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Every Day Matters: How Timely Action Can Save Your Sight · Perspectives: A VLRC Podcast

• 0:01
  NARRATOR: This is Perspectives, a VLRC podcast.
• 0:05
  DR. AHUJA: We are often taking our vision for granted, and until you have a
• 0:09
  problem with your sight, you don't realize just how precious it is.
• 0:12
  [Theme music]
• 0:14
  JENNIFER: Welcome back to Perspectives, a VLRC podcast.
• 0:16
  I'm Jennifer Urosevic, President and CEO of Vision Loss Rehabilitation Canada.
• 0:21
  VLRC has created this series as part of an eight-part collaboration with the
• 0:26
  Vision Health Partners Coalition on the National Strategy for Eye Care.
• 0:30
  Today's episode: When Diagnosis Leads to Treatment.
• 0:33
  We're looking at what happens after someone is diagnosed with a condition that
• 0:38
  needs specialist medical or surgical care.
• 0:40
  My guest today is Dr. Nina Ahuja. She is an ophthalmic surgeon, a clinical
• 0:45
  professor at the Department of Surgery at McMaster University, and President of
• 0:50
  the Canadian Ophthalmological Society. Nina has spent over two decades in the
• 0:54
  operating room and medical education, and she's been the national voice
• 0:58
  advocating to help bring the national strategy to life.
• 1:01
  If you've ever wondered what actually happens once you're referred to a
• 1:06
  specialist, or why timely access to that care matters so much, this conversation
• 1:10
  is for you. Each episode in this series contains the national strategy for eye
• 1:17
  care. Today's conversation is focused on two pillars: equitable access, and
• 1:22
  integration into the health care system. Nina, thanks so much for joining us
• 1:28
  today.
• 1:28
  DR. AHUJA: Thank you, Jennifer, for having me. It's a real privilege to be here,
• 1:32
  and also thank you for creating this wonderful series.
• 1:35
  JENNIFER: No problem. We're really excited to start this conversation.
• 1:41
  You've got such a wealth of experience, from being an ophthalmologist, to being
• 1:46
  President of the Canadian Ophthalmological Society, to being a clinical
• 1:50
  professor, really educating the next generation of ophthalmologists.
• 1:53
  How do these three areas help you and inform each other?
• 1:58
  DR. AHUJA: Well, the advantage of being in clinical practice is you really get
• 2:03
  to see the front line and how things work, how patients present, the systems
• 2:08
  within which we're working, where the limitations are, where the strengths are,
• 2:13
  and where we can make things better. Having the educational background as a
• 2:18
  professor at McMaster has given me a lens over time where I've learned to look
• 2:23
  at the evidence. Where do we need to look at data?
• 2:27
  How do we bring together different perspectives to make sure that we're
• 2:32
  looking at all the factors that need to be included when we're looking at the
• 2:38
  best way to move something forward? When it comes to my role at the Canadian
• 2:44
  Ophthalmological Society as advocacy chair, which is the role I was in prior to
• 2:49
  becoming president, the big advantage there was having that 20,000-foot view of
• 2:54
  the system within which we work, and how things can be moved through a system to
• 3:00
  bring about initiatives, programs and collaborations that can move eye care
• 3:04
  forward collectively with our partners across the vision health spectrum.
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  So bringing those three elements together, frontline experience and exposure,
• 3:12
  together with the academic lens of the evidence-based approach, and then having
• 3:17
  that 20,000-foot view, is really able to build a comprehensive approach, in my
• 3:21
  mind, when we're thinking about some of the challenges and strategies that we
• 3:26
  want to bring forward.
• 3:28
  JENNIFER: Love that. I think that really resonates, and I think that's been the
• 3:33
  success of the advocacy that the Vision Health Partners Coalition has achieved.
• 3:38
  We all bring a piece of the full continuum of health care.
• 3:42
  But we also bring, like myself and like yourself, that clinical frontline
• 3:47
  perspective to the bigger picture, and then being able to look at how we create
• 3:54
  change from a system perspective. So now I just want to dive back into the early
• 4:01
  days. What got you to pursue a career in ophthalmology?
