Thursday, October 27, 2016

Eulogy for My Father

Dr. Houshang Khorram


It is a very difficult honor to have, to share with you some thoughts about my father, and his life. He led a life so full, and so full of service and dedication to this community, that it is simply moving. My father had a tender heart. He would be moved to tears, and his voice would quiver by anything that brought love. When he was preparing to retire a year ago, as he was wrapping up the last months of his life as a pediatrician, he told me he would shed tears every day – families would come into his exam room and cry at his coming retirement, and he would cry with them. For several months, he put off accepting the invitation to the retirement party the hospital wanted to hold for him, because he knew it would be an emotional evening. Now, unfortunately, I inherited my father’s heart. My children tease me about the emotion that wells up within me about the simplest things. I’ll say, “This is great popcorn,” and they’ll say, “Are you going to cry?” So today, of all days, these emotions are sure to well up. If I have difficulty speaking, bear with me, and know that this is a bit of my father coming through. Mine are not tears of sadness but of love, and fullness, and celebration of a wonderful life.

Middlesboro knew my father first and foremost as a beloved pediatrician. He grew up in Iran, in Yazd, during the 1930’s and 40’s. Yazd was probably not that different from Appalachia at that time – poverty, disease, needless suffering. And my father chose to tackle these issues by studying medicine. He was accepted to university in Shiraz, where during his medical studies he met my mother, who was a nurse. They married, they had a son, and they moved to the United States where this promising young doctor continued his studies at Johns Hopkins University. And a daughter was born. To stay in the United States, my father had to go where doctors were needed, and he came to Eastern Kentucky. He practiced medicine for 50 years, and forty six of those years were spent here in Middlesboro. Over the past few days, the tributes have poured in from this community – words like: “He was one of a kind. Touched so many lives and the little ones he took care of so tenderly for so many years.” “I loved him… He saved my baby girls life.” “Our grandson was a baby and had just started talking when we'd taken him to see Dr. Khorram. As he was leaving the room our grandson said, ‘I love you, Dr. Khorram.’ Dr. Khorram stopped, turned around and came over and hugged him. Our grandson really loved Dr. Khorram! He's 19 and would drive himself to go see Dr. Khorram when he was sick!”

This was my father. A kind, gentle man, who spent his life caring for children. There is no possible way I can capture all of the feelings that have been expressed about his passing, and I don’t think I need to, because, after all, he was a part of your lives and a part of your hearts. What can I say, that you do not already feel deeply yourselves?

Although he must have known the impact he had on this community, he never talked about it, never acknowledged that he was even aware of it. You see, he was just thankful to you, for entrusting him with the privilege of caring for your families. He was thankful for such meaningful work. He loved his life serving the children of the area. His work filled him with joy and with purpose. On weekends, he was waiting for Monday, so he could get back to doing what he loved.

When I was here five years ago, he took me to his office one weekend. And I stood in the silent office, looking at the hundreds of pictures on the walls. The pictures of his patients, who over the years, would bring in school photos for their beloved doctor. Many of the pictures were faded, some were more than 40 years old, the faces of children, with gap-toothed smiles, and lopsided haircuts, and innocent eyes, all captured in time, all a witness to his work.

From the time my dad hit sixty – that more than 20 years ago! -- we would ask him about retirement. To retire was simply not something he wanted to do, or saw the slightest reason to do. “I love my work,” he would say, “I help people. They thank me. What can I do in retirement that would be better than this?” And so he kept doing what he loved into the 83rd year of his life. He did finally retire, this January, and over these past few months, he would often talk about how much he missed his practice. I put a pause on my own practice of medicine two years ago, and I would joke with my dad that he outlasted me in the profession by 30 years.

For my dad, his work, this service, was a quiet testament to his Faith. He grew up in Iran, where Islam is the predominant Faith. He was born into a staunch Muslim family, and raised his early years as a Muslim. But something was quietly happening in the background that he was not aware of. In 1844, a new Faith had been born, the Baha’i Faith, an independent world religion that is now the most widespread religion after Christianity. It was, and remains today, reviled by the fanatic elements of Iran, with tens of thousands of Baha’is having given their lives, and many today remaining imprisoned for their Faith. It calls to mind the early years of the Christian martyrs at the hands of the Romans. Something significant had quietly happened during my father’s childhood in Yazd. His mother, at significant risk to herself, and with great courage, had embraced the Baha’i Faith. She had done so secretly because of the danger.

My father found out about this unexpectedly. He had learned a schoolyard taunt against the Baha’is and had come home happily singing it. His mother took him into the basement, away from the family, and firmly told him, that he was to never say such disrespectful words about the Baha’is again. It was then, that for the first time, my father suspected that his mother was a Baha’i. Soon thereafter, she openly proclaimed her faith before her husband’s family, who cast the entire family out of the household. It was then that my father began in earnest to learn about this Faith that his mother had embraced. This Faith , which he had been raised to ridicule, became his own, and became the motivating force of his life. If my father had not become a Baha’i, there would likely have never been a Dr. Khorram in Middlesboro. So, it is this Faith that we have to thank for this man’s presence in this community.

My father was attracted to the core tenants of this new Faith, that teaches that there is only one God, that all the religions come from the same divine source. That their spiritual teachings, that tell us to be kind, loving, just, and fair, run through them all. That they differ, not because they come from different Gods, or because some are false and others true. No, they differ because their historical contexts differed and the needs of humanity differed. It was in these teachings, the teachings of Baha’u’llah, that my father saw the renewal of the same light that shone in Christ. It was in Him that he saw the fulfillment of the prophecies of the Bible, and that all the world’s great holy books speak of: the coming of a promised time when peace shall cover the earth, when the lion shall lie down with the lamb, when swords shall be beaten into plowshares, when we shall study war no more. My father was optimistic and practical. He knew that the Kingdom would not descend magically from heaven, but would be built by our hands, through toil and effort and dedication. It would be built by each of us fulfilling our two-fold moral purpose – to refine our own characters, and to contribute to the advancement of humanity.

