People say hindsight is 20/20, but in hindsight, how many people have you actually met that have perfect vision? Over three fourths of people you meet need some form of glasses or contact lenses, and chances are that you yourself need them. Glasses can be obtained with ease from optometrists, but if your eyes have more serious problems than myopia, you might have to see an ophthalmologist. Ophthalmology is a branch of medicine and surgery which deals with the diagnosis and treatment of eye disorders, and becoming an ophthalmologist requires going through med school, same as working in any other branch of medicine. Dr Allie Lee is a clinical assistant professor at the Department of Ophthalmology at HKU, and we are very honored to have been able to have a discussion with her.
Introducing: Dr Allie Lee!
Dr Lee is an alumni of HKU herself, having earned her medical degree from the University. Back when she was a student, medical school still comprised 5 years of study and one year of practical work before graduation. She completed her residency and fellowship in Corneal and External Eye Diseases at Hong Kong Eye Hospital, and has been granted fellowships by the Hong Kong Academy of Medicine in Ophthalmology, the College of Ophthalmologists of Hong Kong, and Membership of the Royal College of Surgeons. An academic from the beginning, Dr Lee only recently joined the Department of Ophthalmology in HKU. When she was starting out, there was a steep learning curve, as all doctors encounter, and it takes 5-6 years to pick up a new specialty and learn and improve it to a level of satisfactory performance. Joining the university leads to a busy life teaching, researching, and seeing patients, so Dr Lee decided to focus and train her clinical skills. As she says, if one doesn’t focus on clinical skills 100% from the start, improvement will be slow and performance will be low. Now, she believes that her skills are up to snuff, having practiced until her skills were almost instinct, so she can afford to spend time researching and teaching.
Dr Lee holds a keen interest in ocular surface oncology, ophthalmic microbiology, and complicated lens surgery. Ophthalmology is divided into multiple smaller fields, concentrated around different parts of the eye: the retina, the cornea, the eye muscles, etc. Dr Lee personally specializes in the anterior section of the eye. During her training, she discovered that although she encountered ocular surface cancers in her training, Hong Kong was less developed in this area, and our treatments were nowhere near international levels. The problem was that although not many people had this problem, they were unable to help those that did due to the lack of proper treatment. She hopes that her research can improve the field and bring better patient care in these cases. As for ophthalmic microbiology, in the anterior section of the eye, infections frequently happen. For example, pink-eye, or conjunctivitis. Not only does she find the subject interesting, she also hopes that through research, she can narrow down the best treatments for such infections and strain out the most helpful ones.
Surgical Life:
Dr Lee is a fellow of the Royal College of Surgeons, and has earned the title through thorough training and research. To aspiring surgeons, she says that the most important thing to remember is that all surgery is just about surgical training, and skills improve with the volume of training. Although doing surgery on the eye is more difficult than many other areas, which she encountered on her rotations, all types of surgery contain a learning curve. It’s quite impossible to go from 0 to 100 in a short period of time, and time is required to absorb and practice the new skill - the exploring period. Of course, the aforementioned period is also a period of high stress, as it’s the most likely time where problems arise. However, one must keep in mind that not every surgical performance will be 10/10, and the most important thing to do is to remember what parts to improve, and stand back up and do better the next time. Medicine is a field that tests grit, and it’s okay to fail. Not everyone will succeed every time, but the main point is to stand back up after a failure and try again.
As for eye surgery, it’s more difficult than other surgeries due to the fact that the operations take place on such a small scale. For instance, the open incision is about 2.2 mm, the working space is about 3-4 mm2, and the suture thread used is even thinner than a hair. However, as with all surgeries, there is a learning curve, and with practice, and practice, and more practice, it will come more easily.
Research:
As a clinical assistant professor, Dr Lee also takes on research of her own, and she shares with us how she carries out clinical trials. Traditionally, bacteria culture is used to determine the type of pathogen or disease, but it’s not as applicable in the cases of viruses. In the case of the eye microbiome, not all pathogens can be identified by culturing, and not being able to culture a type of bacteria does not mean that it’s not there.
