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What Makes a Good Physician?

Study Puts Greater Weight on Personality.

■ For decades, medical school admissions officers have been looking for tests that would more accurately predict the chances of professional success for aspiring physicians. With applications far outnumbering the available slots, it's critical not to waste acceptances on students who will not be good physicians.

A recent article in the Journal of Applied Psychology focuses on a personality test given to 600 Belgian medical students. Researchers followed these individuals for 10 years to determine which personality traits best predicted success as a doctor.

Least successful in their careers were those individuals whose tests showed them to be neurotic and prone to emotional upset. Most successful were those who were open, agreeable and conscientious.

Interestingly, the researchers found that students who were open and extroverted began to blossom in their later years of medical training, when patient interactions became more numerous and classroom time diminished. The authors note that the personality test used in their study has been shown to work across different cultures, ethnicities and backgrounds, which may give it a high predictive value as a standardized assessment of personality.

Medical school admissions officers will still be faced with balancing the results of standardized tests such as the MCAT with the information gleaned from the personality tests. For example, should a medical school accept an individual who scores in the 50th percentile in the MCAT test and in the 95th percentile in conscientious ness over an applicant who scores extremely high in the MCAT but shows stress-prone personality traits?

Moreover, should brilliant individuals whose goal is to pursue a career in research be denied admittance to medical school because they have less-than-sparkling personalities?

Eye MD Leads Polls in US Senate Primary

By Jerry Helzner, Senior Editor

■ Rand Paul, MD, the son of Texas Congressman and former Presidential candidate Ron Paul, is the frontrunner in the polls for the Republican nomination for US Senator representing Kentucky. Dr. Paul, who has received the endorsement of conservative icon Sarah Palin, is matched against Kentucky Secretary of State Trey Grayson in the May 18 primary election.

Both men are vying for the seat of retiring Republican Sen. Jim Bunning.

Dr. Rand Paul first attracted national notice when he campaigned vigorously in behalf of his father's Presidential bid in 2008. At times, as in New Hampshire, Dr. Paul took part in door-to-door grassroots efforts for his father.

Dr. Rand Paul leads the Republican US Senate primary in Kentucky.

Dr. Paul, 47, is a graduate of Baylor University and the Duke University Medical School. He also completed his residency in ophthalmology at Duke. Dr. Paul practices in Bowling Green, Ky., where he performs glaucoma surgery, corneal transplants and refractive procedures. As a member of the Bowling Green Noon Lions Club, Dr. Paul founded the Southern Kentucky Lions Eye Clinic to help provide eye surgery and exams for the poor.

Dr. Paul essentially occupies the ideological conservative wing of the Republican party, where he supports smaller government, balanced budgets and greater civil liberties. He is a believer in a strict interpretation of the Constitution and is founder and chairman of Kentucky Taxpayers United, which advocates lower taxes and actively opposes any tax increases.

Dr. Paul and his wife, Kelley, have three sons.

Slump in Corporate LASIK Continues

■ LCA-Vision, a leading corporate provider of laser vision correction services under the LasikPlus brand, said that the 71 surgery centers it operated last year performed 11,718 procedures in the final three months of 2009, as compared to 19,424 procedures in the same period a year ago. Same-center revenues were down by 33.3% in the latest reporting period.

The weak fourth quarter continues a slump in LCA-Vision's refractive procedure volume. For all of 2009, the company performed 72,776 procedures vs. 115,153 procedures for all of 2008.

Two of its corporate com petitors, TLC Vision and Vision Care Holdings, filed for Chapter 11 bankruptcy protection in recent months.

“We are balancing cash conservation in the current challenging economic environment against our longer-term objective of managing to profitability and growth when the economy improves,” said LCA-Vision Chief Financial Officer Michael J. Celebrezze. “Our combined cash conservation and expense reduction measures last year included closing 12 underperforming vision centers, reducing marketing expense by $18.6 million, reducing our head-count by 19%, and renegotiating our equipment contracts. The payroll and equipment cost reductions resulted in an annual savings of approximately $11 million. We ended 2009 with more than $54 million in cash and investments and currently operate a network of 62 LasikPlus vision centers.”

Chief Operating Officer David L. Thomas commented, “Our decision to reduce fourth-quarter marketing and advertising spending to less than $6 million in an effort to align marketing expenses with perceived consumer demand resulted in less than desired procedure volume. We are increasing marketing and advertising spending in the first quarter of 2010 to $9 million. Consumer marketing is critical to driving procedure volume and, in the past several months, we have conducted an extensive analytical evaluation of all marketing drivers with the objective of taking a more comprehensive data-driven approach to marketing.”

