Padmashri Dr. Amod Gupta, a respected teacher-of-teachers, is known all over the world. A passionate teacher and researcher, Dr. Gupta retired from Advanced Eye Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh after an illustrious career spanning over four decades. In this interview, he replies to our questions asked by Dr. Tandava Krishnan.
eOphtha: You have been a teacher for more than 3 decades. You have seen the transition from bed side teaching to teaching which predominantly hinges on a power point presentation. Your thoughts on it.
Answer: Very interesting question at a time when ppt. presentations hold sway in the class room and the conference hall. There is no way a ppt. slide can substitute a bedside/clinical exam. For us in Ophthalmology ‘the bedside’ is ‘the slit lamp side’. When you examine a patient on the slit lamp, each step in the exam is preceded by a question in our mind, do I see flare? Do I see Iris atrophy? Or do I see new vessels in the angle? When you discover what you are seeking it forms a long lasting memory. Seeing the same sign on a powerpoint slide is a passive phenomenon like watching a movie, in that it is an information in the first place you are not actually seeking, and this unsolicited information is likely to be lost sooner than later. Certainly, sign seen on a ppt. slide can be a quick revision for the expert who has already elicited it by clinical examination in the past. Moreover, a clinical exam creates a unique context by way of the patient’s complaints, the challenge of her illness and her entire persona. Contextual learning forms lifelong memory. Besides you learn how to communicate and show empathy. Moreover, the supervised ‘the slit lamp side’ learning provides an opportunity in real time for the instructor to make corrections in errors in examination technique and interpretation of the signs. In short powerpoint presentations can be a good resource for a refresher course but never for primary learning.
eOphtha: Uveitis is now well and truly being acknowledged as a sub specialty in ophthalmology as against being considered a mere extension of retina. Visionary like you have played a decisive role in this transformation. Can you please share your experience about how this metamorphosis came about?
Answer: Uveitis and even the retina subspecialty were very low priority in the ophthalmology curriculum in India saddled as we were with loads of trachoma and the cataract blindness in the 50’s and the 60’s. Cataract surgery was an easily learnt skill not requiring much cognition and produced gratifying outcomes for all the stakeholders namely the patients, doctors and the society. Moreover cataract surgery till the 80’s was a technically non-demanding requiring not even a slit lamp for the diagnosis. A flashlight and the direct ophthalmoscope was what you needed to examine an eye patient. Any patient who did not have a cataract, trachoma, corneal ulcer or an opacity was nobody’s burden. Most of the medical schools till late 80’s did not even have a slit lamp for use by the faculty or the residents in training. There was hardly any exposure of Indian doctors to see first-hand how things were changing in the rest of the world limited as we were by financial constraints. The opening up of economy, socio-economic and technology developments, rising aspirations of the society and setting up of institutes in private sector all played key role in development of subspecialties in Ophthalmology.
When I joined the PGI in 1974, we already had besides other clinics, a special uveitis clinic that had registered nearly 600 patients by that time. My chief Prof Jain was among the first who showed HLAB27 positivity in acute anterior uveitis (IJO 1979), viral uveitis in 1974, a VKH disease series in 1978, fungal endophthalmitis in 1965, APMPPE in 1982, Wegner’s granulomatousus in 1988. His report that VKH disease and sympathetic ophthalmia were similar diseases was cited by Duke-Elder in System of Ophthalmology text book. I was interested in retinal diseases and got attracted to the inflammations of the posterior segment because unlike the medical retinal diseases, posterior uveitis was a major challenge then and has remained so even now. It offered immense opportunity to publish papers. We lacked mentors in India back then and this gap was filled admirably well by Prof Rao who not only trained some of the pioneers like Dr J Biswas in the US but he frequently visited India to hold our hands in bettering our understanding of uveitis. He personally invited and encouraged faculty from overseas to attend our meetings at their own expense and ensured that we got exposed to their thoughts, presentations, and publications. I owe my entry into the IUSG, then an exclusive club of international uveitis experts, in a meeting held in the Fisherman Cove, Chennai, thanks to guidance and encouragement by Prof Rao in the year 2000. He encouraged me to present my work on PCR positive TB retinal vasculitis in this meeting. The meeting was organized by Dr. J Biswas who was already a member of the IUSG, the first one from India. I also got an opportunity to present my preliminary data on serpiginous choroiditis in a meeting in Chennai the very next day that was attended by a large number of IUSG members. Seeds of the Uveitis society of India were born around that time and it took a few years to formalize the same. He also encouraged many of us to speak in international meetings including the AAO, IUSG and other European meetings. I give full credit to Prof Rao for setting up the uveitis subspecialty in India. Our role had been to follow the path shown by him. And as they rest is history. Today, the Indian uveitis experts hold their head with great pride in any international meeting and their presence cannot be ignored any longer.
