Ophthalmologist & Retina Specialist, Carmen Puliafito, M.D.

Hi, it's Doctor Robert Seikard. Welcome to episode 16 of Doctor Podcast. And today I'm really pleased to have as one of my guests a giant in both ophthalmology and medical education. Doctor Carmen Puliofito. Dr. Puliofito and his inventor colleagues were responsible for creating an incredibly important new technology in in the early 1990s called Oct, or optical Coherence Tomography. If you've had an eye exam in the last 10 or 15 years, most likely you have been imaged by this technology called OCTOCT has imaged approximately 30 million people over the years.

It's helped us to diagnose diseases of the eye and the retina and optic nerve in a very early phase and has literally saved the vision of millions of people. So, Carmen, thanks very much for coming today. I really appreciate your taking the time to do this. I know you got your start at Harvard and MIT up in the Boston area. Can you tell us about that, how you got started and how you got there? Well, I grew up in Buffalo, NY Oh OK. And I spent the 1st 21 years of my academic career at Harvard. I was there as an undergraduate, as a medical student and as a resident.

When I was a resident I was interested in going into academic ophthalmology, and when I was a senior resident I was searching for a topic to study and to be an expert in. And I went to the American Academy of Ophthalmology meeting in 1981, and there were rumors of a great laser system for cutting membranes in the eye, the ND YAG laser, which was not shown at the Academy and was barely shown in the United States. And I decided to become an expert in lasers. So that's how you got started and eventually you and and your colleagues up at Harvard and MIT came up with this Oct, optical coherence tomography.

Can you tell us about that, how that happened? Well, the strategy that I had was to to collaborate with a basic scientist at MIT, and this is a tremendous resource. And I went to MIT and went to physicists and asked them, are you, you went, would you be willing to work with me on lasers in the eye? And one of them, Eric Hippen, a senior professor, said, I've got a graduate student who might be interested in doing this, Jim Fujimoto. And Jim and I began A collaboration that it has lasted 30 years.

And what he brought to the table was an extraordinary expertise in optics, optoelectronics, and he came to understand the clinical problems that we were dealing with in ophthalmology. And together we were able to develop this technology Oct. Which allows us to image the retina in the back of the eye, the optic nerve, with a high degree of magnification and resolution so that we could see disease processes very early on. Right. We can see common diseases like diabetic eye disease, diabetic retinopathy and macular degeneration.

Oct is essential in diagnosing these diseases and coming up with strategies to treat, treat patients. And Oct has now expanded into fields like gynecology, cardiology. It's being used to analyze pathologic specimens. So it's a very powerful tool. Right. The other great thing about Oct just for the audience is there's no X-rays or radiation involved in Oct imaging, unlike CAT scans and X-rays. So it's very safe that there's no risk to Oct imaging. It's low level light. Right. The way I explain it to patients sometimes is they're more familiar with ultrasound, which is using sound waves to basically analyze tissues.

This uses light waves and by doing that it allows us to image things with very high magnification and high resolution. Yes, and usually we're using invisible light to do this. Right, wavelengths that we can't really see. Yes. Pretty amazing, because when I was a resident and in training we used to look at the retina with an ophthalmoscope and it would give us a a pretty reasonable view, but we couldn't see things down to a microscopic level. And now with Oct, it's almost like looking at pathology specimens in a laboratory under a microscope with 100 power magnification.

So it's really pretty incredible now after your your Oct career, you went on to work at the New England Medical Center and Tufts and you were chairman of the board there I believe and also the head of the ophthalmology department. Can you tell us how that evolved? Well, I was recruited from Harvard to go to Tufts, which had an extremely small ophthalmology department with only three or four faculty members. And my mission was to create a new eye institute, and I called it the New England Eye Center.

And Boston is a very competitive medical town. And we created a major institution with 30 faculty members and a substantial research program, which continues on to this day. And I spent 10 years there running the eye center. Right where the people are Harvard annoyed with you that you went across town and and were competing with them? Yes, I mean there's there's a lot of institutional rivalry in Boston. Right. But still you managed to create this incredible department there and then you said you were there for about 10 years, yes?