My father believed that the teachings that God has given for this day through the Baha’i Faith are the practical means of ushering in the Kingdom of God on earth – the teachings that there is only one God, and that all religions come from the same God. That humanity is one. He recognized that this is easy to say, but difficult to do, because we have to give up our prejudices – prejudice of race, class, religion, color, and nation. We must give up anything that allows us to feel superior to others. He believed in the equality of men and women, the harmony of science and religion, the importance of knowledge, the need for all to be educated – all tenants of this new Faith of God. My father saw that to truly incarnate the principle of the oneness of humanity, our current social structures, whether political or economic, have to be completely transformed and recreated… because you can’t have peace without justice. That’s a lot going on in the mind and heart of a pediatrician sitting at his home at 1714 Cirencester Avenue.

I share this with you, because I know that my kind and quiet father would have wanted you to know where his motivation came from. He thought about these things each day. He prayed about them each day. He gained purpose through them. He wanted the same for everyone.

When I think of my father, as a father, his gentleness and his humor are the two things that stand out. During the most difficult times of my life, he was there. I would put my head on his shoulder and cry, and even though I was in my twenties, he would comfort me, “It’s okay,” he would say, “It’s okay.” And in those tender moments, he was just as likely to say something that would make me laugh and wipe away the tears. He always made us laugh. Even in the most serious or sacred moments, he had the ability to distill a situation to its funniest elements. I keep expecting him now, to sit up and say something, to make us all laugh.

My father was not afraid of death. He spoke of the coming transition often – not because he was sick, or because he thought he would die soon, but simply because death is a practical part of life. After all, none of get out of this life alive. The Baha’i writings shed quite a bit of light on life after death, and as part of the service, we’ll share some of those insights with you. My father knew that when the body dies, the soul is like a bird that is released from a cage. The soul is eternal, a sign of God, and continues to progress towards God through all eternity. How we live our life in this world, combined with the grace of God, determines our station in the next world. The Baha’i teachings speak of nearness and distance from God – a continuum, more like a ladder, rather than just a heaven and a hell. So our work in this life, is to prepare for our next life, through worship and through service.

The Baha’i burial is a simple one. This body, which has been associated with the soul and which returns to dust, is treated with respect. It is washed and wrapped in cloth. A ring, is placed on the finger, bearing the beautiful inscription, “I came forth from God, and return unto Him, detached from all save Him, holding fast to His Name, the Merciful, the Compassionate”. There is a special prayer that is said before the burial, which will be read tomorrow at the graveside. Other than that, there is no set form. We’ve chosen the readings and prayers that we think my father would have wanted us to reflect on, and to bring us all comfort and understanding, and to advance his soul into the next world.

It broke my heart when I read the three-word message from my sister: “Pups died. Come.” But that anguish passed quickly. He often said that he hoped his end would be quick, that he did not want to become a burden for anyone or to linger. And his wish was granted. After so many years in the wards of a hospital, it seems to me somehow appropriate that he died at home, sitting in a chair, after having just gotten the mail from the mailbox. A few weeks had passed since I had last spoken to him, but by some stroke of luck, or divine grace (we never seem to know which it is) I called him just a few hours before he died. The conversation was sweet, as it always was. He asked about me, he asked about each of my four children, how they were doing, and what they were up to. He laughed that my daughter, Nava, had complained about her college applications on Facebook. He asked about Mara my wife, he asked about my sister, Jaleh, and her boys, and it always made me laugh that he would ask about Saipan, the island in the Pacific where my family and I had lived most of our lives. We laughed a lot, as we always did. And we said goodbye.

This past summer, my father had spent a week gathered together with his two children and all his grandchildren, and this brought him great happiness. Two years ago, I, along with two of his grandchildren, Wyatt and Nava, had the privilege of accompanying him to the Holy Land, to pay respects at the Baha’i holy places. He had wanted to go “one more time” as he put it, and it was a privilege to make that trip with him. There was nothing left undone. He lived as rich a life as anyone can live, surrounded by a community and an extended family that embraced him and loved him. His life was generous, and full. And that is why when my emotions well up in these days, they are not feelings of grief, but of love and gratitude.

This is a sacred time, this time of transition of the soul from its association with the body, to its full glory in the next world. According to the teachings of the Baha’i Faith, the soul continues to progress in the worlds of God, through the mercy of God, and through a combination of two things which those of us here can do: the prayers we offer, and the charitable acts we accomplish in the name of the departed. This highlights a great emphasis of my father’s Faith and of his life – the necessity to combine worship, with service. I think my father exemplified this. So please, do pray for the progress of his beautiful and radiant soul. And if you are able, illumine your prayers with some act of service in his name, some contribution to any charity in his memory. And as you do so, say, “This is for you, Dr. Khorram”. His soul will rejoice.

Thank you, Baba. Thank you for your gentle spirit, your example of a life lived in service, of faith expressed through deeds. Thank you for the gift of your humor, your generosity, your steadfastness, and loyalty. We honor you today. Thank you for honoring us.

Friday, May 13, 2016

My Experience with Manual Small Incision Cataract Surgery (MSICS or SICS) Training at Arasan Eye Hospital, Erode India

Two surgeons being trained simultaneously at Arasan Eye Hospital -- one in SICS, the other in phaco.  The instructor monitors the cases in progress.
I'm currently finishing two weeks of training in manual small incision cataract surgery (MSICS or SICS) at Arasan Eye Hospital, in Erode, Tamil Nadu, India, and thought it would be useful to share my experience.  It was a very positive experience.  Before I came I had difficulty finding out much detailed information about the training or the experience, so I hope this is helpful to you.


Surgical Background

Many of the ophthalmologists who come to Arasan to learn MSICS or phaco, often with limited experience with the procedure.  I think that the experience you bring with you to the training affects your experience and the speed at which you gain mastery.

In my case, during my residency at Northwestern in Chicago in the early 1990's we were trained in ECCE and phako with a superior tunnel incision.  There were no foldable lenses widely available yet.  After my residency I headed out to the Pacific because of my interest to serve in an underserved area.  I was for a year at the LBJ Tropical Medical Center in Pago Pago, where because of limited technology, I did ECCE with manual Simcoe I/A.

During the ensuing 5 years, I was at the Commonwealth Health Center on the island of Saipan, in the Mariana Islands.  There I continued with ECCE with manual Simcoe I/A.  At that time, the Blumenthal mini-nuc emerged, and I tried this technique a few times, but wasn't able to master it.