Research Digest

New & Noteworthy Journal Articles

Compiled by Andrew E. Mathis, PhD, Medical Editor

► Not so fast. This August into September, the world's billion-plus Muslims will observe Ramadan, the lunar month of the Islamic year dedicated to daylight fasting. Observant Muslims abstain from all food and water from dawn until dusk, with many Muslims often eating a large predawn meal during that month. A study in the January 2010 issue of Eye reports that such fluid-loading early in the morning can cause intraocular pressure to fluctuate greatly.

A group of ophthalmologists from Selcuk University in Turkey measured IOP at eight in the morning and four in the afternoon in 12 women and 19 men, both during Ramadan and at one month following the Eid ul-Fitr holiday that marks the end of the month. Statistically significant differences were found in IOP at both times, with IOP being higher (P=.005) in the morning and lower (P=.013) in the afternoon. The authors also found that basal and reflex tear secretions were significantly higher in the morning, but no significantly different in the afternoon.

While the authors abstained from making recommendations or drawing firm conclusions from their research, they do link their finding that IOP in their patients drops from above-average levels to below-average levels over an eight-hour period to the effects of dehydration.

► Predicting IOL needs. Two articles that appeared in January 2010 may have an impact on intraocular lens choices by surgeons and patients. The first study, which appeared in Ophthalmology and was adapted from a presentation at the ARVO annual meeting last year in Fort Lauderdale, Fla., studied 206 patients who had undergone bilateral sequential phacoemulsification over a two-year period. The goal was to determine whether postoperative error in predicted refraction in one eye could be used to alter IOL power in the other eye and thus improve vision. The authors found that accounting for 50% of the observed error in the first eye did reduce the error in predicted refraction for the second.

The second study, published in the Journal of Cataract & Refractive Surgery sought to find the optimum amount of spherical aberration in IOLs to maximize visual acuity after photorefractive keratectomy. In this study, 102 eyes in 77 patients at the Cullen Eye Institute at Baylor College of Medicine in Houston, image quality was evaluated at a variety of levels of IOL aberration, and then the data were subjected to statistical regression analysis. While the amount of spherical aberration required to produce the best image quality varied greatly in this study, the authors nevertheless believe that the aberration amount could be predicted based on corneal high-order aberrations.

► Anti-VEGF agent in glaucoma surgery. Among the several interesting articles in the February 2010 issue of Acta Ophthalmologic, which is dedicated to glaucoma, is a Japanese study of the use of bevacizumab (Avastin, Genentech) as a preoperative medication in trabeculectomy for neovascular glaucoma.

Twenty patients were given intravitreal injections of the anti-VEGF agent 10 to 11 days before their surgeries, while 32 patients, who acted as a control group, underwent the surgery without the injection. The surgeons found that patients pre-treated with bevacizumab had decreased rates of postoperative hyphema and increased surgical success rates (95% achieving an IOP of <21 mm Hg).

While bevacizumab has been in use among posterior-segment specialists for a decade, use of the drug in glaucoma is a relatively new development. This study adds to the growing body of data that suggests that bevacizumab can be a useful adjunct for neovascular glaucoma.

► Mountains of evidence. Mountain climbing has been associated with altitude sickness, but is there an inherent risk to vision as well? A group of ophthalmologists in Zürich, Switzerland, sought to answer this question by studying the healthy eyes of 28 men and women who climbed Mount Muztagh Ata in western China.

The patients were randomized into two groups that scaled the upper half of the 7,546-meter mountain (24,757 feet), with one group having a shorter acclimatization time afforded them after reaching 6,265 meters than the other group. Ultrasound pachymetry was performed on all patients at four points in the climb. BCVA and daily pulse oximetry were also measured. Results were reported in the February 2010 issue of Archives of Ophthalmology.

The group with the shorter acclimatization time had a greater central corneal thickness (CCT) over baseline, with a statistically significant increase at 6,265 m. Both groups experienced substantial increase in CCT, with a rapid decrease upon descent. Furthermore, there was a strong correlation between CCT and symptoms of altitude sickness, including cerebral edema. The study may indicate that CCT could be a predictor of cerebral edema among people experiencing altitude sickness.

► Stroke of genius? Doctors in the Netherlands have found that patients who lose vision after suffering a stroke may recover part of the visual field because of a gradual shift in the border of the patients' visual field defects.

The researchers, who reported in the January 2010 issue of the British Journal of Ophthalmology, used a Goldmann perimeter with 11 patients to stimulate the border area of their visual fields. The location of the border was assessed before, during and after the stimulation. They found that the border had moved.

This study is significant in that it may help stroke patients adapt to daily living activities, including reading, which is often compromised in patients who suffer from strokes.

