Search for tag: "ophthalmology"

Interviewer: Age-related macular degeneration is a leading cause of vision loss in adults in the United States. The effects on the central vision caused by this disease can significantly impact your life, including the ability to do daily activities, the things you enjoy, and it could also lead to a loss of your independence. However, the good news is, if caught early, the progress of the disease can be slowed.

Dr. Monika Fleckenstein is a professor of ophthalmology and vision sciences at the Moran Eye Center. She's a retina specialist with an emphasis on this condition. Dr. Fleckenstein, let's start with what is age-related macular degeneration. What's going on?

Dr. Fleckenstein: Yeah. So age-related macular degeneration, and we usually say AMD, this is a disease in the back of your eye, and it causes that your central vision may get worse over time. As the name says, the most important risk factor is your age, where you cannot do a lot about it. But we also know other risk factors, which is, for example, smoking or unhealthy lifestyle. And we also know that there's a strong genetic component in this disease.

Interviewer: You called a . . . it impacts your central vision. Is that what you said? Explain what that means.

Dr. Fleckenstein: Yes. So if you look at a paper and try to read, you do this with your very central vision. So this is the area of sharpest vision. This is an area in your eye which we call the macula. And the very center of this macula is the fovea. This is actually the area of sharpest vision, and this is the area you need for reading, for recognizing faces. So this is the highest resolution in your eye.
How Age-related Macular Degeneration Impacts Daily Functioning

Interviewer: I want to know how age-related macular degeneration impacts people's vision in their daily functioning. Talk to me about that, from what you've seen with your patients.

Dr. Fleckenstein: We have different stages of age-related macular degeneration, early stages where you may not experience any symptoms, and then we have the later stages of the disease that you may develop a grayish area in your central vision. In certain subtypes of the disease, you may even develop a central dark area where you're not able anymore to recognize faces or read.

The symptoms patients experience is dependent on their disease stage, but usually, when I see patients with earlier stages, I actually ask them, "Do you have difficulties in dim light?" And so when you go to a restaurant and if you try to read the menu and the light is dimmed and maybe candlelight, this is actually where the patients realize first symptoms. Then also, when they come from bright light outside entering a room, and they may realize it takes them longer to adjust to these changing light conditions as before in their life or compared to the people they are surrounded by. So these are typically the first symptoms of the disease.

And so in later stages, when there is the real damage of the cell layers, the photoreceptors, patients may experience that they have difficulties to read. In very late stages, patients may even not be able anymore to recognize faces. And this is probably, you know, the end stage of the disease where they are not able anymore to read or recognize faces.
Early Detection of Age-related Macular Degeneration

Interviewer: And the importance of early detection in age-related macular degeneration, it's pretty critical, from what I understand. Can you expand on that?

Dr. Fleckenstein: Most sad situations are those where patients have the wet stage and did not receive treatment, and then you face a stage where treatment is not possible anymore or is not really effective anymore if patients have developed scar tissue. And this is why it's so important that if you realize symptoms, never hesitate to reach out to your doctor and ask to have a look.

And when I'm seeing actually my patients with earlier stages of the disease, I explain to them the symptoms of the later stages and tell them, "Please never hesitate to contact me and my team if you experience these changes." And I even tell them it's, you know, "Even if you do not have these specific changes, but if you have a weird gut feeling, please reach out," because sometimes, you know, patients just experience something is off, something is weird here. I cannot really say what it is. Never hesitate. Try to be seen by an ophthalmologist just to make sure that nothing is going on.

Interviewer: And if it's caught early, there are some things you can actually do about it. Tell me about that.

Dr. Fleckenstein: In the earlier stages of the disease, there are certain constellations or certain findings in the back of your eye where we would recommend that you take certain nutrition supplements. So it has been shown in a large clinical trial, the AREDS study, that a certain combination of supplements may delay the progression to late stages, but just if you have a certain constellation of the disease. So the study has also shown that just taking these supplements without having any sign of AMD will probably not have a positive effect. But if you have certain signs, it has been shown that the disease may be slowed down.

In general, we would always recommend, but this is more or less a general recommendation to the whole population, to have a healthy lifestyle, not to smoke. And actually Mediterranean diet has been shown, not only in age-related macular degeneration but also in cardiovascular diseases, that this can be beneficial to prevent the development of macular degeneration and also of the late stages. And Mediterranean diet, this means vegetables, fruits, olive oil, fish. So more a combination of nutrition into this direction.
When to Get Checked for Age-related Macular Degeneration

Interviewer: So since catching it early is so crucial, how often should somebody actually get their eyes checked for macular degeneration?

Dr. Fleckenstein: Yeah. So this really depends on age. So the American Society of Ophthalmology, they actually recommend to have an eye check when you become 40. Then it highly depends if your ophthalmologist finds anything, if you have any signs of a disease in the back of your eye. With ages of 65, we would recommend yearly eye exams. But of course, if you have a positive family history for age-related macular degeneration or if you have certain risk factors, I would recommend to be seen by an ophthalmologist more often and even in earlier ages.
Diagnosing Age-related Macular Degeneration

Interviewer: And in the diagnosis part, are you able to diagnose the disease? How far in advance before a person starts experiencing symptoms are you able to diagnose the disease with the equipment you have?

Dr. Fleckenstein: So we can see on a micron level changes in the back of the eye. Within the last decades, we have seen such a rapid improvement on resolution. And again, we can see tiniest changes in eyes. We indeed also see patients without any symptoms who are not aware of having any problems, and we may pick up earlier signs of the disease, and we can certainly see if macular degeneration is present or not.

Interviewer: That peace of mind is probably great for a lot of patients when you tell them, no, that's not it, that's something else.

Dr. Fleckenstein: Yes. But, you know, I tell my patients as well, as the time has changed so much and we have these dynamics right now, having the diagnosis of AMD today is something completely different than 20 years ago.

Interviewer: And why is that?

Dr. Fleckenstein: Because first of all, I believe within the next 10 years, you know, we will have more treatments available, and for the wet late stage where everyone is so scared about, we have wonderful treatment available, and this treatment really works well. And I always say I have respect for the wet late stage, but I'm not scared of it anymore because if this is treated well, patients can keep their vision for many, many years.

Dr. Chan: What was it like to move from Beijing, China, to Provo, Utah? How does applying for the Foreign Service compared to applying to medical school? What are some innovative ways to make money while in medical school? And how does the field of ophthalmology make a really big impact in such a short amount of time?

Today on Talking Admissions and Med Student Life, I interview Ian, a third-year medical student here at the University of Utah School of Medicine.

Announcer: Helping you prepare for one of the most rewarding careers in the world. This is Talking Admissions and Med Student Life, with your host, the Dean of Admissions at the University of Utah School of Medicine, Dr. Benjamin Chan.

Dr. Chan: Okay. Welcome to another edition of Talking Admissions and Med Student Life. Fantastic guest today, third-year med student, Ian. How you are you doing, Ian?

Ian: Doing great. This is quite the honor.

Dr. Chan: I've been waiting for this, Ian, because you have a lot of eclectic activities and we're going to talk about them. All right. Let's go back to the beginning.

Ian: Okay.

Dr. Chan: When did you decide to go to med school? Where did that come from?