Eventually, I opened my own practice, acquired a phaco machine, and went back to phaco with a superior tunnel, but quickly transitioned to temporal clear cornea with a foldable lens through a 2.75 mm incision and topical anesthesia.

So, that's my background and skill level I brought with me.  I had experience with every step of the procedure except for prolapse of the nucleus into the anterior chamber.  But, it had been years since I have done the other important steps of the procedure.  I hadn't made a scleral tunnel or put in anything other than a foldable IOL for at least 10 years.


Why SICS?

My goal in getting training in SICS was to be able to take several trips a year to underserved areas for volunteer work.  I have done surgical expeditions in the past with SEE International, however, they now require all their surgeons to have SICS training, as that is the primary procedure being used in most eye camps.  So, that's what motivated me to spend two weeks here learning SICS.


Why Arasan?


For some time I tried to set up "in the field" training with SEE International, but it just didn't work out.  Although I am American, I am living in Europe now, and while SEE offers wet-lab training in MSICS in the US once or twice a year, it was too far to travel simply for a weekend of wet-labs.  I did a bit of research, and there are quite a few hands on training programs in India, but most of them are a month or longer in duration.  Arasan, however, provided a 2 week training program in MSICS.  That was doable for me.  I emailed Arasan, and got initial information from Anitha, who manages the doctors who visit.  I wanted to talk to some of the other people who had done the training, and Anitha sent me the emails of all the doctors who had been here over the past year.  Everyone I heard from was generally positive, so I decided it would be a good way to get training.




Cost

At Arasan, the cost of all their training programs are on a "per case" basis, and they guarantee you that number of cases during your time here.  If you want additional cases than the minimum amount, there are additional charges.  The prices fluctuate from year to year, and I think are adjusted somewhat according to country of origin, or level of training.  Information is available through contacting Arasan.  In my situation, a US trained experienced ophthalmologist, seeking MSICS training in 2016, the price for 30 MSICS cases was $2,500, with additional cases at $100 per case.  While I was here, there was also a physician here from Germany who had no surgical experience (apparently in Germany, you complete your residency without any intraocular surgical experience) who was here for two weeks of SICS training, and three weeks of phaco training.  There was also an ophthalmologist here from Jordan who had come for one month of PPV training.  The costs of phaco is higher than for SICS, and the cost of PPV higher still.  They were both very happy with their experience here, and felt it was a very good value, as did I.  The course fee needs to be transferred to Arasan to confirm your participation ahead of your arrival.  It actually goes to Arasan's charitable branch, Save Sight Foundation.  Contact Arasan for the costs for your situation.

This cost does not include lodging, food, airport transport, medical license, etc. It's just for the training.


Medical License and Visa

Anitha will hook you up with an application for a temporary medical license.  Arasan will front the cost, and you'll repay once you arrive.  It does take a few months to get it though, so you need to plan ahead.

There seems to me one official, and one unofficial route to get a visa.  Officially, Anitha told me I had to get a student visa, which required that I go to the Indian Embassy and apply in person. That was a pain, but I did it.  Unofficially, you can do the training on a 30 day tourist visa, which you can apply for online, at much less expense.  One of the doctors while I was here had come in on a tourist visa.  He had put is address as "Arasan Eye Hospital", and when he was coming in, they asked him what kind of tourism he was doing there, but he got through.


What to Bring

You don't need to bring any surgical instruments.  You don't need to bring scrubs or lab coats (even though they tell you to bring two -- I did and never wore them, nor did anyone else).  You don't need to bring formal clothes.  You just need cool "business casual" clothes -- khakis or pressed pants, with polo shirts or short-sleeve button-down shirts.  That's how most of the people in India are dressed, as are all the doctors at the hospital.  The women, of course, wear sari's or kurti's, which you can buy here, but it's not really expected.  Most people in Erode wear sandals.  Because I was walking in the streets, I felt more comfortable wearing casual close-toed shoes.  In the OR, you'll wear slippers that are provided.  No one wears short pants despite the heat.  I brought a couple of pair, and wore them in the apartment.

If you're from a country that uses toilet paper, bring a role.  If you're staying in the guest house, let Anitha know you'll need some and she'll send someone out to get it.  It's not easy to find in the small shops that line the walk to the hospital.

If you have an interesting case to present, bring the presentation with you.  On Wednesday mornings, there is no surgery, but instead is a case conference at 9 AM.  It's nice to participate in, and they welcome a presentation of 10-15 minutes -- either a case, or a topic of interest.  Throw in some slides of your home country or your practice, as it makes it more interesting.  After the conference, everyone has breakfast together on the second floor.


Preparation

Although the surgical experience, and operating room mentorship was excellent, I think Arasan fell a bit short in helping you prepare to get the most out of your training.  I took the initiative to download Aravind Eye Hospital's free SICS book, which is quite good, but it is "the Aravind way", not the Arasan way of doing the surgery.  I also spent a lot of time watching videos online of MSICS to get a sense of the procedure.  However, I think that the program would be strengthened if they recommended some reading themselves, and more importantly, had their own surgical videos online so that you could be better prepared to have a knowledgeable start once you got here.  For a teaching center, it has very few online surgical videos.  Although this was not so critical in my case, I imagine that for those learning phaco or PPV, it would be most useful to be given some recommendation of books to read, as well as surgical videos to review prior to arrival.  The better prepared you are, the more you'll get out of the training.


Duration

Initially I was told it was a 15-day training course, running from a Monday, through a Tuesday.  I thought it was odd, as I would have preferred to not have to stay around for another weekend, but I thought it was a set program.  As it turns out, it's really not.  You can tell them how much time you have, and they will work to get the minimum number of cases to you in that time.  In my case, a special election was called, which meant that there would be no surgery during the final Monday and Tuesday, so the hospital worked to get me the 30 cases within a 12 day period.  Now, the ability to accomplish this may test your abilities.  In my case, I did the 30 cases within six OR days.  My case load per day went like this: 2, 3, 3, 5, 8, 9.  Those last two days were a killer.  So, don't be in a hurry.

