is less important for promotion to Associate Professor than it is for promotion to full Professor, but the promotions committee likes to see a cohesive story in your body of work. • Decide on tracks and tenure Most institutions offer specific promotion tracks; for example, I chose the clinician-­educator track, meaning that my primary focus was on patient care and my secondary focus was on teaching. Someone with a lab and an NIH (National Institutes of Health) grant may choose instead to be on the research-clinician track where the primary focus is on research. The chosen track is important because it defines the areas in which you will be expected to demonstrate expertise, and it can also modify specific requirements such as the number of publications necessary. The other distinction that should be discussed is whether or not you are seeking academic tenure. Historically, tenure had certain implications in terms of financial and academic security. However, this seems to be evolving, and tenure may not hold the same meaning it once did; I recommend speaking with your university to learn the differences between tenured and non-tenured positions at your institution. At mine, the promotions process for a tenured position is more rigorous than that for a non-tenured position, even though tenure does not render a financial advantage. If you choose to seek tenure, it is often granted at the level of Associate Professor, which makes the promotion to Associate Professor a critical and special one! • Learn about the process Speak with mentors and colleagues who have gone through this process already. Tap the many great resources available in the form of books [1] and online content. Many universities have an office of professional development that can guide you through an academic promotion. At ours, they even host workshops to teach you how the process works and how to build your curriculum vitae (CV); take advantage of these if they are available. Being familiar with the institution’s criteria is critical so that you do not end up facing a roadblock like I did. Just as I thought I was ready to begin preparing my dossier, I learned that the

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institution rarely promotes faculty without a certain institutional award. I had not yet applied for that award, and its application cycle occurred only twice a year, so my promotion was deferred for several months. Proactively familiarizing yourself with the process will help you avoid a similar delay. • Actively discuss your timeline with your chair Your chairperson plays a critical role in the promotions process. Not only does the chair need to support you throughout, but she or he is the actual person who presents you to the committee. Therefore, planning must happen in a joint fashion—sit down with your chair once or twice a year and share your goals and timeline for promotion. Make sure your chair agrees, and ask if she or he has any recommendations for what you need to do to stay on track and strengthen your candidacy. • Save all evaluations and compliments Regardless of what track you pursue, you will need to build a portfolio demonstrating expertise and excellence in your focus area. This extends beyond simply listing your activities—they want to see evidence! This means that course evaluations, audience comments, student feedback, and even informal compliments are important to include. Trust me, digging up these items years after the original events was painful, so start saving these now. File away any sort of feedback you receive for an activity with which you were involved or led. Clarify whether patient-originated materials can be included in your portfolio, as some institutions do not allow their submission even if de-identified. • Update your CV frequently By far, the most time-consuming part of my promotions process was getting my CV updated. I realize now that it would have been much easier to have treated it like a living document all along; if you take away one thing from reading this chapter, this should be it! First, make sure that your CV is formatted per university guidelines. Each institution has its own layout, headings, and even font requirements, so format your CV properly from the start. Then, with every publication, meeting, talk, and award, update it right away. I promise that this will make your promotions process infinitely easier down the road.

Determining When to Make the Jump As discussed above, the decision of when to initiate the promotions process should not come as a surprise to yourself or your chairperson. It should be a carefully calculated point in a years-long timeline, and you should view this as an overarching “deadline” for yourself. The optimal time to initiate the process depends on many factors, including the faculty member (and strength of her portfolio), the institution (some institutions rarely promote faculty before a minimum amount of time spent at their current rank), and the chosen track or tenure status (affects stringency of criteria). I learned that at my institution, you only have one chance to secure tenure;

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if you are presented and denied promotion, you will not be able to apply for tenure again. Based on my discussions with colleagues, it seems that most aim to be promoted to tenured Associate Professor around year 6 or 7. If your institution has a strict tenure clock (meaning that if you do not achieve tenured Associate Professor rank before year 10, it could jeopardize your ability to remain employed there), this is something to keep in mind as well. The overall promotions process will take approximately 6–12 months on average, requiring patience and persistence. The promotions committee only meets a finite number of times per year, so once you decide that you are ready to initiate the process, ask your chairperson about those dates. Note that your promotions packet is typically due at least a couple of weeks before the committee meeting date, so carefully track all these deadlines.

Putting Your Dossier Together The dossier essentially refers to the entire packet of documentation submitted to the promotions committee. This will consist of your portfolio(s), letters of support, CV, and all other supporting materials. Remember that several of these items are dependent on other people, so be sure to request these things early and send reminders accordingly. • Curriculum vitae In addition to the usual elements of a CV, an academic CV includes components you might not currently have listed such as research grant sponsors and funding amounts, previous trainees and where they currently are working, professional development activities such as teaching workshops, and leadership roles. Additionally, all abstracts, presentations, and lectures require the full meeting name, event date, and location. I remember having to dig back years to retrieve this information—not fun! Please also refer to the prior section for CV formatting tips. • Letters of support Check out your institution’s requirements regarding who is eligible to write these and how many are needed. I was surprised to discover that none of my letter writers could be internal faculty or faculty with whom I had collaborated/ worked in the past. For example, neither your senior cornea colleague nor your residency program director would be appropriate. All your letter writers should be above your current rank, and should be well-respected figures who can speak to your accomplishments, reputation, and future potential as an academician. Colleagues who share your academic interests and know your work are ideal. One advisor told me that the purpose of these letters is to show that you have established a reputation in the field. Your chairperson will generally ask you for a list of potential letter writers (typically more than the number of letters necessary), and then request the letters

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on your behalf. Be ready to share your CV and personal statement. Remember that everyone is busy, so do not hesitate to reach out to your chairperson’s administrative assistant frequently to check on the status of your letters as I found this to be the most rate-limiting step in the process. Portfolio and supplementary material A portfolio is a body of evidence and will be required for at least one of your focus areas. For instance, a teaching portfolio is where you will include your course evaluations, student comments, and samples of your work. You will also need to convey your impact as a teacher; pre- and post-activity test or self-assessment scores are an example of this. Include as much detail as possible (citations, screenshots, website links) and organize the portfolio to make it easy to navigate. This is your opportunity to showcase all that you have done. A major educational initiative you spearheaded which occupies one line on your CV can easily be overlooked, so use your portfolio to emphasize its complexities and the important role you played in its execution. Chairperson letter Your chair will need to formally express her or his support of your promotion and offer qualifying statements about your accomplishments and contributions to the department. As with your other letters, aim to have this completed far in advance of the submission deadline. Institutional forms Some institutional forms (confirming your start date, verifying your educational background, etc.) may need to be completed as part of your packet. Tend to these early on because they often require data entry and signatures from executive-­level administrators and can therefore take more time than you expect. Personal statement At my institution, inclusion of a personal statement was optional. If you do write one, it should succinctly highlight your professional achievements, interests, and career goals. It should complement, not simply reiterate, your CV and portfolio. Internal promotion committee endorsement Another requirement that caught me off-guard was the internal promotion committee endorsement. This may not be universally necessary, but be sure to verify either way. An internal promotion committee is formed by members within your own department who collectively signal to the university-level committee whether or not you are ready for promotion based on specialty-specific standards. Because this committee has its own meeting schedule, acquiring this endorsement may take many weeks. I would recommend sending them any requested documents (I was asked for my CV and personal statement) as early as possible. On a side note, informally running your CV and portfolio by a member of this internal committee from time to time may be a good way to gauge your readiness for promotion.

Once these materials are ready, proofread them carefully and ask at least one other person to do the same. Do not let something like a spelling error tarnish the

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quality of your dossier that you have worked so hard to put together. Then, send these documents to your chairperson’s designated contact (do not wait until the last minute). That person will compile all elements and submit them to the promotions committee. I would follow up in a few days to verify receipt if a confirmation was not provided. Then, get ready for…

The Big Day! The culmination of your months-long preparation is when your chairperson presents you and your dossier to the promotions committee behind closed doors. This is a big deal, even for the chair. At my institution, all the chairpersons presenting that day line up outside the meeting room and are granted entry one at a time. Once before the committee, the chair will present you to the room. Each committee member will have reviewed your dossier beforehand. Following the presentation, a discussion ensues, leading to a final vote. My chair was kind enough to share the good news with me post-meeting, but this may not always happen because the decision at this point is not finalized. Assuming that the committee has voted to promote you, the decision will still need to be rubber-stamped by the Board of Trustees; at my institution, this does not happen until 2 months later! As I stated earlier, patience is key in this process.

Celebrate Your Accomplishment Once you have official word of your promotion to Associate Professor, celebrate! But remember all the people who helped you navigate this journey and be sure to thank them. Update your letter writers with the good news and a note of appreciation. Share your gratitude with all the administrative personnel with whom you worked. It’s OK to give yourself a short period of “time off”—you deserve it—but be sure to regain focus. Don’t become complacent in your tenured role; keep working hard, continue treating everyone with kindness and respect, and start thinking about your next promotion because it will be here before you know it. Until then, relish your accomplishment. And when you sign off as “Associate Professor” for the first time on an e-mail or letter, smile knowing how much effort went into this and be proud of yourself for achieving such an important academic milestone.

Reference 1. Cain JP, Stevenson DK. How to create your package for promotion. In: Roberts LW, editor. The academic medicine handbook. New York: Springer-Verlag; 2013. p. 357–67.

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C. Y. Weng Christina Y.  Weng, MD, MBA  is an Associate Professor of Ophthalmology and the Vitreoretinal Diseases & Surgery Fellowship Program Director at the Baylor College of Medicine in Houston, Texas. She has a faculty appointment at the Level 1 trauma center, Ben Taub General Hospital, where she is the Director of Medical Student Clinical Electives and Physician Champion of the Diabetic Retinopathy Teleretinal Screening Program. She is a prior recipient of the Dan B.  Jones Teaching Award. Dr. Weng graduated cum laude from Northwestern University and then went on to medical school at the University of Michigan where she was elected to the Alpha Omega Alpha (AOA) Medical Society. While in Ann Arbor, she pursued an MBA degree from the University of Michigan-Ross School of Business and graduated with high distinction. Dr. Weng completed her ophthalmology residency at the Wilmer Eye Institute-Johns Hopkins University and surgical retina fellowship at the Bascom Palmer Eye Institute-University of Miami. Dr. Weng is involved with multiple clinical trials such as the DRCR Retina Network diabetic retinopathy trials and the AGTC Phase 1/2 subretinal gene therapy studies for congenital achromatopsia. Her other research interests include clinical/surgical outcomes, medical economics, healthcare quality metrics, and telemedicine. Dr. Weng is active in the American Academy of Ophthalmology (AAO), Retina Society, Association for Research in Vision and Ophthalmology (ARVO), and Vit-­Buckle Society. She serves on the Board of Directors for the American Society of Retina Specialists (ASRS), American Society of Cataract and Refractive Surgery (ASCRS), and Women in Ophthalmology.

Chapter 33

A Less-Paved Road: Switching Careers and Taking an Unorthodox Path Anne E. Fung

Summary Points • Follow your curiosity and seize opportunities. • Learn from challenges and strengthen your natural abilities. • Remember what matters most.

From one angle, my training and career are conventional (and admittedly fortunate) with college in the Northeast, medical school in New York, residency at Stanford, a fellowship at Bascom Palmer, and then into a functional, productive private practice partnership. Yet from another angle, Chinese studies major/economics minor, Hong Kong newspaper marketer, private multispecialty practice partner for a decade, resident research chair, and now biotech global development leader may seem less conventional. And both of these are my journey. Curiosity, opportunities, and a deep wish to make a difference have brought me this far along this path – and these same drivers will likely keep showing me even more adventures in the future. The idea of helping others as an ophthalmologist was an early seed. I was raised on my father’s stories of making a difference – one patient at a time – at the dinner table. Patients were his “portal to the world” and he equally enjoyed the opportunity to learn about their corner of the world and to provide medical and surgical care to fix a complex retinal detachment or to treat neovascular age-related macular A. E. Fung (*) Medical Retina Consultant, Pacific Eye Associates, California Pacific Medical Center, San Francisco, CA, USA Global Development Lead – Port Delivery System, Ophthalmology Clinical Science, Genentech, Inc., South San Francisco, CA, USA © Springer Nature Switzerland AG 2021 C. Y. Weng, A. M. Berrocal (eds.), Women in Ophthalmology, https://doi.org/10.1007/978-3-030-59335-3_33

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degeneration (AMD). The joke in our home went something like, “Anne can be whatever she wants to be – a cornea specialist, glaucoma specialist or even a retina specialist…” And yet, the first opportunity to be different came during college  – when it became apparent that medical school pre-requisites could be fulfilled during elective course time if I selected an interdisciplinary major such as Chinese studies with a minor in economics. Chinese studies allowed me to understand the culture and history that I was born into through studies in political science, economics, history, and language. I loved learning more about the land of my ancestors – a land that I felt distant from as a third-generation-born American. And economics … well, I don’t recall how I ended up in Econ, but learning about supply, demand, and the subsequent impact on prices has forever changed how I experience the world. As senior year progressed, this learning felt entirely academic and insufficiently experiential, and thus the next opportunity was born. Seeking real-life experience in Asia, I reasoned that working in the media would give me wide exposure to Chinese culture and a new city in a short time. Canvassing every English-language newspaper, TV, and radio station with my resume amazingly turned up positive responses  – lucky for me, an ability as a native English speaker and writer was in high demand! Three months after graduation, solid MCAT scores in my back pocket, I set off for Hong Kong with a friend and a marketing job at the Hong Kong’s Standard newspaper. Working to help produce promotional events such as US movie premieres (yes, we entertained the stars!), student debate contests, interactive events across radio and the paper, and working alongside Hong Kong natives in a newsroom that mixed Cantonese and English was thrilling, rewarding, and intense. Yet my belief that the media could serve an important role in educating the masses became challenged when I learned that section cover stories could be bought and essentially written for the sponsor. At that point, my calling to medicine was cemented; if I was going to work 10-h days, at least I knew I could make a difference one life at a time as a physician. My ability to care for and to educate a patient about her disease could have the impact that I sought. And so – fax, FedEx, and interview flights at the ready – I applied to medical school from Hong Kong and completed 2 years at the newspaper. Medical school in New York City and residency back in California afforded the next interesting opportunities; working in Stanley Chang’s basic science lab culturing fibroblasts onto explanted silicone oil, Jack Coleman’s ultrasound lab, Harvey Fishman’s lab with retinal pigment epithelial cell culturing/transplantation, and presenting at ARVO each year deepened preclinical and clinical research experience. And in balance, living in dynamic cities through which Asia friends transited continued the exposure to a world outside medicine, each friend bringing a different look into the lifestyles and beliefs of their worlds. Eventually I realized that this interest in people and different lives was introducing me to the worlds of my patients – helping me to understand the perspectives from which they came, educational levels that impacted their comprehension of information, and their different relationships with health, disease, and their bodies – so that I could tailor words and care for each patient. I also became interested in how research was (or not) taught in

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a methodical fashion to medical students and residents. After hearing “Use a manuscript that you liked to learn how to write a good paper” and “Just do research” as guidance for our resident research projects, I thought “I will make sure my residents someday can have better resources if they want them…” The next major opportunity came during a gap year before fellowship. A chance encounter with Harry Flynn at ARVO that year led to a medical retina fellowship with Philip Rosenfeld and Carmen Puliafito during a particularly dynamic year. Stephan Michels had completed the design and protocol for Rosenfeld’s PrONTO investigator-sponsored trial (IST), so my task was to assist with recruiting, enrolling, and following 40 patients to record vision and optical coherence tomography (OCT) changes on days 1, 2, 4, 7, and 14 after their first and second injections of ranibizumab (Lucentis). The Phase 3 studies of Lucentis were completing at that time and OCT was still emerging as a must-have tool for monitoring AMD, so the community was still unaware of the efficacy of ranibizumab to improve vision and anatomy. PrONTO revealed that anatomic and vision improvements were evident as early as day 1; our image montages summarizing change over the first year were the community’s first visualization of the effects our patients were experiencing with the emergent anti-VEGF era. The montages produced during late night click-click-­ outline-copy-paste-align sessions that wore through the paint on my Dell laptop pointer button were garnering wide attention and I found myself being pushed ahead by a tidal wave of interest in this new tool for neovascular AMD treatment. Popping out of fellowship, the rapid pace continued with research analyst calls, development of my own IST ideas and proposals, starting clinical practice, and trips for the Genentech Lucentis speaker’s bureau. One might think that opportunity drove the pace, and yet, I also had a personal curiosity to see how much of my professional success was proximity to my father versus my own work. I loved working with leading international minds on cracking our understanding of nAMD pathophysiology and understanding how these novel anti-VEGF tools (ranibizumab and bevacizumab) could best be used to treat our patients. It so happens that my personal and professional loves converged in time; my husband and I were married on July 1, 2006  – the day after ranibizumab was approved by the FDA. At the age of 35, I felt young, invincible, and was passionate about my career. My new husband was and continues to be incredibly supportive and proud of my work – so it was work that I prioritized. Seeing several 40+ female physicians in the hospital with newborn babies -sometimes twins – gave me confidence that family could wait; I mistakenly thought the rumors of “the clock is ticking” were inflated and ironically called manuscripts “my first children.” My mother is one of the most influential individuals in my life – an extremely talented calligrapher, potter, chef, registered dietician, CEO of my childhood home and dedicated mother to me, her only child, gave me a deep security, confidence, and myriad skills in the arts, language and science. Paying this forward as a mother to my own children was a lifelong priority and wish; unfortunately, when the time felt “convenient and ready” to have children, biology thought differently. Life was then complicated by a few years of intensive work with fertility specialists, but we were finally blessed with the arrival of our daughter and 2  years later, our son.

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Looking back, I am not sure how I would have done things differently, but today, technology has progressed and options to defer fertility are thankfully more available.

Tipping Points: Handling Different Balances On Parenthood and Career For me, being a “present” mom – as my stay-at-home mom was for me – was an unspoken responsibility that I felt and continue to feel strongly. Yet being a full-time clinician, business partner, head of the research department, active author and presenter, wife, and mom of two young kids added up to more than I could manage. I made the decision to give up research – because helping to manage the practice and to see patients were not optional work, while research was. And I was content. But then serendipity brought me to a night of frustration when a pivotal LinkedIn e-mail crossed my inbox – “Genentech is looking for you”… I laughed, and yet, I clicked. “Ophthalmology Medical Director” – I laughed and clicked again. “Leading the Investigator Sponsored Trial program, identifying and answering clinical questions to inform patient care decisions”… This time, a text to a friend ended in a realization that maybe I could do things differently – perhaps I could shift the balance and do more research and less patient care. Now 6 years into my work at Genentech, I continue to be wonderfully challenged and inspired. What a privilege it is to learn from experts in every field around me – from protein engineers who stitch amino acids together for bespoke molecules, to biostatisticians whose minds work in a mathematical fashion that I only dream of and who are able to translate mathematical concepts into English for me, to product technical colleagues who teach about the eleven Singapore-origin “quality” drug batches required for FDA submission – years ahead of expected patient need – to managed care colleagues who have opened up windows so that I can see different US health systems from the inside – integrated delivery networks, commercial payers managing risk for companies – to Medicare supporting a growing US retiree population without bankrupting the system. And importantly, the opportunity to work closely with our most respected retina colleagues  – to amplify their good thoughts, to support their great hypotheses, and to give them a voice. And yet I keep those threads that are most meaningful to me – my patients and resident teaching. I am privileged to still have the opportunity to be a physician to Florence, Donna, Pearlie, Chef, Chris, Shirley, Edna, Dr. Lyon, Jack, Roy, and many others. I love staying close to patient care – to watch the biology unfold with our various agents and to see the layers of the macula at increasingly fine resolution so that we can understand the original drivers of disease – and hopefully one day, truly mitigate them. My residents continue to inspire me with their questions and new perspectives. I hold to the conviction that teaching effectively helps residents not

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have to recreate the wheel; by not recreating, their energies can be devoted to expanding the field’s knowledge.

Helpful Tools Along the Way Crystallizing What Matters Most  In seeking help to more gracefully navigate aging with my parents, an elder-care social worker directed me to read Atul Gawande’s book Being Mortal [1]. Dr. Gawande’s words have deeply impacted my approach to patient care and my family – asking patients about what activities/lifestyle they value most, orienting our care around those goals, and taking stock of what matters most to the individuals in my family and myself too have helped us to orient our time and resources to achieve them. It has clearly emerged that time together – me with the kids, my husband, my parents – is our main priority, and so I draw on technologies around me such as Instacart to pick and deliver groceries or an occasional Lyft ride so that I can work during commute time. Earlier in my career, the “rocks, pebbles, sand” exercise [2] became a staple – ensuring that we don’t first fill our “jars” with sand (i.e., the small things that take up space); rather that we first put in what matters most – the rocks, followed by pebbles, and lastly sand – helps us to ensure that there are space and energy for priorities and to let go of lower-priority small tasks. Here’s a diagram for you to work with, drawn by my son Charlie. What would you write on the big rocks? (Fig. 33.1). Writing Out Your Lifeline  This tool requires only a pen and paper or whiteboard. Draw a line – on the left, write this year, with your age and the ages of the people who matter to you. Then space out 5 year increments and keep adding up the math for you and the others. Soon, you’ll see how time and age might change how you think about what matters most, and when. Who else? My age 2020

2025

2030

2035

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2045…

Words to the Wise If you are reading this chapter, you have been blessed with gifts and skills that can make a big difference in this world. Now, it’s your choice to reflect on what matters most to you, what most piques your curiosity, and how these fit into your lifeline. Opportunities to take different paths will present themselves to you at surprising moments. If you do decide to make a change though, always remember to be fair to your partners – both personal and professional. Understand that your decision may

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Fig. 33.1  Rocks, pebbles, sand: orient life around your core values and what matters most. If these are your ‘rocks’, have they been the first to fill your ‘jar’?

have serious impacts on their lives and be sensitive in the midst of your excitement. Plan ahead for a smooth transition, and do not burn bridges. In parting, a few summary thoughts: • • • • • •

Follow your curiosity Dare to be original and to take smart risks Be fair to your partners Learn from challenges and strengthen your natural abilities Anchor to your lifeline Remember what matters most Enjoy the journey!