• 4:05
  DR. AHUJA: For me, ever since I was a child, eyes were the first thing that I
• 4:12
  noticed about people. I don't know what it was, but I loved looking at the
• 4:17
  different colours. Some people had smiles in their eyes, and other people just
• 4:22
  looked off into the distance like they were thinking.
• 4:25
  So I always enjoyed that. And then as I was moving through school, I used to
• 4:31
  enjoy science. I loved learning about the senses, and I myself needed glasses
• 4:35
  from the age of about 13. So it became kind of a personal thing.
• 4:40
  I recognized that I couldn't see the blackboard in class, and therefore my
• 4:45
  parents took me to an optometrist. I was prescribed glasses, and that fixed the
• 4:50
  problem. As I moved through school, I continued my interest in science and
• 4:54
  biology, and I was drawn to health care. I enjoy working with people.
• 4:59
  I enjoy helping people. Medicine was a nice blend of science and helping people
• 5:04
  and physiology and all the other things that come with it, so I was very drawn
• 5:10
  to that field. But again, I always had that interest in eyes.
• 5:15
  So at one point, I was very serious about optometry.
• 5:18
  And then I felt that I wanted to do different types of care.
• 5:23
  Optometry was essential. It was extremely interesting.
• 5:25
  It's extremely valuable, of course. But I wasn't sure if I wanted to focus in on
• 5:29
  the field of eyes. And so when I got into medicine, I was certainly drawn right
• 5:34
  back to it. So it became a bit of a full circle moment for me as I went through
• 5:39
  medical school and discovered some of the procedures and innovations that were
• 5:42
  coming out in that field.
• 5:44
  JENNIFER: That's incredible. It's amazing what a young child's dreams turn into.
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  What an incredible career. And then as you moved through your career and chose
• 5:54
  your specialty in ophthalmology, you were really able to expand into some
• 5:59
  leadership opportunities as well. Take me through what drew you to those
• 6:04
  leadership opportunities.
• 6:06
  DR. AHUJA: I was very fortunate. When I started in practice in Hamilton in 2003,
• 6:11
  I had joined a group, and it was affiliated with McMaster University in
• 6:17
  Hamilton. They had not re-established an ophthalmology residency program.
• 6:21
  They used to have one a while back, and then it had stopped.
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  It was discontinued. And people like Dr. John Harvey and others were very
• 6:33
  motivated to bring this training program back to McMaster University.
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  That happened within the first couple of years of my joining the department, and
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  so I was brought in to faculty to help develop the program.
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  I've always wanted to support students, and therefore I took on that role and
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  then progressed through various roles as well.
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  What got me into the leadership space specifically, beyond doing the leadership,
• 7:01
  was when I saw various leaders in health care doing their very best, some
• 7:06
  creating excellent environments where people felt seen and heard, they were
• 7:10
  thriving, they felt connected, and others, unfortunately, despite the best of
• 7:14
  their abilities, creating environments that were very toxic.
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  When I saw that, and saw that there wasn't accountability in many of those
• 7:24
  instances within the system, I became very frustrated, and I thought, I need to
• 7:29
  do something about this. That's where I stepped into the leadership development
• 7:35
  space, and went to various business schools and did various programs to
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  develop an expertise in that, which has since evolved into emotional
• 7:44
  intelligence and rewiring for mental performance, and a whole approach to
• 7:49
  leadership development that isn't tactical specifically.
• 7:52
  It uses those strategies, but it also goes into who we are as people.
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  How do we view the world? How do we interact with it, and how does that impact
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  our leadership? So it was really an evolution that stemmed from observations
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  and experience, both on the side of being a leader and of being led, because
• 8:12
  you're always in those situations. And then seeing an overall perspective of how
• 8:16
  we can make things better, so that people in our organizations, in our education
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  systems, and wherever we are can really thrive in those environments and feel
• 8:25
  uplifted.