Ian: Probably, like, high school, you know? I don't know. I think it was probably just I liked science classes and I feel like . . . you know, medicine just kind of appealed to me. I don't have any doctors in the family.

Dr. Chan: Is this Utah?

Ian: No, I went to school in Beijing.

Dr. Chan: Okay.

Ian: So my dad works for the Foreign Service. I grew up overseas mostly. So I was in the International School of Beijing. I don't know. I broke a lot of bones, so maybe that's why. And I had to get my bones set and casted and all that stuff.

Dr. Chan: Why were you breaking bones?

Ian: I don't know. Just accident-prone. I'm not particularly athletic.

Dr. Chan: Okay.

Ian: And that's probably part of the problem. But anyway, like middle school, I was playing tag. Well, elementary school, I played soccer. I broke my leg. Playing tag, broke my arm. Middle school, I was playing tag again, broke my arm. So I didn't realize the first time that was a bad idea. Broke my wrist actually. And then I broke my collarbone playing rugby in high school. And then I broke my thumb a couple years ago, but that hardly counts.

Dr. Chan: Okay. So what you're saying is brittle bones?

Ian: Brittle bones.

Dr. Chan: Accident-prone?

Ian: Brittle bone, accident-prone.

Dr. Chan: So this is in China? Were you going to hospitals a lot?

Ian: I mean, I went to the Western hospital a couple times.

Dr. Chan: Oh, there's a Western hospital?

Ian: There's a Western hospital.

Dr. Chan: Okay. All right.

Ian: For the, you know, wealthy Chinese and foreigners.

Dr. Chan: Okay. All right. So you're there and then they just kind of . . . great doctors, great care.

Ian: Yeah.

Dr. Chan: All right.

Ian: Yeah, I guess so. I mean, I'm not that interested in orthopedics either. I just think the kind of idea appealed to me. My brother and I watched "Scrubs," so, you know, that kind of thing.

Dr. Chan: And, you know, slightly off topic, how was it growing up in Beijing?

Ian: It was great. I liked it a lot.

Dr. Chan: There's this image of a lot of pollution, people wearing masks.

Ian: Yeah.

Dr. Chan: Ten million people in the city. I'm not even sure what the number is.

Ian: There's certainly more than that, like probably over 20 million, I think. At least, you know, in the greater Beijing area, there's, you know, tens and tens of millions. I read an article recently, well, not recently, but a few years ago, that was saying that they planned on creating this huge urban corridor between Beijing and Tianjin that would have like 100 million people. And they were going to build . . . they have some high-speed rails going through and they were just going to basically build all that up.

But anyway, it was good. I kind of lived in the suburbs, so my friends and I liked to pretend we lived in an American suburb, go to McDonald's, and, you know, once I got my learner's permit or whatever, we'd just kind of drive around.

Dr. Chan: Was it behind gates or walls, or was it just kind of open? I assume there's security everywhere though.

Ian: No, I mean, it was pretty open. We lived in gated compounds, but it's not like it was unsafe outside the gated compound so that we were stuck in the compounds. We'd always go out, and our school was about two miles away from my house. And so we just had our own community. We didn't go into town super often.

Dr. Chan: How big was the school? How many students?

Ian: My high school there was 600.

Dr. Chan: Oh, fairly big.

Ian: It was pretty big. And then it was a high school, middle school, and elementary school together, so total 1,800 or so.

Dr. Chan: All taught in English though?

Ian: All in English. Yeah, you had to have . . .

Dr. Chan: Chinese classes, though, if you wanted to, right?

Ian: Right. Yeah, with varying levels of efficacy. The schools, it was about 1,800 people and you had to have a foreign passport to go there. So it was all foreigners.

Dr. Chan: Okay.

Ian: Yeah. I'd say maybe 40% Americans.

Dr. Chan: That's pretty cool. You probably had friends from all around the world.

Ian: Yeah.

Dr. Chan: Yeah. Learned to speak Chinese I assume?

Ian: Some.

Dr. Chan: Some?

Ian: Not amazingly. Like I said, we'd like to pretend we lived in American suburb. So there wasn't too much language learning, but I got a bit of a foundation.

Dr. Chan: Were you able to travel the countryside and kind of see all the sites?

Ian: Yeah. We traveled quite a bit. Let's see. When I was in high school, they had trips every year organized by the school. That was pretty fun. Called China Links or China Studies. So for that, my freshman year, we went to Inner Mongolia and rode bikes for a week, which was really fun. And then I think in 11th grade, we went to Pingyao, which is this ancient walled city.

Dr. Chan: Is that where the terracotta warriors are?

Ian: No. That's in Xi'an.

Dr. Chan: So Pingyao is like an overnight train ride away from Beijing. When you're in high school, you're vaguely aware of geography.

Dr. Chan: You think it's normal. Everyone lives in China.

Ian: Yeah, exactly. And you take a taxi, I'm in town. You know, I don't really know where anything is relation to each other. But then our senior year went to Yangshuo in Kweilin, which is . . . you know, they have all those paintings of the rolling hills in China. And that's sort of where that originates from. They have all the cool mountains and rivers and stuff. Feng shui is really great.

Dr. Chan: So graduate from international school.

Ian: Mm-hmm.

Dr. Chan: Where'd you go to college?

Ian: I went to BYU.

Dr. Chan: Okay.

Ian: The only place I applied. My brother went there. My sister went there. My parents went there.

Dr. Chan: Legacy.

Ian: That's right. It's the family tradition. And back then, they published the graph, you know, where it's like, "Oh, your GPA and your ACT score. If you are above this, you'll get in. And if you have this, you'll get a scholarship." I don't think they publish that anymore. But back then, it was just this great grid system. So I was like, "Oh, okay. I'd be pretty assured that I would get in."

Dr. Chan: So how's it feel to jump from Beijing to Provo? Pretty similar?

Ian: It's not the same, you know? It's like similar feel. There was definitely some culture shock.

Dr. Chan: Like what? What was kind of shocking?

Ian: I mean, I'd come back for summers to Utah because both my parents are from Provo, and I had a lot of family in Provo. So from that aspect it was nice, but on the other hand, it was sort of just kind of a different background. But fortunately, BYU, there were a lot of people that I knew from high school and stuff that went there too. So it's not like I was alone in my in my culture shock. But a lot of people who just had different experiences. But, you know, I think college is always sort of a shock for everybody.

Dr. Chan: Yeah. It's a big jump. Living in the dorms. I assume you lived in the dorms?

Ian: I lived in the dorms, Helaman Halls.

Dr. Chan: Helaman Halls, got to love it.

Ian: It's classic.

Dr. Chan: All right. So you get to BYU, still thinking medicine. What kind of activities did you start doing? How did you kind of solidify that and how did you get ready for med school?

Ian: I'm trying to think. So I started off as a biology major, and then I went and served a mission in California speaking Chinese. That's sort of where I, you know, finally, actually solidified my ability to speak Chinese.

Dr. Chan: I know it's several years in the rearview mirror. Little disappointed with the California call?

Ian: Yeah, you know . . .

Dr. Chan: Were you kind of hoping for the Hong Kong, Taiwan?

Ian: I knew when I got the package. It wasn't thick enough, you know. Couldn't have any visa papers in it, but oh well. It ended up being fine.

Dr. Chan: Water under the bridge?