Currently, DNA sequencing is used in detection. It’s cheaper, easier, and targets specific parts of the microbiome. It can detect the pathogens which culturing cannot, such as viruses or dead bacteria, sterilized and killed by tears and enzymes. Of course, as with all research, the modelling in the research and the conditions in real life are different, and one must be flexible and adapt.
Another interesting issue of research brought up is the ethnicity differences and how it affects patient treatment. Currently, most research is done in the UK or USA, with a main study pool of white people. As a result, the results of the research have to be taken in a generalized way, and are not always 100% applicable, as Asian eyes differ from those of Caucasians. It’s always best to use research done on the local population, but if not possible, available information should be taken and adapted case by case, disease by disease.
Med school tips:
As a former medical student herself, Dr Lee has quite a bit to say about choosing to walk the path of medicine. For aspiring medical students, she urges us to consider whether we really like the subject before choosing it. We should choose the subject because of our own fondness and passion for it, and not just because of expectations or good grades. She encourages us to use the time now to decide and contemplate our choices, and recommends us to do more attachments, research, or participate in programs and activities to determine whether we really find this enjoyable.
In the current HKU medical program, medical students enjoy one enrichment year in their third year, and they can choose to pursue an intercalated degree program, involve themselves in internships, study overseas, or self initiate programs. Dr Lee considers this an excellent opportunity for students to broaden their horizons and expose themselves to more types of activities, as well as gaining experience. As she says, medicine has a long career life of 30+ years, and not only is the enrichment year enjoyable, you never know when you might need to use any skills you pick up during that time period, so it’s also worth it in the long term.
To become a specialist in Hong Kong, graduates from medical school have to undergo training at Hospital Association sanctioned places. Dr Lee herself undertook that training in Hong Kong Eye Hospital, and in her opinion, the most important thing in a young doctor’s early career is to get themselves into a good training center. Specialist training happens in recognized centers, with clear rules and standards set, as well as qualified trainers. With good doctors as mentors in specialist training, one will be able to do better.
However, Dr Lee says that right now, the most important thing for use is to research more options for our future, and not to limit ourselves to just medicine. After all, if you change your mind, you can always do a post-graduate medical degree!
For those who are dead set on medical school, Dr Lee says the first thing is to clear the academic requirements, but she expresses her faith that we will be able to do that easily, ha ha. However, for her, the most important thing would be to hold passion for the subject. If you hold an interest in studying something, you will find a way. She encourages us to join more ECAs and activities, as well as do research about medical school, stating that we should absorb all we can and be open to learning new things, as to better prepare for our future. Of course, one should also be resilient and flexible, able to adapt to any sudden obstacles that spring up in the path. However, medical school is less scary than she thought. Although it was very busy in the beginning, it got better, and she thinks the heavy workload in the beginning not only helped her adjust to university and the chock-full life of a doctor, it also helped her learn better time management and stress management. Of course, now that she’s a clinical assistant professor, she has more time to research areas in which she has an interest in, and it’s far better than she imagined.
Treating patients:
As a clinical assistant professor, Dr Lee still has responsibilities at the hospital, and thus sees many patients. As a result, she has quite a few anecdotes to share. For instance, her experience with dry eye disease, a common but complicated disease. For many years, the ocular surface was considered to be sterile and without germs, and even the Human Microbiome Project, when established in 2007, had research on skin and guts but no research on eyes. Although the ocular surface was commonly considered to be germless due to tears, enzymes, and antibodies in eyes that could kill pathogens, it was realised around 2015 that this was not the case. Dry eye is one of the conditions that is caused by an imbalance in the outer eye germ balance, and affected by the numbers and diversity of the pathogens. It differs from person to person, due to each person’s unique ocular ecology, and she hopes that by carrying out further research on dry eye and microbiomes, it can discover the link between the two, and be able to improve patient care and help in more cases.