References 1. Gawande A.  Being mortal: medicine and what matters in the end. New  York: Metropolitan Books, Henry Holt and Company; 2014. 2. Rocks, pebbles, sand. https://www.uh.edu/~dsocs3/wisdom/wisdom/lessonsoflife.pdf.

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Anne Fung, MD  leads the global development program for a small, surgically implanted device being investigated in Phase 3 trials for patients with neovascular age-related macular degeneration and diabetic eye disease and continues to care for patients with medical retina diseases in San Francisco. She appreciates the opportunity to bring the first-hand perspective of patients and their needs in the private practice setting together with the talented team of scientists, biostatisticians, product engineers, and other collaborators to develop new therapeutics and get them to patients safely and quickly. Prior to her role as Global Development Lead, Anne served as the Head of Ophthalmology U.S. Medical Affairs team connecting Genentech’s research science to clinical retina practice so that physicians and payers can better care for patients. Anne joined Genentech in 2014 to help guide the Medical Affairs group in identifying and answering timely clinical questions for Lucentis and lampalizumab. Since 2005, Anne has been active in private practice at Pacific Eye Associates/California Pacific Medical Center in San Francisco where she led the clinical research program, serving as primary investigator on two of her own investigator-­sponsored research trials in neovascular age-related macular degeneration (AMD), site primary investigator for several multi-center trials, and director of the CPMC resident research program. Anne’s academic interests include therapeutics and diagnostics for age-related macular degeneration, resident research education, and journal publication standards. Anne is an active member of the Macula Society, Retina Society, Women in Ophthalmology, Women in Retina, The CONNECT Network, the Association for Research in Vision Ophthalmology (ARVO), the American Academy of Ophthalmology (AAO), and the American Society of Retina Specialists (ASRS). A graduate of Wellesley College and Cornell University Medical College, Anne completed her Ophthalmology residency at Stanford University Medical Center and a fellowship in Medical Retina at the Bascom Palmer Eye Institute in Miami.

Chapter 34

Setbacks and Second Chances Tamara R. Fountain

Summary Points • No one escapes failure, rejection, or other setbacks in life. • Rejection may have to do more with timing and fit than your ability. • Failure can help you grow both personally and professionally. Failure is not an option.

This is a famous paraphrased quote ascribed to a flight controller on the Apollo 13 mission. What may not have been an option for that rocket scientist is most certainly an option realized in everyone’s life at one time or another. If failure is so universal, why don’t we hear more about this most basic of human experiences? Medicine is one of the most competitive professions in the American labor landscape. Most of us would not have made it into or out of medical school and residency if failure had been a common professional experience. But eventually, failure—and its experiential cousins, rejection and denial—will touch all our lives in some way. No one is immune—not the chair of a department, CEO of a health system, or president of a medical society. If we all recognized how common failure is, and how healthy it can be for a life well-lived, perhaps we wouldn’t be so fearful or stigmatized by it. Here is one story.

T. R. Fountain (*) Department of Ophthalmology, Rush University Medical Center, Chicago, IL, USA Ophthalmology Partners, Ltd., Deerfield, IL, USA © Springer Nature Switzerland AG 2021 C. Y. Weng, A. M. Berrocal (eds.), Women in Ophthalmology, https://doi.org/10.1007/978-3-030-59335-3_34

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Bones and Blood As the end of second year of residency neared, I’d settled on pursuing a cornea fellowship—not so much a reflection of overwhelming anterior segment enthusiasm but more a visceral avoidance of retina, glaucoma, and peds, three rotations that had failed to ignite any passion at that point in my residency. My third year began with the plastics rotation. Yes, my program did not introduce residents to this discipline until third year. When I saw the bones, the blood, the saws, hammers, and screws, it hit me—I was actually an orthopedic surgeon in an ophthalmologist’s body. I pulled out of the cornea match and set about pursuing my new dream of oculoplastics. I encountered my first hurdle. Then, as now, the American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) match was early, during a resident’s second year. As a third-year resident, I was already a year behind. This wasn’t the deal-breaker one might have thought it would be, however. I just had a baby in the spring of second year; I was beginning my last year of residency as a new mom. Applying late would create a perfectly timed maternal gap year between residency and fellowship. I couldn’t believe how my newly hatched plan was falling into place. I knocked out several fellowship applications before the holidays. By February of third year, I had snagged seven interviews and started researching flights to visit each program. Oh, and did I mention that by this time, I was pregnant again? I hit the interview trail 7 months pregnant looking smart in a brand-new navy maternity suit. At one interview, famously conducted along with the fellowship director’s wife, I was peppered with several questions, apparently lifted from the manual of Questions Illegal to Ask in any Job Interview—“You’re pregnant, right?” (No, I just love cake.) “Are you planning to have more children?” (No, but neither have I planned the two I’ve conceived so far.) “What does your husband think about you doing a fellowship?” (I don’t know, he thinks I’m visiting my parents right now.) The questions are real, the parentheticals were what I wished I had said. I fielded each inappropriate question with diplomacy and restraint. Except for that interview, no preceptor seemed to make a fuss about my pregnancy. I certainly didn’t. I wouldn’t be pregnant by the time I started fellowship in a year and a half (I’m not an elephant after all), and like legions of working mothers before me, I too would find suitable childcare arrangements so I could devote the time and energy needed during fellowship. I was not naïve about the challenges, but I was committed to obtaining ASOPRS training. I returned from interviews exhausted, but nonetheless optimistic about my future.

Derailment When the decision letter came in the mail (e-mail was still years away), I was prepared to be happy wherever I matched though I hoped for one of my top three. I was not prepared for the letter I received. I did not get any of my top three—I didn’t get any of my top seven. I had failed to match. Anywhere.

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Residents in my program didn’t not get fellowships. It was simply unheard of. But in my case, hear about it everyone did. I felt shame, embarrassment, but mostly, profound disappointment. I was hurtling toward the culmination of 12  years of training for a career that had just been shockingly derailed. There was little time for self-pity. I had a residency to finish, a second baby to deliver, and a cross-country move to make for my husband’s job. Residency ended and all my co-residents went on to fellowships. I had my baby and packed up the moving van headed to Chicago. Not one month out of a high-­ pressure residency, I was an unemployed mom of two babies in unfamiliar city with no family, no friends, no job prospects, and no idea if or when I would work again. My husband was an investment banker who had to be on his desk downtown for a firm-wide conference call every morning by 6:30 a.m. Four nights a week, when not traveling, he was expected to entertain visiting clients. He was rarely home before 10 p.m. I barely saw him during the week, and the kids never did. It was a lonely and isolating time. I leaned a lot on my parents in Minneapolis for support. My father’s reaction was to reassure me that, despite he and my mother bankrolling my undergraduate and medical education, I had his blessing if I wanted to walk away from medicine altogether to be a full-time, stay-at-home mom. Touched as I was by this sentiment, I silently recoiled at the notion of giving up all that I had worked for. With due respect to full-time parents, that was not a role I had ever envisioned for myself. My mother, while equally supportive, was more pragmatic. She counseled me that liberation is all about choices. While family took priority now, I should preserve the ability to work, earn my own money, and support myself if I ever needed to. My one “gap” year turned into two. The kids were thriving while I was slowly dying—professionally. I had poked around at possible part-time comprehensive ophthalmology positions in Chicago, but nothing seemed attractive enough to leave my kids for and, frankly, my heart just wasn’t in it. I still dreamed of going into plastics.

“Why Not?” One day in late summer of 1993, over a year since finishing residency and between diaper changes and “Barney, the Dinosaur” reruns, I got a call from one of my former co-residents. He had heard there was a new ASOPRS plastics fellowship opening up in Los Angeles. He excitedly told me the preceptor was going to need to select his first fellow outside the match to start that next July. I thanked him for letting me know, quietly hung up the phone, and returned to the day’s domestic duties. Later that day, my mom called. We spoke frequently. She asked about the kids; I asked how her tomatoes were coming in. I casually mentioned that I’d gotten a call about a fellowship opportunity. I could hear the hopefulness in her voice, “Oh??” I continued, “Of course I can’t consider something like that.” There was a long pause. Then my mom said two words that would change my life.

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“Why Not?” I reminded her I had two toddlers. And this opportunity was 2000 miles and two time zones away. And my husband could never come with me. And did I mention I had two toddlers? She listened to each obstacle I threw out. When I was done, she had concluded that the biggest thing holding me back was me. And she told me so, encouraging me to at least talk to my husband about it. It was a couple days before I worked up the courage to bring it up. I didn’t think my husband would ever support my leaving and taking the kids with me. To my surprise, he was actually relieved on some level. He knew how unhappy I was not working. He himself felt guilt that his new job took so much time away from me and the kids. Leaving for California for 2 years might be just what our young family needed—a pathway to my own career and a reprieve for my husband’s losing battle with work-life balance. There would be so many more hurdles to jump if I ever landed this fellowship— e.g., CHILDCARE—but I figured the highest hurdles—securing my husband’s blessing and overcoming my own fear—had just been cleared. The next one, however, loomed large. This unemployed, stay-at-home mom had to nail this interview. I found an old business suit I could still fit in. My parents flew in to Chicago to keep my kids alive while my husband worked and I headed to the land of palm trees and movie stars for the biggest interview of my life. I spent 2 days at USC-Doheny Eye Institute with new ASOPRS preceptor Dr. Don Liu. We hit it off and I felt his program would be an exceptionally good fit for me. Despite the bonhomie, Dr. Liu struggled with the literal baggage that came with my candidacy—I’d be moving across the country, away from my husband with two toddlers in tow, to begin, after 2 years out of the workforce altogether, a demanding 2-year fellowship. At the time, even I admit it all seemed a bit far-fetched to think I had any chance at this opportunity, but my dream was within grasp. There was nothing that would stop me from reaching for it, no matter how far I had to stretch.

Golden Girl I left LA after those 2 days, Dr. Liu telling me he would get back to me when he had finished all the interviews. There was nothing to do but wait. A couple weeks later, a call came from southern California. It was Don Liu. He didn’t offer me the spot, but he did want me to sit down with a VIP in ASOPRS leadership. While she did not have direct clinical contact with his future fellow, Bernice Brown, associate professor at USC and a past-president of ASOPRS, had to approve of Dr. Liu’s final selections. I arranged to meet her on the exhibit floor of the AAO annual meeting that next week in Chicago—how very convenient for me. I had never met her, didn’t even know what she looked like (no Google search in 1993). I arrived at the appointed

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time and place on a busy thoroughfare of the main exhibit hall. I spotted a distinguished-­looking woman seated and talking to a young man (Was he an interviewee too? I wondered). She stood to say goodbye to him. As she unfolded her long frame, I guessed she was over 6 feet tall. Already nervous, I was now intimidated. She extended a long hand to me and motioned to the chair. “You must be Tamara. Please sit.” Her voice was low and husky. She reminded me of Bea Arthur, the stage and television actress of “Maude” and “The Golden Girls” fame. While not hostile, I would not describe her demeanor as warm in any way. Her smile was formal and somewhat cold. My palms started to feel clammy. Thank goodness, I’d already shaken her hand. Dispensing with much of the pleasantries that normally launch a conversation between two strangers, she jumped right into it. “So, I understand you live here in Chicago. And if you took this fellowship, you’d be moving to LA for two years WITH your two small children and WITHOUT your husband?” Her eyes bore holes through my skull. A bead of sweat formed at my temple, and I swear, my vision faded momentarily at the periphery. I thought to myself, when she put it that way, it DID sound ridiculous. Was she right? Was it reckless to think I could be a fellow and a new mom on my own? I sensed my dream, once again, slipping away—likely, this time, for good. Strangely, this resignation brought me a calm and clarity. Certain this was now a lost cause, I was no longer nervous. I turned to her and replied. “Yes, that’s exactly what I had planned to do. I want it that much.” She held my gaze for an interminable second, then leaned back in her chair and smiled—for real this time—with her eyes as well as her mouth. “That’a girl!” she laughed. My jaw dropped open in confusion. She went on to tell me her improbable journey to becoming one of the most respected women in the very patriarchal, male-­ dominated field of ophthalmic plastic and reconstructive surgery. She suspended her education when she started a family and went back to medical school as a new mom. She must have recognized a similar, somewhat insane, and irreverent fire in me.

Prospect to President Don Liu called me the next week. I would be packing my (diaper) bags and moving to LA that next July—it was no longer a dream. I would later learn I had edged out a single, third-year male resident from UC Irvine to land the fellowship. I send a note of gratitude every few years to Don Liu. He really took a chance on this young black woman—out of the workforce for 2 years, effectively a single mom to two toddlers—as his first ASOPRS fellow. Almost exactly 25 years after I interviewed for Dr. Liu’s fellowship, I was elected President of ASOPRS. Bernice Brown died a few years ago. I wish I’d told her how her advocacy for me changed the direction of my life.

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Every now and again to this day, a particularly thorough credentialer will inquire about the 2-year gap in my work history. The first time I fielded the question, I was still quite self-conscious about stopping out of medicine—I mean, who DOES that? I answered, hesitantly, “Well, I was a full-time mom.” The chirpy young voice on the other end of the phone line started chuckling, “That’s awesome, Dr. Fountain! We just have to make sure you weren’t institutionalized or incarcerated.”

Post Script This was one story. What is yours? If I had one take-home message to give it would be this: Don’t be discouraged along the journey in your professional (or even personal!) life. The one sure way to lose one’s dreams is to give up on them. Rejection doesn’t necessarily mean you’re not worthy or qualified. Sometimes it just means it wasn’t the right timing or fit. There is merit in trying again, but be prepared—things won’t always work out. Have a plan B (or C) ready just in case. Failure is not only an option, but a near-certainty for all of us. It may knock you down, but you don’t have to let it knock you out. Tamara Fountain, MD  is Professor of Ophthalmology at Rush University Medical Center and maintains a private practice in oculofacial plastics in Chicago’s northern suburbs. She graduated with a B.A. from Stanford University and an M.D. from Harvard. After completing a residency in ophthalmology at Johns Hopkins Wilmer Eye Institute, she pursued fellowship training in oculoplastic surgery at Doheny Eye Institute/University of Southern California. Dr. Fountain was nominated to be president of the American Academy of Ophthalmology (AAO) for 2021. She is past membership secretary and at-large member of the AAO’s Board of Trustees and served on the advisory board of its EyeNet magazine. Past Academy service also includes membership on the Young Ophthalmologist, Ethics, and Health Policy Committees. She was part of the inaugural class of the Leadership Development Program and has received the Academy’s Secretariat and Life Achievement Awards. Dr. Fountain was the President of the American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) in 2018, having served as executive secretary and chair of both the thesis and oral exam committees in the past. She has also received the Orkan Stasior Leadership Award for service to the society. Dr. Fountain served for 15 years as a committee member and director for the Ophthalmic Mutual Insurance Company (OMIC) and was Chair of the Board of Directors 2014 and 2015. She is a past president of the Illinois Association of Ophthalmology and has been involved in programming for both Women in Ophthalmology and the Chicago Ophthalmological Society. She was elected chair of the Alumni Fund for Harvard Medical School in 2016.

Part X

Working with Industry

Chapter 35

Collaborating with Industry Nancy M. Holekamp

Summary Points • Women ophthalmologists are underrepresented and comparatively underpaid when physician collaboration with industry is studied. • Physician collaboration with industry around new product innovation, clinical trials, and translational research can enhance career success, professional stature, and income. • Women ophthalmologists can benefit from practical advice to join and prosper in this consequential and influential sphere of our profession.

Introduction Physician ties to pharmaceutical or medical device companies are becoming more accepted and even encouraged as such collaborations around new product innovation, clinical trials, and translational research can be avenues of career success, professional stature, and income. When studying wage and equity gaps that may exist between men and women ophthalmologists, this is a critical area to examine. In 2016, JAMA Ophthalmology published, “Representation of Women with Industry Ties in Ophthalmology” [1]. The authors analyzed data on payments to ophthalmologists from biomedical companies for the years 2013 and 2014. They compared the percentage of men to women in the following categories: overall industry collaboration, industry research, consulting, speaking roles, royalties and licenses, and grants. Also noted were mean and median payments from industry to female vs. male ophthalmologists. The results are no surprise. Women ophthalmologists are underrepresented and comparatively underpaid. N. M. Holekamp (*) Pepose Vision Institute, Saint Louis, MO, USA Washington University School of Medicine, Saint Louis, MO, USA © Springer Nature Switzerland AG 2021 C. Y. Weng, A. M. Berrocal (eds.), Women in Ophthalmology, https://doi.org/10.1007/978-3-030-59335-3_35

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In 2013, for example, women comprised 19.5% of all ophthalmologists, but represented only 14.6% of those with ties to industry. In this study, the data indicates women were underrepresented among ophthalmologists in receiving industry payments for research (10.6%), consulting (15.7%), honoraria (6.4%), industry grants (14.3%), royalties and licenses (7.7%), and faculty/speaker roles (4.2%). Mean payments to women were $11,419 compared with $20,957 for men (P = 0.001). Median payments to women were $3000 compared with $4787 for men (P  =  0.007). In 2014, the results were similar [1]. These statistics mirror the rest of medicine [2]. While this important publication convincingly illuminated the existing gender inequity regarding ophthalmologist collaborations with industry, the study was not designed to explain or solve the disparity observed. Underrepresentation of women in this professional sphere is likely complex and multifactorial. Even so, if we believe that women add to the discussion and that “collective intelligence” is raised by the presence of women, we have work to do [3]. What is the path toward greater equity and stronger representation in this consequential and influential sphere of ophthalmology?

 ow I Began Down the Path Toward Collaborations H with Industry The year was 2006 and I had been in practice for a little over 10 years. While on the American Academy of Ophthalmology Ethics Committee, I developed an interest in the ethics of evidence-based medicine and had begun to lecture widely to residency programs as well as at regional and national ophthalmology meetings. Out of the blue, Genentech asked me to be their keynote speaker for the Launch of Lucentis to their national sales team in Palm Springs, California. I was caught off guard, but since their competition was off-label Avastin, they were seeking oratory on clinical trials and the importance of the rigorous scientific method. I had not interacted much with industry before, so this was new to me. Like any mid-career retina specialist, I sought advice from my seasoned, sage mentors. I recall vividly one male mentor’s strong statement, “Don’t do it. That is not who you want to be associated with. That is not the kind of career you want.” I remember being stunned, even speechless. There was no congratulatory phrase at being recognized for my ethics expertise, there was no compliment for being a sought-after speaker, there was no encouragement to be a part of the most exciting, paradigm-shifting development in our field. Once recovered from my astonishment, I said to myself, “Yes, this is exactly what I want to do. It is exactly the career I want.” I have never looked back. This anecdote has several lessons for women interested in a fulfilling ophthalmology career enhanced by engaging, intellectually stimulating, and productive interactions with industry: 1 . Develop a unique expertise and then use it to stand out in a crowd. 2. Work toward becoming a good public speaker. 3. Say “yes” to new opportunities, even if unsure of where they will lead. 4. Seek your mentors for advice but follow your own passions. 5. Go for it – if collaborating with industry is something that interests you.