Ian: Exactly. My dad went to Taiwan. My brother went to Taiwan. I was just trying to follow in the family tradition. But it's okay. California was fun and I had a great time.

So I did that for two years. Then I came back and switched my major to Chinese because I liked studying Chinese and it was fun. And I figured it'd be easier and that could sort of pad my schedule of Chinese classes. And, you know, kind of more of a unique angle. And then I . . .

Dr. Chan: Were you shadowing doctors? Were you doing community service? What kind of stuff were you doing?

Ian: I didn't do a ton of shadowing. I did the Red Cross. I sort of did some volunteer teaching of CPR for a while. And then I joined the Chinese flagship program, which is a two-year thing. One is domestic and the other is abroad. So it's like a study abroad program. Federal government gives you $15,000 and you go overseas, you go to China, and we did one semester at Nanjing University.

Dr. Chan: Yeah, I remember that on your application.

Ian: And then one semester, internship.

Dr. Chan: There's a lot of China stuff in your application.

Ian: Yeah. I just really, you know, took the China angle and ran with it.

Dr. Chan: Yeah, that's cool.

Ian: It got me in here.

Dr. Chan: That's your corner.

Ian: Yeah, exactly. So I was in China for a year. For my internship, I was at an ER at this Western hospital, same place where I went when I broke my collarbone and stuff and my wrist.

Dr. Chan: See, circle of life.

Ian: Yeah, exactly, circle of life.

Dr. Chan: Now you just need to match in that residency out there.

Ian: Yes, that's right. Yeah. The Beijing United residency, it's the highly coveted.

Dr. Chan: It's combined classics ENT, ortho, opto.

Ian: Yes. That's right. Just so I can get everything . . .

Dr. Chan: It's only eight years. It's a secret . . .

Ian: It's eight years, and don't forget traditional . . .

Dr. Chan: Dr. Stevenson has the secret website. He can send you a little more about it.

Ian: And traditional Chinese medicine fellowship that you can do.

Dr. Chan: Acupuncture.

Ian: Exactly.

Dr. Chan: We could make a lot money if we created that.

Ian: Yeah, I know. That's true. Like, all the alternative medicine things not covered by insurance. So, yeah, I went back there and then . . .

Dr. Chan: And I think you did research in Chinese language or something like that? Didn't you?

Ian: Yeah, I did. I got a grant. Well, I did one research project. It was sort of a public health research project, where I went to Taiwan. And I got a grant from BYU to do this. I went to Taiwan, and I did a survey of medical students to see what kind of their specialty choices were, because Taiwan has this rapidly aging population, to see how many people would be interested in going to geriatrics, essentially.

That was only mildly successful. I did get some people to fill the survey out, but it wasn't as easy as I expected. And then I did a two-month research internship thing at Academia Sinica, which is the big research institution in Taipei. So that was really fun.

Dr. Chan: Cool. All right. So applying to med schools. Obviously, you got in.

Ian: Mm-hmm.

Dr. Chan: You know, talking about your jump from Beijing to the Provo, how was that jump from undergrad to med school? Easy? Hard?

Ian: It was fine. I think it was fine for me. It was a little harder just because, you know, there was a lot of transition. I had just gotten married, and I barely got into med school, first off. You know, I had good test scores. I had a good MCAT, and I had a good GPA, and I had all this other experience. I thought I was going to be the bee's knees and everyone would be clamoring to, you know, admit me.

Dr. Chan: Wanting Ian?

Ian: Yeah, exactly. So I only applied 11 places, which was . . .

Dr. Chan: Oh, that number is low.

Ian: Yeah, it was kind of stupid in retrospect. And then I also applied really ambitiously. I was like, "Oh, well, I'm such a boss. I will definitely get in." And I ended up not . . .

I got an interview at Duke early, and so that was encouraging, and I thought I was really awesome. And then there was some snafu with my application here where they rejected one of my letters and then they didn't tell me until after the deadline and I was going to have to wait for another cycle. I ended up appealing it and it was fine. But I interviewed a little bit later here, and then I interviewed at UVA, and then I got in here off the waitlist.

Dr. Chan: Okay.

Ian: And that's it. So I didn't have any other offers.

Dr. Chan: Did you call up UVA and Duke and say, "Take me off your waitlist. I'm in"? Or were kind of secretly hoping . . .

Ian: No. I was rejected from Duke.

Dr. Chan: Okay.

Ian: I was rejected from Duke in March. And then at UVA I was on the waitlist.

Dr. Chan: The waitlist, it's not a good place to be.

Ian: Yeah. You never know.

Dr. Chan: People have told me it's actually better . . . a lot of people feel that it's better to not be accepted or rejected because then you know, because the waitlist is just this indefinite, ambiguous future.

Ian: Yeah, a nebulous thing.

Dr. Chan: You can't really plan things around.

Ian: Yeah, exactly. So, yeah, it was it was pretty . . . I was having some sort of existential crises at the time, you know. I was like, "Do I really want to apply again?" Fortunately, I got off the waitlist here, and I think it only took like three or four weeks.

Dr. Chan: Were you thinking about the Foreign Service at all?

Ian: I did take the test. So I took the written exam and I passed it. The next section is the PNQs, personal narrative questions.

Dr. Chan: Oh. I thought it was a group interview thing they do?

Ian: There is. That's the third step.

Dr. Chan: Oh, okay.

Ian: So the second step is the PNQs. And that's probably the hardest because it basically entails lying about your accomplishments and like making yourself sounds unbelievably awesome, like unbelievably awesome. Like, "No one of my age group . . ."

Dr. Chan: Doesn't this kind of sound like med school applications?

Ian: Yeah, it does. It definitely does.

Dr. Chan: You have to toot your horn a little bit.

Ian: Yeah, you definitely do. This one is actually kind of . . . like, it's crazy. I read my brother's, and I had to break out in laughter several times. Like, "You didn't do that."

And so, you know, lots of fabrication goes into it. I didn't fabricate well enough, and so I didn't pass that section. But anyway, that was sort of out. Or I think I was waiting on the results of that. I think I heard in May or something that I didn't pass that part. And then also there was this sort of investment banking program thing out of . . .

Dr. Chan: Wow. You really were kind of . . .

Ian: I was scrambling. I was definitely scrambling.

Dr. Chan: You were just married. You could have told your wife that you just wanted to . . .

Ian: I was engaged. I was not quite engaged.

Dr. Chan: You just want to stay home and play video games and mine gold coin?

Ian: Exactly. And have her go gold farming. Play World of Warcraft or something.

Dr. Chan: Yeah, I'm sure that would have been really great at the beginning of your relationship.

Ian: Well, she told me that if I went to work for Goldman Sachs then I might have to marry someone else.

Dr. Chan: Whoa.

Ian: Yeah. She did not want to be married to an investment banker.

Dr. Chan: Okay.

Ian: So anyway, fortunately, I got into BYU. So we didn't have to cross that bridge.

Dr. Chan: And then easy, harder than undergrad? I mean, what was your biggest surprise as far as curriculum goes, as far learning?

Ian: I thought it was pretty manageable, honestly. The first two years were quite nice. I watched most lectures from home on my laptop at 2x speed. And, you know, I'm a big proponent of diminishing marginal returns. So I'd study for maybe six hours a day, but any more than that and it's sort of hard to focus. You know, certain days, of course, you study more and certain days you study less. Just sort of trying to balance life and stuff like that.

