Setting Our Sights on Academic Ophthalmology

Session 149

Academic ophthalmology is a vast and rapidly advancing field. Dr. Edmund Tsui joins us to share his journey to becoming a uveitis specialist, dispels myths, and more!

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Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points.

[01:31] Interest in Ophthalmology

Edmund’s journey through to ophthalmology began when he was in college. He was able to participate during the summer months in multiple research labs on basic science and also clinical research. This introduced him to the field of ophthalmology.

In one of the summer programs, they looked at random blood flow and humans which was his first exposure to ophthalmology and the technology involved. After which, he pursued a thesis project in his undergrad. It looked at a mouse model of a disease called oculo-dental-digital dysplasia. And that somehow solidified his interest in ophthalmology.

Edmund was pretty much set on ophthalmology the whole way through. But he really wanted to do his due diligence and explore as many fields as he could because you never know what you’re going to come across during medical school.

That being said, he did explore ENT and did some research in cardiology. He explored surgical oncology as well as some surgical specialties and procedural specialties as well too.

During each of these rotations, it solidified his interests in ophthalmology. But at the same time, he was able to pursue research projects and also shadowed other people within other specialties. So that helped a lot as well, too.

[03:52] Traits that Lead to Being a Good Ophthalmologist

In ophthalmology, they do a lot of work with their hands. They operate under the microscope and use a slit lamp microscope to examine patients. So they’re very detail oriented.

Most of them would also consider themselves as very visual learners because in a lot of the ophthalmology field, it is based on your examination of the patient. They also do many types of ocular imaging, mostly non-invasive.

“One of the most interesting aspects of ophthalmology is the amount of imaging that we do in the office.” Click To Tweet

[04:54] Biggest Misconceptions or Myths Around Ophthalmology

A lot of people may think that all they do is prescribe glasses and do cataract surgery or that most people do LASIK. But there’s a lot of different aspects of ophthalmology that the general population doesn’t care about.

One of the biggest misconceptions that they come across is that they only do a couple of certain things but the truth is they are highly specialized.

“Every single millimeter of the eye has its own subspecialty fellowship.” Click To Tweet

[06:04] Types of Patients as a Uveitis Specialist

As a uveitis specialist, Edmund practices at the Stein Eye Institute at UCLA. He sees very interesting patients and a lot of interesting cases.

Uveitis means intraocular inflammation of the eye or inflammation of the eye. So these patients tend to have underlying autoimmune diseases. They could have infectious diseases of the eye.

They also deal with patients that have other associated autoimmune conditions. So they may have rheumatoid arthritis. They may have Crohn’s disease, ankylosing spondylitis, and a whole variety of autoimmune conditions.

“Many of the autoimmune conditions can be associated with uveitis.” Click To Tweet

The eye is one of the main organs that can be affected by autoimmune diseases. And it’s really interesting in their field to tease out that diagnosis and figure out the underlying cause of inflammation for the patient. This explains why they also work very closely with other medical specialties such as rheumatologists to help manage both the eye disease and also the systemic disease.

[08:25] Working with the Hands

They don’t operate on eyes until they get into residency. And that’s a big fear that people have. But there are a lot of virtual reality simulators for them to learn how to use the instruments.

It also definitely involves a lot of hand-eye coordination. They need to know how to use foot pedals as well as they operate with both their hands and feet. So all four limbs are moving at the same time.

“There are a lot of different simulators that they use in residency before they start operating on patients to learn how to perform microscopic eye surgery.”Click To Tweet

[09:40] Typical Day

At NYU, they had a fairly large program. They had seven residents per year, for a total of 21 ophthalmology residents which is considered a fairly large program.

Typically, they would start off the day with a lecture from about 7 to 8am. They have one-hour lectures on various subspecialty. And then they’re pretty much in the clinic from 8 am to 5 pm.

Depending on the day of the week, each day may be different with regards to performing surgery or seeing post-operative patients or doing preoperative evaluations.

“What's nice about ophthalmology is that there's a very graduated learning system in place.”Click To Tweet

When you’re a junior resident, you start off learning the eye basics. You don’t do surgery quite as much, but you do extrapolate surgery. So surgeries that may involve the ocular surface, like removing a terrarium. Then you move on to doing strabismus surgeries or lazy eye surgeries.

And as you hone your skills by doing simulations and other procedures in the clinic, you gradually begin to do intricate procedures, possibly cornea transplants, glaucoma surgeries, and also retinal surgery assisting. That’s with the ultimate goal of being able to perform cataract surgery independently by the end of your residency.