Yes, I was Chairman of the Board of the the Medical Board at New England Medical Center, which is now called Tufts Medical Center and I was Chairman during a period of time of great stress. It was in the mid 1990s and the Mass General and Brigham, the two largest academic medical centers combined into one had tremendous market power and we lost our contract with a major HMO then known as Pilgrim Healthcare. And so the New England Medical Center had real financial problems and we were on the verge of selling ourselves to Rick Scott and Health, HCA, Columbia HCA.

And interestingly, I had a patient who Bruce Selya who is a federal judge and chairman of the board of an integrated healthcare system in Rhode Island, Lifespan, which had Rhode Island Hospital in Miriam Hospital and was a major force there and got him interested and partnering with New England Medical Center. So New England Medical Center was essentially rescued from becoming a for profit hospital through a merger with Lifespan, and I helped orchestrate that. Wow, that that's an amazing accomplishment.

So, but you didn't stay there beyond the the 10 years you then moved on to the Bascom Palmer Eye Institute and University of Miami, right? And in Florida, why'd you do that if if you were being very successful at Tufts and creating this major eye institute? Well, I was. One of the things that's been a common thread in my career is I've been interested in building institutions and helping institutions that needed transitioning to a higher level of performance. And Bascom Palmer is one of the great ophthalmologic institutions in the world.

But that time it was ranked #2 at U.S. news and World Report, but it had some organizational and leadership issues. So I looked at this as and and there was a hunger for change and building and I thought it would be an attractive place to go for that. Sounds like you like challenges. I like academic program building. All right. Tell us what you did at at Baskin Palmer, how you developed that into the number one ophthalmology program in the entire USAI think it's been that way for about 15. Years now?

Yeah, it's been that way since I was there. I've spent three years there, and we were eventually ranked #1 after three years, and it's remained #1 until this time. What did I do? I encouraged the spirit of innovation. At Bascom Palmer. We were the first to use Avastin, which is, as you know, a very powerful drug for the treatment of macular degeneration. Right. Which is also diagnosed, by the way, with the Oct machine. Prior to Oct, we really couldn't visualize the macular degeneration, yeah. Yeah.

And and Bascom Palmer had had was a tremendous Center for innovation because it was the place where Vitrectomy was invented and we're fluorescing angiography of what macular degeneration was, pioneered by Doctor Donald Gas. But it had let itself slip. It didn't have an Oct when I got there, I had to bring my Oct with me on. The plane. On the plane and so creating a a culture of innovation and then recruiting a whole group of new faculty members and expanding the geographic reach of of Bascom Palmer.

We were located a single location in Miami in downtown Miami and I built centers in Palm Beach in Broward County which is Fort Lauderdale plantation and Naples on the West Coast of Florida. So this expanded the accessibility of of Bascom Palmer services. And I think what happens with a lot of academic institutions, particularly in the past was they became very insular and we're waiting for patients to come to them, right. But but transportation is more of an impediment to getting medical care than many physicians recognize.

So you basically expanded the institute so that it had more reach, so patients not living right near Miami were able to get the same high quality healthcare eye care. Yeah, I mean, I recruited a generation of clinicians that are still there today and also built the scientific base, increase the number of NIH grants, greatly got a core grant from the National Eye Institute. So I was there for about 7 years and left Bascom Palmer in in great shape and continue to do very well. Right. So the the people at Harvard and mass sign here were probably happy that you left town, but what about the the people at Tufts?

Were they upset that that you left? Well, I think change is inevitable, and I think people understand change. I've liked every place I've been and I've regretted leaving them, regretted leaving places. But I was succeeded by Doctor J Duker, who was chairman for 20 years and did a fantastic job right. He was one of my recruits. Oh, up at Tufts, right? Is he still there or or there's? He's moved on to executive position and industry with High Point Pharmaceuticals. I see, right. And you also expanded the research that's done at Baskin Palmer, right?