Dr. Chan: So all very doable? Do it well.

Ian: Oh, totally.

Dr. Chan: Were you involved any extracurriculars or student interest groups during the first couple of years?

Ian: Yeah. I was in the AMA group. And so I was a delegate to the AMA.

Together: Against Medical Advice.

Ian: Against Medical Advice. The American Medical Association.

Dr. Chan: Which is a very ironic position to take when you're in med school.

Ian: Yes, of course. The Association Against Medical Advice. So the AMA, that was fun. So I went to Chicago and Hawaii to two of the meetings.

Dr. Chan: Sweet.

Ian: And so that was interesting. And then I was in the Health and Human Rights Club. I sort of helped run that.

Dr. Chan: What's that about?

Ian: So it was started by . . . I think her name is Susan. I hope she doesn't listen to this because I'd feel bad. I'm pretty sure . . .

Dr. Chan: Ian, over 10 million people listen to this.

Ian: I know. The circulation . . .

Dr. Chan: There will be a few Susans.

Ian: That's right.

Dr. Chan: Susan, wherever you are, a shout-out to you.

Ian: She was a fourth-year student, and she sort of started this group. She was really into global health and that kind of thing. And so, essentially, sort of to raise the profile of human rights issues in health care and get people to . . . We threw a couple panels and lunch lectures with people who are involved with the community. Dr. Franchek was our faculty advisor. She does a lot of stuff with ACE, adverse childhood experiences. She's a pediatrician.

So yeah, just stuff like that, just sort of more humanist, societal issues, and consideration of those as a student.

Dr. Chan: That's really cool. I heard about that group, but didn't know too much about it.

Ian: Yeah. It was cool.

Dr. Chan: What about jumping into research? Did you do any research the first couple of years?

Ian: Yeah. So I did the MSRP.

Dr. Chan: Medical Student Research Program.

Ian: I'm just throwing down the acronym jargon here.

Dr. Chan: And I'm interpreting for the audience.

Ian: Yes, that's right. So I'd heard I heard good things about ophthalmology, so I got involved with the Fourth Street, the homeless clinic down at the Fourth Street for ophthalmology, and then I contacted a research mentor at the Moran, Dr. Tian. He is from China, and so we kind of connected over that. And then all his people . . .

Dr. Chan: I love it. You play all . . .

Ian: All the people in his lab are from China.

Dr. Chan: When you started corresponding with them, did you talk in Chinese?

Ian: Yes, exactly.

Dr. Chan: And then you just showed up

Ian: Yes, exactly. He's like, "Oh, another Chinese researcher." He gets a lot of Chinese research fellows who come from China, and then his wife works in the lab and she's Chinese, and then he has a graduate student who is American and doesn't speak Chinese. He's the only one. So I did some bench research there dissecting mice eyes and stuff like that.

Dr. Chan: Cool.

Ian: And had a good time. I coauthored this paper with a Chinese fellow researcher. So, yeah, that was fun. I got to use my language skills and did a research project there. I'll be presenting it at the Association for Research in Vision and Ophthalmology in April or whatever. But yeah, so that was good. Did that and then I sort of was working with him as well.

Dr. Chan: I became aware of another activity you were doing during the first couple of years. I was going to ask you about that because I find it fascinating. So how did you make a little money during the first couple of years?

Ian: Well, you know, had a little bit of extra time watching my lectures on 2x speed. So I decided to drive for Uber.

Dr. Chan: Fascinating. Do you know of any other med student who was an Uber driver or Lyft driver?

Ian: I know Scott from my year.

Dr. Chan: Okay.

Ian: Eldrich. He did some Lyfts. I know he did it previous to med school and maybe over the summer.

Dr. Chan: So how many hours a week were you Ubering?

Ian: Well, I got a little bit obsessed when I was first starting out. I'm trying to remember exactly how many I did, but it may have been like 50 or something like that.

Dr. Chan: Fifty hours? Okay. Wow.

Ian: It may have been, the first week or two. Because it's kind of like a game, you know? You sign up on the app and you get pinged and you're like, "Okay. I'm going to go."

At one point, I remember I was looking at my phone at 10:00 p.m. one night and it was surging. That's when the price doubles or triples and you can make more money. And so it was surging, so I jumped out of bed and I threw on some clothes and went out.

Dr. Chan: Practicing, like, "I'll go to the OR."

Ian: Yeah, exactly. I was like, "Oh, I can make so much money." I think I made like eight bucks for a five-minute trip. But anyway, it was just fun. I like to chat with the people.

Dr. Chan: Yeah. So would you reveal that you were studying medicine in medical school?

Ian: Yeah.

Dr. Chan: Or would you not talk about yourself? I mean, how did that play out?

Ian: It kind of depended on the conversation, just where it went, and we'd just chat and see what they were up to. And, you know, I'd tell them that I was a medical student just making some money on the side. So, yeah, it was fun.

I met . . . let's see. I'm trying to remember. I think I met some friends of one of my classmates. It was like one of my classmate's parents or friends of her parents or something like that. Yeah, I met some interesting people.

Dr. Chan: Sundance just happened. So were you really excited because . . . you know, a celebrity sighting might go up. Would you get anyone famous ever in your car?

Ian: Well, no. The stupid thing is I started like mid-February. It was right after Sundance, which doesn't make any sense because you can make a ton of money doing Sundance, but I also drove a Toyota Corolla. It was like a 2004.

Dr. Chan: Are those your wheels?

Ian: Yeah. I was missing a hubcap when I started too. I'm sure I rolled up and people were like, "Really?"

Dr. Chan: Did you have little snacks? I heard people putting little snacks in the backseat to kind of sell the experience.

Ian: I didn't do that because it's kind of ridiculous. You don't get any benefit from having a good . . . You need good ratings, but I got five stars by just chatting, just driving this crappy car, you know? And I think anything else would have been kind of overkill.

Dr. Chan: Okay.

Ian: But anyway, I did that for a couple months. And then after that, Trevor Annis, he has some friends who run this company that collects signatures for political campaigns. And so we did that. That was more lucrative than Uber. So I started doing that instead. So we were gathering signatures for . . .

Dr. Chan: So backing up . . .

Ian: Oh, yeah.

Dr. Chan: Going back to Uber, any medical emergencies? Did you ever have to use medical school skills? Any babies being born?

Ian: No babies. So no babies, no traumatic injuries.

Dr. Chan: So there was no blending of your two worlds, Uber and medical school?

Ian: Unfortunately not. On the other hand . . .

Dr. Chan: You ever drive anyone right to the hospital?

Ian: It's probably fortunate that that didn't happen because I would have been like, "Oh, yeah, let's see. Well, we learned in Foundations . . ." I wouldn't have known anything.

Dr. Chan: And again, going back to Uber, what insight do you have about human behavior? People just love going to the airport? I mean, you must have picked up some things just doing that so much.

Ian: You know, I think people are generally friendly and are generally pleasant. That was one of the things that I maybe picked up. There were a couple, you know, bad apples. One, ironically, was an investment banker who talked about how he used women for breeding.