She also shares her opinion on how the urban environment of Hong Kong affects people’s eye health. In study-oriented places such as Hong Kong, Singapore, Japan, etc, up to 90% of people need vision correction by the time they turn 12. Although myopia is best managed in childhood, there is no 100% effective method, and it’s multifactorial, for instance, genetics, or studying. One of the main ways of myopia control is to go outside and do exercise or relax one’s eyes, but due to the social atmosphere and the current school scheduling, it’s very difficult for students to find free time, and they are unlikely to give up that free time. Another serious problem is how the air pollution in Hong Kong affects people with sensitive eyes. People with eye allergies or sensitive eyes are prone to rubbing their eyes due to the irritation from the pollutants in the air, and too much rubbing can permanently change the shape of the cornea and damage their eyesight.
To quote Dr Lee, being a doctor is like standing by a river and pulling people out and saving them. There are only so many doctors and so much they can do, and if people keep pushing other people in, it’s impossible to save everyone. Although in student life we can count on success by working hard, real life is not so simple. It’s possible to do everything right and still have it all go wrong. As a doctor, many things are out of your control, and the main thing is to try your best. Instead of trying to convince a patient by telling them what they need, we should manage their ideas, expectations, and concerns, using that management to convince them to undertake the best treatment plan. Of course, it’s impossible to save everyone, so one must remember that we can only help those who wanted to be helped, and that it’s pointless to expend 100% of your time and energy on one single patient.
In Dr Lee’s opinion, the best way of treatment is not treatment, but education and prevention. By instilling good behaviours and habits into people (for instance exercise and good hygiene), they are less likely to fall prey to some conditions, which lead to an overall healthier life for them. It’s best to educate the next generation so that they understand the risks and how their lifestyle could be affected. As education and prevention increases, the number of cases decrease. It’s hard to change people once they’ve formed their habits, and it’s hard to implement significant changes in society, especially due to the desire to conform and survive. The best way is to catch their bad habits when they’re younger, and carry out education to help them improve.
Hope for the future:
Although huge improvements have been made in fields of science and technology, especially in Artificial Intelligence, Dr Lee thinks there’s still some way to go before AI can carry out surgeries successfully. However, she believes that AIs have a more useful purpose in ophthalmology: Carrying out screening tests. Two of the most prevalent diseases in ophthalmology are diabetic retinopathy and glaucoma, and in both cases, symptoms and identifying markers are clearly defined, and there is a clear diagnostic criteria. In the case of diabetic retinopathy, it’s possible that patients have already contracted this disease without exhibiting symptoms, i.e. asymptomatic patients. For such patients, or even for people at risk of this complication, regular screenings are required to manage their eye health. However, in these scans, all that happens is that an ophthalmologist looks over their eye scans and diagnoses them. Due to the high amount of people at risk, it’s not feasible to expect ophthalmologists to screen so many people so regularly, without a significant hit to their time, energy, and labor.
It’s highly possible that AI screenings of these two conditions will be the first AI development in the ophthalmology field, as due to the clear-cut diagnostic criteria, it’s quite easy to write an algorithm to identify the symptoms and severity with ease. Although it’s not routine yet, as the AI program requires high computer storage, processing power, and technological centers to run, it’s quite possible that in the near future, or in centers with higher resources, this pilot program could soon become commonplace, catching, diagnosing, and treating many more people and helping them too.
Although artificial intelligence could one day lead to the replacement of surgeons as top operators in medicine, that day is still far off. And, Dr Lee shares, it’s quite impossible for all of us to be replaced, and not just because of the far off development of the technology. After all, the doctor-patient rapport is still one of the most important relationships that form in medicine. Even if a surgery goes perfectly, the patient still might not be satisfied, and form their own opinion subjectively. Communication is one of the most important skills, just as important as surgical skill itself, and by establishing communication between the doctor and the patient, we can better treat and help the patient, something that an AI is not yet able to do.