eOphtha: There seems to be a mismatch between the expectations of an ophthalmologist and a physician. Request for a physician clearance prior to an anti-VEGF injection or a request for a physician evaluation to rule out systemic Tuberculosis is usually rewarded with a clearance for a cataract surgery! How do we best bridge these gaps?
Answer: I agree with your opinion. I have heard of this miscommunication most often from my colleagues in the private sector. Our knowledge of developments in medicine may date back to the days of our graduation and may be outdated by decades. Most unfortunately, in India we have followed a siloed approach. We do not track or update developments in other disciplines in medicine. Moreover, there is very little formal or informal interaction among the physicians. In some of the multidisciplinary academic institutes like PGI, we are fortunate that we are able to communicate our concerns and challenges to our colleagues in Internal medicine, pulmonary medicine, endocrinology, cardiology, and other disciplines without any hesitation. Need of the hour is to have multidisciplinary meetings in which physicians from different disciplines and sectors can come together and apprise each other of the developments in their field. This vacuum can be filled admirably well by organizations like the IMA. In this regard, Indian rheumatological society has taken a lead in inviting a uveitis expert to their annual meeting for a lecture and attended enthusiastically by all the attendees. AIOS should approach their counterparts in other disciplines for getting a slot for lectures by the ophthalmology experts for updating their colleagues in other medicine disciplines.
eOphtha: Being a TB endemic developing country, we are in a unique situation where we cannot directly extrapolate the findings of studies conducted in European or North American countries. Making treatment decisions based on serological tests like quantiferon TB gold best exemplifies this situation. What is your advice in this regard?
Answer: I agree with you that we should develop our own data base of the diseases and the challenges in management that are unique to our people. I find tendency among our doctors very disturbing to ape blindly the recommendations coming from the western world. Even today, I find in conferences that I attend, elaborate presentations and discussions on data of the western world without any reference to our own population, data or experience. We certainly need to know what the other world thinks but applying it blindly to our own population is inviting disaster.
eOphtha: At the community level, despite rapid advances in knowledge and technology, our ability to tackle ophthalmic diseases beyond cataract is largely limited to urban areas. How do we best address this large scale morbidity?
Answer: I think it is a universal phenomenon. And there are no easy solutions. Advances in knowledge and technology are always first available in select tertiary care centres, and gradually trickle down to the secondary and primary care centres and individual practices in urban and rural areas. In the past more than 3 decades, I have seen increasing number of ophthalmologists who wish to specialize in fields beyond cataract surgery as they find this field oversaturated and are moving to areas like glaucoma, oculoplastic, squint etc. In my own area, when we wished to form a vitreoretinal society in the early 90’s we could not find even 20 retina specialists and today we easily have more than a 1000 members who are exclusively practicing retina and not all of them in the urban areas. Likewise there is a healthy growth in the members in the uveitis society of India who wish to practice only inflammatory diseases of the eye. It is very encouraging to see young ophthalmologists setting up multidisciplinary eye centres in small town and cities.
eOphtha: As time progresses, we see more and more dependence on investigations to make clinical or therapeutic decisions. While they are usually justified, it adds on to the expenditure which is incurred by the patient. In a country like India where only a small proportion of the population are medically insured, is there a case to reorient ourselves to clinical examination and train ourselves to minimise investigations to reduce the financial burden on the patient?
Answer: I agree that there is over dependence on labs/investigations among the physicians. Most obvious being the fear of litigation if you missed diagnosing a life threatening or disabling disease. The knowledge base of medicine is growing exponentially and no matter what, nobody can keep track all the changes that are happening. As our knowledge gets dated with time, we start losing confidence in our clinical ability to make a diagnosis. Fear of missing a brain tumour in a patient with headache is so overriding that you end up ordering a CT scan. Conversely, you are answerable to the health insurance companies that may question your wisdom in ordering an investigation that was not needed in the first place. This conflict has led to the development of continuing medical education programs, earning a certain number of credit hours every year to compulsory recertification at fixed intervals. In the annual meetings of the American Academy of Ophthalmology, most of the time slots are devoted to courses designed to update the basic skills of the practitioners. On the other hand, in many of our own meetings in India emphasis by some of the star performers is to showcase their own exceptional skills in what they can do and what attendees cannot do. Unfortunately the teachers in India have taken a back seat. Perhaps they need to teach again the basic ophthalmology.
eOphtha: There is a wide discrepancy among the medical colleges in the quality of training imparted and therefore the skills acquired by the students. What is the best way to bridge this gap? Do you think there must be an authentic rating system to grade various colleges according to the quality of students they nurture? What according to you is lacking in the current medical curriculum in India?