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Fig. 35.1  The Venn diagram of industry interests intersecting with physician interests Shared Interests Industry Interests

Physician Interests Patient benefits

Practical Advice Many, if not all, of the most important recent advances in ophthalmology have come from industry working with doctors working with patients to create new treatments supported by scientifically rigorous clinical trial data. However, industry has certain priorities, stakeholders, and objectives. Likewise, doctors have certain interests, obligations, and motivations. The ethical interactions between the two depend upon where these two Venn diagrams of self-interest intersect. And it is likely that within that window, patients will also benefit (Fig.  35.1). Ultimately, all successful collaborations between doctors and industry must help patients. So, how do women get involved with industry? How can female ophthalmologists become a Key Opinion Leader, a frequent podium presence, the first author on a New England Journal of Medicine article? The same way men do.

 ips for Women Who Want to Become Physician T Collaborators with Industry 1. Private practices and academic institutions are equivalent stepping stones toward collaborating with industry Much of the collaborative work with industry is done by private practice ophthalmologists. These physicians have intentionally designed academically oriented practices, a distinct possibility in ophthalmology compared to other areas of medicine. Industry is attracted by the incredibly smart and innovative physicians who choose private practice over university employment. The ease of working with community physicians is alluring: central institutional review boards (IRBs) for clinical trials, lower overhead costs on research support, a “gazelle”-type approach to decision-making as the layers upon layers of institutional bureaucracy are missing. Simultaneously, industry is attracted to the ­prestige of professors (at all levels) at major universities due to their strong research interest, high visibility, and mentoring of the next-generation of doc-

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tors. But, industry is also hindered by many of the restrictions universities place on physician-­company relationships, such as prohibiting any commercial industry interaction, slow and inefficient university IRBs for industry-sponsored research, and conflict of interest regulations for their faculty. There is wide variability between institutions and perhaps even wider viewpoints on interactions with industry among university faculty. Thus, each situation must be navigated individually. 2. Collaborating with Industry is an extracurricular activity, to be done outside the normal working hours of seeing patients. It requires extra effort. Seeing patients is the number one priority for almost all ophthalmologists at any stage of their career. This is fulfilling, challenging, and often exhausting work. But many of us have the capacity and interest for more and seek more. This means capitalizing on opportunities outside normal business hours: early-­ morning e-mails, lunchtime teleconferences, late night paper writing or PowerPoint preparation. This is particularly challenging for women, as women traditionally are the primary “homemakers” or “child caregivers.” This has to fundamentally change for women to rise as Key Opinion Leaders (KOLs). Freedom to choose this path is a key initial step, but women must have the same flexibility as their male colleagues to choose extracurricular activities that lead to interactions with industry. Women need a supportive partner as well as strategic planning on the home front. Women should delegate those chores and responsibilities they dislike which can easily be done by others. This will free up time for family and the professional opportunities that are enticing and engaging. 3. Being connected via text or email is a 24-7 requirement. Industry is responsive, and things can move fast. Employees on the commercial or scientific side of pharmaceutical or medical device companies seemingly have their cell phones with them all the time. Texts and e-mails are answered with lightning speed. Everyone is uber-connected. For Big Pharma, global initiatives mean that the people you are working with are in many different time zones. E-mails involve many people, and teleconferences are planned to fit many different schedules. If aspiring to rise within these circles, you too must respond in kind. Be prompt, polite, and accommodating to all industry contacts. Be grateful for the opportunities. Meet your deadlines. Be sure to offer timeliness and value. There are a lot of your colleagues vying to work with industry too. The decision-makers in industry are human – they will work with the people they like, the people who make them look good, and the people who make their job easy. 4. Get involved in Industry-sponsored clinical trials. Private practice and university-based ophthalmologists have equivalent opportunities to participate in clinical trials. As a young inexperienced doctor in either practice setting, getting involved in large phase 3 clinical trials as a sub-­ investigator is a key first step. Access to clinical trials may seem mysterious, but an older colleague can help you see behind the curtain. Approach senior ­colleagues involved in trials and ask to be a sub-investigator and then recruit, recruit, recruit! Companies notice who places patients (and how many) into a study. If you fail to recruit a single patient, you will be black-listed from future

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trials. Startup costs and efforts are too high to waste on poor-performing sites. Physicians reputations are easy to get and difficult to dispel. Completely conquer your first trial effort. Also, be sure to attend the investigator meetings to see how they are run, who the key people are, and how you can network. Volunteer, ask questions, get involved. You will need to be noticed in order to rise. 5. Join the major research societies in your subspecialty – and use them as a training ground for podium presentations and research experience. Here is a little-known fact: at every major ophthalmology meeting, regardless of subspecialty, a significant percentage of the audience is industry personnel. They carefully watch each and every speaker. They are judging presentation skills, scientific acumen, and social networking among peers. In short, they are looking for the next generation of ophthalmology leaders to tap for collaboration. So, take your own research to these meetings and present it. And present it well. It takes practice. While attending these national meetings, sit in the audience to identify and emulate the clear communicators, the storytellers, the ones who captivate their audience. It is likely that industry has identified them too. It has been said that “Five minutes in front of the right audience is worth more than a year behind your desk.” This adage is certainly true of ophthalmology meetings.

 ips for Women Who Are Physician Collaborators T with Industry Discovery consists of seeing what everybody has seen and thinking what nobody has thought. –– Albert Szent-Gyorgi Biochemist, Winner of the Nobel Prize in Physiology or Medicine in 1937

Industry needs physician collaborators, and every good company understands that diversity improves group dynamics, productivity, and creativity. Therefore, industry needs women. But, women ophthalmologists must provide value-added. They must frequently, frankly, and freely share their opinions and perspectives as clinicians. For example, a company was going to recommend the FDA add “bubble formation” as their anti-VEGF drug was drawn up into a syringe onto the prescribing label, even though no downside to safety or efficacy was shown. Only clinicians would have the knowledge that “bubble formation” is inconsequential, as we tap the syringe to coalesce and express them out. It is a small example to show how we clinicians have a unique perspective, and one that industry personnel have no access to – unless they talk to us. The best way to have a good idea, is to have lots of ideas. –– Linus Pauling, Winner of the Nobel Prize in Chemistry and Nobel Peace Prize.

One avenue often used by industry for obtaining physician input is the “Advisory Board.” It usually consists of 10–15 physician “advisors” in a windowless room at

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(usually) a major airport hotel along with 5–7 industry personnel. Women have to be willing to travel (often frequently) to these meetings to be relevant. The Ad Board topic is chosen by industry for strategic purposes and usually presented in a peer-to-­ peer fashion by KOLs who have established frequent working relationships with the company. Often, clinical trial data is presented with the hope that rigorous discussion will uncover new insights into the results. Here it is keenly important for women to speak up. Again, industry is looking for the next generation of thought leaders, collaborators, and coauthors for manuscripts. If a physician happens to see the data differently and suggest a unique post-hoc analysis that fits the strategic objectives of the company, it may lead to industry resources being delegated to explore further, followed by a podium presentation at a major congress, and potentially a paper in a major ophthalmic journal. I can afford to lose some money on a bad investment. I can actually afford to lose a lot of money on a bad investment. But I can’t afford to lose any of my reputation, because I cannot buy that back. –– Warren Buffet

Industry personnel are not allowed to present at major ophthalmology congresses unless they have an MD and are a member of that society. Thus, once again, industry needs physician collaborators, and they need women. This is a well-trodden path to getting more women speakers on podium. However, important caveats exist: Never say anything on podium that is not supported by the data. Never allow industry to draw conclusions beyond what the results of the study support. Never allow industry to “market” their product via a scientific presentation. Physicians are the guardians of evidence-based medicine and recommendations for patient care. As physicians who collaborate with industry, we must retain a healthy skepticism and keenly scrutinize all data analysis and interpretation. Reputations have been irrevocably damaged by over-reaching podium pronouncements colored by physician conflicts of interest or other biases. It is particularly important that women avoid this fate, as often a few will shape beliefs about an entire gender.

Final Thoughts on Women Collaborating with Industry What you think, you become. –– Buddha

I recently encouraged a female colleague to attend a pharmaceutical company advisory board. She was relatively early in her career and expressed to me that she didn’t feel as if she belonged with the other prominent retina specialists at the meeting. My reply was simple, “You have the same training as everyone else, you see patients every day and form strong opinions, and you have developed unique ideas no one else has. You are an important representative of our profession. If you aren’t at the Ad Board, the company won’t benefit from the value you add.” Thus, an initial critical step to increasing women representation as collaborators with pharmaceutical and medical device companies is to convince women they

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belong at the table. Let the disparity in gender representation described in the first paragraphs of this chapter serve as a challenge to the many smart, capable, and confident women in our field to actively seek out and solicit interactions with industry. We will all be better for it.

References 1. Reddy AK, Bounds GW, Bakri SJ, Gordon LK, Smith JR, Haller JA, Thorne JE. Representation of women with industry ties in ophthalmology. JAMA Ophthalmol. 2016;134(6):636–43. 2. Rose SL, Sanghani RM, Schmidt C, Karafa MT, Kodish E, Chisolm GM.  Gender differences in physicians’ financial ties to industry: a study of national disclosure data. PLoS ONE. 2015;10(6):e0129197. 3. Woolley AW, Chabris CF, Pentland A, Hashmi N, Malone TW. Evidence for a collective intelligence factor in the performance of human groups. Science. 2010;330(6004):686–8. Nancy M.  Holekamp, MD  is a Professor of Clinical Ophthalmology and Visual Sciences at the Washington University School of Medicine in St. Louis, Missouri. She is also Director of Retina Services at the Pepose Vision Institute in St. Louis. Dr. Holekamp received her Bachelor of Arts degree from Wellesley College Summa cum Laude. She received her Medical Degree from the Johns Hopkins School of Medicine Alpha Omega Alpha. Dr. Holekamp completed an internship in internal medicine and a residency in ophthalmology at the Washington University School of Medicine. Her fellowship training in vitreoretinal surgery was with the Retina Consultants in St. Louis. Dr. Holekamp has received numerous honors and awards, including being named in the “Best Doctors in America” annually since 2005 being included in in the US News & World Report Best Doctors list and Castle Connolly Top Doctors list. She has received the Achievement Award, the Senior Achievement Award, and the Secretariat Award from the American Academy of Ophthalmology (AAO), and the Honor Award and Senior Honor Award from the American Society of Retina Specialists (ASRS). She is co-founder and chair of Women in Retina. Dr. Holekamp is actively involved in clinical research, having been principal investigator or sub-investigator in over 30 national clinical trials dealing with age-­related macular degeneration, retinal vascular occlusion, and diabetic retinopathy. Her efforts in research have resulted in 74 peer-reviewed publications, 21 book chapters, and more than 100 speaking invitations both nationally and internationally. She is a member of the major subspecialty societies, including the Retina Society and the Macula Society. She acts as a reviewer for all the major ophthalmology journals and as a consultant to several ophthalmic pharmaceutical companies. After 6 years on the American Academy of Ophthalmology Ethics Committee, she has developed an interest in medical ethics.

Chapter 36

Why Industry Values the Female Perspective J. Nicole Sheeler

Summary Points • The female perspective is essential due to gender differences, and ultimately, it ensures balance. • Women should communicate to ensure their impressions and perspective are included in product development and factored into key decision making by industry partners. • Protecting your ideas is critical and the proper non-disclosure agreement (NDA) should be in place prior to entering into discussions with industry representatives.

Women’s roles have evolved over the past 150 years in all facets of both their personal and professional lives. In 1845, women were finally allowed to become property owners and on June 4, 2019, we celebrated 100 years of Women’s Suffrage. These momentous decisions were the catalyst for women to have additional rights and opinions which form some of the cornerstones of our history. The last several decades have seen women undergo a metamorphosis from traditional family and home roles to one that seeks full-time careers in addition to their familial responsibilities. Early in my career, a colleague once mentioned to me that she was terminated because she informed her boss that she was pregnant. It was the mid-90s, and my 30-year-old thought process considered this archaic. The harsh reality society dictated during the 1960s is that women needed to stay at home if they were pregnant and that wasn’t that many years ago. The successful Virginia Slims marketing campaign in 1967 stated it succinctly, “you’ve come a long way, baby.”

J. N. Sheeler (*) RetinaLink, Fort Worth, TX, USA © Springer Nature Switzerland AG 2021 C. Y. Weng, A. M. Berrocal (eds.), Women in Ophthalmology, https://doi.org/10.1007/978-3-030-59335-3_36

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I started my career in Retina Marketing at Alcon Laboratories, Inc., in 1998. I could count the number of women retina specialists on one hand. Dr. Alice McPherson in Houston, TX, was the first female retina specialist and surgeon. Dr. McPherson was a pioneer in so many ways: ophthalmology, retina, surgery. Dr. McPherson paved the way for future women retina specialists including Drs. Maria H. Berrocal, Susan B. Bressler, Janet L. Davis, Julia A. Haller, Nancy M. Holekamp, Joan W. Miller, Emily Chew, and Cynthia A. Toth. These remarkable women have certainly led the way for future female retina specialists and have provided a foundation for current female specialists. As an employee at Alcon Surgical for 20  years, it’s critical to understand the importance of the female perspective in the operating room and clinic since women perform different functions compared to men. It is simply a gender difference. One needs to seek the female perspective to gain balance. Unfortunately, there are times when women have an excellent opinion of the situation and are unable to voice it. Their opinions are affirmed only when a male confirms them.

Cognitive Gender Differences Two Minds, The Cognitive Difference Between Men and Women, published by Stanford Medicine, noted that new technologies have generated a compelling argument that there are inherent differences in how men’s and women’s brains are wired and how they operate. Women’s reading comprehension and writing ability consistently exceed that of men, on average. They outperform men in tests of fine motor coordination and perceptual speed. They’re more adept at retrieving information from long-term memory [1]. This suggests women are adept surgically. Men, typically, can more easily juggle items in working memory. Additionally, they have superior visuospatial skills [1]. This confirms men excel at multitasking. Based on Stanford’s study and these gender differences, it is critical when considering new or improved surgical devices and technology that women are present at advisory boards (“ad boards”). This study also illustrates a correlation and proof source when I coordinated ad boards. At that time, they were traditionally composed of all male ophthalmologists. In the last few years, women have been invited to participate and share their experience and impressions which are vital to overall advisory board objectives and their success. A female perspective in microsurgery is critical due to the fact that women tend to have smaller hands than men. This provides a huge difference in the designs of surgical equipment and ancillary instruments. This also can be applied to the clinical setting when injecting anti-VEGF medications, and ultimately it can impact outcomes for patients. Industry is evolving by including females and ensuring that they offer their opinions. Their opinion is as valuable as that of their male counterparts. It doesn’t take men as long to be taken seriously. As a society, we are going through a transformation.

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Industry Objectives for Advisory Boards Advisory boards are typically a small gathering of approximately 12–15 healthcare professionals (HCPs). The objective of them is to seek opinions from a variety of ophthalmologists including cataract, refractive, glaucoma, and retina specialists on specific medical devices, future technologies, and pharmaceuticals. These boards offer HCPs, who may or may not use the company products, an opportunity to provide their viewpoint. The agenda historically incorporates corporate presentations, including marketing and research and development. Questions are asked to understand trends and opinions and, moreover, to seek opinions on current or future product development, and to gain a consensus viewpoint. It is basically an ophthalmic “think tank” on what industry can provide HCPs based on their specifications.

Participation in Industry Ad Boards Several ophthalmic corporations have made it an initiative to actively include women in ophthalmology. This is extremely encouraging and a positive step. When participating, there are several items to consider. 1 . Provide constructive comments. 2. Don’t be a contrarian; yet, provide your constructive opinion. 3. Ask for your colleagues’ opinions. 4. Enter into discussions.

Why? Industry needs varying opinions so they can develop and/or modify their technologies. Additionally, varying opinions are formed; they vary not just by gender, but based on specific academic programs, fellowships, and practice settings. For example, the Duke faculty may approach disease states or surgery differently depending on where they trained.

Working with Industry If you have a great idea—a novel invention, new compound, or device idea—companies like to know about them. New developments in surgical technique or potential devices that may be beneficial can spark investment.

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It is extremely important to have the proper paperwork, specifically a non-­ disclosure agreement (NDA), in place prior to sharing your idea. Quite frankly, this protects you and the company. Although an idea that ultimately becomes a marketable and sellable product is thrilling, one needs to be realistic. For example, I once attended a meeting years ago with several corporate representatives and HCPs. One of the attendees had a new tamponade approach and wanted to communicate his idea. We stopped the meeting before anything groundbreaking was disclosed and then his academic institution provided the proper legal documents for him to outline his concept. Remember to protect yourself and your idea.

Life Gets in the Way Life gets in the way and the reality is it’s what you don’t plan for and how you respond that matters. Getting the female perspective from younger ophthalmologists may be challenging because they may have younger children, they may need to take call, or they might not have as much experience as more senior ophthalmologists. Younger ophthalmologists are a generation of their own, as all generations are, so it’s important to include them and gain their perspective. This parallels much of society too. According to a JAMA Ophthalmology article published in 2015, women have only come to represent 20% of ophthalmologists. Parity in female and male distribution among ophthalmologists with industry ties may lag behind that of representation because influence takes additional time to achieve [2]. Women are now starting to demonstrate that they have an interest in being included in evaluating new technologies, just as their male counterparts have been for decades. Keys to Success  Introduce yourself to industry and communicate that you are interested in evaluating new technology. Attend professional meetings. Talk to your local industry representative to gain knowledge of what is going on.

What Does a Retina Surgeon Look Like? One important catalyst for recognizing female retina specialists and why they chose retina has been the introduction of #ilooklikearetinasurgeon in 2017 on www.retinalinkglobal.com. The genesis of this project was related to the #ilooklikeasurgeon campaign which was covered by the BBC in 2015. In a post, a surgeon named Stephanie asked why her male colleagues were called “doctor” while she was called by her first name each day. Over the past several years, #ilooklikeasurgeon and #ilooklikeanengineer have started a conversation. In August 2017, Audina M. Berrocal, MD, approached

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Fig. 36.1 RetinaLink #ilooklikearetinasurgeon

RetinaLink and we started outlining #ilooklikearetinasurgeon. Then, we met at the American Academy of Ophthalmology annual meeting in New Orleans and discussed the foundation for #ilooklikearetinasurgeon with Drs. Maria Berrocal, Lejla Vajzovic, Camila Ventura, and Avni Finn. At the Vit-Buckle Society in March 2018, #ilooklikearetinasurgeon launched and was one the most-read posts on RetinaLink in 2018. Highlighting female retina specialists is an ongoing feature on www.retinalinkglobal.com (Fig. 36.1). Overall, the future for women in ophthalmology is bright. Each year, there are more residents and fellows joining the ranks to become ophthalmologists, many of whom are female. Transformation takes time, perseverance, and tenacity. Always remember your opinion is valuable and industry will look forward to working with you. Collaboration and partnership move all of us forward.

References 1. Goldman B. Stanford Medicine. Sex, Gender and Medicine. Two minds - The cognitive differences between men and women. Spring 2017stanmed.stanford.edu. 2. Ashvini K. Reddy, MD; Gregory W. Bounds, BS; Sophie J. Bakri, MD; Lynn K. Gordon, MD, PhD; Justine R. Smith, FRANZCO, PhD; Julia A. Haller, MD; Jennifer E. Thorne, MD, PhD. Representation of Women With Industry Ties in Ophthalmology. JAMA Ophthalmol. 2016;134(6):636–643. https://doi.org/10.1001/jamaophthalmol.2016.0552.

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J. N. Sheeler J. Nicole Sheeler  is RetinaLink Founder and Retina Strategist with over 25 years of experience in retina. Nicole worked at Alcon Laboratories for 20  years in Surgical Marketing and Advocate Development in both the United States and around the globe. After working with the global retina community for so many years, she missed collaborating with retina specialists. In 2014, RetinaLink was formed as a global communication platform to share Whitepapers, surgical techniques, and videos; highlight retina specialists and fellows; and ultimately, launch #ilooklikearetinasurgeon in 2017. All digital content is accessible on retinalinkglobal.com and RetinaLink’s Social Media channels. RetinaLink’s other cornerstone is consultation in marketing, strategy, advocacy boards, connecting thought leaders, and developing collegial discussions to outline surgical technology and how companies can partner with healthcare providers better. Nicole has her Bachelor of Business Administration in International Business and Marketing from the University of Texas at Austin McCombs School of Business.

Chapter 37

Demystifying Pharma and BioTech: Applying Ophthalmology to Make New Tools Anne E. Fung and Jayashree Sahni

Summary Points • The nuanced resource-intensive, methodical process to create a new drug or device tool for patients is reviewed including Phase I-IV trials. • Ophthalmic clinical skills are needed throughout the process beginning with identification of unmet patient needs to protocol design and authoring to data interpretation and communication. • Applying clinical ophthalmology skills in biotech and pharma can be a satisfying alternative to traditional clinical practice.

You have acquired skills: 4 years of medical school, 1 year of general internship, 3 years of ophthalmology residency, 1–2 years of fellowship, 3+ years if a PhD too. Your exam begins across a room – esotropia, proptosis, chalazion. Informed consent has been honed to your own style – highlighting pertinent positives and negatives efficiently and in a manner that incurs the fewest clarification questions. Coding, billing, and tracking reimbursements are second nature. You conduct patients and technicians through multiple lanes, procedure rooms, and ORs like a circus ringmaster. These capabilities have made you successful in clinical practice. And yet they can be applied in other ways toward different and perhaps surprisingly meaningful ends. In this chapter, we will review how these capabilities may be applied to create,

A. E. Fung (*) Genentech, South San Francisco, CA, USA California Pacific Medical Center/Pacific Eye Associates, San Francisco, CA, USA J. Sahni Roche Innovation Center Basel, F. Hoffmann-La Roche Ltd., Basel, Switzerland

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Development

Early Discovery Target discovery Validated target

Basic Research

Lead identification Lead optimization

Target Selection

Lead to Candidate

Pre-clinical safety

Drug safe in animals

Basic science acumen

Surveillance FDA Approval Post marketing monitoring

Phase I EiH

Drug safe in humans

Phase II PoC

Phase III RCT

Phase IV

Drug effective in X00 humans Drug effective in X000 humans Pragmatic clinical acumen

Fig. 37.1  The drug development process may be divided into eight stages beginning with basic research to discover new interventions in pathophysiology through testing efficacy and safety in increasingly large populations, to health authority approval, and then continued surveillance after approval. While basic science and pragmatic clinical ophthalmic acumen are needed at all stages, the emphasis shifts over development stage. EiH early in humans, PoC proof of concept, RCT randomized clinical trial, X00 hundreds sample size, X000 thousands sample size

develop, or foster a new technology in the biotech or pharmaceutical world to create new tools for ophthalmology. Because the drug or device development process can seem opaque due to its length, complexity, and regulations, most of us don’t have patience to follow along. Yet the fact is, medicines and devices are tools that we use to address patient problems and we can still use more; the expertise of many people is needed to bring a new product from initial idea to final testing of its safety and efficacy in a large group of patients. Let’s first break down the drug/medical product discovery process into stages according to the phases of clinical studies: Discovery, Phase 1, Phase 2, Phase 3, Phase 4, and beyond (Fig. 37.1).