When I said, "I'm sorry your wife threw you out of your house," he's like, "Oh, that's okay. I use women for breeding." I was like, "Man, you're a horrible human." And then he didn't even tip me, which was just horrible.

Anyway, I was young. You know, in the service industry, you try to accommodate people. You don't want to call them out too much.

Dr. Chan: Did you ever learn about really great hidden restaurants because people kept on going there?

Ian: No, not really. It was more like just airport and then some other sort of random community work, stuff like that.

Dr. Chan: And then jumping to the signature gathering, would you be the guy outside the supermarket doing your thing or going door-to-door?

Ian: Yeah. Door-to-door.

Dr. Chan: Going door-to-door?

Ian: Yeah.

Dr. Chan: Going back to the doors? Wow.

Ian: Yeah. That's the life.

Dr. Chan: [inaudible 00:23:35] missionaries. Yeah.

Ian: Yeah, that's right. Hey, it beats sales, because you're not really selling anything. You're just kind of gathering signatures. It doesn't cost them anything. The company is called Gather.

Dr. Chan: Were you paid by signature or just by hour?

Ian: Paid by signature.

Dr. Chan: Okay.

Ian: So we were collecting signatures for Tanner Ainge, who was running for Congress. I think it was . . . whose seat? Jason Chaffetz. He announced he wasn't running for reelection.

Dr. Chan: Ultimately unsuccessful.

Ian: Yes, he was ultimately unsuccessful. Because in Utah if you get enough signatures, you can get your name on the ballot even if you don't get nominated at the party convention.

Dr. Chan: That was pretty controversial. There was a lot of a kerfuffle about this.

Ian: Yeah. I mean, I think it's good. I think it was sort of designed to diminish the Republican Party's stranglehold on the primary process. But anyway, so we got $5 a signature, which is pretty awesome.

Dr. Chan: Five bucks a signature? Wow.

Ian: Yeah. It's pretty great. And so we'd just go door-to-door.

Dr. Chan: How would they verify it though? What would stop someone from just signing or faking . . .

Ian: So they'd send it to the Lieutenant Governor's office, and then they would verify all the signatures. So they'd you pay 50% . . .

Dr. Chan: So it's more than a signature? You'd have to probably write down your contact information, address, and all that stuff? Okay.

Ian: Yeah.

Dr. Chan: So there's some background info that people are required to give.

Ian: Right, that they can verify. And then they'd pay you 50% up front and then they'd pay you the rest of whatever. So if your signatures were verified at 90%, then they'd pay an additional 40% or the rest . . . like 40% or whatever of the $5 at the end once all the signatures have been verified. So that was pretty good.

Dr. Chan: So would this company . . . just any cause? I mean, would you have the choice to be like, "You know what? I don't support this candidate or I don't support this petition"?

Ian: Yes. You do have a choice. You don't have to do it if you don't want to. But if you don't want to make money . . .

Dr. Chan: Okay.

Ian: You know, I was just a hired gun. After that, we did ballot initiatives. So we had the marijuana bill. We had Utah . . . let's see. It was the . . .

Dr. Chan: I love it. You're bringing up all these controversial things. We'll just go there on this podcast.

Ian: I know, yeah. It was marijuana ballot initiative. There was one for schools and one to change the signature gathering process to make it easier for people to get on the ballot. And so I gathered signatures for those. That was only $2 a signature.

Dr. Chan: Would they give you some talking points or . . .

Ian: Yeah, they gave us some talking points. I mean, I could repeat them if you really want me to. It's been a little while though.

Dr. Chan: I'm just kind of fascinated because again . . .

Ian: It's been over a year.

Dr. Chan: . . . there is this perception that people who do those things are volunteers because they really believe in these things.

Ian: Yeah. That was a nice . . .

Dr. Chan: Apparently, there's this other side of the industry where they're hired guns.

Ian: Yes. And I think some of the initiatives had part volunteers, part us, like us hired guns. But they don't know. So the thing is, they think we're volunteering, so they're like . . . even if they didn't want to sign, they'd be like, "Oh, you know, I don't really want to sign, but thank you so much for doing this and supporting our democracy." So I think that's a very different response.

Dr. Chan: You would say in your brain, "I'm actually supporting capitalism."

Ian: Yeah, exactly. You know, they go hand-in-hand, democracy and capitalism. And as long as we're talking about side hustle, the only thing we've been doing since last February or end of January . . .

Dr. Chan: I love that they call it side hustle.

Ian: Yeah.

Dr. Chan: Like, in addition to your other activities outside of med school.

Ian: Yes, that's right. So we bought a car, a Subaru Outback.

Dr. Chan: I remember you telling me this story.

Ian: So we rent that out through an app called Turo. So it's a 2009 Subaru Outback. Anyone listening, you're welcome to rent it. It's a little bit more expensive during the winter season. We raised the prices because we have a ski rack on it.

Dr. Chan: So it's kind of an Uber way of a rental car agency.

Ian: Yeah, it's kind of an Airbnb for cars. So it's more passive income. We drop it off at the airport. In fact, I'll go pick it up tomorrow morning. And then we have another renter picking it up tomorrow night.

Dr. Chan: But you own this car?

Ian: We own the car.

Dr. Chan: So if it gets stolen, or someone doesn't return it, or drives it and abandons it in Wyoming . . . there are probably these things that start happening, right?

Ian: So we charge a certain amount. We get three-fourths of that, and one-fourth of it . . .

Dr. Chan: There are damages.

Ian: Yeah. We have insurance through Turo. So we don't have to use our own personal insurance. Our first renter crashed the car within three hours of renting it, which was a huge headache and a nightmare because it was our first renter. We don't know if they're going to screw us over.

Dr. Chan: Yeah. And I'm sure your wife . . . this is more of your idea than your wife's idea, right?

Ian: No, it was her idea.

Dr. Chan: Her idea?

Ian: So the way this happened is I had a friend applying here and he was telling me he did this. I don't know if you remember [inaudible 00:28:41]. Anyway, he was one of my companions on the mission for, like, seven months. And so he was doing this and I was like, "Oh, this is actually not a bad idea."

So I mentioned it to my wife, and then she was like, "Oh, yeah, let's do it." And I was like, "Well, actually, I don't know if I want to do it anymore. Sounds like it might be more hassle than it's worth." And then she was like, "No, we definitely should do it." So we went and bought a car that week and then started renting it. Anyway, I get much more stressed out about the car than she does.

Dr. Chan: It's good. You know, your car is kind of part of you.

Ian: And this car has had tons of issues. In addition to this crash . . . I won't get into the details, but it was a huge headache. The engine died, and it turned out the oil burned out, which is horrible, like one of the worst things that can happen to your car.

Dr. Chan: That's really bad.

Ian: The engine was [inaudible 00:29:26].

Dr. Chan: Oil is the blood of the car.

Ian: When we bought the car, we bought it used. They had this warranty, this comprehensive warranty. I thought warranties were a scam, but we got it transferred to our name and stuff, and fortunately this is the best warranty ever and they replaced the engine for free.

Dr. Chan: Oh, wow.

Ian: It was like a $4,300 repair. So we got a new engine, and then the alternator went out. They replaced that for free. The axle broke. They replaced that for free. The axle on one of the front wheels, like in a weird way, and that would have been an expensive repair.