[11:21] Taking Calls

Call is one of the important things of residency. They had a fairly big program so call was divided up amongst all the residents. They had three big hospitals that they would cover, so call was heavy.

They do have a lot of calls as ophthalmologists. They take a lot of trauma calls. As residents, they would cover the private hospital, the county hospital, and also the VA hospital. And since there are seven of them each year, they would alternate every seven days or so. And it was up to them to determine their schedules. So they had a fair amount of calls.

“Taking calls helps you develop a lot of independence. You learn a lot as an ophthalmology resident while having that backup senior resident to help you out during the learning process.”Click To Tweet

Then when you’re a faculty member and attending they generally take trauma calls to see if there’s any injuries to the eye. They can help out in surgery if needed, or help on after emergencies as well.

[12:42] What Residency was Like for Him Coming from Canada

Edmund actually came from Canada to do his medical education here in the States. There are a lot of hoops that he had to go through in his journey from Canada to the United States.

There are visa hurdles but there are different types of visas that one can apply for during residency. Those may or may not limit your options in terms of staying in the United States or going back to Canada.

You have to consider those visa options, as well, when you’re looking for fellowships as those can also limit your options, potentially.

Ultimately, when you’re looking for your first faculty position, you have to take into account the programs.

[14:28] Choosing Academic Medicine over a Community Setting

Edmund really likes the academic and research aspects that a large hospital system provides. He has always been involved in resident and medical student education during residency and also as a fellow. And that played a role in him deciding to go into an academic healthcare setting.

In his role as a uveitis specialist at UCLA, they teach medical students about ophthalmology. They teach residents and they also fellows within uveitis that they teach. And Edmund really enjoys taking the time to teach trainees and also perform research. So his time is split between research and education, also clinical care.

[15:38] Life Outside of the Hospital

“Our specialty is amenable to having a fair amount of time outside of the hospital.”

Ophthalmology is an outpatient specialty, so five days a week, Monday to Friday generally, and then call as needed, which leaves them with their weekends to enjoy their hobbies and pursue other things. Edmund is able to go to the gym and hang out with friends so it’s pretty flexible.

[16:19] The Training Path

They start off with four years of college and then four years of medical school, one year of intern year either in preliminary medicine or preliminary general surgery, which is also a transitional year.

Then you do three years of ophthalmology residency. Following your residency, you then have the option of subspecialization, or you can go into practice as a comprehensive ophthalmologist.

If you want to sub specialize in your final year of your residency, you then have to apply for fellowships, which cover every millimeter of the eye.

Different fellowships include cornea, glaucoma, both medical and surgical retina, pediatrics, neuro ophthalmology, onco, plastics and of course, uveitis. So there’s a lot of different areas of knowledge that you can explore and apply into.

“Most programs are moving towards the integrated four year residency now, so there's less choices in terms of prelim medicine surgery or transitional year.”Click To Tweet

[17:38] How to Be Competitive for Matching

'Ophthalmology is considered traditionally one of the more competitive specialties.'Click To Tweet

To be competitive, you have to do everything that medical students should do. The classic thing is getting good grades, getting good letters, but also trying to explore ophthalmology early on.

Meet those mentors that can go to vouch for you. Learn more about the eye. Maybe possibly get involved in some of the departmental research, whether it be a case report or a small study that can allow you to present at some of their national or international conferences. That helps you get your name out there.

People are generally very friendly, they’re always open to talking to you. There are a lot of different mentorship programs available for medical students within ophthalmology.

Edmund encourages everyone to take a look at those and also just reach out. Many of them are incredibly friendly and are always open to taking questions and helping each other out.

“Exposure to ophthalmology is generally pretty limited in most medical curriculum, and to be a competitive applicant, you should explore early.”Click To Tweet

[19:10] Message to Osteopathic Students

Especially now with the step one score that is being changed the pass fail,there’s probably going to be more of a shift towards potentially more holistic view of application. So he doesn’t think necessarily there’s a ton of negative bias, think there are osteopathic multi directives and fellowships. All the fellowships are open to either MD or osteopathic applicants. Yep. And residences are that way now starting in 2020, the single accreditation process

I see so that makes a lot more flexible for applicants. and think going through the same strategies, as, getting the research in, meeting mentors early on, can really help your overall application process and making you really stand Out in the process.

[20:23] Message to the Future Primary Care Providers

Primary care physicians can help refer patients to ophthalmologists to help diagnose and manage conditions in your eyes.

The early exposure, either to just basic examination of pupils, visual acuity, or even attempting using the slit lamp really helps in primary care specialties or even in emergency room settings.