Why Are New Medicines/Devices Needed? The identification of effective and safe therapies that ameliorate disease is central to the practice and progress of medicine. For patients, new medicines may offer greater efficacy, longer durability, fewer side effects, improved quality of life, increased productivity, or importantly, extended vision or lives. When we look at the history of the anti-VEGF (vascular endothelial growth factor) drug discovery program for retina, it is hard to overestimate its impact on patients and society. Before anti-­ VEGF therapy, neovascular age-related macular degeneration (AMD) was the most common cause of blindness in developed countries globally [1]. The advent of antiVEGF drugs has revolutionized not only wet Age Related Macular Degeneration AMD but also a range of retinal vascular diseases, with profound benefit to patients with these conditions.

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For physician-scientists, Pharma and Biotech can offer the opportunity to develop innovative medicines, communicate their benefits and limits, and, thus, influence care standards for thousands of patients at a time. Applying clinical capabilities in the drug development process is an often unconsidered, yet potentially rewarding, alternative or supplement to individual patient care. The access to sophisticated technologies, opportunity to collaborate with bright minds across disparate sciences (e.g., chemists, informatics engineers, biostatisticians, pharmacokinetic, and medical scientists), the dynamic business of medicine, and the entrepreneurial nature of Pharma and Biotech are other exciting possibilities for both applying medical skills and broadening horizons [2].

Taking on the Development Process Developing medicines is a long, resource-intensive process [3]. On average, it takes at least 10 years for a new medicine to complete the journey from initial discovery to patient access, with clinical trials alone taking 6–7 years on average. The average cost to research and develop each successful drug is estimated to be $1.4 billion. Although thousands and sometimes millions of compounds may be screened and assessed early in the research and development (R&D) process, only a few ultimately receive approval. The overall probability of clinical success (the likelihood that a drug entering clinical testing will eventually be approved) is estimated to be less than 12% [4]. While these factors are daunting, there are still patients who do not respond completely to existing therapies. About 70% of patients recover at least one letter of vision with anti-VEGF therapy, an impressive number and much better than the past, yet sobering news for the patients in the 30% that do not recover vision [5]. A deeper understanding of the rigorous R&D process provides insight into how ophthalmic clinical skills may be applied to facilitate and accelerate the process as well as provide a surprisingly satisfying endeavor for ophthalmologists.

 asic Research and Pre-discovery: Are You a Lab Rat B at Heart? Starting at the discovery phase, the first step to a new medicine or medical product is the elucidation of a disease’s pathophysiology and the realization that it may be possible to alter a signaling pathway to prevent or repair disease. This phase of research is most suited to those who love working out mechanisms of disease, applying the growing field of -omics (genomics, proteomics, microbiomics) or deep learning to discover associations, testing out signaling or receptor

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interventions, or working with protein or drug delivery engineers in cellular or animal models. Once the pathway has been discovered, the next step is to design a small molecule (usually a chemical) or engineered protein (e.g., antibody structures, aptamers, etc.) and evaluate its safety and efficacy in representative animal models. Once a solid non-­clinical and preclinical (i.e., pre-human) toxicology profile has been established, the product can proceed into the translational phase for first-in-human studies. The anti-VEGF drugs were the product of decades of research and were thus underpinned with extensive knowledge of the basic pathophysiology of the disease area. The biology of VEGF is a unique illustration of how fundamental discovery at the bench has informed and transformed therapeutic discovery and development aimed at the bedside in a relatively short timespan of less than 15 years [6]. Biopharmaceutical companies perform basic research independently and, very importantly, in partnership with researchers from across the biomedical research ecosystem, including academia. A deep and thorough understanding of the inner workings of human disease at a molecular level is now possible because recent advances in molecular medicine and computational capacity tools have significantly increased the potential of discovering and developing innovative medicines. The discovery process includes the early phases of research, which are designed to identify an investigational drug and perform initial tests in the lab [3].

Discovery Step 1: Target Identification and Validation The first step in the process is to identify biological targets for a potential medicine. Many targets are initially identified using scientific literature [7] or public databases such as DrugBank [8]. A drug target is a molecular structure in the body that, when it interacts with a potential drug compound, produces a clinical effect (treatment or prevention of a disease, for example). The drug can be created in a variety of ways, including creating a molecule from living or synthetic material, using high-­ throughput screening techniques to select a few promising possibilities from among thousands of potential candidates, identifying compounds found in nature, or using biotechnology to genetically engineer living systems to produce disease-fighting molecules. Target validation is the process of demonstrating the functional role of the identified target in the disease phenotype [9]. The investigators conduct studies in cell, tissue, and animal models to determine whether the target can be influenced by a medicine. Target validation is crucial to help scientists identify the most promising approaches before going into the laboratory to develop potential drug candidates, increasing the efficiency and effectiveness of the R&D process.

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Discovery Step 2: Lead Identification This step aims to find a molecule, a “lead compound” that could become a new medicine. Early safety tests to investigate how the body processes the investigational compound (i.e., pharmacokinetics and the impact of the investigational compound on various functions within the body) or the pharmacodynamics help researchers prioritize lead compounds early in the discovery process. These are normally performed in living cells, in animals, and via computational models. Successful drugs must be all of the following: 1 . Absorbed into the bloodstream. 2. Distributed to the proper site of action in the body. 3. Metabolized efficiently and effectively. 4. Successfully excreted from the body. 5. Demonstrated to be not toxic in the tests performed.

Discovery Step 3: Lead Optimization Lead investigational compounds that survive the initial screening are then “optimized,” or altered to improve their properties, to make them more effective and safer. Changing the structure of a compound can give it different properties. For example, it can make a compound less likely to interact with other chemical pathways in the body, thus reducing the potential for side effects. Hundreds of different variations or “analogues” of the initial leads are produced and tested. The resulting compound is the candidate drug which will undergo years of further testing and analysis before potentially being reviewed and assessed for approval by global health authorities such as the FDA (Food and Drug Administration) or EMA (European Medicines Agency).

Discovery Step 4: Preclinical Testing Once one or more lead compounds are identified, researchers conduct in  vitro (“vitro” is “glass” in Latin) tests in the lab and in vivo (“vivo” is “life” in Latin) tests in living cell and tissue cultures and animal models to determine if they are ready to be studied in humans. After starting with thousands of candidate compounds, preclinical testing is used to identify one or more lead compounds that will go on to be studied in clinical trials. These studies must provide detailed information on dosing and toxicity levels. FDA requires researchers to use good laboratory practices (GLP), defined in medical product development regulations, for preclinical laboratory studies [10].

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From the Lab into Humans  arly Clinical/Translational Research: Generating First/ E Early-­in-Human Data Once a sufficient dosing and toxicology profile of a candidate drug or device has been established in lab and animal models, a candidate product next enters several phases of extensive human studies to demonstrate safety and effectiveness before receiving approval from global health authorities. This process involves three phases of clinical trials, each with its own specific goals and requirements.

Phase I: Initial Human Safety and Tolerability In Phase I trials, the candidate drug is tested in humans for the first time to assess the safety and tolerability of the medicine and to establish the clinical pharmacology profile of the product, typically in fewer than 50 patients at a few clinical trial sites. When the candidate drug is administered systemically, these studies are usually conducted with a small number of healthy volunteers [11]. Because an invasive intravitreal or intraocular procedure is typically required for the administration of the drug/device in ophthalmology, these studies are carried out in a small number of trial patients with the specific disease state rather than healthy volunteers [12]. Phase I data primarily focuses on safety and also generates data on the pharmacodynamics and pharmacokinetics of a drug to answer questions about how the drug is absorbed, metabolized, and eliminated from the body. These closely monitored trials are designed to help researchers determine the safe dosage range and also produce data to inform whether the candidate medicine should move on to the next stage of development. Efficacy data may be obtained, but often have limited interpretability due to the small sample sizes (i.e., underpowered). While health authorities are notified of the development activity, the primary audience for the data is the company developing the new product so that they may decide whether to invest further in the product’s development.

Phase II: Dose-Ranging and Proof-of-Concept In Phase II trials, researchers evaluate the candidate drug’s safety and effectiveness in a larger cohort of 100–500 trial patients with the disease or condition under study at more clinical trial sites. Many Phase II trials compare the safety and efficacy of multiple doses of the candidate drug against an inactive substance (placebo) or the standard-of-care therapy [13]. Researchers also analyze optimal dose strength and dosing intervals and examine the possible short-term side effects (adverse events)

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and risks associated with the drug. Health authorities are again consulted for this trial phase, but the decision-makers on whether to proceed with further development based on these data is again the sponsor company. If the drug continues to show promise, preparations begin for the much larger Phase III trials.

 ate-Stage Clinical Research: Generating Data for Health L Authority Review Once the final 1–2 doses are selected and the product is deemed to bring sufficient additional benefit to patients, the product enters the final stage of clinical testing before health authority approval. While basic science acumen is still required in late-stage development, clinical practice, safety science, trial conduct, and health authority regulation knowledge become prioritized skill sets for protocol design, authoring, conduct, and communication.

Phase III: Determination of Reasonable Efficacy and Safety In Phase III trials, the candidate drug is tested in cohorts powered to detect meaningful differences in efficacy and safety between the arms, typically in the hundreds to thousands of patients [11]. Additionally, two replicate trials (two trials with the same protocol) are typically required to confirm that the outcomes are true and not due to chance. Accordingly, many more clinical research sites (80–300) are needed to recruit, treat, and monitor the patients. No more than two doses of the new drug are tested against the gold standard therapy. The main audiences for Phase III studies are now multiple and diverse. • Health authorities such as the FDA and EMA will primarily evaluate Phase III trial data to determine whether they agree with the sponsor company on the efficacy and safety profile of the new product when compared with the standard of care. Only a determination of equivalent, non-inferior, or superior efficacy and safety will enable the product to be approved for patient use in that country/region. • The sponsor company also uses Phase III trial data to determine whether the product is sufficiently safe/effective to merit a continued investment to scale up production, distribution, and sales/marketing activities to make the product available to patients. • Payers such as insurance companies and government bodies use Phase III data to evaluate efficacy and safety, but even more importantly, the cost-effectiveness of the new therapy against existing treatments to determine payment coverage in their population. • Physicians, other health care providers, and patients learn about the Phase III trial efficacy and safety data on the new therapy in a general, averaged popula-

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tion from the package insert, publications in the literature and at congresses, and marketing materials so that they may make informed decisions on whether a medicine/product is appropriate for a particular patient’s situation.

 ollowing Approval and Once Available for Use by Physicians F and Patients  edical Affairs: Generating Additional Data for Clinical M Practice Decisions and Reimbursement As a product enters Phase III development and then following approval, a group of Medical Affairs scientist/clinicians partner with clinical physicians, professional societies, patient groups, and health systems to answer practical questions around patient care and reimbursement. Briefly, the data generation and communication activities within Medical Affairs may include the following: • Exploratory data analyses: Rich datasets are generated in the conduct of Phase II and III clinical trials. Clinicians outside companies may propose subgroup analyses of these datasets and images to answer pragmatic questions about certain populations such as gender, phenotype, clinical response in the short- or long term, or concomitant medication interactions. Medical Affairs medical directors are the internal partner for the conduct of these analyses in collaboration with company statisticians and scientists from other disciplines as relevant. • Health economic analyses with insurance datasets: Partnering with health economists can answer effectiveness, safety, or other patient impact questions using datasets such as MediCare, Vestrum, or UK Health. • Investigator-initiated trials: Clinicians outside companies may submit proposals to companies for funding and/or drug product to support a trial that is conceived, executed, and reported by the clinician to develop pilot data, typically in a new dosing approach or disease state. Medical Affairs personnel including medical science liaisons and medical directors assist clinicians in the application process and a sponsor company review group decides which projects to support with drug product and/or funding. • Phase IV studies are discussed next.

Phase IV: Additional Data Generation Following First Approval During the conduct of the larger Phase III trial program and following health authority approval, additional information is learned about the new product – for example, efficacy in a population subset may be significantly greater, additional health economic data or patient-reported outcomes may be needed, a new safety signal may

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emerge, a different dosing strategy may be beneficial, or potential benefit in yet another disease state may have become evident [14]. Phase IV trials are designed and conducted to answer these additional questions for healthcare providers, patients, and health authorities. Phase IV trials are typically larger and may be conducted by the late-stage research or medical affairs group of a sponsor company. Health authorities are consulted for this trial phase, but data are typically used to enhance the community’s understanding of the product. A sponsor company may elect to file some of the data to provide additional information for patient care in the package insert label. But if an approval is desired for a new disease state, separate replicate Phase III trials are typically required to generate comprehensive data for health authority review and approval.

Applying Ophthalmic Clinical Skills in Biotech and Pharma In this review of development and post-approval activities, it should be apparent that the application of clinical ophthalmology skills is very helpful and can make a significant difference in the quality of work and decisions produced. Additional detail on how ophthalmic knowledge may be applied is detailed here: • Medical elements of the Clinical Development Plan (CDP). This document organizes the proposed path from beginning to end of the discovery of a new product. Beginning from making the case for the unmet need in a particular disease state, to identifying what data/endpoints will help determine whether the product is indeed meeting that need and what supportive pharmacology/toxicology and manufacturing data are needed, this document provides a comprehensive overview. Through this overview, gaps in logic or opportunities for efficiencies may become evident. A physician contributes patient, disease state, and clinical practice knowledge to the CDP [14–16]. • Protocol design, authoring, amendments. –– Clinical trial protocols are required throughout the development phases from I to IV to summarize the background science, rationale for study, hypothesis being tested, clinical and statistical methodologies, and clinical and safety assessments and endpoints. The specific data and weighting of these sections vary by phase of trial. For example, Phase I protocols emphasize preclinical and toxicology data, whereas Phase III protocols will review Phase I-II trial data. A physician again deeply uses disease state and practical clinical ­knowledge to author this document in collaboration with experts in adjacent scientific areas such as biostatistics, pharmacology, and toxicology. Fluent ophthalmic knowledge is particularly important to describe methodology in sufficient detail and to bring specificity to clinical endpoints. For example, an “OCT endpoint of retinal thickness” can incur substantial debate as to whether center point thickness, central subfield thickness, and Heidelberg or Zeiss instrument methodology should be the standard. Assessment reproducibility,

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patient tolerance of the exam, instrument availability, and pragmatism of the assessment in clinic are all considered when deciding on elements of the protocol. –– Health economic and reimbursement data generation: As the drug development process is long and uncertain, companies that have invested in a product’s development seek to recoup the investment and also fund further development. The development investment is thus reflected in drug cost. As a result, payer bodies such as insurance companies, governments or patient groups often seek to evaluate the product’s benefits (such as improved efficacy/safety, reduced treatment burden, or impact on patient adherence) against the product’s cost over time. Practical experience from the clinic in coding, billing, and reimbursement provides context, methodological help (i.e., which code should we search for in the database and what are potential downstream effects of non-adherence) in the design, and conduct of these analyses during the later stages of a product’s lifecycle. • Informed consent authoring. As you have learned from practice, informed consent is critical for the conduct of medicine. Explaining proposed procedures to a patient in language that is accessible, understandable, sufficiently comprehensive, yet efficient is a true skill. Bringing this skill to the authoring process is one of the most important gifts a clinician can lend. Communicating clearly to patients is our first duty to potential trial participants; additionally, a well-­ constructed consent that is as brief as possible and meets the needs of Institutional Review Boards saves time in review processes. • Medical monitoring. Physicians serve as Medical Monitors for clinical trials to serve multiple needs as follows. –– Investigator education/communication: Once the protocol has been designed and written, educating peers on the why and what of the details is needed through investigator meetings and documents. –– AE (adverse event) monitoring and response: When AEs occur, answering/ discussing investigator questions about management or the investigational product’s potential role in the event is necessary. –– Protocol questions, deviations, amendments, situational updates: As the study enrolls and follows patients, addressing new information or situations that arise and modifying the protocol if required may be needed. For example, COVID-19 dramatically impacted the ability of patients and physicians to conduct exams or treatments and required adjustments to trial conduct. • Data interpretation: Once the last patient has reached endpoint milestones, data may be collated for review. A solid grounding in biostatistics combined with clinical acumen assist the team in interpreting the safety and effectiveness of the product; often these determinations are not clear – how do you judge whether a finding of more numerous but mild events versus a finding of a few eye-threatening events is better or worse?

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• Data communication: Significant publication experience becomes critical at this stage to clearly communicate the rationale, methodology, results, and interpretation of the clinical trial in manuscripts and congress presentations. Honing the mental organization, writing style, knowledge of the publication process, and experience in how our scientific community processes information through practice and experience makes for a more efficient and ultimately impactful communication. • Health authority interactions: Ophthalmic knowledge about the unmet needs of the disease state, clinical assessments, and data needed by patients and physicians to make good clinical decisions is needed for this interaction with health authorities. It is our hope that this summary has unveiled the logical and yet intensive multiple steps required for a new ophthalmic product to journey from idea to approval for patient and physician use. Clinical acumen, investigator and publication experience, coding, billing and reimbursement savvy, and professional leadership experience may all contribute significantly to this process of creating a new drug or device tool for the ophthalmic community. And in turn, the opportunity to collaborate in the process with scientists and experts from other disciplines can provide ample learning experiences that may entertain and satisfy the most curious of minds. As clinicians, we already contribute to the growing body of knowledge in the daily care of our patients through discussions with peers or serving as trial investigators; yet it can be amusing and exciting to consider how else the art and practice of ophthalmology may be applied to creating new tools for the future.

References 1. www.nei.nih.gov/learn-about-eye-health/resources-for-health-educators/eye-health-dataand-statistics/age-related-macular-degeneration-amd-data-and-statistics. 2. Kaufman EA. Physician Exec. 2001;27(2):80–3. 3. www.fda.gov/patients/learn-about-drug-and-device-approvals/drug-development-process. 4. DiMasi JA, Grabowski HG, Hansen RW. Innovation in the pharmaceutical industry: new estimates of R&D costs. J Health Econ. 2016;47:20–33. 5. Rosenfeld PJ, Brown DM, Heier JS, et al. Ranibizumab for neovascular age-related macular degeneration. N Engl J Med. 2006;355(14):1419–31. 6. Apte RS, Chen DS, Ferrara N. VEGF in signaling and disease: beyond discovery and development. Cell. 2019;176(6):1248–64. 7. Gashaw I, Ellinghaus P, Sommer A, Asadullah K.  What makes a good drug target? Drug Discov Today. 2012;17:S24–30. 8. DrugBank – www.drugbank.ca. 9. Lindsay MA. Target discovery. Nat Rev Drug Discov. 2003;2:831–8. https://doi.org/10.1038/ nrd1202. 10. www.fda.gov/media/86541/download. 11. www.fda.gov/patients/drug-development-process/step-3-clinical-research. 12. Chakravarthy U, Bailey C, Brown D, et al. Phase 1. Ophthalmol Retina. 2017;1(6):474–85. https://doi.org/10.1016/j.oret.2017.03.003. Epub 2017 May 23.

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13. Sahni J, Patel SS, Dugel PU, et  al. Boulevard Ph2. Ophthalmology. 2019;126(8):1155–70. https://doi.org/10.1016/j.ophtha.2019.03.023. Epub 2019 Mar 21. 14. www.covance.com/content/dam/covance/assetLibrary/whitepapers/Regulatory-White-PaperWPCDS029.pdf. 15. Christopher D, Breder MP.  Design of clinical drug development programs. The Center for Drug Evaluation and Research – FDA; 2010. 16. Sietsema WK. Strategic clinical development planning designing programs for winning products. Washington Business; 2005. Anne Fung, MD  leads the global development program for a small, surgically implanted device being investigated in Phase 3 trials for patients with neovascular age-related macular degeneration and diabetic eye disease and continues to care for patients with medical retina diseases in San Francisco. She appreciates the opportunity to bring the first-hand perspective of patients and their needs in the private practice setting together with the talented team of scientists, biostatisticians, product engineers, and other collaborators to develop new therapeutics and get them to patients safely and quickly. Prior to her role as Global Development Lead, Anne served as the Head of Ophthalmology U.S. Medical Affairs team connecting Genentech’s research science to clinical retina practice so that physicians and payers can better care for patients. Anne joined Genentech in 2014 to help guide the Medical Affairs group in identifying and answering timely clinical questions for Lucentis and lampalizumab. Since 2005, Anne has been active in private practice at Pacific Eye Associates/California Pacific Medical Center in San Francisco where she led the clinical research program, serving as primary investigator on two of her own investigator-­sponsored research trials in neovascular age-related macular degeneration (AMD), site primary investigator for several multicenter trials, and director of the CPMC resident research program. Anne’s academic interests include therapeutics and diagnostics for age-related macular degeneration, resident research education, and journal publication standards. Anne is an active member of the Macula Society, Retina Society, Women in Ophthalmology, Women in Retina, The CONNECT Network, the Association for Research in Vision Ophthalmology (ARVO), the American Academy of Ophthalmology (AAO), and the American Society of Retina Specialists (ASRS). A graduate of Wellesley College and Cornell University Medical College, Anne completed her Ophthalmology residency at Stanford University Medical Center and a fellowship in Medical Retina at the Bascom Palmer Eye Institute in Miami.