It's nice to work out some of these details of how many cases to expect per day, and how many days you can stay, before your arrival.  After I arrived, I had to change my tickets because of the election.  If I had known of the possibility of having a trip of two-weeks duration, I would have planned accordingly, and avoided the extra cost of changing my flight.    Now, as it turns out, I finished my 30 cases on a Tuesday, with a new ticket to leave on the coming Saturday.  Anitha said that I could operate on a "regular" schedule of 3 cases per day for the remainder of the time, but if I wanted more than that, I'd have to pay the additional $100 per case.  I asked for 5 cases per day, and pointed out that I had spent $400 to change my tickets because of the election, and Arasan graciously agreed to give me 5 cases per day for each of my last two OR days, instead of 3, at no extra cost.  By the end of my time here, I had completed 40 SICS cases, which is higher than the average 30 cases.


Arrival

Coimbatore is the nearest major airport, about 100 km away.  Anitha arranged for a driver to pick me up.  It was about a 1.5 hour drive to Erode.  I arrived in Erode in the early afternoon.  We stopped by the hospital to say hello, and to meet the chairman, Dr. Paneer Selvam.  Anitha collected the money I owed for the medical license, and the transportation, as well as the stay in the guest house.  I asked Anitha ahead of time how much it would all come out to, so that I could bring enough cash with me. They accept USD and EUR for this payment.  I asked about where to exchange currency and the hospital's accounting office exchanged some money for me just so that I'd have some cash over the weekend.  The exchange was 5% less than the published rate online, which is pretty typical for currency exchanges.

One thing worth mentioning is that very few places in Erode accept credit cards.  There are a few ATM's available.  But I'd recommend bringing enough cash to last you.


Guest House vs. Hotel

Dining area at the guest house
Before I arrived, one of the doctors that had written me suggested that many choose to move into a hotel after a few days in the hospital's guest house (actually guest apartments, owned by the Chairman).  When I looked online at hotels, it looked like they were a bit far from the hospital, so I decided I would start at the guest apartment and get a lay of the land.  My concern was that the guesthouse would be on the hospital premises, which could feel a bit claustrophobic.  The one I stayed in was a 10-15 minute walk from the hospital.  It is a very basic apartment, clean, but a bit sparse.  Two of us were staying here, each with our own room.  The hospital also provided a housekeeper who came by a couple of times a day to cook lunch and dinner for us and to clean our rooms, and do laundry.  She was a lovely woman, even though we didn't speak one another's languages.  The rooms each had a bed and a bathroom and importantly, an air-conditioner and ceiling fan.  The living-room, dining-room, and kitchen did not have air-conditioning.   It would have been nice to have one in the living room area, just to make it nicer to socialize.  Because we're here at the hottest time of year, my colleague and I would eat together, and then go to our rooms where it was cool.  I recommend that you pay it "as you go" in case you decide to move out to a hotel.  There are two guest apartments, one for men and one for women.  I believe we actually stayed in the one designated for the women, and from what I understand, this is the only one that has a cook.  Clarify that with Anitha when you talk about the details.

The wireless internet at the apartment was pretty good, but would tend to drop out at times.  It was fast enough for most everything, but it was a too choppy to do video Skype.

Bedroom at the guesthouse
The other doctor, who was here for a month, stayed at the Radha Prasad Hotel.  It was quite a nice place, with fairly modern rooms, cable TV, a nice restaurant and rooftop swimming pool, and it only cost $20 per day (welcome to India!).  The hotel is too far from the hospital to walk in the heat and the traffic, so he took rickshaw taxis back and forth a total of four times a day, for about 50 rupees (or 75 cents) a ride.  The meals at the hotel are inexpensive, and they have room service, so you don't have to sit and order for every meal.  Because he was staying for so long, they gave him courtesy English speaking channels on the TV and did his laundry for free.  He had internet, but I'm not sure how good it was.  I think with meals and transportation, his costs were $30 per day.  The hotel is quite a bit nicer than the guest apartment.  You can compare that with the costs they give you for a room in the guest apartment.  There are other hotels around, but I'm not familiar with them.

Living room at the guest house
In the end, I decided to remain at the apartment for a few reasons.  First, I liked being within walking distance of the hospital and not having to deal with taking transport back and forth. Second, I really liked our cook.  She made Indian food for every meal, which I love.  (We each paid 1200 rupees for two weeks worth of meals, which is about $20.)  And it was easy to just walk out into the dining room and eat whatever she had made instead of going through a menu for every meal.  I enjoyed having meals with my colleague who was staying in the apartment.  Our schedules did not always match, but we usually ate together once a day.   I am also the kind of guy that likes being in the neighborhood rather than a hotel, and my needs are pretty basic, so the room in the apartment suited me well.

I am glad I brought earplugs.  It is a bit noisy at night, and though I never sleep with earplugs other than on a plane, I'm glad I had them with me.  They helped block out the noise and I slept soundly.  The Radha Prasad Hotel, though also on a busy street, seemed quiet inside.




The Daily Schedule

You're here to learn surgery.  So, your main time is in the operating room.  Every evening, Anitha will send you a message telling you what time your cases start the next morning.  In terms of required time, you just need to be there for your cases.  That's all.  But there are some other learning opportunities available.

With some of the OR staff
The morning OR time is for residents and people receiving training.  There are two operating rooms, each with up to three surgeries going simultaneously.  Morning surgery starts around 7 AM, and can go until 2 PM.  The hospital closes from 2-4 PM for lunch.  At 4 PM, the attending physicians (or "consultants" as they are called here), do their surgery until 6 PM or later.  If you are here to learn phaco, it's good to attend the afternoon surgery and watch.  There are monitors connected to most of the microscopes.  For SICS, I did not find it very useful, because most of the attendings are doing phaco.  I did attend a few sessions of surgery in the afternoon, but for me, who already is well-versed in phaco, it was more social than surgical.  I did enjoy watching a combined phaco-trab.  I also discovered that the residents do surgery on Saturday mornings.  This isn't time that we had surgery scheduled, and I realized that for those of us learning SICS, sitting in and watching the resident's surgery would be very useful.  Unfortunately, this opportunity wasn't communicated.

In the evening, if you wish, you can also go to the post-op ward.  The "sisters," as the nurses are called, will ask you for your initials and how many cases you did that morning.  They will then round up your patients and bring them for you to examine.  Post ops are not typically seen by the operating surgeon, but rather examined two days post op by the residents in the post op clinic.  I went every day.  It's good feedback to see how your patients look after your surgery, and I would highly recommend doing this.  You don't see the patients pre-op.  You just do the surgery.