They can really help triage patients and tease out the upper malaise that needs to be either urgently referred to like a cute painful red eye or things that may be less acute such as cataracts that occur in older age.

“Regardless of which specialty you go to, take the time to take advantage of the learning opportunities for ophthalmology since they already have such limited exposure.”Click To Tweet

[21:44] Other Specialties They Work the Closest With

As an ophthalmologist who focuses primarily on uveitis patients, Edmund works very closely with a lot of different medical specialties. They treat and manage underlying systemic diagnosis of autoimmune conditions.

One of the things he has worked most closely with are rheumatologists. They work with both adults and pediatric rheumatologists to manage many complex autoimmune inflammatory disorders. They co manage some of the medications that these patients receive.

They also work very closely with infectious disease specialists because some patients can be immunosuppressed and also develop some findings of infection or inflammation in the eye because of those diseases. Other specialties they work with are neurologists and other internal medicine specialties.

“It's a really multidisciplinary specialty.”Click To Tweet

[22:45] Special Opportunities Outside of Clinical Medicine

One of the things Edmund finds most interesting in ophthalmology is research. All the technology in ophthalmology has progressed very rapidly in the past several decades.

They have a lot of non invasive imaging modalities to detect disease in the eye and to characterize various eye conditions.

“The opportunities for research outside of clinical medicine are very robust with technologies.”Click To Tweet

They have something called optical coherence tomography, which can take very high resolution pictures or cross sections through various tissues of the eye. They have other imaging modalities, such as forcing angiograms, which look directly at the blood vessels in your eye as well too. And these imaging modalities are all located inside the Eye Clinic. They obtain them on a routine basis and interpret the images themselves that same day.

[24:12] What He Wished He Knew that He Knows Now

One of the most interesting things as a brand new attending is you are the one doing the billing and how the insurance works.

So if he were to tell himself back in residency, he would want more of those lectures teaching you about billing and healthcare, and insurance and things like that. That would really help minimize the barriers that patients have in getting access to those very valuable things.

Especially in the field like uveitis or in ophthalmology, where patients need various testing for autoimmune diseases. They need various body imaging, and things like that. So learning more about how to overcome some of those barriers is very important.

[25:01] The Most and Least Liked Things About His Specialty

Edmund loves the amount of interesting diagnoses that autoimmune conditions can manifest in so many different ways in the eye. They’re always discovering new ways that they manifest in the eye.,

“The eyes are really the only place that you can non-invasively view the vasculature.”Click To Tweet

Edmund really enjoys the multimodal imaging aspects of the eye. So as mentioned, all the different machines and instruments that they have in the clinic, and machines that are being developed all over the world. They’re very fortunate to be able to use some of these prototypes as well too, and help contribute to some of the development of these non invasive imaging modalities. So that’s one of his favorite parts of ophthalmology.

Moreover, Edmund doesn’t think there’s anything particularly that he doesn’t like about ophthalmology. He just really loves what he does so there’s not a single aspect of it that he can actually single out.

[26:41] Major Changes Coming to the Field

As mentioned earlier, there’s a lot of technology within ophthalmology. Right now, artificial intelligence is playing a huge, huge role in many medical specialties.

“In fact, the first FDA-approved use of artificial intelligence in medicine was within ophthalmology to diagnose diabetic retinopathy.”Click To Tweet

So the major changes that we’re going to see coming to their specialty is the broader implementation of artificial intelligence for different diagnoses. It’s about how they can assist ophthalmologists in diagnosis, maybe even in the operating room. They can help predict or guide the surgeon as well to predict for complications to happen.

Five to ten years from now, they’re going to see much more widespread implementation of artificial intelligence.

[28:07] Final Words of Wisdom

Edmund 100% loves what he does. They have incredible patients and they develop these incredible relationships with their patients because they see them so frequently.

One of the best aspects of his specialty is the amount of interdisciplinary care that they do. They have meetings with rheumatologists. They communicate with them very frequently about patient care. And there’s just a lot of interesting dimensions to uveitis. So even if Edmund wasn’t a uveitis specialist, he would still pick ophthalmology.

His advice to students who may be interested in ophthalmology is to get involved in either outreach programs or vision screening programs just to get a taste of what ophthalmology is like.

He highly encourages shadowing various specialties – not just ophthalmology, but other specialties to help you understand what you like as well.

Sometimes they’re looking for students to be involved in research as well too. So the most important piece of advice is just to ask because they all love sharing your passion for the specialty. Check out their association, American Academy of Ophthalmology.