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Jayashree Sahni, MD  is a Senior Expert Translational Medical Director in the Ophthalmology Division at Pharma Research and Early Development (pRED), F.  Hoffmann-La Roche Ltd., in Basel, Switzerland (2015 onwards). She is accountable for establishing and executing the clinical strategy for molecules in early drug development and the clinical translation of biomarkers for early detection, staging, and assessment of therapeutic response in retinal diseases such as diabetic retinopathy, age-related macular degeneration (AMD), glaucoma, and inherited retinal dystrophies. In her 5 years at Roche, she has led and successfully completed 2 X Phase I studies in Glaucoma and 3 X Phase II studies (faricimab – first bispecific antibody in ophthalmology) in neovascular AMD and diabetic macular edema. She currently leads pRED Ophthalmology’s Phase II program in geographic atrophy (GA) and 2 clinical stage gene therapy programs. She has experience leading preclinical and clinical-stage projects with small molecules, large molecules, anti-sense oligonucleotides, gene therapy, and medical devices through discovery and development. She set up and leads a key strategic collaboration to build novel analytics platform using artificial intelligence (AI) and machine learning (ML) for retinal images to identify new predictive and prognostic biomarkers. Her team is also leading biomarker development efforts for precision medicine in ophthalmology to support Roche’s portfolio, integrating genetics, retinal imaging, informatics, and tissue/fluid biosamples. Jayashree also holds a faculty position as a Senior Clinical Lecturer (Associate Professor equivalent) at University of Liverpool, UK, in the Department of Eye and Vision Science, Institute of Aging and Chronic Diseases. Her research focuses on studying the genetics of central serous chorioretinopathy and identifying novel retinal imaging biomarkers for understanding disease pathology, therapeutic response, patient stratification and selection, and application of new AI and ML tools for medical image analysis. From 2008 to 2015, she held a clinical position as a consultant (attending) ophthalmologist and retina specialist at St Paul’s Eye Unit, Royal Liverpool University Hospitals NHS trust and was the Director of the Liverpool Ophthalmic Reading Center, supporting multicenter clinical trials in retinal diseases. She received her MD from Nagpur University, India followed by a Fellowship of the Royal College of Ophthalmologists (FRCOphth) in 2008, and Doctorate in Medicine (PhD equivalent) from University of Liverpool in 2008. She completed two clinical fellowships in medical retina at the St Paul’s Eye Unit in Liverpool and in inherited retinal diseases at the Moorfield’s Eye Hospital, London, UK.

Part XI

Work-Life Balance

Chapter 38

Work-Life Balance and Avoiding Burnout Camille V. Palma

Summary Points • Work-life balance is multifactorial and includes themes such as time-­ management, resilience, and avoiding burnout. • Multiple strategies to improve work-life balance, satisfaction, and resilience are discussed. • Utilize a combination of strategies to improve quality of life.

Work-life balance is like the elusive pot of gold at the end of the rainbow. Deep down we suspect it is an imaginary reward for a chase that seems to never end. We have a tendency to only think about work-life balance from the standpoint of time-­ management, but this approach falls short. Rarely do we spend equal time and effort in both work and home. To achieve success, we must also strive to increase our overall wellness and satisfaction. Simon Sinek offers up the idea that work-life satisfaction occurs as a result of feeling safe in both places [1]. Safety is built through consistency, good relationships, support and having meaning in our actions. This idea of safety parallels a recent shift in physician burnout literature. Many researchers now look for ways to increase wellness, resilience, and well-being rather than just avoiding burnout [2]. We should look for ways to thrive in all aspects of life rather than just try to survive. I have outlined a number of strategies that incorporate each of the aforementioned concepts. My hope is that the reader will pick up at least one or two pearls that she can implement to improve her quality of life and decrease the burden of work-life stress.

C. V. Palma (*) Department of Ophthalmology, Cook County Health and Hospital System, Chicago, IL, USA © Springer Nature Switzerland AG 2021 C. Y. Weng, A. M. Berrocal (eds.), Women in Ophthalmology, https://doi.org/10.1007/978-3-030-59335-3_38

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Time-Management Work-life balance is traditionally a puzzle of time-management. The idea that we are stuck in a “time-bind” was popularized in the late 1990s. Our jobs dictate the division of time between work and personal life. We prefer that time is distributed differently, but are unable or unwilling to do so, usually because of the demands of our jobs [3]. Researchers have expanded on that concept to suggest that this “time-­ bind” can be understood as a “perceived imbalance between work and f­ amily/personal life [4].” This definition has evolved to describe work-life balance as “a process in which people seek to change things in accordance with changes in their own priorities, physical, psychological, or both, and these can be triggered in their turn by factors such as: age; changes in working conditions; the demands of new technology; and poor management [5].” We often think that if we can just be super organized, we can “fit it all in.” In one study, 40% of physicians did not think their work schedule left enough time for personal or family life compared with 23.1% of controls [6]. When we feel stressed and out of balance, we blame our dissatisfaction on not having enough time. If our lives were just a game of hours, work would always win because as physicians, we spend more waking hours at work than we do at home. Finding satisfaction in the interplay between work and non-work life is more complex than the allocation of time. And yet how we manage our time, both at work and at home can go a long way in establishing stability and minimizing stress. The next few paragraphs offer a number of time-management strategies to improve and organize life for those of us who try to do it all.

Schedules One of the strongest predictors of burnout is the level of control over our schedules and hours worked [7]. We have a tendency to only fill our calendar with work-­ related items and special events. Instead, fill up your calendar with everything in your life. This includes family dinners, exercise, work meetings, and even sleep. The idea behind this integrated approach is to elevate all of your priorities to the same degree of importance. Because self-care, exercise, and routine family events are not typically scheduled, they are often sacrificed. By organizing and including everything on the calendar, we reclaim control over how our time is spent and give non-work items the same level of importance. This organizational strategy not only gives us more control over how we spend our time, but also forces us to be accountable for the things we actually care about.

Priorities It is important to identify what is important in our lives and set boundaries. Identifying our priorities requires reflection. It sounds simple but if we don’t spend time reflecting on what we value, we do not know where to spend our time. There will always

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be more opportunities than hours in the day. Physicians have difficulty giving themselves permission to engage in activities that promote self-awareness and self-care [8]. If we continually say yes to things that do not align with our values, we will quickly feel the tug of work-life stress. For example, I enjoy cooking, but it is a much lower priority for me than spending time with my family and exercising. If I come home and spend 2 h cooking at the expense of activities that I value more, I feel dissatisfied and stressed. When instead, we outsource dinner and then go for a family walk, I feel good. I do not have enough time to do it all. But I should be able to fit in the most important activities on most days. Time is a limited and precious resource, so aim to spend it in a way that maximizes your satisfaction and values.

Delegate While being in control of certain things such as our schedules at work has been shown to be protective against burnout [7], too much control can also be problematic. Excessive workload is a known factor that contributes to burnout [9]. Our administrative burden at work is increasing, and certain things such as computerized physician order entry cannot be delegated. Try looking critically at the things that consume your time and see what can be delegated to staff and administrators. Use macros and templates for your EMR. Consider utilizing workflow efficiency and other practice management tools to streamline your clinic operations. At home, many women assume the role of “head of household” and feel burdened by the overwhelming number of tasks that must be done to keep life afloat. Outsource anything that makes your life easier. If you have a partner, sit down with them and consider what cannot be outsourced, then divide and conquer. Recognize that not everything will get done “your” way and accept that that the final product may not achieve perfection. Good enough IS enough. I have mentioned that I like, but do not love, cooking. With a full-time job and a newborn at home, I have very limited time after work. Since I still want home-cooked meals and my husband does not cook, our solution has been to hire a nanny who also cooks dinner a couple times a week. On the nights she doesn’t cook, we order out. It’s not a perfect solution, but it is one that alleviates stress and keeps us fed.

Unplug Phones and computers are incredibly useful tools, but they are highly addictive and most apps are designed to keep you scrolling. Remember that we are horrible multi-­ taskers. It is easy to disappear into emails, social media, or even our EMRs. We lose both time and connection with others when we do this. Unplugging can be challenging when we have on-call responsibilities because we rely on our cell phones to communicate with patients, peers, and hospitals. I have found that wearing a

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smartwatch set to only notify calls and texts allows me to be discreetly available without being overtly attached to my phone. My phone has become less distracting because I can put it away and calls feel less intrusive. Other options include keeping the phone face down when in social situations, or in a central spot at home where you still feel available but not attached to the device. Disabling or uninstalling apps that suck your time might also be helpful. Avoid using multiple devices at the same time. Do not use your phone while on the computer and put both away while in front of the television. Ideally, turn your television off. You would be amazed at how much time you reclaim when you limit TV consumptions to weekends only (or not at all!)

Perfection Sometimes work-life balance is found only when we let go of everything and accept that life is messy and uneven. We are a highly intelligent and motivated group and with that comes a tendency to want things to be “just so” under our own control. There are too many factors beyond our control that impact what happens at work and at home. The drive for perfection results in taking on more responsibility than we can often realistically handle. Sometimes this is rooted in fear. Fear that we won’t be perfect or that something won’t be done the right way. Fear that we will seem weak or incapable. Fear that we might miss important milestones or career advancement. We can’t be everything to everyone. Let yourself delegate, compromise, and even accept imperfection. Balance does not always mean equal. Sometimes balance just means accepting what is.

Resilience Resilience is a central element of physician well-being. Burnout is an epidemic and women are particularly vulnerable [8]. The more we can boost our well-being, the more resilient we will be, regardless of how our time is divided between work and home. Researchers are recognizing that physicians who are resilient are less likely to experience burnout and that the same strategies that increase resilience are protective against burnout [10]. Resilient individuals are also more likely to feel satisfaction with their lives overall, both at home and at work. The following are strategies less focused on time-management and more focused on building resilience and minimizing burnout.

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Mindfulness Incorporating a mindfulness practice into your daily routine promotes resilience and has been shown to reduce stress and enhance general well-being [9, 11, 12]. Mindfulness has been defined as “the awareness that emerges through paying attention on purpose, in the present moment, and non-judgmentally to the unfolding of an experience moment-to-moment [11, 13].” Meditation apps such as headspace are popular and easy to use. Most of us can find at least 10 min per day to be fully present. In my last job, I commuted 2+ hours each day. I would practice mindful breathing while driving to and from work. The beauty of mindful meditation is that it can be done anywhere.

Self-Care Self-care is so important to our well-being that some researchers advocate that “making time for activities outside of work should be embraced as an aspect of professionalism and supported along the continuum of medical training and careers [10].” Self-care looks different for everyone. For me, self-care is taking time to practice yoga. Yoga changes my brain chemistry. It relaxes me, brings me joy, and centers me. I am a calmer, happier person when I take time to practice. When I am calmer and happier, I focus more easily on work-related and creative tasks and have an easier time being present at home. Find your personal need. What brings you joy? It may be more sleep. It may be traveling, writing, or reading a book. It may be wine night with your friends or learning a new skill. Identify at least one non-work activity that makes you feel good and nourish it.

Exercise Exercise is a form of self-care but stands independently as an effective wellness strategy. Incorporate exercise into your weekly regimen, even if it is not something that you particularly enjoy. A study commissioned by the American College of Surgeons Committee on Physician Competency and Health showed that surgeons who exercised according to the CDC guidelines had higher levels of wellness and less burnout than their peers [14, 15]. Exercise is often the first thing that gets dropped when we get busy but is possibly the most important thing to maintain because of the direct physiologic impact that regular exercise has on our overall health, mood, and mental clarity. Studies have shown that working longer than 55 h a week raises the risk of heart attack and stroke and can increase levels of anxiety and depression [16, 17]. Physicians not only work a median of 10 h more per week

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than population controls, but tend to have greater struggles with work-life integration than other US workers [14, 18].” Remember that exercise does not happen in a vacuum. Use this activity as a time to spend with your family and friends, get outside, and even build mindfulness. Get moving!

Support Life is not a solo sport. Invest in your support network. Medicine can be isolating. With less time to see patients and mounting, seemingly never-ending administrative responsibilities, our isolation will only get worse in the future [8]. We need community and connection with others to thrive at home and at work. Studies of resilience show that physicians do best when communication with peers is high. Small group support and increased communication skills have been shown to protect against burnout [8]. Having good relationships at work also increases the likelihood that we feel safe and satisfied with our jobs [1]. Personal relationships are so important they get their own chapter earlier in this book. Your partner, friends, and family are your biggest supporters and advocates. Remember that joy builds resilience and that building and maintaining relationships with patients, colleagues, family, and friends is a form of cultivating joy [2].

Sleep It is so tempting to carve out time from sleep to fit more into our days. And occasionally, that is perfectly fine. But do not make a habit of sacrificing sleep for other priorities. We all know in our heart of hearts we are the best, most patient, smartest versions of ourselves when we are well-rested. Here are a few quick tips from the National Sleep Foundation for improved sleep [19]. Put away your screens and avoid exposure to blue light (yes, this includes the television) for at least 2 h before going to bed. Sleep in a cool, dark room. Minimize intrusions and distractions by putting your phone on Do Not Disturb or Airplane mode on nights that you are not on call. Wake up and go to bed at the same time every day, even on weekends. Avoid caffeine, large meals, and alcohol late in the day. Exercise during the day will help you sleep better at night. Well-rested you is the best you. Try to bring your best self every day.

Institutional Factors We know from numerous burnout studies that institutional factors impact our job satisfaction and that satisfaction at work is an important part of feeling balanced [2, 8, 10]. Many of us work in large groups or under large hospital systems with

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negative institutional factors that we may not be able to change. At home, we typically run our households and serve as primary caregiver to our families. As women and physicians, we need to remember that we are in a position of authority even if we don’t always feel in charge. Think and act like a positive leader. Be a source of safety, encouragement, and good communication for those around you. Do the same at home. Encourage interprofessional collaboration and offer social support to your colleagues and staff [8]. Step up, lean in, and model the behavior of a leader that builds resilience, not burnout.

Conclusion As I wrote this chapter, my newborn was strapped to my chest in various carriers and feeding positions, my arms somehow balancing the need to support his head and simultaneously reach the keyboard. The irony of writing about work-life balance while I was struggling to adjust to a radically new normal was not lost on me. Some days I was able to follow the advice in these pages, and on others I blatantly ignored all the strategies and just survived. My last pearl is to treat yourself with grace and forgiveness, no matter the outcome of the day. We will all have days where our strongest efforts barely keep our heads above water. We are not always our best selves and the pot at the end of the rainbow sometimes disappears from the horizon. Do not give up. Balance, satisfaction and overall wellness not only look different to each of us, but also look different as our needs and daily circumstances change. Be kind to yourself, sleep well, and know that tomorrow offers a fresh start.

References 1. Team Tony. 2017. Be the last to speak: Simon Sinek on the 10 rules for achieving greatness. [podcast] The Tony Robbins Podcast. Available at: https://www.tonyrobbins.com/podcasts/ be-the-last-to-speak/. 2. Serwint JR, Stewart MT. Cultivating the joy of medicine: a focus on intrinsic factors and the meaning of our work. Curr Probl Pediatr Adolesc Health Care. 2019. https://doi.org/10.1016/j. cppeds.2019.100665. 3. Keyfitz N, Hochschild AR, Robinson JP, Godbey G. The time bind: when work becomes home and home becomes work. Popul Dev Rev. 1997;23:655. https://doi.org/10.2307/2137582. 4. Tausig M, Fenwick R. Unbinding time: alternate work schedules and work-life balance. J Fam Econ Iss. 2001;22:101–19. https://doi.org/10.1023/A:1016626028720. 5. Byrne U. Work-life balance: why are we talking about it at all? Bus Inf Rev. 2005;22:53–9. https://doi.org/10.1177/0266382105052268. 6. Shanafelt TD, Boone S, Tan L, Dyrbye LN, Sotile W, Satele D, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med. 2012;172:1377. https://doi.org/10.1001/archinternmed.2012.3199. 7. Keeton K, Fenner DE, Johnson TRB, Hayward RA. Predictors of physician career satisfaction, work-life balance, and burnout. Obstet Gynecol. 2007;109:949–55. https://doi.org/10.1097/01. aog.0000258299.45979.37.

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8. Epstein RM, Krasner MS.  Physician resilience: what it means, why it matters, and how to promote it. Acad Med. 2013;88:301–3. https://doi.org/10.1097/acm.0b013e318280cff0. 9. West CP, Dyrbye LN, Shanafelt TD. Physician burnout: contributors, consequences and solutions. J Intern Med. 2018;283:516–29. https://doi.org/10.1111/joim.12752. 10. Zwack J, Schweitzer J. If every fifth physician is affected by burnout, what about the other four? Resilience strategies of experienced physicians. Acad Med. 2013;88:382–9. https://doi. org/10.1097/acm.0b013e318281696b. 11. Gogo A, Osta A, Mcclafferty H, Rana DT. Cultivating a way of being and doing: individual strategies for physician well-being and resilience. Curr Probl Pediatr Adolesc Health Care. 2019;000:100663. https://doi.org/10.1016/j.cppeds.2019.100663. 12. Rosenzweig S, Reibel DK, Greeson JM, Brainard GC, Hojat M.  Mindfulness-based stress reduction lowers psychological distress in medical students. Teach Learn Med. 2003;15:88–92. https://doi.org/10.1207/s15328015tlm1502_03. 13. Kabat-Zinn J.  Mindfulness-based interventions in context: past, present, and future. Clin Psychol Sci Pract. 2003;10:144–56. https://doi.org/10.1093/clipsy/bpg016. 14. Shanafelt TD, Oreskovich MR, Dyrbye LN. Avoiding burnout: the personal health habits and wellness practices of US surgeons. J Vasc Surg. 2012;56:875–6. https://doi.org/10.1016/j. jvs.2012.07.016. 15. Physical activity basics. Centers for Disease Control and Prevention 2019. https://www.cdc. gov/physicalactivity/basics/index.htm. Accessed 20 Oct 2019. 16. Kivimäki MT, Jokela MI, Nyberg S, Singh-Manoux A, Fransson E, Alfredsson L, et al. Long working hours and risk of coronary heart disease and … 2015. https://www.thelancet.com/ journals/lancet/article/PIIS0140-6736(15)60295-1/fulltext. Accessed 25 Oct 2019. 17. Afonso P, Fonseca M, Pires JF. Impact of working hours on sleep and mental health. Occup Med. 2017;67:377–82. https://doi.org/10.1093/occmed/kqx054. 18. Shanafelt TD, Boone S, Tan L, Dyrbye LN, Sotile W, Satele D, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med. 2012;172:1377–85. https://doi.org/10.1001/archinternmed.2012.3199. 19. Sleeping tips & tricks. National Sleep Foundation. https://www.sleepfoundation.org/articles/ healthy-sleep-tips. Accessed 22 Oct 2019. Camille V. Palma, MD  graduated from Stanford University where she earned a B.A. degree in psychology. She earned her medical degree from Baylor College of Medicine in Houston, Texas, and stayed there to complete an internship in Internal Medicine. Dr. Palma completed an Ophthalmology residency at Case Western Reserve University in Cleveland, Ohio, where she served as Chief Resident in her final year. She then completed a fellowship in Vitreoretinal Surgery and Diseases at Northwestern University. She is certified by the American Board of Ophthalmology. She holds memberships in several professional societies and organizations including the American Society of Retina Specialists, American Academy of Ophthalmology, Women in Ophthalmology, and the Chicago Ophthalmology Society. Dr. Palma is passionate about education and has been actively involved with the vitreoretinal fellowship at Northwestern University. She is currently on staff at Cook County Health Hospital Systems and works closely with residents and fellows. Dr. Palma started dancing at a young age and has always had an interest in movement and body awareness. In 2015, she completed a 200-h teacher training through Corepower Yoga and is a

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certified yoga instructor. She teaches vinyasa-­style yoga classes in Chicago and has led numerous classes tailored specifically for ophthalmologists at local and national meetings. She is passionate about sharing mindful movement techniques with her peers and increasing professional awareness of physician wellness and resilience.

Chapter 39

Making the Most Out of Academic Meetings Janice C. Law

Summary Points • Know why you’re going to the meeting – set meeting goals. • Plan your learning objectives and sessions in advance of the meeting. • Beef up your networking skills to use at meetings, don’t be afraid to self-­ promote, and practice your 1-min elevator pitch.