Retina Roundup

Timely and Important Retina News of Interest to All Ophthalmologists

Compiled by Andrew E. Mathis, PhD, Medical Editor

► Trappings of Success. Regeneron Pharmaceuticals and Bayer Healthcare AG have announced interim phase 2 results of the DA VINCI clinical trial of their VEGF Trap-Eye treatment for diabetic macular edema. Reporting on the first 24 weeks of the study, researchers found that patients given intravitreal injections of VEGF Trap-Eye had mean improvements in visual acuity of between 8.5 and 11.4 ETDRS letters, depending on dosing.

In the study, 219 patients were randomized into five study arms: four different dosage groups and a control group receiving only laser therapy (the current standard of care) every 16 weeks as needed. Two of the four dosage groups received monthly doses of either 0.5 or 2 mg monthly. The other two groups both received 2-mg doses, but either at eight-week intervals or on as-needed basis, and they also received a “loading dose” of the drug, which consisted of three 2.0-mg doses.

Besides the impressive improvements in visual acuity, which were more than six ETDRS letters better than improvements seen with laser, the interim data included no serious drug-related side effects. The DA VINCI study will continue for another year before final data are presented.

► Anti-VEGF trial results. While the National Eye Institute continues to carry out the massive CATT clinical trial comparing Genentech's ranibizumab (Lucentis) to bevacizumab (Avastin) in treating wet AMD, studies smaller than the 1,200-patient CATT study have been reporting data. Among the most recent data is a paper published in the February 2010 issue of Ophthalmology reporting the results of a trial conducted by scientists at Southern California Permanente Medical Group. This study measured improvement in visual acuity in 324 patients receiving intravitreal bevacizumab and 128 patients receiving ranibizumab.

The doctors at Kaiser Permanente found the drugs to be equivalent in their ability to effect visual acuity improvement in patients with wet AMD. Roughly a quarter of both groups (22.9% in the bevacizumab group; 25.0% of the ranibizumab group) attained a visual acuity of 20/40 or better. The only significant side effects were two cases of endophthalmitis in each drug group.

Genentech met the results with measured skepticism, noting that the Kaiser Permanente study had no control group and that the drugs were administered unmasked, i.e., with the patients aware what they were receiving. Genentech also noted that the lead researcher concedes that the study lacks sufficient power to draw conclusions regarding safety.

While Genentech maintains that the company does not interfere with how physicians treat their patients, it has stated its clear preference that bevacizumab not be used off-label to treat AMD. (The drug has FDA approval for treating several types of metastatic cancers.) The CATT study will close in a year, with results to be seen in the spring or summer of 2011.

► Speaking of Anti-VEGF… What if cost is a factor in treating a patient with AMD? A team of retinal physicians at the Wilmer Eye Institute of Johns Hopkins University School of Medicine attempted to provide guidance by examining the cost-effectiveness of three treatments for choroidal neovascularization caused by AMD: ranibizumab (Genentech); pegaptanib sodium (Macugen, Eyetech), an inhibitor of VEGF165; and photodynamic therapy (PDT) with verteporfin (Visudyne, Novartis).

The authors of the study, which appeared in the February 2010 issue of Retina, found that the two-year cost of treating a patient with CNV secondary to AMD ranged between $3,100 and $54,100. The least expensive treatment was PDT, which was also more effective than treatment with pegaptanib. Not surprisingly, treatment with ranibizumab was the most expensive treatment studied, but it was also the most effective.

However, the cost of treatment with ranibizumab, the authors found, was above the threshold for cost-effective ($50,000 per quality-adjusted life year) the authors used in the study. While the authors concede that, because data are hard to come by, information on maintenance of improvement of visual acuity in patients treated with ranibizumab might be less over a longer period, they nevertheless suggest that more comparisons between AMD treatments be investigated for their cost-effectiveness, including bevacizumab.

► Sugar and salt. A pair of re searchers at the University of Medicine and Dentistry of New Jersey have found a positive link between diet and worsening of diabetic retinopathy. Writing in the January 2010 issue of Archives of Ophthalmology, Monique S. Roy, MD, and Malvin N. Janal, PhD, state that, in African-American patients with type 1 diabetes, dietary habits including high caloric and sodium intakes are directly correlated to risk factors for progression of diabetic retinopathy to its most severe forms.

The authors studied 469 patients at risk for progression of diabetic retinopathy, administering a food-frequency questionnaire and having the patients undergo dilated retinal examinations, grading of their retinopathy based on fundus photography and testing their blood for hemoglobin levels.

The authors suggest that low caloric and sodium intake levels in African-American patients with type 1 diabetes can have a positive effect on the progression of diabetic retinopathy. Their findings augment the data in an article in the January 2010 issue of Ophthalmology, which reports that better glycemic control (as well as blood pressure monitoring and abstaining from smoking) was correlated with lower rate of visual impairment in patients with type 1 diabetes. OM