Yes, yes, we recruited probably 10 scientists. So you got a lot of grants you mentioned from the NIH and and so on. And once you created that incredible eye institute which has been number one for for many, many years, you then decided to to move on to California and you became the Dean of the Keck Medical School there at the University of Southern California. Can you tell us why you did that and what you wanted to accomplish there? The the medical school at USC had received $110 million grant from the Keck Foundation about four years before I arrived, and they were poised to grow.

And they were looking for new leadership to provide new direction and to provide a reincarnation of the medical school, so to speak. Right. And the opportunity was considerable and and I decided to take a chance and do it. All right. So tell us about the some of the major accomplishments while you were there? Well, one of the things that I'm I'm happiest about and proudest about in my career is, is that I've been able to recruit wonderful people to every institution I was at and at. At USC, I was able to recruit the leaders of about 10 clinical departments and the head of our Stem cell Institute, head of our Neurogenetics Institute.

The top three research scientists at USC, Paul Thompson, Arthur Toga and Andy McMahon, are three people that I recruited. We raised almost a billion dollars for programs. Billion. A billion, $1 billion. Yes, we got another 220 million from the Keck Foundation. And so it was an opportunity to build and I was there for about 9-8 and a half, nine years. Wow, that's that's an incredible accomplishment. Now, did you also practice ophthalmology and and see patients while you were Dean? I did. I did it.

Yes. I did it 2 * a month. OK. And your specialty is in the area of retina? Yes, I'm a retina specialist, so had an interest in macular degeneration, diabetic retinopathy in particular. Right. And Oct imaging, right, And Oct imaging has evolved. You mentioned that it's now used in other specialties, especially cardiology, OBGYN and so on in the last few years. There's something called Octa or Oct angiography that's in basically evolved from what you started. Can you tell us a little bit about that and what the significance of that is?

Well, one of the things with the first generation of Oct, we could get optical sections. It's really made an optical biopsy of the retina and the retina has about 10 layers. So it's a multi layered structure. So we can get great pictures with Oct angiography and angiography means measuring blood flow, angio meaning vessel. We're able to look at blood flow in the retina and blood flow in the retina is abnormal in diabetic retinopathy and macular degeneration. So this is changed proved to be a very powerful tool, and I did some of the earliest work with Oct angiography.

Right. Part of that you'd have to inject the fluorescein injection in into a patient's arm and then watch this fluorescein die go through the blood vessels. So this is a less invasive way to visualize the blood vessel. So in in the retina and other layers of the eye that that's pretty amazing after you left that position, you've now been involved in in several research product projects and several companies and educational companies as well. Can you tell us what you've been doing since then and consulting?

Yes. I've done a lot of consulting, looking, worked with industry looking on how to translate technologies in their application into the clinic. And that was an important part of Oct because one of the things we did with Oct is we created a startup called Advanced Ophthalmic Devices. And we, we created a commercial entity to build OCT's and to develop it, which we eventually sold to Carl Zeiss Meditech in Germany. And so I continued to consult with drug companies about optimal ways of using drugs for treating diseases like macular degeneration, and I did educational consulting about running educational programs for doctors.

Right. We spoke earlier, you mentioned you. You also have your own podcast, I believe. Tell us about that. I have a podcast called Retina Synthesis and it is directed toward Retina Specialist. They're about 3000 retina specialists in the United States. We publish weekly and we look at new drugs for treating retinal problems. And you might think that's a small area, but there are literally hundreds of drugs being studied, being considered for treatment of diseases like macular degeneration and diabetic retinopathy.

And the reason why that is, is that the number of patients with diabetic retinopathy is expanding rapidly because diabetes is a global epidemic, right. And macular degeneration occurs typically in patients in their mid 70s and 80s and 90s, and that is the most rapidly growing part of the population. So there's tremendous need for better strategies for treating these disorders. So there's all kinds of interesting basic scientist work that goes all the way from gene therapy to specialized drugs that last longer in the eye.