Dr. Chan: I just have in my mind when people return rental cars, they do really nasty things to the inside of it sometimes. So I don't know if you've had to deal with that?

Ian: Not so much.

Dr. Chan: Like sand.

Ian: It's not super sandy here. I don't know if you know of any nice beaches around.

Dr. Chan: Like cups of Coca-Cola being turned over. The rental car agency just kind of cleans it.

Ian: I think people have a little bit more of a sense of conscientiousness when it's someone's personal car that they're renting, you know? They feel a little bit more responsible.

Dr. Chan: So at Subway at 1:00 in the morning, they could just . . .

Ian: So we have . . .

Dr. Chan: . . . throw their food down.

Ian: Yeah, exactly. Not so much like that. So we haven't had that many issues that way, just mechanical issues with the car definitely.

Dr. Chan: Jump to third year. What rotations have you done already?

Ian: So I have everything but surgery and internal medicine. So I started with peds, and then I did psych, family, OB, and I am finishing up neuro.

Dr. Chan: Best rotation so far?

Ian: I think family.

Dr. Chan: Why?

Ian: Because I went up to Heber. It was like rural-ish, rural enough to be rural, but not too rural, so I could come back on the weekends and stuff.

Dr. Chan: You use Uber to come back?

Ian: Yeah, of course. No, actually, I blocked my car out for that month or whatever. My preceptor is really great, Dr. Lofgran. He was really nice. And he taught me a lot and he let me do a lot as well. So, you know, you start feeling like a real doctor and . . .

Dr. Chan: Full scope family practice.

Ian: Yeah, full scope. He didn't really do any kind GYN/OB stuff, but he did everything else and . . .

Dr. Chan: Babies, kids?

Ian: Yeah. Babies, kids, adults.

Dr. Chan: Elderly.

Ian: Yeah. And it was just really nice. They all liked him a lot. And you could tell that they all had a relationship and it was really fun. I liked it. It was kind of nice to be outside of the mothership, you know? Out in Heber. And you feel a little bit more isolated, but in a good way. So, yeah, I think that was good.

I liked aspects of OB/GYN. I think the medicine, like the actual intellectual part of GYN in particular was really interesting. I didn't love the rotation though. The hours were kind of long. And neuro has been interesting. Peds was okay. Psych was good. But, yeah. So there you go.

Dr. Chan: I'm not going to hold you to it, but what are you thinking of doing?

Ian: Probably ophthalmology.

Dr. Chan: Okay. Have you done a rotation, an official rotation?

Ian: Yeah, I did do . . . I forgot to mention, my two electives, I did ENT and ophthalmology, two weeks of each.

Dr. Chan: And did you just feel like these are your people, like this is fun, this interesting? I mean, did it resonate with you in some way?

Ian: So I think it's hard to get a sense, especially for something like ophthalmology where you're just in a dark room and you can't do that much.

Dr. Chan: Yeah. The surgical field is very small.

Ian: Yeah. You know, I looked in the slit lamp and I looked through the lens and I got better at looking at the back of the eye and that kind of thing. But we don't really get much ophthalmology training in school. So it's sort of hard to say what's going on too much.

And the doctor that they put you with in the rotation, whose name I will not mention, he is not particularly interested in having students around, or at least that is the impression that I got. So it wasn't the best experience for that week. My week at the VA was pretty good. It didn't blow me away, but it wasn't like . . . You know, nothing is really like . . .

Dr. Chan: What attracts you to the field then? Why do you want to pursue this?

Ian: I like the hours, I like the lifestyle, and I think I do like . . . I think the patient population is good. You know, older people. And I also like the fact that they can get in there and really fix things. Cataract surgeries are amazing.

Dr. Chan: Because lifestyle, like hours, you can pick a lot of fields, like dermatology. So I'm just still curious why the eye?

Ian: I think it has also the potential to make a big impact. I see myself doing humanitarian work in the future overseas, and ophthalmology strikes me as a field that you can make a really big impact in a short amount of time. There's not much post-op follow-up or care necessary. And I think these sort of medical humanitarian initiatives across the world are very effective.

Dr. Chan: That's a really good point because if you think about it, if someone has really bad cataracts and can't see . . . I don't know. Half-hour or hour operation . . .

Ian: Ten minutes.

Dr. Chan: Okay. Ten minutes when Ian is in charge.

Ian: Exactly. When you're as efficient as I am . . .

Dr. Chan: And you go from not seeing to seeing, mean, that's huge. It is amazing. That's life changing.

Ian: Yeah. It is amazing. And I think, you know, retinal issues and stuff like that . . . I'm attracted to neurology stuff as well.

Dr. Chan: I wish other fields of medicine worked that way. I get the sense . . . I feel that in medicine there's a chronicity, a chronic nature to a lot of diseases.

Ian: Absolutely.

Dr. Chan: But I think ophthalmology, especially with cataracts, there's this ability to go in and boom, take care of it. It's done.

Ian: Yeah. I think that aspect is quite rewarding. But it also has that sort of chronicity of care for other diseases, like macular degeneration and stuff like that. You know, there are also a lot of cool gadgets and stuff people always talk about. But I think just, in general, it's a good field for both lifestyle, you get some medicine, you got some surgery, and at the end of the day, you can feel like you made a big impact.

Dr. Chan: All right. Cool. Well, last few minutes, Ian. This has been great. You recently published an article. Why don't you just talk about it? What are your thoughts and feelings?

Ian: Okay. Well, you know . . .

Dr. Chan: I am giving you the mic.

Ian: Yes. Here we go. I published an article . . .

Dr. Chan: Let me say this. Dr. Chan neither agrees or disagrees with Ian's following position.

Ian: Yes, thanks. Way to CYA there a little bit.

Dr. Chan: I was just covering myself there.

Ian: Yes, that's right. So this is I think an issue that would resonate with any third-year medical student and has in my experience. So I recently published an article in Doximity called "Clerkship Evaluation Scores Are Useless."

Because leading up to medical school, getting into medical school, you know, there's a big emphasis on test scores, which are an imperfect measure of your ability, but at least are . . .

Dr. Chan: Kind of goes against holistic review.

Ian: Right. And at least are somewhat standardized. Holistic review is fine too. Getting your other extracurricular activities in, research, that's fine. I think everyone's sort of on a level playing field, but once you get into third-year, you get these evaluations from attendings, which are based not so much on your ability as much as what the person usually gives people.

So for anyone that's listening and is in their first and second year, this is a piece of advice that I wish I had gotten at the beginning of third-year, which is if you are ever offered an option for where to go for your rotations, don't pick what you're interested in. Pick what the third- and fourth-year students ahead of you tell you will get you the best score, because that's what matters.

And these clerkship scores, they are so arbitrary. And you can work your tail off and get a terrible evaluation just because, you know, somebody gives bad evaluations.

And it's from a scale of 1 to 4 and a lot of people don't really understand the system either. And so they just sort of . . . it's like they may as well be throwing a dart at a dartboard when they're evaluating you. So it's frustrating.

Dr. Chan: So I read your article. My take from it was that a medical student, you . . . and I assume this has happened to you. It happened to me. You work really, really hard. You show up early, stay up late, do a lot of research, get to know your patients, do all this work, and you're getting positive vibes, positive compliments.

Ian: Right. And even positive written feedback.