Answer: Unfortunately this gap is only increasing. There is a mad rush to increase the number of seats in postgraduate programs in India. Barring honourable exceptions like PGI or the AIIMS, most of the PG training programs in India lack the basic infrastructure and if it exists there is no provision for maintenance of the equipment. Commonly, access to equipment is denied to the other members of the faculty or the residents. The current system of inspections by the MCI team has failed to serve the purpose. For any improvement to occur in the quality of our residency programs there has to be a benchmarking of not only the infrastructure, and listing of the critical and basic equipment but equally importantly the competence of the teaching faculty. The professional associations like the AIOS should set up the benchmarks. In the US, quality of residency programs is maintained by agencies like the ACGME, ABMS and the ABO which are all private initiatives. All institutes must display on their websites the infrastructure, the equipment, the faculty with their CV including their research interests and area of expertise, the curriculum, and the training program. The curriculum is the most neglected document. You can poll the faculty and the students of the institutes to find out how many are even aware of the existence of the curriculum if it exists in the first place. While the MCI gives broad guidelines of objectives and curriculum, it is the prerogative of the affiliating university board of studies to design and approve the courses. I have not seen any Indian university displaying curriculum for public scrutiny. I do not find any visible effort by the university board of studies to constantly review and incorporate dynamism in curriculum of the courses they approve.
eOphtha: Balancing between research and clinical work is the most difficult job, very few can achieve it. How can one master that?
Answer: As clinical doctors, doing clinical work, work that we do the best, gets us into our comfort zone because that is what we can do without feeling the pressure. Majority would like to stay there and not accept the challenge of doing anything new or uncertain. However, many of us especially in academic institutions stop getting kicks by doing things that are repetitive and wish to get into excitement world of discovering the unknown. Seeing your observations in print and further getting cited by other researchers in the field is very heady and addictive. While many are drawn to research by their passion, it is a common observation that not always the most curious minds find their way into science streams at the graduate or even the doctoral levels. It is especially true of the faculty in many of our medical schools. In my experience, the real passionate researchers do not feel this pressure and I find that busiest clinicians are also the most prolific contributors to the existing knowledge. Essentially what you need is a curious and committed mind. It is the people who found their way into research by chance and not driven by curiosity seek alibi in clinical work. Academic environment and support provided by the institute plays a great role by way of providing for captive time for research activities.
eOphtha: Medical knowledge is dynamic. What is your advice to young ophthalmologists, who wish to provide the best possible treatment to their patients?
Answer: As I said medical knowledge is expanding exponentially and no one can master it all. It is the mandate of society that when a patient entrust his life in the hands of a doctor without any reservations, it is only just that the doctors have the most updated knowledge and skills. In the present times there are any number of free resources to keep updating knowledge on a daily basis in your own field and the allied specialities. Besides, there are a number of professional conferences and CME programs throughout the year that provide opportunity to learn the most current standards of care. One can freely interact with leaders in the field and clear their doubts. A common tendency for the doctors is passing on their challenging patients to others. They most certainly should do that. But they should not bury their challenging patients under the carpet. They must introspect why they had to refer a patient to their colleague and what prevented them in providing care. Skills have an ever shrinking half-life. Young physicians must update their skill sets and make it a way of life otherwise they risk becoming irrelevant very soon and left far behind their peer group. Ultimately, what you need is a commitment to be the best.
Professor Amod Gupta was a professor of Ophthalmology at the Post Graduate Institute of Medical Education and Research, Chandigarh (India) and currently the Professor emeritus of Ophthalmology, Government of Punjab. He was the Dean at the PGI from 2010 to 2014. He headed the department of Ophthalmology at the PGI from 1989 to 2015. He raised the Advanced Eye Centre in 2006, one of the most advanced ophthalmic centres for patient care, training and research in India. More recently, with a competitive research grant of Rs 5.00 crore by the DBT, he set up a Centre of excellence for study of intraocular inflammations at the Advanced Eye Centre, PGI.