And so we bring experts, thought experts together every week and we interview them and get this information out to the retina community. Right. It's difficult to get a new drug approved. You have to do a lot of basic science research and then do clinical trials which take years and hundreds of millions of dollars and then get FDA approval. So you're you're working with some of these people to try to get new and better drugs? Yes. I mean for instance gene therapy has been studied for macular, wet macular degeneration probably for about the last five years.

And right now there's a pivotal trial looking at that and that's probably, you know we're probably three to five years away before that reaching clinical utilization. But the field is never going to end. What we see now is a horizon that's filled with opportunities to improve the care of patients with vision problems. I mean it's it's it's an exciting time to be working in vision, research and bringing products to market, bringing products so that the, the practicing Dr. and patients have access to them, right.

You mentioned gene therapy. Are there any trials of using the mRNA type of vaccine technology to help with the retina problems and other eye problems? There's an mRNA. There's there's no vaccine work that I'm aware of with retina, but there are scientific approaches using MRMRNA for treating macular degeneration. What about using adenovirus variants to inject genes into the retina for very genetic diseases? Very common, very common. All the gene therapies used the adenovirus as the vector for bringing in the new, the new gene and we're getting better.

There's some exciting new technology about this. The eye is the eye is ideal for gene therapy because it it is isolated from an immune response

and every one of the gene therapies has some immune response, but some of the newer gene therapies have a very minimal immune response. So I'm I'm convinced that gene therapy is going to be a major part of ophthalmic therapy within the decade. Yeah, it seems to be that way, especially with the CRISPR technology on top of that, which allows you to edit genes, so. Yes. If you find a genetic defect, you could potentially use an Adenovirus to inject the correct gene or the healthy gene into somebody with a genetic defect.

Yeah, we're right at the beginning of this. Right. Takes time to do that. You also mentioned you're involved in some educational companies and and consulting as well, so that that's very important on this topic. It leads us to discussion of of AII. Ask all my guests about artificial intelligence. What do you think the role of artificial intelligence is in ophthalmology now, and where do you think it's headed in the next few years? Well, I think artificial intelligence is going to be a huge part of ophthalmology.

I think already we do lots of imaging for for diabetes, for macular degeneration and there are going to be algorithms that are gonna be developed and implemented by AI to assess patients and to come up with treatment strategies. That's clear cut. And I think just to bring Oct back into the picture, Oct is an automated examination of the retina. And what you're going to see with a lot of medicine and including ophthalmology is that there's going to be a lot more remote diagnosis, minimally invasive remote diagnosis, so that the the ophthalmologist is really going to be more like a pilot with all kinds of information available, right.

And this will make the examination easier for the patient and more productive. But it's hard to see that AI won't have a tremendous impact. It's not gonna cut the number of ophthalmologists that we need down because we have a a shortage of specialists and in the end you're still going to need a clinician to make the final decisions about what to do. Do you think we'll ever get to a point where a patient comes to an office or a clinic and tells a computer what their problem is? Their chief complaint?

Their vision issue. Their eye issue? The machine then scans the patient's eye, does the exam, comes up with a diagnosis and treatment, and maybe the ophthalmologist is just the one who injects medications or does the surgery. Is is that where it's headed? And will patients accept having a computer as their doctor? I think it will elevate the standard of care and I think it's coming. I think the, the clinicians, you know the doctor patient relationship is still core to medicine, right. And I don't think that's going to go away, but the mechanism by which we evaluate patients and get and make clinical decisions will improve, be better informed.

My my fear sometimes is with all this artificial intelligence and medicine, there's a risk of of it being hacked. Just like we have people who are hacking now and causing all sorts of trouble in finance and other companies, there's possibility of hacking in AI, healthcare. And what happens when that occurs? Hers. Who's responsible? Who does the patient go to if if there's been some hacking and the wrong treatment is prescribed? Or are there problems like that? Well, I think it's definitely a challenge, and I'm not aware that we've gone.