There is also the opportunity to attend the outpatient clinics.  I never did.  If you are early in your career, or have a particular interest, I suppose it could be enjoyable.

Apparently, there are also lectures at 4 PM on most days.  I probably would have attended some if I had known about it earlier in my stay.  This is the sort of thing I think could be improved -- being handed a written schedule of the hospital happenings upon arrival, so you can know what opportunities are available.

Outpatient clinic area
So, at the fullest, you could arrive for your surgical cases in the morning at 7 AM, stay on for morning clinics, have a lunch break from 2-4 PM, be back in surgery to observe at 4 PM, see your post ops at 6 PM, and then go home for the evening.

Of the three of us who were here this month, none of us did all of that.  I went for my surgical cases, finishing up by 9-10:30 AM or so on the days when I had 3-5 cases, and finishing at 1-2 PM on the days I had 8-9 cases.  And then I came briefly back to the hospital at 6 PM to see my post ops.  The first two or three days I went to watch surgery at 4 PM.  So, basically, I was in surgery for a part of the morning, and the rest of the entire day was free, except for 15 minutes seeing the post-op patients in the evening.

The doctor that was learning PPV only went to the operating room for his cases, which were for a few hours in the mornings.

And the third doctor that was here to learn SICS and phaco did what I did, although he usually attending the 4 PM OR time to watch phaco, and also attended some clinics.

The OR is open for surgery in the mornings on Monday, Tuesday, Thursday, and Friday.  Nothing on Wednesday or Saturday (except resident cases Saturday mornings).  So, putting this all together, what it means is that you have a lot of free time.  A lot.  If you have an average of 4 cases a day, you'll be done before noon every day, and you may choose to come for 15 minutes in the evening to see post ops.  So, bring something to keep yourself busy.  I was a bit puzzled by this, wishing the surgical schedule was more full, but on the days I did do 8 or 9 cases, I was totally exhausted, and it really was too much.  You do need to start off slowly.  So just have some things to occupy yourself.  It's unusual to have as many as 8 cases a day.  Because my stay was unexpected cut short by the election, they wanted to make sure I got my allotted 30 cases while I was here, so they loaded the cases heavy at the beginning of that week.


Erode


The walk to the hospital.  The road doubles as the sidewalk.
The town is a bustling mid-size Indian city.  If you are from the West, you'll be shocked by the seeming random pattern of the traffic, the absence of sidewalks, the noise.  I loved it all.  But I'm sure some could find it overwhelming.  And the town does not really have much in it, in terms of tourist sites.  Take a look at Trip Advisor to get a sense of things you might want to do.  North of the guesthouse, there is a park, and on the weekend I took a walk through it, and paid 10 rupees to enter some kind of a sanctuary, which was a nice walk.  And I did some shopping for my family.  But other than that, there was not much else to see or do.  So again, bring something to keep yourself occupied.


Extra Touches

The hospital has a few SIMS cards available which you can use while you are here and insert in your phone.  This gives you a local number while you are here, and makes it easier to communicate with the hospital and gives you internet data access at local rates.

The hospital also has a driver, and on a couple of occasions, Anitha arranged for him to take me to some shops to buy souvenirs for my family.  That was nice, and I enjoyed getting to know the driver.


Trip to the Eye Factory

One of the things that Anitha does is to arrange a weekend trip for you to a company that produces IOL's and other surgical equipment and ophthalmic products.  I remember visiting the Alcon headquarters in Fort Worth, Texas many years ago, and I imagined it would be a similar experience.  I didn't go, because I didn't want to spend 5 hours driving there and 5 hours driving back.  But the week before my arrival, one of the other doctors went, and he said that other than the drive, which was painful, it was an enjoyable excursion.  The company puts you up in a nice resort hotel, pays all the expenses for the weekend, and has some executives dine with you.  It's in Pondicherry, which is on the ocean, and supposed to be a nice resort town.



The Training

The training itself was quite good, and I would recommend it.  After all, there are few places you can go, and get hands-on experience, with good instructors, for 2-4 weeks.  The primary instructor for me was Dr. Vinit, who had completed his residency at Arasan just 6 months ago.  The residents get tremendous surgical experience here.  Dr. Vinit was great surgeon, and a helpful teacher.  He did the first case, explaining each step, then let me loose to do the rest.  During the first week, he was always gloved and gowned, and I had him step in quite a few times when I was uncertain, mostly because it is a human being that you're operating on, and I didn't want to risk complications.  So, if a capsulorhexis was going astray and I was having difficulty getting it to recover, or if I noticed a zonular dialysis, or was having difficulty prolapsing the nucleus, I'd have him step in and show me how to do it.  After all, I'm not here to prove anything.  I'm here to learn.

By the end of the first week I felt fairly comfortable with all the steps of the surgery, and had quite a few cases that went comfortably from start to finish.  But I did find that it was a difficult transition to make from phaco, mostly because once you have gotten the hang of it, phaco is so nice.  Easy incision, nice getting the lens out, a tiny incision with a foldable lens, and you're done!  Dr. Vinit told me, as I was sharing my frustration, that SICS is much harder to master than phaco, and takes much longer to learn.  The incision has blood, the tunnel takes time, the incision is large, prolapsing the nucleus can be challenging, it can be awkward getting the lens in, so generally, it can feel frustrating.  It's all part of the process.  He also told me that if it were easy, I wouldn't have to come here to get training.  Good point.  By the end of the second week, I was comfortable and confident, which I did not expect to happen in just two weeks, but it did.  My cases were going smoothly, and I realized, "wow, I've learned how to do this!"


Extra Steps to Improve Your Learning

Besides the instruction, there are a few things you can do yourself to improve your learning experience.

1.  Record and watch your cases.  One thing that one of the doctors I had contacted before I arrived told me was to bring a USB stick (thumb drive, pen drive, flash drive) and ask them to record your cases.  Give them the "pen drive" (which is what they call them here -- if you use one of the other terms, no one will know what your'e talking about), and ask them to put your cases on it.  They will have the pen drive ready for you around 4 PM, and that evening, it can be useful (but painful) to review your cases to look for areas of improvement.