Dr. Chan: Yeah. Two to three, four weeks later, you get your official score back. And the numerical score is lower.

Ian: Yeah, it's like 2 out of 4.

Dr. Chan: Yeah. And there doesn't sound like there's an adequate explanation. And your question is, "Is this the best system? What is going on?"

Ian: And there are other people you work with for one day, and they give you 4 out of 4 just because they're like, "Well, I want to help them out." Nobody really understands the system or that it has an impact. I think some people don't think it has an impact. Some people think that a 2 is a reasonable score, whereas other people think if you don't do anything really egregious, you should get a 4. So I think the scoring system is just sort of arbitrary.

Dr. Chan: I enjoyed your article. I think you actually talked about a solution. And I'll say this with a caveat. This issue is not unique to our school. This is a problem across the country.

Ian: Yeah. Absolutely.

Dr. Chan: So what's your solution?

Ian: I think that there are a number of solutions that could be implemented. I just included one in my article for the purposes of the 1,000 word count. But, you know, I think this would be a reasonable solution, which is to take the numbers away, because a lot of times, the written evaluation . . . many times, there's not much thought that goes into them, but that's okay because that just doesn't tell them anything.

But if there is thought taken and they do describe your behavior and the things you were good and bad at, I think that's a better view of what kind of student you were.

And the number sort of lends this veneer of objectivity when no objectivity was used in their creation. A test score, there is some objectivity because you got the question wrong or you got the question right. You either got the point or didn't get the point.

Whereas with these scores, they're sort of arbitrarily assigned. And so, they lend this sort of veneer of objectivity that then course directors or residency directors can look at and be like, "Okay, he's a 4 student," or, "He's a 2 student."

I think, as humans, we generally tend to do that. And then we dismiss the other . . . or maybe we glance at the actual description, but we look at the numbers first.

Dr. Chan: So more of a qualitative instead of quantitative.

Ian: Yeah. I think a qualitative assessment would be reasonable, whereas this quantitative assessment is just all over the board. And I cited an article in there that I think said that scores are all over the place, but often the qualitative description of a student is still reliable.

Dr. Chan: So I think just to provide a counterpoint . . . I love it. I think this is fascinating. When you apply to residency programs, you'll have something called MSPE, the Medical Students Performance Evaluation.

Ian: Right.

Dr. Chan: And there is this scoring aspect to it, but there's also a written narrative where I think they try to take the written narrative and kind of create this big paragraph to kind of provide a counterbalance. I'm not sure, you know, if that's as successful as it can be.

But I hear what you're saying. Taking away this arbitrary score and focus more on the comments. What if the same thing starts happening with professors or faculty? Everyone says "excellent" instead of circling the score. Everything starts sounding the same. How do programs differentiate?

Ian: And that's the problem. You know, there's always going to be some amount of . . . the only reason why we have this system is because certain residences are more competitive than others.

Dr. Chan: Correct.

Ian: And it's more and more difficult to match. And so you need to find a way to stratify students into those, I guess, who are worthy of going into their desired field.

But, you know, my perspective is that most students, like 99%, maybe 95% of students are just fine. They're where they're supposed to be. They show up, they do their work. There's maybe 2% that are amazing students. And there's maybe 2% or 3% who are just horrible humans, like sort of sociopaths who somehow got through the process and are just terrible. And I think . . .

Dr. Chan: I love it, Ian. You're talking to the admissions dean.

Ian: Yeah.

Dr. Chan: My goal is not to admit those people.

Ian: Yeah, exactly. You've got to get rid of those people. And so scoring and evaluations, they serve a purpose. They maybe highlight this top 2% and then they maybe screen out this 2% or 3% sociopathic psychopaths, and then the rest of them are just okay. So it's hard to stratify. And any system might be somewhat arbitrary in that sense.

Dr. Chan: I think it's really hard because you're talking about assigning value to human behavior being administered by a lot of different people. And it's this complex system interacting with each other.

Ian: How do you create a metric that is truly objective?

Dr. Chan: I guarantee you that the various faculty in the different departments and divisions have had training modules about "This is what you do. This is how you fill these in." And they've sat there . . .

Ian: And it makes no difference.

Dr. Chan: And they certify that . . . you know, people take attendance. And you can say, "Where did these HIPAA modules come from?" It's the same problem. So how do you train people to do what's right and what's best? But then when they sit through all this training and they go out and they still kind of do this, "Okay, well, then we need to pull them out. They can't teach our students." Then it's, "Okay, we're at the university. Everyone should be teaching the students. That's kind of part of our mission." So I'm very sympathetic.

Ian: Some people are harsher than others. That's the way it is.

Dr. Chan: How do you manage that? How do you control that? How do you modulate for that?

Ian: Well, I think taking away the numerical score just sort of minimizes the impact, which I think is probably better. I think then they have to focus on your research. They have to focus on your Step scores, which are also not the best, but at least everyone's sort of on a level playing field. And they focus on other things, whereas on this, it's just sort of arbitrary.

Dr. Chan: These residency programs are getting thousands of applicants. And they're just kind of like . . . they're just trying to . . .

Ian: You have to stratify.

Dr. Chan: Or thin the herd.

Ian: Yeah, exactly. Weed out the weak.

Dr. Chan: Yeah. How do we do that? And then start using things like Step-1 scores or Step-2 scores, all that kind of stuff.

Ian: Yeah. But anyway, I think clerkship scores have a bit of a ways to go.

Dr. Chan: Okay. Cool. All right. Well, Ian, we're out of time.

Ian: Okay.

Dr. Chan: I've loved this. We'll have you come back.

Ian: Oh, that's . . .

Dr. Chan: You and your wife, you're these little mini entrepreneurs. I think it's just . . .

Ian: Emphasis on mini.

Dr. Chan: All right. You're these mega entrepreneurs.

Ian: No, definitely mini. Definitely mini entrepreneurs.

Dr. Chan: If your wife is listening, please, we want more ideas.

Ian: Yes, that's right.

Dr. Chan: I want Ian, drones, Uber. I want some medical care.

Ian: Exactly.

Dr. Chan: Eye exams. I want some sort of idea to put it all together.

Ian: Yes, that's right. I'm going to have the Uber of ophthalmology. My practice is the Uber of ophthalmology, whatever that means.

Dr. Chan: I like that.

Ian: Yeah. There you go.

Dr. Chan: All right. Cool. Thanks, Ian.

Ian: Thank you.

Announcer: Thanks for listening to Talking Admissions and Med Student Life with Dr. Benjamin Chan, the ultimate resource to help you on your journey to and through medical school. A production of The Scope Health Sciences Radio online at thescoperadio.com.

Interviewer: A new understanding of glaucoma could lead to new treatments, up next on The Scope.

Announcer: Examining the latest research and telling you about the latest breakthroughs, the Science and Research Show is on The Scope.

Interviewer: I am talking with Dr. David Krizaj, an investigator at the Moran Eye Center and Professor of Ophthalmology at the University of Utah. Dr. Krizaj, you've found a way to possibly block glaucoma. That sounds pretty significant.

Dr. Krizaj: Glaucoma is the primary cause of irreversible blindness in the world. So it affects more than three million of Americans. At least 50% of the people who have the disease have no idea that they do have it. And by the time they start experiencing loss of vision it's already too late.