I'm not aware of instances of hacking in artificial intelligence, and of course artificial intelligence right now in medicine is very small. Right. It's still small, but it's it's growing fast. And you know, people like Musk, Elon Musk, are fearful that we, we may get into complications and problems with that and the machines take over. You don't. You don't think that's going to happen? No. So ultimately it will be a good thing. That's good. Now you also have in addition to being a physician and researcher educator, you also have an MBA degree.

When when did you get that and how was that helped you in in your? Career. I got that in my mid 40s while I was Chairman at Tufts and it's it helped me understand management challenges at the at my positions at Miami and and California. Right. So it helped you with the business aspects of medicine and and growing the centers. Do you recommend that doctors get MBAs to to help them? With that, I think it's helpful for the right and if if you're interested, it's useful. Right. And since you're an expert in in healthcare, in many aspects of healthcare in different positions that you've had, we've all heard that the healthcare system is broken from patients and doctors and politicians and administrators and regulators.

What, what's your thinking on that? And and how do you think we can fix a lot of the problems you have? And is it fixable? Are we just such a huge country with so many people that they're always going to be these? Problems. Well, I think there are two sets of problems. One is a public health problem, which is taking care of common diseases, prevention of serious diseases, things like hypertension, obesity, cardiac disease, public health challenges, vaccines, vaccinations. And then the other two issues are access to care and finance.

If you we have a wonderful technologies and treatments in medicine in the United States, but they're not available to everyone and they're and many individuals have a tremendous problem accessing them either because of financial reasons or because lack of being plugged into the system. Right. They're just not aware of what's available, the knowledge and experience information. How do you fix that? That's a huge problem. Many of my patients, for example, have no idea what diabetes is, even though they have it.

They don't know what their A1C blood tests are. They don't check their blood sugars. They take medications but don't go to the doctor for a year or two. How do we fix that kind of a problem? Well, I think we need to have better science, basic science education in the high schools. I mean it's. Got to start early. So, so basic concepts about what constitutes good health and creating some confidence in the public that medicine and science can be helpful rather than coming up. A lot of there are lots of alternative modalities that are not medical or scientifically based that people are interested in, so confidence in medicine as a scientific field needs to be out there.

Right. And it's I don't think it's taught currently in in schools and by the time you're in your 20s or 30s or 40s and start getting these chronic diseases, it's it's a little too late and we're playing catch up and that's why Healthcare is so expensive that's that's a problem. We need access to care, which is a financial issue. Then we need a more more universal access to healthcare. We've done we've we've improved a lot in the last 15 years with access to care, but we need to continue working on it.

Right. Still a lot more to go. So finally, what's your advice to young physicians who are just starting out? And what what would you recommend to make their careers even better in the future and to help society? Well, I think that in terms of medical practice, physicians should understand the economics of medical practice better, what it means to be in a group, what it means to be employed by an HMO, what it means to be employed by a for profit organization. So they understand the incentives that everyone has for their performance.

So I think that's one one thing. They don't teach us that in medical. School. No. And it's a source of It can be a source of unhappiness. When I was Dean at USCI actually had a group of students that I had taken online course in accounting, which was a way of getting them to understand basic financial issues. So understand the sociology and economics of healthcare if you can, and you can take some specialized courses. There are seminars, there are lectures, and if you're truly interested you can get an MBA, but I'm not recommending that for everyone, right?

So that's one thing, I think if you're interested in new technologies and research, and this is mainly for people who are interested in academics, reach out to basic scientists. To engineers. If you've got a good idea, pursue it. It might might do very well for you. OK. And pick a specialty that you love. Right. Then It's not a job. It's something you enjoy doing every day. Well, that's great advice. Really, really good advice. Thanks very much for that. Well, it's been a a pleasure speaking with you today.

Thank you very much for taking the time to come here. It's been a delight to see you and thank you very much. Thank you, Robert. All right. My pleasure.

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