2.  Get recordings of your instructor's cases.  One of the things that I found even more useful was to ask them to put a few cases from your instructor on the pen drive.  Most of them have a case file on the computer, and it can be a great help to study these.  Even though there are lots of videos on YouTube, there is nothing like watching the specific technique of your instructor.  I wish I had been able to do this in advance, and it's one area where Arasan needs to raise its presence -- more online videos.

3.  Use the wet-lab.  I incidentally found out that there is a wet lab available.  I spoke to the Chairman about getting in there, and so he arranged for one of the senior residents to accompany me one evening.  They gave me three cadaver eyes, and I spent 45 minutes or so practicing tunnel incisions.  It was very worthwhile, and I went into surgery the next day, much more confident about that step of the procedure.  The senior resident guided me and made recommendations and answered questions I had very ably.

4.  Ask for fresh blades when you need them.  Blades are reused.  If you are used to using a fresh blade with each case, you'll find this a struggle.  I had a lot of trouble with my scleral tunnels, but when I realized that a big part of it was because of the dullness of the blade, and I asked for a new blade, everything went so much better.  You're paying for the training, so don't worry about the cost of the blades.


Things Arasan Could Do Better

Based upon some of the things mentioned above, there are some things that Arasan could do better.  They are not major, and could probably be fully implemented within 2 weeks.  I think they would significantly improve the experience of those being trained, and also just give a sense that things are well-organized.

1.  Add some formal elements to the training.
  • Recommend texts or videos for candidates to study before arrival.
  • Make recordings of cases available online for candidates to study before arrival.
2.  Improve organizational elements
  • Prepare a printed weekly hospital schedule for candidates so that they know what is going on throughout the hospital each day and what learning opportunities are available to them.
  • Have a formalized system where their cases are automatically recorded and the nurses automatically ask them for a pen-drive and put the cases on it for them.  Right now, if this happens, it is completely at the initiative of the doctor being trained, and the nurses seem a bit unsure about recording, transferring files to the USB, etc.  It's an important teaching tool. Make it a part of the program.
  • Make a folder of video recording, by instructor and case type, available to all candidates upon their arrival.  The nurses should ask each doctor for their USB drive, and transfer the folder onto it for them.
  • Make candidates aware of the free time before they arrive for their training and encourage them to come prepared with something to keep them occupied.
3.  Generally, I think if Arasan thought of it as a "course" instead of simply "surgical training", it would help them develop the program.  A "course" implies formal organizational elements, which currently are a bit lacking.  It is currently mentorship in the operating room.  Having the organizational elements above, and perhaps adding time where the instructor would review your surgical recordings with you, or go over the instructor's surgical recordings would add a didactic element that could greatly improve the teaching.


A Great Experience, and Solid Training

In my two weeks at Arasan, I completed 40 cases.  After the last day of surgery (today), I felt like I had mastered the surgery.  I'm sure there will still be a lot to learn in the next 100 cases.  I would definitely recommend the training at Arasan.  Both my colleagues felt the same.  The one who got phaco training hopes to come back in a few months, after having done some cases in his home country.  He felt the same as I did -- the instructors were exceptional, and the volume was great.  My colleague who received PPV training spoke very highly of it.  He now feels comfortable doing basic PPVs -- enough to clear out a vitreous hemorrhage, or to removed a dropped nucleus/IOL, and to fix retinal detachments without PVR.  He felt it was very worthwhile, and relatively inexpensive.

It was a great experience.  There are a few things Arasan could to do make the experience better and smoother, but the key elements are here:  the quality of the instruction and the volume of the cases.

Info about Arasan can be found on their website, and on their Facebook page.

Our trainer, Dr. Vinit, in the center.





Tuesday, May 21, 2013

Diabetic Eye Disease - My New Book, Website and Blog


It's finally happening.  I'm two days away from the launch of my new book, Diabetic Eye Disease - Don't Go Blind From Diabetes. 

I have set up a new blog and website, Diabetic Eye Expertdedicated to the topic, and will be offering online courses and webinars through the site.

Take a look, and make sure to sign up for a list of courses!

Sunday, October 14, 2012

Free Course Through Stanford

This week I wrote my column in the Saipan Tribune on Tina Seelig's "A Crash Course on Creativity," which is being offered free, online, starting October 17.  I think that many problems we face as a society have to do with problems in thinking (the other set of problems have to do with problems with morality, but that's another column).  Chances are that you, your family, your community, also face challenges, and creative thinking is at the foundation of working through these issues.

Here is my column:


Free class through Stanford

David Khorram, MD
We face a lot of problems in the Commonwealth. Heck, we face a lot of problems in the world. But of course, we feel our own problems more acutely, and since 1997 when the Asian currencies were devalued, it seems we started on a downward skid that we've been unable to recover from. Economically, things have gone from bad to worse, and a whole host of non-economic woes currently strike at the morale of the community. It seems like everyone is just shaking their head, a bit bewildered by it all, and not sure how to pull out of any of it.

In my mind, there are a few things that need to happen. First, we need to stop relying upon a limited number of people who fill our institutions to solve our problems. There is an unlimited reservoir of problem-solving ability within our neighborhoods, and ultimately, we need to take ownership of the challenges we face, and set out, in families and neighborhoods, to put our minds together to make things better.

This may sound airy-fairy. You know, “let's all work together, and the world will be a better place.” It sounds like fluff. But it's not meant as such. The idea of taking ownership is centered on the idea of removing ourselves from a role of passive recipients to active protagonists. As I perceive it, the predominant perspective of the problem is that “if the government would just get its act together, everything would be fixed.”

There is legitimacy in the desire to improve efficiency and eliminate corruption in our institutions. But we need to frame our problems differently. If, for example, healthcare institutions are not working as I wish they would, what can I do to improve healthcare (or the need for healthcare) in my family, in my neighborhood? The solutions I come up with are heavily influenced by how I frame the problem and the questions I ask. We need to learn to ask new questions, to think differently, which essentially means, to think creatively.

Part of our “stuckness” has to do with limitations in our thinking. I feel it myself, because, well, I don't have any concrete answers, other than the need to think differently. How do we do this? How can we think more creatively?