Interviewer: And so what happens? What causes glaucoma?

Dr. Krizaj: The causes are still, to a large extent, unknown but there are major risk factors such as ethnicity, age, and especially increased intraocular pressure which is actually the only factor that we can treat at this point. The main problem here is that we don't actually know how pressure is elevated. So the major impetus has been to look at the molecular mechanisms behind this disease.

Interviewer: So does that mean that the pressure in your eye changes often or normally?

Dr. Krizaj: It changes almost hundredfold when we get out of bed. But that's just for . . . or when we do yoga, for example. But that's just for short periods of time. The problem is if the change is chronic and over a long period of time. Basically, what pressure in the eye is, is a difference between the production and drainage of ocular fluids.

Interviewer: What are some of the properties that you've discovered that people didn't really know about before?

Dr. Krizaj: One major challenge has been to identify the mechanosensors that allow the cells to regulate pressure under normal circumstances. The second major challenge has been to identify the mechanisms through which increasing pressure kills the cells that sends signals to the brain because it's the death of these cells that causes blindness.

Interviewer: And that's what you've done, is that right?

Dr. Krizaj: Exactly. We believe that we have identified the mechanosensor both . . . and which turns out amazingly to be the same in the front of the eye regulating pressure and in the back of the eye in cells that communicate with the brain.

Interviewer: And so why is that important? Why is that significant that it's in both of those places?

Dr. Krizaj: So if we could target this pressure sensor mechanism we would have the first time ever therapeutical approach to regulate pressure while we are neuroprotecting cells. This has been a Holy Grail of glaucoma research, I would say, over the past 30 to 40 years. And we have in fact, collaborated with medicinal chemists here at the University of Utah who have designed antagonists that are specifically optimized for eye drop delivery or ocular delivery and were able to block the disease in mice so far.

Interviewer: Yeah. And that's really amazing. When you add this drug or these eye drops to the mice, what are some of the changes you see?

Dr. Krizaj: So we have a mouse model where we can elevate intraocular pressure by artificially suppressing drainage. So pressure goes up and we found that when we add these antagonists developed by our collaborator, Glenn Prestwich and Ryan Looper at the University of Utah, pressure drops back down like a rock within minutes. And if we do this, and my graduate students have done heroic experiments where they applied these drops three times a day or two times a day for four months. We find that if we do this consistently we can completely prevent the generation of these neurons which is synonymous with glaucoma.

Interviewer: So how does that work?

Dr. Krizaj: Every cell has its own internal bone structure. And it's just like in humans. If these bones are too stiff and non-pliable, the cells become brittle and very sensitive to damage. And we believe this internal cytoskeleton, as we call it, is really a problem in increased drainage. So we found that when we block the mechanosensor there is an increasing calcium ions in these cells which dissolve this cytoskeleton and as you say makes cells more pliable.

Interviewer: Interesting. I was thinking about this. A few weeks ago, I was pumping up a basketball. And I put too much pressure in the ball and it basically burst. But if that were made of a more pliable material, maybe a more rubbery material, then it should be able to withstand more of the pressure and not see as much damage. Is it similar in that way?

Dr. Krizaj: As in everything in life, flexibility is really the rule of the game. We should always strive to be flexible.

Interviewer: That's right.

Dr. Krizaj: And I think ourselves have figured that one out as well.

Interviewer: In terms of this treatment, what are some of the next steps?

Dr. Krizaj: We want to do the final optimization of these drugs that we're developing and then immediately go into Phase 1 clinical trials. So we formed a company which holds the intellectual property for these compounds. And we really think that there is very strong potential of actually helping people who were resistant to the current drugs.

I don't think this project would have taken off the ground if my Chair, Dr. Olson, has not discerned the potential from the very start and then basically supported it from the get go at every single step of the way. So I and my colleagues in the department are very lucky to basically be able to work in such a collaborative and nurturing environment.

Announcer: Interesting, informative, and all in the name of better health. This is The Scope Health Sciences Radio.

Dr. Miller: Treatments for a damaged cornea. We're going to talk about that next on Scope Radio.

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Dr. Miller: Hi, I'm here with Dr. Mark Mifflin. He's a Professor of Ophthalmology here at the University of Utah. I'd like to talk a little bit about what patients might expect if they go in for corneal transplantation or mention of some of the newer technologies related to corneal repair. I know you're an expert in that area so you might just tell us a little bit about that.

Dr. Mifflin: Traditionally, corneal transplantation involves basically replacing the front of the eye, the windshield, if you will, which is the curved clear dome of our eye is the cornea. And so in the traditional technique that is actually cut with a special instrument and replaced with a clear cornea from a human donor cadaver eye. The cadaver tissue is processed through an eye bank and it's very safe. It's much safer than obtaining, for example, a unit of blood from a transfusion.

The tissue is carefully screened and selected and amazingly does not need to be tissue-matched, unlike a kidney or a heart or something like that because the cornea does not have blood vessels and the eye has what we call immune privilege, meaning it's designed or evolved or whatever one believes to not scar and to not create an excessive immune response to injury or surgery.

In terms of some of the newer procedures, within the last ten or so years we have made really amazing advances in just transplanting the part of the eye that is actually diseased. So for example, in a condition called keratoconus where basically the structural part of the cornea is weak and distorted, we can replace the anterior part of the cornea, leaving all of the posterior structure intact. This speeds recovery, decreases the rate of rejection and generally results in better vision.

Dr. Miller: How does one choose between the best surgery or technique?

Dr. Mifflin: Well, typically the surgeon has to kind of choose for the patient, and some of the more advanced techniques are not always possible. There are other diseases where only the very inner layer of the cornea is damaged or diseased, and certainly replacing the inner layer only allows for a very quick recovery. For example, comparing traditional cornea transplantation which might take six months for visual recovery, transplantation of the inner layer or the endothelial keratoplasty that we do now may result in good vision in as little as two weeks.

Dr. Miller: That's a huge difference. How many patients do you think would qualify for the partial thickness corneal transplant?

Dr. Mifflin: It's pretty much become the standard of care. It's not that the traditional technique is wrong, but certainly, for example, in our center here at the University of Utah we always try to do the most advanced technique if we believe that it's going to result in the best outcome for the patient. Not all surgeons are necessarily trained in the most advanced techniques, but certainly these things are literally becoming the standard of care for most patients.

Dr. Miller: Dr. Mifflin, could you talk a little about the durability of the corneal transplantation or the partial corneal transplantation?

Dr. Mifflin: Durability in terms of survival rates and longevity of the graft is actually very good. Graft rejection or failure is quite low, in the range of perhaps as low as 1% for some groups or maybe up to 30%. The most difficult transplant patients that we deal with in terms of making the graft work long-term are children. Unfortunately, children do sometimes need corneal transplantation and the success rate is lower, although sometimes there's no option and corneal transplantation is required to prevent irreversible amblyopia or loss of vision due to basically what in layman's terms is known as lazy eye.

Dr. Miller: So either transplantation technique should result in equivalent duration, longevity of the transplant?

Dr. Mifflin: Yeah, and typically transplants will last anywhere from . . . there have been documented successful transplantations lasting more than 60 years. I've only been practicing for 20 years, but most of my transplants from 20 years ago are still doing fine.

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