He has been at the forefront of clinical research in Ophthalmology and especially in the field of retinal and uveal diseases. In the last nearly 25 years, his contributions have been outstanding in discovering new diseases, their clinical manifestations and new management strategies which have brought about paradigm shift in the management of several blinding diseases. His researches have been recognized internationally. A passionate teacher and researcher, he has published 377 original research papers in national and international journals which have been extensively cited (6404 Scopus. H index of 40). His coauthored books on ‘Optical Coherence Tomography’, ‘Diabetic Retinopathy’ and “Uveitis: Text and Imaging” are read all over the world.
In the early 1990’s, he first introduced the use of high technology in eye care in North India and was the first person to start Vitreo-retinal surgery in the entire North India for hitherto incurable retinal diseases. He was also elected the President of Vitreo-retinal society of India. He pioneered the setting up of the subspecialty of Uveitis and Intraocular inflammations in India and was the founder President of the Uveitis Society of India. He is an acknowledged international leader in Ocular tuberculosis and was elected to the most prestigious the International Uveitis Study Group. He has worked extensively on intraocular tuberculosis and described a new disease entity, ‘Tubercular Serpiginouslike Choroiditis’ now recognized world over and successfully treated thereby preventing blindness from this hitherto incurable disease. He discovered contaminated glucose infusions in rural settings as a previously unknown risk factor for developing fungal endophthalmitis in otherwise healthy young individuals. His work on the use of atorvastatin in the management of diabetic maculopathy is extensively cited in the contemporary literature and provided initial evidence for recommending statins in patients with diabetic retinopathy. In view of his outstanding contributions in Ophthalmology, he was awarded the first R N Mathur award(1996) and Dr P Siva Reddy International Award (2008) by the All India Ophthalmological Society, Chandigarh Ophthalmological society (A D Grover Memorial oration,1999), Ahmedabad Academy of Ophthalmology (Cash award of Rs1.00lac,2000), Gold Medals by the All Assam Ophthalmological Society (1996), Haryana Ophthalmology Academy(2004), Bombay Ophthalmological Association(2011), Bangalore Ophthalmological Society (Life time achievement award,2013), Punjab Ophthalmological Society (Dr Daljit Singh oration, 2005) Jharkhand Ophthalmological Society, (B P Kashyap memorial oration,2006), Andhra Pradesh Ophthalmological Society (P Siva Reddy Award-2011), Asia Pacific Academy of Ophthalmology(Distinguished Service Award 2007) American Academy of Ophthalmology (Achievement Award-2009) , Ranbaxy Research Foundation (Ranbaxy Research award- clinical research 2008), Cochin Ophthalmic Club (Prof T Gopinatha Menon memorial oration and Gold medal 2011), RK Seth Memorial oration (Delhi-2011), First B Patnaik memorial oration (Vitreo-retinal society of India-2011), TNC Vedantham memorial oration (Radhatri Netralaya, Chennai,2013) Prof M K Mehra oration of KGMC, Lucknow (2014), Dr Anila Khuteta memorial oration of Rajasthan Ophthalmological Society(2014) and “Teacher of Teachers Award-2012” by LVP Eye Institute, Hyderabad and “Teacher of Teachers Award- 2015” by Center for Sight, New Delhi. He delivered the first Dr. SS Grewal oration of North Zone Ophthalmological Society in Oct 2015.
He was also elected Fellow of National Academy of Medical Sciences (FAMS-2006) and delivered the prestigious VR Khanolkar oration (2007-08). Recently, he was honored by German Ophthalmological Society with ‘von Szily Medal and lecture-2015’. He was nominated fellow of Panjab University by the Vice President of India (2016-2010) . He delivered Dr JL Sharma Oration of the Eye7 group of hospitals, Gurgaon in 2016, Dr. G Venkataswamy Endowment lecture and medal of Uveitis Society of India 2017, Dr. MC Luthra oration of the Drishti Eye Institute, Dehradun 2018, Padma Shri Dr. Dhanwant Singh Oration of the Ludhiana Ophthalmological Society, 2018 and Prof A N Pandey oration of Bihar Ophthalmological Society, 2018
As a recognition of his unique personal achievements, he was awarded the Padma Shri (2014), the fourth highest civilian award in India, by the President of India.