Well, as it turns out, creative thinking can be learned. I've been stunned to find that Stanford University offers a five-week “Crash Course on Creativity.” It's available online and it's free. It requires minimal time-between one to five hours a week. The course is taught by Tina Seelig, the executive director of the Stanford Technology Ventures Program. I've listened to a few of the lectures, and it's all about learning to think about problems creatively. The course starts next week, Oct. 17.

Over 24,000 people from around the world have enrolled. Wouldn't it be great if another 20,000 people signed up and they were all from the CNMI? If nothing else, this kind of participation would shift the conversations in our community, as we learn to think about the problems we face, and become proactive agents of change as individuals, as institutions, as a community.

If we all take it upon ourselves to dedicate the next five weeks to learning to think more creatively, then there is a greater possibility that we can gain insights that will help resurrect our community. As long as our thinking remains unchanged, our slow slide continues.

All you need to participate is an Internet connection. “A Crash Course on Creativity” is an amazing opportunity to augment our most important resource-ourselves. Sign up at venture-lab.org/creativity. If you want to just casually watch a few of the lectures, visit my blog, www.MarianasEye.blogspot.com, where I have posted links.
****

David Khorram, MD, is the medical director of Marianas Eye Institute. He is listed in “Guide to America's Top Ophthalmologists.” He is the author of the book, World Peace, a Blind Wife, and Gecko Tails, which is available through Amazon.

Sunday, August 7, 2011

Guamology Interview for World Peace, a Blind Wife, and Gecko Tails

I was interviewed about my book back in 2009 by Kel Muna, a film-maker, and host of the Guamology.com website. Since then, Guamaology has gone off-line, as Kel has become busy planning the Guam International Film Festival. I enjoyed the interview, and thought I'd post it here since Guamology is no longer around.

World Peace, A Blind Wife and Gecko Tails. It's such a great title. How did you come up with it? Did you have any alternate titles before settling on your final choice?

As I was having friends review the book, I'd ask them, "What is this book about?" and the typical answer was that because the pieces covered a potpourri of subjects, the title would have to be reflective of that. I also wanted the title to be a bit intriguing and memorable. Someone suggested that many of the pieces were about world peace, so that became the opening of the title. The blind wife and gecko tails are references to specific pieces in the book. I also wanted to give reference to our tropical location, and that's why I chose "Gecko Tails" as part of the title. My first thought for a title was simply, "Thoughts from an Island".

How does it feel to know that Blind Wife is required reading for sociology students at the University of Guam, where before Blind Wife it had been Mitch Albom's "Tuesdays With Morrie"?

Honestly, I'm a bit stunned. I'm always surprised when someone tells me that something I've written is meaningful to them. I receive the reflection papers that the students write after reading the book, and it's both rewarding and humbling to know that something I've written has in some way touched someone's life. "Tuesdays with Morrie" is such a powerful book. I can't really get my head around the fact that Blind Wife has displaced it from the reading list.

I understand that Blind Wife is a compilation of all of your most popular columns from the Saipan Tribune. When and how did you come to write for the paper?

I started writing for the Tribune as a columnist in 2004. I had wanted to be more disciplined in my writing, and I felt like having a weekly deadline would help. I also am a curious person by nature, and like to pull ideas from various places, so the column provided me a place to share the things I was learning or thinking about.

When did you get the idea and interest of turning your columns into a book? How long did the process take to put the book together?

The book came about as a result of panic. About a year before it was published, I decided to take more time off from work and write a book I had been thinking about for some time. I had given a series of talks on the subject of establishing unity in communities. People told me that I should turn that into a book -- "7 Habits of Unity" or something like that. So I took time off to write this book, but really didn't have a clear idea of where I was going with it -- the tone, the audience, the purpose. And because of this uncertainty I began to have all kinds of personal doubts and misgivings while trying to write it. I spent a lot of time just staring into past my computer screen into space. After nine months, I realized that the year was coming to a close, and I had nothing to show for it, and that I'd feel like a total loser if the year ended and I hadn't published a book. So, I realized I could pull together my columns, which were already written and which had been well-received in the community, and publish them. So this book came about because I wimped out at writing the other one.

Your writing style is very easy to relate to as well as reflective. Did you have a formal education in writing?

I got the same training that we all get by virtue of going to school. I didn't take any special writing courses or workshops. But I did have some terrific teachers who taught me the value of re-writing, and the need to read your own writing out load to make sure it makes sense and that it flows. One of my comparative religion professors had a journalism degree, and he emphasized the need to write clearly for a broad audience, even in a term paper. So, I think that's where the conversational tone of my writing comes from. I also believe in being authentic. Even though at times I write about some lofty principles (like being truthful 100% of the time, or not dwelling on the faults of others, or eating well and exercising daily) I know it's difficult, because I fail with the same struggles. I try to make sure I'm conveying that I know I'm on the same human level as my reader.

How did you decide on the number of entries to include in the book? Did an editor choose for you?

I wanted to have about 50 pieces, just because it was a nice round number. I went with 52, because that's the number of weeks in a year, so it's like a year of columns.

Your writing style and reflection of topics are uplifting and the overall tone reminds me of one of my inspirations, Seth Godin, a blogger who totally thinks outside the box. What is your source for inspiration when it comes to writing your entries?

I've never really thought about this before. I think my writing is just a reflection of me, my thoughts, my surroundings and my responses to them. So, in some way, the answer to the question of what inspires my writing is the same as what inspires my life. The biggest sense of inspiration for me is a conviction that the world is moving inexorably toward a fully integrated global society, and that the social structures of old are crumbling, making way for new paradigms, and ultimately for a spiritually rooted civilization. That's what I see when I see the current economic collapse -- the collapse of a system that was not based on sound spiritual principles, and so, it's collapse provides the opportunity for a new, more holistic one, to emerge. The source of this mindset and this perspective -- this overall optimism -- is my exposure the the writings of the Baha'i Faith. Check them out. They are revolutionary both in terms of social organization and human relations, and in terms of the individuals relationship to his or her own existence. www.bahai.org.

Do you get writer's block? If so, what do you do to get over it?

I do have difficulty writing at times, but I don't like to call it "writer's block" because that phrase formalizes the simple fact that at times, everything is difficult. It turns it into a monster. I mean, there are some days I don't want to go to work, but I don't call it "worker's block". That's just an excuse to stay home. "Sorry, can't come in today. I've got worker's block." The best way to get over difficulty writing is to write. It's that simple. As one writer has succinctly phrased the remedy, "ass to chair".

