How have multicenter, randomized clinical trials affected clinical practice?
Randomized, multicenter clinical trials are the cornerstone of medical research. They provide the best evidence on new drugs, procedures, devices, etc. Other types of studies yield valuable information, but randomized trials provide the type of evidence that potentially changes medical practice on a large scale. I have designed a number of these studies over the years. A great deal of effort from a diverse team of people—MDs, PhDs, study coordinators, and monitors—is required to bring an idea to fruition. Design is the most difficult part of a study, because bias or potential bias must be eliminated then; it cannot be removed once the study is complete. The quality of the design can make a study some of the most well regarded and influential research on the topic or a publication that is just swept aside.
Over the course of my career, I have been involved in research that has looked at new drug regimens, devices, drug delivery systems, surgeries, and drug combinations. The Additivity study was one multicenter, randomized trial that was conceived, designed, and managed completely in house.1 My fellow investigators and I obtained funding independently for this 18-center study. Its purpose was to determine which drug class added better to a prostaglandin. This was the first of a series of studies that took on this topic that is so important to patients. Despite a small difference in mean IOP, the Additivity study showed that both the efficacy and the consistency of IOP lowering should be considered when deciding on adjunctive therapy to a prostaglandin.
What are some challenges that you have faced as department chairman?
Sources of funding are no longer as available as they once were, schools are less supportive of departments than in the past, and ophthalmology has been marginalized at many schools (fortunately not at The University of Texas Health Science Center). The scope of my responsibilities goes way beyond my busy clinical practice, and it is difficult to balance and give proper attention to everything.
One of the most significant challenges that I have faced is maintaining and expanding our department in the face of diminishing resources. In the past 3 years, we have added 10 new subspecialty-trained faculty members in glaucoma, oculoplastics, neuro-ophthalmology, cornea, pediatrics, and retina in addition to comprehensive ophthalmology to expand and complement our already talented group. We have also set up satellite clinics to serve our community and educate our residents and medical students.
Growing a clinical research enterprise is a challenge, because most new faculty members did not learn to perform independent research during residency or fellowship. For that reason, we have a program devoted to teaching young faculty to perform research, and we have dedicated specific departmental resources to aid their research endeavors. We have a team of dedicated study coordinators, a full-time statistician, and a fulltime medical/grant writer to help our faculty, junior and senior, with their research projects. We also have weekly clinical research meetings covering the breadth of specialties in ophthalmology and have set aside lecture time for research curriculum for the residents. An additional challenge is maintaining and growing our excellent basic science group, known especially for its imaging and study of retinal processes, and developing the needed clinical interactions to translate the group's work into clinical practice. As a chair, my focus is not just glaucoma anymore but a wide range of areas.
What has motivated you to serve as a news physician for newspapers, radio, and television?
Awareness and education are paramount to public health efforts. Most people will not see an ophthalmologist until they are symptomatic. I am involved in public awareness as a means of improving the lives of people beyond those in my practice or cared for in my department. All of my MD faculty members are involved in public awareness in television, radio, and newspapers. Outreach is the first step to combatting blindness.
What is the biggest future challenge in ophthalmology?
With the aging population and growth of groups that show risk factors for eye diseases (certain ethnic groups, diabetics, etc.), a larger number of patients will need eye care. Because resources and funding are decreasing, caring for this increased patient load will pose a significant challenge. Meeting it will require a new model of care, one yet to be envisioned and developed, that involves all eye care providers and is led by the ophthalmologist. In a similar vein, as medical systems coalesce, the independent practitioner and independent group may become a thing of the past. Ensuring that ophthalmologists have a strong voice in the changing model for patients' care is paramount to maintaining quality eye care for the next generations.
Where do you most like to fish, and what is the largest fish you have caught?
I have no one favorite place to fish. I am an avid fly fisherman, and the greatest thing about it is the beautiful locations to which it takes me (and my wife, Ash). I could be fishing for trout in Montana or the Alaskan bush one month and fishing the saltwater for bonefish or permit in Belize or the Seychelles another month. In this type of fishing, size does not matter.
- Feldman RM, Tanna AP, Gross RL, et al. Comparison of the ocular hypotensive efficacy of adjunctive brimonidine 0.15% or brinzolamide 1% in combination with travoprost 0.004%. Ophthalmology. 2007;114(7):1248-1254.