Reasons to Attend an Academic Meeting Why do we go to academic meetings? The obvious answer - to improve our knowledge and skills, to contribute to science, and to test new technology or instruments. But it is just as important, if not more so, to go to academic meetings and medical conferences to network, to collaborate, and to come away inspired. Each of these has a purpose in an ophthalmologist’s career trajectory. Not one of these elements should be left out during a meeting experience. And according to Sallie Krawcheck, CEO and Co-Founder of Ellevest and author of Own It: The Power of Women at Work [1], women need networking and collaboration the most to be successful.

J. C. Law (*) Vanderbilt Eye Institute, Department of Ophthalmology and Visual Sciences, Vanderbilt University Medical Center, Nashville, TN, USA © Springer Nature Switzerland AG 2021 C. Y. Weng, A. M. Berrocal (eds.), Women in Ophthalmology, https://doi.org/10.1007/978-3-030-59335-3_39

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Education How effective is the educational mission at academic meetings? Recent papers [2] have looked at the challenges of scientific meetings disseminating new and relevant information in a world where information is already instantly shared through webinars, social media, push-notifications for short sound bites, 3-min videos, and full PDF articles. Conference planners are now finding ways to make the meeting an experience worthwhile through innovative methods of engagement and interaction. Is there any reason for in-person learning? I believe the answer is yes. If you have the privilege of getting away to a meeting, I know that in-person learning sticks better for me than reading an article to receive CME credit. Being present in the room at meetings gives us the opportunity to pick the brain of an author, hear and contribute to lively discussions, and learn from the feedback of audience members. Meetings are most constructive if you participate in something you couldn’t experience from the comfort of your home or smart device: surgical wet labs, skills transfer, witnessing the reveal of a new technique, live surgery, and exhibitors’ demonstrations. At a recent educator’s meeting, I was invited to participate as a billionaire judge in a Shark Tank competition for medical education innovation. It was a brilliant way to engage with select leaders and audience members to share novel ideas while receiving diverse criticism and suggestions for success. Judges, innovators, and audience members all gained from this unique session that could have only been experienced in person.

Challenges for Women at Meetings Work-life balance (or work-life integration) is a well-known topic among all ophthalmologists and especially women. When we are away at meetings, meeting-life balance (or integration) is also a real challenge. Work projects, e-mails, family worries, and other personal reasons can get in the way of us being fully present to learn, network, or get the most out of meetings. New moms especially  – give yourself grace as you practice the rhythmic sequence of meeting session and hotel room family check-ins. This is a healthy and much commonly understood balance of being part of both domains while away. Many moms will say meetings are where they also get the most-needed respite. There are no children or babies to wake them up, and the alarm clock is optional. Sometimes just getting away from the office and house gives us the quiet time we need to catch up, reset, and take care of long-awaited business or to-do lists. Permission is granted to do what you need to be successful during your meeting time. However, it will take mindfulness practice skills to be present in the moment and to ignore distractions that come up if trying to experience all aspects of the meeting. That is why it is critical to prioritize at these meetings and set meeting goals and learning objectives as described below.

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Types of Meetings and Programming There are a lot of meetings a physician can attend throughout the year. Every year I select meetings that fulfill the three core needs to my clinical practice: subspecialty education, practice management or business, and advocacy. There are additional meetings I attend for professional development in my other domains at work related to medical education, leadership, and women in ophthalmology. The benefits of attending the American Academy of Ophthalmology (AAO) annual meeting is that one can have all of these session types in one place, making it very efficient and cost-effective if scheduling conflicts and cost are prohibitive to attending multiple meetings in a year. Try to diversify your meetings from year to year to expand your perspectives and learn new ways to solve new and old problems. There are advantages and disadvantages to big meetings and smaller (few hundred participants), more intimate meetings. While you can’t choose the size of your society or organization’s academic meeting, you can be selective in the format of courses you attend that maximizes your experience. Interactive courses, workshops, and smaller scientific sessions where the presenter may be able to see you and interact with you can help facilitate both learning and relationship building. Another way to get up close and personal is to volunteer to be a floor manager for scientific sessions at the AAO annual meeting. This will help you get a front row view while you manage the session’s time clock and check in speakers. Many young ophthalmologists have met key leaders and legends in ophthalmology through this volunteer opportunity while maximizing personal learning time!

Set Clear Meeting Goals As mentioned earlier, there are many reasons to attend a meeting. While all six aspects are important, I set a primary goal for each type of meeting. One example, while I was a newly minted Associate Residency Director after fellowship, I made a goal of meeting key opinion leaders in medical education. It was my second annual meeting at the Association of University and Professors of Ophthalmology – I had just given a podium presentation on my research and wanted not only to hear expert feedback but also to insert myself into the community. I bravely walked up to key leaders whose reputation and work I knew well and shared with each my research and asked how similar competencies were measured at their institutions. This afforded me a reason (and an ice breaker) to talk to these leaders, share my work, and find a commonality and a future mentor. If improving clinical and surgical knowledge is my primary goal, I have to be intentional and map out my week and sessions in my phone calendar, so I don’t miss the presentations I want to attend. This is especially true of the AAO annual meeting where there are so many good sessions happening simultaneously or in areas where I have to plan the walking route to make the sessions on time. Also, don’t

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overschedule yourself and try to attend everything like I did one year. I was burned out trying to see and hear everything for fear of missing out. I find it helpful to identify two clinical learning objectives prior to arriving the meeting. This tailored approach is much more effective. One year I wanted to improve my confidence in uveitis management and macular surgery and focused my learning map for this. Another year I wanted to improve my coding skills and sought more updated information about retinopathy of prematurity (ROP) and tele-ophthalmology. The mobile meeting guides or electronic program planners allow me to filter and bookmark my preferred formats and relevant topics to help stay focused and reach my learning goals. Don’t forget to share learned knowledge with others. Information that you bring back to your employer/department chair or implement at your institution is a great return on investment and keeps you (and the meeting) relevant in your practice. For instance, inspired by all of the practice management sessions I attended including Academy’s coding workshops, I designed a practice management module for our residency program. This not only resulted in equipping young ophthalmologists with knowledge they need to be successful in their future practices but also benefited our faculty leading to increase in wRVUs and revenue. I also incorporated the AAO ROP case-based training module https://www.aao.org/interactive-tool/retinopathy-of-prematurity-case-based-training in my ROP flipped-classroom which improved learner engagement and sticky learning in my residency program. After each session you attend, jot down one or two sentences that summarize the takeaway points. Add to your notebook how this impacts your work and how you might try to incorporate this into future research or inspire you to change your practice.

Presenting at Meetings Many women also contribute a lot at these scientific and academic meetings through leadership positions and by serving as guest speaker/panelist, moderators, and co-­ planners. As a whole, we need to keep showing up, presenting, taking on leadership roles, and encouraging diversity on panels. Giving yourself to society meetings is a great way to contribute to your field, grow professionally, and meet people who challenge you and inspire you. Early career physicians often ask how to get invited to speak or be considered for committee positions. First identify your passion or research interest: Novel surgical techniques? Advocacy? Stem cell applications? Clinical education? Resident assessments? Starting a practice? And then make it known. How do you get the invite? That happens through networking at the meeting. Women are more likely than men to wait for an invitation and are less likely to self-­ promote to obtain leadership positions [3]. One of my mentors, Kim Lomis, MD, a general surgeon by training and current Vice President for Undergraduate Medical Education Innovations at the American Medical Association, advises, “Try to meet

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those who are already on committees – at receptions or after sessions – to share your interest. Then you’ll be in their mind when spots open. It feels awkward, but you can’t wait for someone to invite you – self-nomination is just fine.” Identify society leaders or committee members and ask if there’s an opportunity to speak on “x” or if you can help start a new initiative on “y.” Start with smaller societies like your state society and ask to help with meeting planning or committee work, then deliver quality work and you’ll get asked to do more and lead more. Another strategy is to initiate the creation of an instructional course with someone who has a little more seniority. The pairing will give program planners more trust because of the reputation and reliability. Once you’ve successfully given this presentation, ask for feedback, keep the dialogue going, then more opportunities will arise to repeat or revise the presentation. You will learn from the senior instructor, meet his or her circle of colleagues, and now have the ability to repeat the course or be senior lead next time.

Networking and Collaboration It’s important to try to meet people inside and outside of your specialty and at different career stages, developing diversity in your social and professional circles, leading you to new mentors, advisors, and future connections. This is where attending scientific meetings in person provides a great advantage over virtual learning. In my informal poll of 50 responders through social media, the primary reason they attend medical conferences was networking (50%) and improving knowledge (26%). Expanding your network beyond your comfortable bubble reaps rewards. On why networking is important, Gretchen Winters, MD, a pulmonary critical care physician at University of Alabama, CHEST Podcast Editor, and member of the education committee for Association of Pulmonary and Critical Care Medicine Program Directors explains, “So much of positions and opportunities you will be offered stems from who knows your face and name and work. Networking not only builds great relationships, but it can lead to partnership on projects, and even to potential leadership roles as you demonstrate your work ethic.” Dr. Reed A. Omary, MD, MS, Professor and Chair of the Vanderbilt University Department of Radiology and Radiological Sciences, shares regarding networking, “[There’s] No better way to learn about new ideas and ways of thinking. Networking is just another name for curiosity when applied to actual people and ideas.” “Networking is not only for career advancement but also for gaining inspiration from people who’ve paved the way,” says Sahar Bedrood, MD, PhD, a cataract and glaucoma specialist committed to mentoring women. Coming away from a meeting inspired to innovate or improve the way we practice drives positive change and is protective against burnout. How do you improve your networking abilities and collaboration success at meetings?

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1. Pre-meeting prep includes practicing your 1-min elevator pitch. This means you have to create one if you don’t already have one. You can prepare as many as you need. I typically have three. The areas I am looking to collaborate or develop in are medical education, physician wellness, and opportunities and needs of young ophthalmologists. 2. Know ahead of time who you want to meet or what you want to achieve and when that opportunity will be. So do you your homework! Pack your business cards and make sure your CV is updated. Try a QR code business card to keep it simple yet high-tech. 3. Ask questions that can also lead to meeting more people in the room. “Who else should I meet on this topic? Is there anyone else that you know that knows a lot about this? I would love to meet Dr. Smith, can you introduce me?” 4. Follow through with an e-mail or text if they shared their cell. Thank them. I take selfie group photos as a strategy to remember our conversation and groups I’ve met and to remind me to follow through.

Step Outside Your Comfort Zone Don’t have a meeting buddy? Attend the first night’s social or ask someone on the first day if they know of any social events or dinner going on. Invite yourself to the event. “Do you think there will be room for one more?” It’s important to put yourself out there and step outside your normal comfort to be able to meet someone new. Dr. Purnima Patel, MD, Associate Professor at Emory Eye Center, and Deputy Editor-in-Chief for the AAO ONE® Network does this successfully. At her local meetings, she helps women at Emory expand their network by meeting other professional women through a dinner network event  – the requisite is that each comes with a guest from a different specialty who is interested in expanding their network. One year at the Women in Ophthalmology Summer Symposium, Dr. Patel initiated an event to help women meet new people they wouldn’t have otherwise. Instead of getting a dinner reservation for 20 already close friends, she and I invited 20 women from different career stages and specialties who became friends at the end of the night. A medical student applying for ophthalmology found herself between Jane Edmond, MD, founding chair in the Department of Ophthalmology at Dell Medical School, and Christina Weng, MD, MBA, Director of the Vitreoretinal Diseases and Surgery fellowship at Baylor College of Medicine, and became acquainted with Jennifer Lindsey, MD, Director of the residency training program at Vanderbilt Eye Institute. Women who were interested in becoming more engaged with the AAO found themselves sharing their 1-min elevator pitch with AAO Vice President of Global Alliances and the AAO Director of Ophthalmic Society Relations. New mentorships formed that night across different generations, conversation around physician wellness permeated, and collaborations on future programming and news articles began to brew as we talked also about future education and integration of new technology in our practices. So many great ideas

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and opportunities were shared over dinner that night, it felt as if we solved all the problems of the world. Inspired by seeing these connections built, I have made it my goal to foster this type of environment at future meetings. A night like this can only be successful if everyone stepped out of their comfort zone. As professional women, we have so much to give to younger women who are just beginning their journey. Intentional networking with them is just as important as strategic networking with others in positions we aspire to be like. “Develop the mindset of helping others become successful. The benefits of networking will follow,” says Ravi Goel, MD, comprehensive ophthalmologist and AAO Senior Secretary for Ophthalmic Practice. We pay it forward when we sponsor a woman to join a committee and mentor a woman to get to the podium. It takes just one opportunity to help someone launch their career, to help their research get noticed or their ideas get heard. I personally think it is important to stress that genuinely shaping your own mindset to helping others become successful is its own reward. And those who do will also experience unexpected benefits of being a mentor, sponsor, and leader.

Using Social Media at Meetings Open a professional Facebook, Twitter, or Instagram account to follow your society or meeting’s hashtags. Doing this allows you to stay up-to-date on key events and sessions. Twitter for scientific meetings is a common place to get breaking news flashes about scientific papers, discoveries, and often allows for summaries of sessions that you might have missed [4]. When retweeting or reposting a society’s announcement, you are helping the society amplify their news and gain attraction. Doing this also gets you connected to leaders virtually. In other words, it is a form of virtual networking. Other leaders with like-minded interests may reach out for future collaboration, speaking engagement needs, or in-person meeting. This is how I discovered the Millennial Eye Live and was later invited to speak at two meetings. If not for Twitter and Instagram, I would not have crossed paths with non-retina subspecialty key opinion leaders nor have such opportunities to engage with new talent shaping ophthalmology. An example of social media connecting leaders not just across the country, but across the world during an academic meeting is my recent interaction with Imane Tarib, MD, a young ophthalmologist in Morocco who created a new society in her country: Young ophthalmologists of Morocco (YOM). She, through social media, promoted our AAO YO events helping us reach international YOs. When it was time to launch her local society meeting, I virtually supported Dr. Tarib’s events and promoted her efforts. Our initial Twitter friendship later transformed into an opportunity to exchange ideas when we met in person at an AAO meeting. Regardless of the different uses of social media at scientific meetings, one of the greatest uses is to continue the dialogue long after the meeting is over. This is best accomplished with visuals or accompanying photos from the meeting or event.

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Dr. Rob Melendez, MD, MBA, a comprehensive ophthalmologist and the AAO’s Secretariat for Online Education, is a great example of someone who uses this technique effectively at meetings, especially for networking and professional development. He tags friends and colleagues to comment or share photo memories he’s taken of the meeting with relevant hashtags through his social media platforms. The momentum of inspiration, learning, and shared advice continues through retweets and reposts, through additional directed questions to key leaders, and added exchange about new developments on the topic or #hashtags. Although the meeting is over, the conversation does not stop and in fact expands.

Post-meeting As the meeting is winding down, take care to use the time to recuperate, rest, and review. Review the key takeaways from each session you attended. How were you going to incorporate what you learned? Share this with a colleague or e-mail your employer, not only to disseminate information but also to help remember it. Send follow-up e-mails to the new contacts that you made. Follow them on LinkedIn, Twitter, or ResearchGate. Send thank you cards to those that mentored or sponsored you.

Summary Whether attending your first meeting or attending as a veteran, there are a few tips to help make it successful and productive. Know why you’re going – set a meeting goal, polish your 1-min elevator pitch, ramp up your social media relationships, plan or map out your learning sessions ahead of time, and be sure to not miss the networking receptions. Create group dinner reservations to expand your network with others you’d like to meet and leverage your connections to sponsor or mentor another woman to exceed her potential. Academic meetings allow us to learn, leave inspired to be the best, innovate for the future, and most of all, network to expand our possibilities, whether it be for our career trajectory or personal growth. One thing I always do after a meeting – take one day off to transition back to the grind, then share what you’ve learned and bring colleagues back with you the next year!

References 1. Krawcheck S. Own it: the power of women at work. New York: Crown Publishing Group; 2017. 2. Sohn E. The future of the scientific conference. Nature. 2018;564:S80–2.

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3. Gipson AN, Pfaff DL, Mendelsohn DB, Catenacci LT, Burke WW.  Women and leadership: selection, development, leadership style, and performance. J Appl Behav Sci. 2017;53(1):32–65. 4. Christiansen SM, Oetting TA, Herz NL, Law JC, O’Brien CP, Patel PS, et al. Twitter at the 2014 and 2015 annual meetings of the American Academy of Ophthalmology. Ophthalmology. 2016;123(8):1835–7. Janice C. Law, MD  completed her ophthalmology residency at Kresge Eye Institute/Wayne State in Detroit, MI, where she was chief resident. She then completed 2 years of vitreoretinal surgery fellowship at Vanderbilt Eye Institute in Nashville, TN, and joined the faculty at Vanderbilt as a full-time vitreoretinal surgeon while serving as the Associate Program Director for 7 years. She is the 2015, 2017, and 2019 recipient of the Vanderbilt Eye Institute Bridge Award given to outstanding faculty educator and mentors and the inaugural recipient of the Laura L. Wayman Award for meaningful contributions to ophthalmology. She is now the Director for Medical Student Education, but continues to play an integral role mentoring within the residency training program. Her research focus is on curriculum development and skills assessment in ophthalmology. She remains passionate about quality improvement after leading Morbidity, Mortality, and Improvement conferences for 10 years. Dr. Law has received national recognition for her service and commitment to patients and ophthalmology, which include an Emerging Leaders Award from Women in Ophthalmology, two AAO Secretariat awards, an AAO Achievement award, and the AAO Commitment to Advocacy Award presented to her and the Vanderbilt Eye Institute. Dr. Law also serves on the executive board for her state society and promotes young physicians to engage in advocacy for patient safety and ophthalmology. On a national level, she is committed to her work as the Chair of the Young Ophthalmologist (YO) committee and works to serve the needs of both domestic and international YOs. Dr. Law is also a graduate of the American Academy of Ophthalmology Leadership Development Program Class XVI.

Chapter 40

Social Media and Privacy Issues Maryam Nazemzadeh

Summary Points • This reflects an oculoplastic surgeon’s real-life experience from no social media presence to 15 K+ followers. • Just like getting through medical school, developing a social presence requires daily commitment to produce content and engage followers and prospective followers. • Share enough about yourself so that you’re relatable, but like anything else, it’s a balance to maintain a professional doctor-patient relationship.

Social media has become quite a force in our personal lives. There is this voyeuristic urge to get a glimpse inside the life of someone else and to share your every move. As they say, “If it’s not on social media, it never happened.” But how did social media creep its way into medicine? How did this phenomenon become such an integral part of our professional lives? To answer that, we must understand the way that the world has changed and how people view themselves. It’s funny to think how active I have become both personally and professionally on social media. Someone who vowed to never have a social media account, and yet here I am today with an entire team dedicated to managing my social media account to enhance my business. When I was in college, Facebook made its debut. I didn’t quite understand the obsession people had with sharing their lives. The transfer of day-to-day information and knowledge was no longer a commodity but an expectation. I finally broke down and signed up for Instagram and Facebook during

M. Nazemzadeh (*) Sanctuary Cosmetic Center, Tysons Corner, VA, USA Rostami Oculofacial Plastic Consultants, Reston, VA, USA © Springer Nature Switzerland AG 2021 C. Y. Weng, A. M. Berrocal (eds.), Women in Ophthalmology, https://doi.org/10.1007/978-3-030-59335-3_40

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ophthalmology residency. Soon after came the boom of social media influencers or “bloggers.” This is when I realized how powerful of a tool social media could be for me professionally. I studied the concept of social media “influence” and what it really meant for me professionally. How could I translate the same concept to my career in oculofacial plastic surgery? What began as a simple experiment in 2017 quickly turned into something much bigger. I wanted to answer a simple question, “Could my social media ‘influence’ give me a professional advantage?” I vowed to post a minimum of 3–4 times per week on Instagram (as well as post stories). Most importantly, I vowed to be open, to show myself, to show my family, and to show who I was both inside and outside the office. I would quantify the so-called, “return on investment,” based on two factors: (1) New patient consults via Instagram and (2) conversion rate of those patients specifically from social media/Instagram. Although my experiment related mostly to the cosmetic aspect of oculofacial plastic surgery, it could relate to any field in ophthalmology and truly any field in medicine. I will start off by admitting that it was a second full-time job. The commitment is intense and requires a lot of attention and time. On average, I was spending anywhere from 3 to 4 h per day developing content, responding to comments, answer direct messages about specific products/services, liking/commenting on targeted accounts, and following targeted accounts. My posts were always related to one of the following six things: 1 . Before and after 2. Inspirational/meaningful quotes 3. Educational videos 4. Personal pictures (yup, that’s right, sometimes even SELFIES!) 5. Family pictures 6. Patient reviews Having a business account with Instagram allows you to quantify each post based on interaction: 1. Calls/E-mail: The number of times visits have clicked the call/e-mail button from your profile page 2. Comments: The number of comments on your post 3. Engagement: The number of unique accounts that liked, commented, or saved your post 4. Follows: The number of accounts that followed you because of your post 5. Get Directions: The number of accounts who tapped “Get Directions” because of your post 6. Impressions: The number of actions taken on your account 7. Likes: The total number of likes on your post 8. Profile Visits: The total number of profile views over the week 9. Reach: The number of unique accounts that have seen any of your posts 10. Saved: The number of times your post was saved 11. Shares: The number of times your post was shared 12. Website Clicks: The number of times visits have clicked the link to your website from your profile page

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Here I summarize my own analytics based on my type of posts and which type of post performed the best in each category: 1. Calls/E-mails: Personal picture 2. Comments: Personal picture 3. Engagement: Family picture 4. Follows: Personal picture 5. Get Directions: Personal picture 6. Impressions: Personal picture 7. Likes: Family picture 8. Profile Visits: Before and after 9. Reach: Personal picture 10. Saved: Before and after 11. Shares: Before and after 12. Website Clicks: Before and after The results were nothing short of shocking, but they did answer my question about social media influence. Simply put, we are our own influencers. If people feel like they know you, they may potentially trust you. They may trust your recommendations more easily as a patient and trust your judgment as a doctor. In their mind, they have already met you, gotten to know you, and feel comfortable with you. Silly as this may sound, this is the power of social media. It gives your patients a glimpse into your life and who you are behind that white coat. The question of privacy is an important one. Why does it matter who I am personally? You could say, “I’m a doctor, I studied hard and trained hard. Who I am personally has nothing to do with who I am professionally.” Ten years ago, I would have agreed, but times have changed, and there is no denying that it also affects medicine and how we market ourselves to prospective patients. In the beginning of my social media journey, I vowed to be completely open. I filmed myself at work, at home, and with my family. Once a month, I allowed my followers to “ask me anything.” I would answer all my direct messages, however mundane or complicated they would be. Prospective patients would often send me pictures of themselves asking for a quick and easy consult. Others would ask me what I was wearing, where my outfit was from, or where I got a certain meal. The questions started to become more and more intimate and excessive. Patients who came in from social media were able to recite my entire life by heart – where I had gone during the past weekend, my daughter’s name, how old she was, how cute she looked at her birthday. I had created a beast and it wanted more and more. Soon I realized that who I was professionally and personally became too intertwined. There were no boundaries, no rules. I became too accessible. Although close to 70% of my patients were coming from social media and my conversion rate was over 90% (over twice the national average), I made the decision to back away. It was not a privacy issue, but simply an accessibility issue. I simply became a commodity and my value and worth as a surgeon were being minimized. Prospective patients over direct message were calling me by my first name. I was just another social media blogger to them, not a surgeon.