If you had to choose only one favorite entry from your book which one would it be and why?

That's a little like being asked, "of all your children, which is your favorite?" Because the pieces are so diverse, can I pick a favorite from a few categories? Of the serious pieces, my favorite is "Thoughts of a Father" which is what I wrote down while awaiting a diagnosis of cancer in my six-year old son. It was a very personal piece and a very raw reflection of the horrors and doubts of such an experience. Of the humorous pieces, the one that is my, and most people's favorite is "The Relationship Between Moral Health and a Blind Wife," which depicts a Saipan scene of the pitfalls of multicultural communication. Of the medical stories, I like "Sweet Sight" which depicts the drama of a blind man regaining his sight.

Tell us about your writing process. How do you find the time to write with a busy schedule/family life?

Most of the time, I'll write about something that has been on my mind for a while. It takes time for ideas to percolate. I start the writing process inside my head. I have a loose idea of what I want to say, but it really evolves as I'm writing. The act of writing is a sort of unveiling. I'm not sure at the start how it will turn out. The interaction between the writer and the page determines the end result. The page is an active participant, molding the writer's words as they emerge. At least that's how it happens for me. When do I find the time to write? When everyone is asleep. I also write on Thursday mornings. It's my operating room day, and in the 20 or so minutes between surgical cases, I'll pause and write.

You are a very respected ophthalmologist. I'm sure you could have your choice to practice anywhere in the world, so why Saipan?

Are you kidding? Because Saipan is the greatest place in the world! I'm living on a beautiful tropical island, serving people who need and appreciate my services. I live in a community that values human relationships, where my kids are growing up without fear. What more could a person want? One of my professional goals was to work in an under-served area, which is why I left the US after I completed my training. Sometimes I think back on the life I could have had -- working in an academic medical center, teaching, publishing scientific papers -- and all the prestige that comes from that. It can be seductive, but I truly believe that I'm in the setting that gives me happiness, which is much more important, ultimately than prestige.

How big of a role does Saipan play in your writing? 
Big.


How has your experience growing up as an Iranian boy in Kentucky contributed to your unique views on life? 


I think more than anything else (and I think this is common among many immigrants), it gave me the perspective of an outsider -- of someone who had to work to fit in, to be accepted. Immigrants were rare in Appalachia when we moved there in the 60's. People didn't know how to categorize us. It was still a time of racial tension, and here was this brown family -- neither black nor white, with strange accents, strange foods, strange religion, strange names, strange strange strange. I carried that sense or having to work to just fit in around with me through my 20's. But once I left the United States, I lost that sense of being an outsider. I think the ethnic diversity of Saipan, where there is no clear majority, is unifying. People are used to people of various colors, with funny names. Here, I'm no more a stranger than anyone else, and ultimately, I imagine many parts of the world will be like Saipan -- a true mix of cultures and peoples. Growing up in rural Kentucky also gave me a sense of appreciation for small towns and tight communities, which is one of the reasons Saipan resonates with me.

What future projects of yours can we look forward to?

I'm not sure. I've been on pause in terms of writing for almost a year. I'm trying to create more space and quite time in my life, and I'm very careful about the things I undertake. I'm contemplating writing some columns again, but not with the same weekly frenzy as before. I'd also like to get back to the "7 Habits of Unity" book, but I'm in no hurry.

Is there anything else you'd like to add?

This is my first interview by a famous film-maker!

Finally,
Our version of James Lipton’s/Bernard Pivo Questions (one word, or short answers please):
What does the Chamorro culture mean to you?
Search

Who’s your favorite local artist?
Greg Elliott

Do you speak Chamorro?
Some

As a person, what turns you on?
Contentment

As a person, what turns you off?
Poverty

What’s your favorite curse word?
Booger (my kids might read this).

What sound or noise do you love?
Laughter

What sound or noise do you hate?
The sound of surgical scissors removing an eye.

What profession other than your own would you like to attempt?
Stand-up comic

What profession would you not like to attempt?
Hitman -- boss is too demanding.

If heaven exists, what would you like to hear God say when you arrive at the pearly gates?
Welcome!

Sunday, November 8, 2009

The Retina Blog

I've got a new blog, over at The Retina Blog. It contains "clinical pearls for retina specialists, fellows, residents and others interested in advances in the field of retina." At least 50% of my practice is dedicated to retinal disease. The field is evolving very rapidly, mostly due to the use of various biological modulators that we inject into the eye. As I read articles and studies that are important to the clinical practice of retinal disease, I summarize them and place them on the blog, mostly as a source of future reference for myself.

Sunday, October 25, 2009

Risk of stroke with Lucentis vs. Avastin

In the February 2009 issue of Ophthalmology, a meta-analysis was reported in a letter to the editor pointing out some risks associated with intravitreal injection of ranibizumab (Lucentis). The letter looked at pooled data from the MARINA, ANCHOR and FOCUS studies which were done to determine effectiveness and adverse effects of Lucentis. The authors of the letter point out that when pooling all the data, the ranibizumab group had a 2.2% incidence of stroke, whereas the control group had a 0.7% incidence of stroke. They conclude that the risk of stroke rises as a result of ranibizumab treatment. When they look at the incidence of myocaridal infarction (MI), the ranibizumab group had a 1.9% incidence whereas the control group had a 3.0% incidence. They did not "conclude" that intravitreal injection was protective for MI, but the incidence is lower in the group receiving the drug vs. the control group.

Since the letter was published, there has been some discussion regarding the implications of this meta-analysis for those of us using Avastin. At the current time the feeling is that this data cannot be extrapolated to Avastin, in part because Avastin is a larger molecule (the entire globulin, vs. the immune arms as with ranibizumab). This molecular characteristic is felt to result in less egress of Avastin into the systemic circulation, and it is to this characteristic that the longer-acting effect of Avastin has been attributed. There is currently an NIH sponsored head-to-head clinical trial comparing Lucentis and Avastin underway. The results are due in 2012. The study is ongoing, and the fact that it has not been stopped is some solace to those of us who prefer Avastin that the study has not to date shown that Avastin is either hugely inferior or has significantly higher side-effects that Lucentis.