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I made the decision to hire a social media manager. Soon after hiring her, I would step away from my social media account, only checking in to make sure the content was accurate. The direction of my social media has changed. Although, I still aim to be authentic and show who I am, I no longer offer so much of myself personally. The direct messages that ask for a quick consult or pricing are answered with, “Hi, this is Dr. Naz’s social media manager, please feel free to set up a consultation with her.” I no longer highlight my day-to-day life outside the office. Everything I show happens in the office to keep the message of, “I’m a very busy surgeon.” The videos that were once shot in the comfort of my own home answering questions related to procedures and treatments are now done by a professional videographer. The goal is to maintain a distance between the patient and surgeon, one not too short that the patient feels that you and her/him are friends and not too long that you become intimidating or unrelatable. Finding your voice in social media will be a challenge, but it is a necessary evil. It has completely transformed my practice. Over half of my referrals are from social media. These are patients who simply begin to follow me and then later decide to book an appointment with me. Of those patients who see me from social media, over 90% will treat (meaning procedure or surgery). Patient privacy is an increasingly important issue in social media as patients are not aware of such implications. The nature of the patient-physician relationship has been challenged with the increasing ease of online communication and social media. Specifically, patients asking for medical advice have significant medicolegal implications for the physician. It is imperative that physicians use caution when giving patients advice over any social media platform and using it as an opportunity to educate patients on protecting their own privacy. I advise my patients to never send me questions regarding their care over social media messaging. Also, “consults” over messaging should not be responded to with clinical information or advice; they should simply be directed to call the office. The American Medical Association has developed formal professionalism guidelines for responsible use of social media by physicians [1]. Additionally, the American College of Physicians and the Federation of State Medical Boards have also issued policy statements regarding physician and the use of social media [2]. The Healthcare Insurance Portability and Accountability Act safeguards personal health information, and these types of laws should be adhered to. In academic settings, institutions often have their own online privacy policies, and some institutions may have a designated chief social media medical officer who can provide guidance about responsible use of social media. Privacy is also an issue when physicians/surgeon want to share their craftsmanship with before and afters. Strict practices should be adhered to when obtaining consents for photography. At our practice, we have our patients sign a consent after their photos have been taken. The consent outlines if and how the patient will allow usage of their pictures: educational purposes, internal marketing (only allowing other patients in the practice to see their photos), and external marketing/advertising/social media (Table 40.1). After a roller coaster ride of a social media experience, these are my top tips for any ophthalmologist interested in creating a professional account:

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Table 40.1  Online physician activities: benefits, pitfalls, and recommended safeguards [1] Recommended safeguards Establish guidelines for types of issues appropriate for digital communication Reserve digital communication only for patients who maintain face-to-face follow-up Observe and counsel Sensitivity to source of Consider intent of Use of social media search and application information patients on sites to gather of findings Threaten trust in risk-taking or information about Consider implications patient–physician health-averse patients for ongoing care relationship behaviors Intervene in an emergency Vet information to Non-peer-reviewed Encourage patient Use of online materials may provide ensure accuracy of empowerment educational resources inaccurate information content and related information through Refer patients only to Scam “patient” sites self-education with patients reputable sites and that misrepresent Supplement therapies and outcomes sources resource-poor environments “Pause before Negative online Advocacy and Physician-produced posting” content, such as blogs, microblogs, and public health Consider the content “venting” or ranting, enhancement physician posting of that disparages patients and the message it Introduction of comments by others sends about a and colleagues physician “voice” physician as an into such individual and the conversations profession Maintain separate Networking and Blurring of Physician posting of personas, personal and communications professional and physician personal professional, for personal boundaries information on public online social behavior Impact on social media sites Scrutinize material representation of the available for public individual and the consumption profession Implement health Confidentiality Physician use of digital Ease of information communication with concerns venues (e.g., text and technology solutions Unsecured networks colleagues Web) for for secure messaging and accessibility of communicating with and information protected health colleagues about patient sharing information care Follow institutional practice and policy for remote and mobile access of protected health information Activity Communications with patients using e-mail, text, and instant messaging

Potential benefits Greater accessibility Immediate answers to nonurgent issues

Potential pitfalls Confidentiality concerns Replacement of face-to-face or telephone interaction Ambiguity or misinterpretation of digital interactions

324 Fig. 40.1  Overall: this is the number of accounts that followed you minus the number of accounts that unfollowed you or left Instagram in your selected time frame. Followed you: this is how many accounts followed you in your selected time frame; unfollowed you: this is how many accounts unfollowed you or left Instagram in your selected time frame [3]

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1. Shape your brand and your message. 2. Understand your audience – this can be done with analytics/insights (built into business Instagram accounts) as you begin to shape your message, you can see the demographics of your audience, time when your audience is most active for optimal engagement, which can help you target your audience even further. And the best part, IT’S FREE! Here is each data point that is offered through a business Instagram account (Figs. 40.1, 40.2, 40.3 and 40.4): 3. Spend time to understand your analytics and create content surrounding posts/ stories that have the best engagement. 4. Be authentic – simply put, your audience will like you more if you’re yourself. 5. Educate – use your platform to explain what you do and how you do it. 6. Balance formality with informality – remember the average person knows very little about our field. Speak as if you were talking one on one with a patient, so keep that professionalism. 7. Include pictures – pictures say a thousand words, so invest in a quality camera with dedicated photo room (to keep lighting, etc., consistent). 8. Be consistent – I highly advise posting at least once a day with at least one story per day. Remember, “out of sight, out of mind.” You want to be the forefront of their thoughts, especially when they are making a decision as to who to see for their concern. 9. Thank your audience – you must respond to every comment and every message. If you don’t have time to do this yourself, I encourage that you hire someone to do so. Bedside manner essentially starts online. 10. Maintain privacy – never give medical advice through any social media platform. If you accidentally do so, save it, take a screen shot, and place in the

40  Social Media and Privacy Issues Fig. 40.2  The places where your followers are concentrated (specified by city and country) [3]

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patient’s file. It is your duty, however, to remind the patient that the information that they share via social media is neither confidential nor safe. 11. Track actively – set up a system to track patients who come from social media to quantify your return on investment (ROI). It is important to train your staff to ensure that this information is collected and tracked. 12. Use hashtags – a way to spread your content to new potential followers is by using targeted hashtags and geo-hashtags. The first step is identifying hashtags relating to your specific practice. The second step is to put yourself in the shoes of a prospective patient and identify the terms that they may search for to find a service provider with your expertise.

326 Fig. 40.4 Followers – hours: average times when your followers are on Instagram on a typical day (broken down by days of the week); days: the days of the week when your followers are most active [3]

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References 1. Professionalism in the use of social media. American Medical Association. https://www.amaassn.org/delivering-care/ethics/professionalism-use-social-media. 2. Farnan JM, Snyder Sulmasy L, Worster BK, et  al. Online medical professionalism: patient and public relationships: policy statement from the American College of Physicians and the Federation of State Medical Boards. Ann Intern Med. 2013;158:620–7. 3. Instagram (obtained as screenshots from account @drmaryamnaz); Business Account: Insights; Activity. Maryam Nazemzadeh,  MD  graduated at the top 2% of her class at The George Washington University, where she majored in Spanish Language and Literature. She went on to obtain a medical degree at The George Washington University School of Medicine, where she graduated among the top of her class and was inducted into the Alpha Omega Alpha Medical Honors Society. She completed her residency in ophthalmology at The George Washington University. After finishing her residency, Dr. Nazemzadeh completed a 2-year fellowship in cosmetic and reconstructive oculofacial plastic surgery in the American Society of Ophthalmic Plastic and Reconstructive Surgery at The University of Pennsylvania. Since completing her training, Dr. Nazemzadeh began her career at a private practice in Northern Virginia, where she performs a combination of functional/reconstructive and cosmetic oculofacial plastic surgery.

Part XII

Personal Finances

Chapter 41

Setting the Course for a Successful Future with Better Financial Planning Cynthia Matossian

Summary Points • Setting goals for your financial future and taking responsibility for those goals are crucial to financial planning success. • Take steps early in your career to save and pay back student loans. • Work with a credentialed financial advisor who will structure the path and encourage you to stay the course. The road to a medical career is a long and expensive one. There are 4 years of college, followed by 4  years of medical school, and 4  years of residency. Sub-­ specialization with a fellowship can add 1–3 years. Important financial decisions need to be made during this time period. Unfortunately, most ophthalmologists, focused on their training and starting a family and their careers, do not feel equipped to make the consequential financial decisions necessary during this phase of their lives. Financial literacy is not typically included in the training curriculum of medical school or residency. Even though both male and female ophthalmologists feel they are ill-equipped in financial planning, there are a few reasons why women are at a higher disadvantage: • Traditionally, more men used to handle financial responsibilities than women. (Fortunately, this trend is changing with an increasing number of women entering the world of finance). Consequently, men found it easy to speak about money. By

C. Matossian (*) Matossian Eye Associates & CM Associates, LLC, Bucks County, PA, USA © Springer Nature Switzerland AG 2021 C. Y. Weng, A. M. Berrocal (eds.), Women in Ophthalmology, https://doi.org/10.1007/978-3-030-59335-3_41

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contrast, it was often considered taboo for females to discuss money and finances. According to one study, 61% of women would rather talk about their own death than money [1]. Women usually outlive men by 7–8 years, meaning that they have to budget for their longevity, be prepared to inherit money, and manage it. Women often take time off from work during their peak career years to have children or provide care for a loved one. This disrupts the accumulation of retirement funds, according to “Women and Life-Defining Financial Decisions” [2]. Among single-parent families, 80% are led by women. Raising a family as a single mom often presents more financial challenges [2]. Women are less willing to take investment risks in the stock market compared to men [3]

A proactive approach to gain financial literacy is key. Physicians, as a group, are curious by nature and open to learning new things. There are many ways to become more informed about financial planning. In this chapter, we will cover financial goal-setting, how to budget and pay back student loans, the importance of working with a financial advisor, and thinking ahead to retirement.

Financial Goal-Setting The first important step to a better financial future is to set your goals and objectives and to revisit them every year. “In order to set your goals, you have to own them. I can’t stress that enough,” says Katherin Romero, CPFA, CRPC, a wealth management advisor with the Lugones & Romero Group of Merrill Lynch, Pierce, Fenner & Smith in Princeton, New Jersey. For young ophthalmologists, a major goal should be paying back student debt and setting a realistic budget. The quicker one can pay off debt, the quicker one can move toward other goals, such as buying a home or investing in their practice.

Better Budgeting Imagine if you had a number of surgical cases on your OR schedule but had no schedule for them. That would make your day very stressful and inefficient, right? It’s similar with budgeting. If you don’t have a plan for your money, you’ll have trouble meeting the life and professional goals that you had envisioned. The importance of budgeting needs to start at a young age. In this chapter, we will focus on budgeting once out of medical school, perhaps while in residency or fellowship. This time period can come with financial challenges. Typically, residents and fellows are not paid a lot. In addition, most training programs are located in urban settings where the cost of living is high. Working in a city means additional expenses for parking, tolls, public transportation, and gym memberships, and even activities such as dining out or participating in leisure events can be a big splurge.

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This is where a budget that tracks the money coming in and the money going out become crucial. When I lived in Washington, D.C., while doing my residency at George Washington University, I found as many ways as possible to scrimp and save to stay within my budget. I only went out to dinner for special occasions  – anniversaries or birthdays. I brewed coffee at home instead of spending a couple of bucks a day at the local coffee shop. I prepared my meals and always brought my lunch to work. Although these steps may not be easy, they enabled me to budget, pay back student loans, and have a little extra for those special occasion meals.

Paying Off Student Loans When I came out of medical school, I owed a lot of money – as I surmise you might if you are reading this chapter. In fact, women hold 64% of all student debt, according to “Women and Financial Wellness—Beyond the Bottom Line” [1]. I had to come up with a strategic approach to repay my loans. I figured out my base salary and calculated how best to budget for my school loans. Back then, we didn’t have online payments; we had a booklet with perforated payment coupons. The tear-off pad started out about two inches thick! Every month, I would carefully rip one coupon, staple it to a check and send it off via snail mail. This process lasted about 10 years until the loan was fully paid. In order to give other students with financial needs the same chance I had been given, it was important for me to repay every penny. Loan repayment will likely require some sacrifices. Early in your career, you may need to live with roommates or buy a pre-owned car, both of which could provide significant cost savings. Find out from ophthalmologists a few years ahead of you how they are balancing student loan repayments with their monthly living expenses. You may glean some new ideas to help achieve your goal more quickly. If you are reading this and you still have a few years of school ahead of you, have a conversation with a financial aid officer at your institution or with your parents to seek some monetary assistance or debt relief. “If you have a plan before you begin your medical journey and you know what you have to do after your education [to pay back loans], you’ll be in a much better place,” Romero says. Working with a financial advisor can help hold you accountable to your goal of paying back student loans within a certain timeframe.

Working with a Financial Advisor Our patients seek medical advice for eye health because they don’t have the skillset to diagnose and treat themselves. It’s parallel with financial health. Even with the best of intentions, physicians with no training in wealth management may fumble and never reach their financial goals. Therefore, it is key to seek financial advice from a trained professional as early as possible in one’s career.

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As soon as I started working as an ophthalmologist, I realized how much I didn’t know about financial management and planning. Serendipitously, I received an invitation to a seminar called “Financial Planning for Women” and decided to attend. The speaker, also female, stressed the importance of a solid financial guide especially with big decisions, such as purchasing a home, managing credit cards, money saving and retirement plans, and employer-matched 401(k) options. The concept of a formal financial advisor resonated with me and I sought her professional services. A personalized blueprint was germinated. Our advisor recommended a tax-deferred college savings program for our daughter through a 529 plan, a program which is still popular today. I continue to meet with my financial advisor, Katherin Romero of Merrill Lynch, twice a year. We meet face-to-face in June and in early December to review our financial benchmarks and decide if fund reallocation tweaks are required. We communicate via e-mail or speak on the phone when necessary. These exchanges have developed into a valuable personal and professional relationship. Goal #1: Start working with a certified financial advisor early in your career. Research their credentials as you would research those of a surgeon. Look for someone who has excellent skills, is supportive, trustworthy, knowledgeable, and with whom you feel comfortable sharing your life plans. It may be an added benefit to find an advisor who frequently works with physicians and understands the medical profession. You are not limited to your local geographical area when searching for a wealth management professional. Since most of the work is completed online and via telephone, your financial advisor can be across the country. However, they have to be familiar with the laws and regulations in the state within which you reside and work. Goal #2: Discuss and fully understand payment for their professional services. Find out how your potential financial advisor is going to be paid for their work. Just like every profession, most are honest, but some are unscrupulous and divert monies for their personal gain. Typically, financial advisors charge an agreed-upon percentage of the overall money they help grow for their clients. For example, if they recommend investments in specific stocks and bonds for you and the market does well, they get a percentage of that growth. On the other hand, some advisors have upfront fees and monthly retainer charges. Make sure you are clear about all fees. Instead of selecting an independent financial advisor, you can choose to work with someone affiliated with a bank. For example, the professionals with Bank of America/Merrill Lynch can help not only as your financial advisors, but also with credit cards, opening business or personal accounts, or getting a mortgage, Romero notes. This may not be the right choice for everyone, but it can be convenient for many busy surgeons.

Retirement Planning There are a vast array of choices from which to select retirement investments, including stocks, bonds, and mutual funds. There also are different types of plans, ranging from 401(k) to Individual Retirement Accounts (IRAs) and more. Advice

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from your financial planner is key regarding the best options based on your age, income, and risk tolerance. The recommendation of my financial professional was to contribute the maximum amount that I could by law into my retirement plans, even if it meant scrimping on vacations. I knew those early investments would pay back in multiples down the road. With guidance from an accredited financial advisor and maximum contributions into properly selected retirement plans, every eye care professional can strategize their financial health.

Disability Insurance Imagine you get hurt and can no longer work as an ophthalmologist. As awful as that may sound, one has to be adequately prepared. Disability insurance specific for your specialty is a must. It’s advisable to purchase disability insurance early in one’s career and re-evaluate it on a regular basis with an insurance expert [4]. There are a variety of disability insurance companies from which to choose. Select a company that has been around a long time and has an excellent reputation. Choose a company that allows you to include specific demands within your policy. For example, let’s say you hurt your hand and can no longer perform eye surgery, you want to make sure you are properly compensated rather than be asked to now practice a non-surgical field of medicine. It’s even better if you can work with a company with a history of providing disability insurance to ophthalmologists. Another key decision to consider: Who should pay for disability insurance? It can be paid by the practice or by the eye care professional personally. If the practice pays for it and you get hurt, then the disability income paid to you will be taxed. However, if you personally pay for the policy, the disability income paid to you is not taxed. The input of a trained financial advisor along with advice from an accountant may be necessary for these complex financial decisions that carry huge tax ramifications.

Malpractice Insurance We have all heard about, or perhaps experienced, situations where a patient decides to sue a physician for malpractice. This is why malpractice policies are essential for all physicians, including ophthalmologists. Also called medical professional liability insurance, this type of coverage typically covers bodily injury or property damage and liability for personal injury, such as mental anguish, according to the National Association for Insurance Commissioners [5]. I wanted to use a national company with expertise in ophthalmology, which led me to the Ophthalmic Mutual Insurance Company (OMIC). Get a few different quotes for comparative purposes and fully understand what is and is not covered, especially when it comes to a “tail” in the event you leave a practice. You may be able to obtain some savings via membership with associations,

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hours worked per week, or the type of procedures you perform, according to an OMIC article. Don’t feel frustrated if the application is lengthy or your carrier asks a lot of questions. They usually do this to help fully evaluate risk and to provide cumulative savings for clients [6]. If you incorporate a new procedure in your practice or begin to offer a new service to your patients, make sure to let your insurance carrier know. Updated communication with your malpractice insurance carrier is a must.

References 1. Merrill Lynch and Age Wave. Women & financial wellness—beyond the bottom line [Internet]. Merrill Lynch. Available from: https://pbigaem.fs.ml.com/content/dam/pbig/crossref/ Registration/ml-womens-study.pdf. 2. Rappaport A, Vrdolijak N.  Women and life-defining financial decisions [Internet]. Winter 2019. Merrill Lynch. Available from: https://www.education.ml.com/Publish/Content/application/pdf/GWMOL/Women_Financial_Decisions.pdf. 3. Rappaport A, Vrdolijak N.  Managing your career [Internet]. Winter 2019. Merrill Lynch. Available from: https://mlaem.fs.ml.com/content/dam/ML/Articles/pdf/ml_managing-yourcareer.pdf. 4. Relvas M. Top ten questions physicians ask about disability insurance [Internet]. White Coat Investor. Sept 30, 2017. Available at: https://www.whitecoatinvestor.com/top-ten-questionsphysicians-ask-about-disability-insurance/ Accessed 2 Oct 2019. 5. National Association of Insurance Commissioners. Medical malpractice insurance [Internet]. Sept 30, 2019. Available at: https://content.naic.org/cipr_topics/topic_medical_malpractice_ insurance.htm Accessed 2 Oct 2019. 6. Ophthalmic Mutual Insurance Company. 6 things an ophthalmologist should know about malpractice insurance [Internet]. Available at: https://www.omic.com/6-things-an-ophthalmologist-should-know-about-malpractice-insurance/. Accessed 2 Oct 2019. Cynthia Matossian,  MD, FACS  is the founder and medical director of Matossian Eye Associates with multiple offices in PA and NJ. She specializes in refractive cataract surgery and dry eye disease. She was named one of Ocular Surgery News’ Premier Surgeon 300 – an elite group of 300 premium refractive cataract surgeons in the USA. She was the 2017 winner of the Ophthalmic World Leaders Visionary Award. She has been named one of the Top 25 Leading Women Entrepreneurs in New Jersey and one of New Jersey and Pennsylvania’s Best 50 Women in Business. She is a Clinical Assistant Professor of Ophthalmology (Adjunct) at Temple University School of Medicine. She has published numerous articles and ­participated in national and international meetings in leadership roles.

Chapter 42

Personal Finances and Career Decisions Linda M. Christmann

Summary Points • Fiscal decisions matter from your first job to your last. • You are in charge of your financial success – learn how and be in control. • Your retirement life is a consequence of all the fiscal decisions you have made in your life.

Dear Meghan, I was so happy to hear that you have decided to go to medical school and study ophthalmology. It is very flattering to have the daughter of my best friend follow in my chosen profession. Over the next few months and years, you will be called upon to make many decisions which will ultimately determine your financial success or will make you a captive of your expenses. Since the loss of your mother, I have wanted to do all I can to advise you as she would have. Thank you for asking for my ideas. This epistle is not only a letter, but also a roadmap for you for the future. I hope you will keep it and consult it, and me, whenever major decisions loom ahead of you. I have put my thoughts in writing to that purpose. Of course, I always want to hear from you regarding your success, and any questions. Since you have been accepted to medical school, some of the decisions are already behind you. Choosing a medical school with free tuition is no longer an option. I am happy to hear that the school you have chosen is one with moderate costs and an excellent reputation. You will have to pay tuition, books, supplies, and then living expenses in addition. The money your mother provided will only go so

L. M. Christmann (*) Retired from LM Christmann Consulting, Bradenton, FL, USA © Springer Nature Switzerland AG 2021 C. Y. Weng, A. M. Berrocal (eds.), Women in Ophthalmology, https://doi.org/10.1007/978-3-030-59335-3_42

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far. Let’s think for a moment about budgeting for medical school, since you have a few months to prepare. (a) You will not be cooking at home as much as you might have previously (unless you call ramen noodles cooking), so budget for take-out or dining. Time to study and sleep rapidly becomes a priority. (b) Remember to set aside emergency funds. Cars always need repairs when you can least afford it. (c) Budget for saving. You will need to travel for residency interviews if nothing else, and the cost of these trips adds up fast. (d) Keep your credit card for emergencies or use it only enough to pay the balance monthly. You might want to have certain expenses which are recurrent, such as your cell phone bill, directly paid from your credit card. It is amazing how those deadlines for payment, and even e-mails reminding you about the due date, slip by when you are very busy.

Budget Development Please forgive me if I am speaking down to you in the next section. I am including it for completeness and for you to use as a reference. My suggestion is that you track your income and expenses in detail for at least 3 months, and then annualize to build an annual budget, taking into consideration the items above. Remember that there are many inexpensive software programs which will help you do this in an ongoing fashion with a minimum amount of work. Quicken is one I have used for some time. Here are some suggested items to track. NB: This is not meant to be advice to supplant your accountant or tax preparer, just a guideline. Income 1 . Wages and/or contract income 2. Interest and dividends 3. Stipend from parents/inheritance 4. Scholarships and/or grants 5. Student loans Expenses (suggested, you may have others, and some may not apply) 1. Business expenses (memberships, subscriptions, meetings) 2. Car expenses (payments, repairs, parking/tolls, gas, taxi/ride share) 3. Cash withdrawals (from checking, savings, investments) 4. Donations (cash or in kind) 5. Educational expenses (tuition, books, supplies, travel) 6. Entertainment (movies/videos, memberships, hobbies, books/newspapers)

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7. Food (grocery store, coffee shops, bars/restaurants, food delivery services) 8. Health care (dental, medical, prescriptions, glasses/contacts) 9. Housing (rent/house payments, repairs/improvements/maintenance) 10. Insurance (car, life, home/renters, health, long-term care, disability) 11. Personal care (products, hair, nails) 12. Pets 13. Savings 14. Shopping 15. Taxes (federal, state, property, tax preparation) 16. Travel (not business related) (lodging, airfare, meals/food, rental car/tolls, taxi/ride share) 17. Utilities (gas, electricity, water/sewer, cable, cell, cable) 18. Uncategorized 19. Refunds 20. Credit card bills Grand Total I have listed the subcategories you might like to include. This helps you do the exercise to decide what you can cut or omit during training. But, keep an entertainment and personal expense budget. You will feel better. You might decide, for example, to decrease clothing expenses during training and perhaps some of your memberships.

Paying for Medical School How to pay for school and living expenses? Here are some ideas to consider as income sources: 1. Military or public health scholarships As you know, I was lucky enough to receive a military Health Professions Scholarship (HPSP) from the USAF [1]. The scholarships are offered by all three major branches of the military, and you will be commissioned as an officer when accepted to the program. The HPSP program pays all your tuition, books costs, and fees directly to the school. Today the obligation is the same as I signed for – one year of active duty service for each year of support for 3 or 4 years, and a minimum of 3 years. The annual stipend is now more than I received, but is taxable, and is about $28,000 per year, during the school term, plus 2nd Lt pay for the 6 weeks of active duty in summer. The rest of the year, you are a student like all your other classmates. You will receive a signing bonus of $20,000 if you sign for 4 years. National Health Service Corps (NHSC) [2] Scholarships are very similar, but they are limited to primary care physicians. The other difference is that you

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would serve your obligation as an officer of the Indian Health Service (IHS), Federal Bureau of Prisons (BOP), or US Immigration and Customs Enforcement (ICE) in a medically underserved community. If you change your mind about ophthalmology, and want to do primary care, consider this option. 2. There are a multitude of private scholarships for which you can apply. Some are particular to your medical school. Some are limited to groups your parent or grandparent might have belonged to. A friend’s granddaughter received a small scholarship from the Navy Tailhook Educational Foundation. Sit down and make a list of all the organizations you can remember that your parents and grandparents were part of and their employers as well. Then you can begin your search of opportunities. You will need to know your assets, so create a table of personal net worth. See Table 42.1 below for reference. While you have a bit of time, it is worthwhile to take a tutorial on Excel basics, unless you are already proficient. Consider the courses offered by ­Microsoft, but many more are available online for free. This will serve you well in future and also will help you document financial need, a requirement for most scholarships. Your expenses will naturally figure into this calculation as well. So, the work you invest will serve you well in several ways. 3. Student loans. The major disadvantage of student loans is the need to pay them back. Many medical students graduate with debt of $200,000 or more, which prevents them from enjoying the lifestyle they had envisioned once training is complete. This should be your last resort. Paying for medical school becomes more painful if you have debt already. If you owe money on a car, for example, try to pay it off before starting school. If you have credit card debt, do all you can to eliminate it now. The Credit Karma site [3] is one example of how to pay off credit card debt. There are many similar articles online. No matter which of these plans, or combination thereof, you adopt, the time in medical school is invigorating and challenging. Most of my friends agree that the time passed in a blur since it is so stuffed with new experiences. Keep a check on expenses, and your eye on the prize! Table 42.1  A simple net worth calculation grid Net worth Asset Home Car Checking account Savings Investment accounts Whole life insurance Other assets

Value

Amount owed

Net (value – amount owed)

Total Note: For life insurance, only use cash surrender value, not the death benefit

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Residency Applications During your third year of medical school, you will be preparing to apply for residency positions. The applications are due in August of your fourth year [4]. Interviews will be expensive, so try to consider carefully the programs to which you are applying. According to the American Academy of Ophthalmology (AAO), “The average applicant applies to 30–40 programs, resulting in an average of seven or eight interviews.” This is very taxing for the beginning of your fourth year in medical school and can be costly. Remember you may be applying for both Post-graduate Year (PGY-2) in ophthalmology and PGY-1  year in a primary care discipline or rotating internship at roughly the same time. Please read carefully all the information in the AAO webpage just referenced. It will guide you through the process. They remind you that roughly 85% of US applicants do secure a position. With regard to the match, a few words. Realize that not all positions may be offered for the match. Rank the programs you are most interested in attending. Do not rank any program, even if you interviewed, if you did not have a good feeling at the interview. Trust yourself, not information from others. Try not to be distracted by phone calls from faculty or friends. As your Mom’s friend, I will say that selecting a residency should reflect what you want to do long term. For example, if you know you want to be a faculty member at a renowned University, prioritize such residencies that foster this goal. If you marry and want to follow a spouse, select a residency which will prioritize patient care and surgery so that you are best prepared to go anywhere. This also follows for fellowship programs. Not every ophthalmologist needs to do a fellowship, but you should plan on one if your career ambitions are academic.

Residency You may be excited to actually get a paycheck instead of a bill, but be frugal. Remember you are in for the long haul. Although your time will be limited, especially during the PGY-1 year, you need to cultivate contacts and have a research project in mind. Budgeting becomes the same exercise as for medical school. You will need to save for fellowship or employment interviews and expenses for meetings. Remember that for nearly all student loan programs, you need not begin repayment during training, but check your paperwork and verify. It is a good time to meet with a financial counselor for the first time if you have not done it before. Although there are thousands to choose from, your residency program will probably have a retirement plan with contributions on your behalf. You can meet one-on-one with a representative of this company most likely for free. Ensure that the person you are meeting with is not compensated to sell you their company’s products. You can hire a financial counselor on your own, but that may be a bigger project than you want to take on at this time.

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It is easy to view your retirement contributions as a savings account to pay for large purchases. Resist this urge! Even if you only invest $5000 the first year in retirement at age 30, this amount will grow to nearly $30,000 by age 65 assuming an interest rate of 5.25%. You should be able to beat this easily in the market. If you invested only $5000 per year (you will invest much more as your income increases), it would be over $500,000 at age 65. You may choose to make a large purchase at this time, but ensure your budget is on track if you will incur, for example, a car payment or lease payment. Ideally, the funds will come out of savings instead of financing. If you do finance, be picky and shop around. You want a finance rate less than your average earnings on your investment account if possible.

Fellowships Do not feel obligated to do a fellowship. If you think you will, try to imagine the trade-off you will get for this time commitment and financial loss of potential income. What do I mean? Let’s assume you are making $65,000 per year as a resident, and that you would make $215,000 your first year in practice, which is reasonable based on my personal experience. By delaying your start in practice, you have postponed $150,000 for 1 year, so this is how much you are paying for the privilege of doing a fellowship, also called the opportunity cost in finance. At the same interest rate of 5.25%, this is a loss of $7875 of interest for 1 year. But you have not just lost it for the year, you have lost it forever. (Later I will explain how this amount compounds over your lifetime.) You may counter, “But I will make more money per year as a specialist,” and that may or may not be true. As a retina surgeon, probably, but as a pediatric ophthalmologist, not so likely. Do your research before you make a final decision. Further, think about whether you would see yourself practicing your subspecialty, or just being able to do some special cases yourself instead of referring out. If it is the latter, think about the reluctance of local general ophthalmologists to refer, for example, a cornea transplant to you when you are competing with them for cataracts. I am not opposed to fellowships, on the contrary. You know I chose to do one, mostly because I was not sure what I would do after completing my obligation to the USAF. It is true that you have an easier pathway to most large cities if you are fellowship trained, and it is a virtual requirement to be a faculty member. Talk with faculty about their decisions, and whether they think in retrospect they were beneficial. Having said that, if you always dreamed of being a retina surgeon, go full steam ahead for it!

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This discussion brings up some essential considerations about employment after training.

Job Options and Financial Consequences The purpose of this section is to show you the financial consequences of your decisions. I want you to go forward with your eyes wide open. Follow your dreams after that. There is abundant evidence that women physicians make much less income than their male colleagues. Medscape regularly surveys physicians on several items, and the Medscape Physician Compensation Report 2019 [5] contains analysis of almost 20,000 physician responses. Primary care male physicians made nearly 20% more than female primary care doctors. However, for specialists, the difference was 24.7%. Doximity recently released their 2019 Physician Compensation Report with responses from 90,000 physicians surveyed [6]. The report had some good news for women physicians, in that men’s salaries held flat, and women’s salaries increased, partially closing the pay gap in some geographic regions. However, the gap overall remained at 25%, or $90,490. There are other studies I could quote, but you understand. Let’s focus now on ophthalmologists and their pay. In the Medscape 2018 Ophthalmologists Compensation Report [7], the average salary of ophthalmologists responding to the survey was $357,000. The report states that the men ophthalmologists averaged an income of $391,000 and women $273,000, a difference of an astounding $118,000 per year! In 2014, NerdWallet’s Andrew Fitch [8] took a somewhat different approach and used the Centers for Medicare and Medicaid Studies (CMS) publicly available database called the “Provider Utilization and Payment Data” for the 2012 payments by CMS to physicians. This data is different from the previous because it is objective, and only the amounts paid to physicians by CMS are reported. NerdWallet analyzed data from over 16,000 ophthalmologists reimbursed by CMS for performing patient services. They found the average CMS payment to women ophthalmologists was $174,894, and men $366,505. In 2017, Dr. Reddy and colleagues [9] analyzed the 2012 and 2013 CMS Provider Utilization and Payment Data. They used somewhat different methodology than NerdWallet but concluded similarly that women ophthalmologists were paid a median of 26.13% less than their male counterparts. Remember this is reimbursement, not salary. OK, I think I have made my point about women and pay differences. Considering the information, let’s examine some of the reasons given to explain this pay disparity.

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 actors That Account for Lower Pay for Women F in Ophthalmology Part-Time Work Some ophthalmologists, both men and women, work part-time, and this reduces their incomes. This is both sex- and age-related. Therefore, to understand part-time data, one must consider what the group looks like both in terms of age and in terms of sex. The AAO regularly surveys its membership about certain data about their practice, and I have been provided some information from the 2018 year-end US membership data [10]. The percentage of members who are women has been slowly increasing and was 25% in 2018. Noteworthy is that 37% of trainees in 2018 were women, a slight decrease from 42% in the 2015  year-end US membership data set [11]. More women than men in ophthalmology are working part-time: 23% of women and 14% of men in the Medscape Ophthalmology Compensation 2018 report [7]. The AAO data highlight that more of the women in ophthalmology are young  – women comprise 40% of ophthalmologists under age 45, but only 24% of ophthalmologists between 45 and 64 [10]. Therefore, the time off for childbearing and child-rearing largely explains the difference in part-time work. Of course, some new fathers also take off time for the birth of their new child. But what is really moving the needle is that more men are working fewer hours as they age. Men comprised 92% of ophthalmologists age 65 or older in the 2018 AAO dataset. We can expect the men and women working part-time to equilibrate more as the young women entering ophthalmology age, more women enter the profession, and the older men begin to retire.

Subspecialties Certain subspecialties in ophthalmology are more highly reimbursed than others. As seen in the 2018 AAO dataset [10], the subspecialties of women ophthalmologists in practice contribute to differences in pay. Although 25% of all practicing ophthalmologists are women, only 8% of refractive surgeons and 17% of retina surgeons are female. Refractive surgery is generally not reimbursed by insurance and thus the surgeon sets the price. Retina surgeons perform complex and multiple procedures and are more highly paid for their expertise. On the other hand, 47% of pediatric ophthalmologists are women. I can tell you that this specialty is not well-paid for time invested. Moreover, this is a larger proportion than what it was in the midpoint of my career when around one-third of the group were women. So, women are disproportionally joining at least one subspecialty which is not well paid.

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There are many theories, but no proof, as to why this sorting occurred – fewer women applicants to the specialties more highly reimbursed or fewer accepted. Or, have women selected specialties which reimburse less for other reasons?

Experience Level As already discussed above, women represented a much greater percentage of young ophthalmologists in the 2018 AAO survey [10] compared to older ophthalmologists: 43% of those 30–39 years of age were women and only 15% of those aged 60–69. It is logical to think that the older ophthalmologists, women and men, were seeing more complex patients due to experience and reputation, and these patients probably required surgery more often. Thus, experience can contribute to observed differences in reimbursement and earnings.

Practice Setting Women members of AAO, as shown in the 2018 data [10] have selected to participate disproportionally in academic practices and employed settings, compared to group practice or solo practice. See Fig. 42.1 below for some examples. Since 25% % Female of AAO Members in Each Practice Setting 2018 Hospital/Healthcare System

43%

Academic Institution

38%

Unknown

34%

Goverment/Military

33%

Other

27%

Research

24%

Multispecialty Group Practice

23%

Ophthalmology Group Practice

20%

Solo Practice

18%

Fig. 42.1  Women as percent of group by practice setting, 2018 year-end US membership data

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of the AAO membership were women, each setting where women comprised more than 25% of the group had a proportional overrepresentation of women and vice versa. However, if you look at absolute numbers, more AAO members, both men and women, are in practice settings. These two observations make the data directionally consistent with data from the Medscape 2018 ophthalmologist survey [7] which noted that 45% of women ophthalmologists were employed, but only 37% of men. Why are women choosing employment? The fiscal consequences of this choice are dramatic. The 2019 Medscape Physician Compensation Report [5] documented an average compensation of $359,000 for self-employed physicians of all specialties and $289,000 for employed, a difference of $70,000 per year. Later I will explain the consequences and resultant net worth for the choice of employment. Again, money is only one piece of the life decision.

 umber of Patients Seen and/or Time Spent Per N Patient Encounter There are several publications which have referenced differences in men and women physicians in number of patients seen. For example, the Medscape 2019 Female Physician Compensation Report [12], slide 19, documented that 50% of patient visits with women were 17 min or more, but only 42% of men had average visits of this length. Obviously, the number of patients seen is directly related to time worked per week. Time is your inventory in business terms – it is what you sell. Yes, your expertise is important, and your rapport with patients is vital, but your time is what limits all of that. The number of patients you can see per day is the minutes you work divided by the time spent per patient encounter. Women spend more time per patient encounter, and average fewer hours per week with patients, a double hit to billing and income. Moreover, knowledge of this data may tend to make employers offer women less pay.

Number and Choice of CPT Codes Billed Per Encounter Women physicians bill less. The first evidence I saw of this was from the NerdWallet Health study [8], based on analysis of the CMS 2012 Provider Utilization and Payment Data. They documented that CMS paid women ophthalmologists on average for 511 patients in that year, and male ophthalmologists 824, for a difference of 38%. Moreover, the payment per patient for women was $297 and men $404, with a difference of 26.5%. Women ophthalmologists billed on average 3.4 codes per patient, and men 4.1, or 17% difference. I conclude from these data that women were billing not only fewer codes but also lower level codes.

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Dr. Reddy and colleagues published a report in 2017 [9] in which they analyzed the 2012 and 2013 CMS Provider Utilization and Payment Data. Their analysis also revealed that women ophthalmologists billed 16.70% fewer codes per year than men. The authors suggest more studies are necessary to reveal the causes for this phenomenon.

Failure to Negotiate We have discussed that women are proportionally more likely to be employed than self-employed. As an employee, you must drive the best bargain you can on salary and benefits. Also, even in practice or academia, you will need to maximize your income and benefits with your supervisor. It has been known for over a decade that women do not negotiate or do not negotiate effectively. I suggest you take a look at the books by Linda Babcock and Sara Laschever, for example, “Women Don’t Ask: The High Cost of Avoiding Negotiation – and Positive Strategies for Change” [13]. Even if you can read some of the book, you will be ahead of many women in many jobs in the USA. Unfortunately, due to failure to negotiate, women are making less than comparable colleagues in the workforce. Slide 8 from Medscape’s 2018 Ophthalmologists Compensation Report [7] documents an average of $391,000 for men and $273,000 for women, a difference of $118,000 per year. Over a career, the lifestyle dictated by such a difference is what we reap.

Bias Bias will never leave us, but as a community of physicians, we must minimize its impact.

Why Does This Matter? To reiterate, the Medscape Ophthalmologist Compensation Report 2018 [7] demonstrated a difference in earnings for women and men ophthalmologists of $118,000 per year. If you know the basics of Excel, you can calculate the future value of this amount per year over a career. Or, look up future value calculators on the web. This means that over a 35-year career, the average male ophthalmologist earns $4.1 million more than the average female ophthalmologist. If invested at the modest interest rate of 5.25% each year, this money would compound to $11,933,760! No, this is not a trick of mathematics – it is real.

346 Table 42.2  All specialties, Medscape female physician compensation report 2019

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Net Worth >$5 million $1–$5 million