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  JENNIFER: That really resonates with me, Nina. What I really like about that is
• 8:30
  that at each step in your career pathway, you witnessed things, then you
• 8:35
  responded to the need. And I know from our experience working together over the
• 8:40
  last few years around the national strategy, that really came out in a lot of
• 8:45
  our work. So I've always appreciated that about the work that you do.
• 8:50
  Thank you for that.
• 8:51
  DR. AHUJA: Well, thank you for that. That means a lot to me.
• 8:54
  JENNIFER: For our listeners who are not familiar with the profession of
• 8:57
  ophthalmology, what does an ophthalmologist's day-to-day look like?
• 9:00
  How much time is in clinic, because you mentioned being in clinic, and how much
• 9:06
  is actually in surgery?
• 9:07
  DR. AHUJA: Well, the day-to-day of an ophthalmologist can be quite varied.
• 9:11
  It depends on where you're located. If you have an office within the community,
• 9:16
  it will look one way. If you're in an academic centre, it will look another way.
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  The academic centres are the universities where we have the training programs,
• 9:26
  where ophthalmologists who are up and coming are learning the skills surgically,
• 9:30
  clinically, diagnostically and procedurally, all the things that we do to
• 9:34
  become specialists. The way that it works is, to become an ophthalmologist, you
• 9:38
  do your undergraduate degree, then your medical school degree, which is four
• 9:43
  years. After earning your MD, you get into a residency training program, and by
• 9:48
  the end of those five years, you become a comprehensive ophthalmologist.
• 9:52
  Many will then go on to do an additional year or two to further subspecialize.
• 9:58
  So if you're based out of one of those centres, your days often start with
• 10:03
  teaching in the mornings, where faculty members are educating fellow faculty
• 10:08
  members, because we're all about continuing education all the time, and
• 10:11
  then of course the medical trainees. Through the day, you'll be spending time
• 10:17
  in clinic, where you're seeing patients, assessing patients, and working with
• 10:20
  the medical trainees, who are the residents.
• 10:22
  So they're ophthalmology residents, going through cases with them, going through
• 10:26
  diagnostics with them, going through the gamut of: What are the medical
• 10:29
  conditions that are impacting this patient's care?
• 10:31
  What are the different perspectives that we need to keep in mind, based on these
• 10:36
  medical conditions, based on the treatments that they've had, based on
• 10:39
  their history? So we go through that. It's a very educational space; that is the
• 10:44
  theme across the academic centres. And the pace is very different depending on
• 10:50
  the clinic and depending on the ophthalmologist, because those centres
• 10:54
  often get the hardest cases, the most complex cases.
• 10:58
  That's where our tertiary care providers are, which means the specialists of the
• 11:04
  specialists are often located at the academic centres.
• 11:07
  Now, in a community base, there are also many specialists of the specialists.
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  We have excellent ophthalmologists in the community as well.
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  We're very fortunate that everyone across the country has passed exams, has gone
• 11:22
  through accredited training for five years, and has passed credentialing exams
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  through the Royal College of Physicians and Surgeons of Canada.
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  We're overseen by regulatory bodies in each province.
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  So the confidence and trust that people can have in ophthalmologists is very
• 11:40
  standardized across the board. In a community, people will be more or less
• 11:44
  focused within a subspecialty, depending on what their interest was as they were
• 11:49
  going through their studies, and also depending on what the need is.
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  So, as an example, if you're in an urban centre, where you've got potentially
• 11:59
  relatively more ophthalmologists, you may have people focusing in on certain
• 12:02
  areas, with a lot of collaboration amongst the ophthalmologists and with our
• 12:07
  optometry partners as well. Whereas if you're in more of a remote or rural area,
• 12:12
  you may have an ophthalmologist who, because there aren't as many
• 12:15
  subspecialists, does the gamut of work across the different specialties, and if
• 12:19
  it gets to a point that's very advanced, then they would send it off to a
• 12:24
  subspecialist in a larger centre, if it's needed.
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  So in those days, you arrive at work, you go through your patient list to see
• 12:32
  who's coming, and patients come through. We work in teams, so we often have
• 12:37
  ophthalmic technicians working with us. Some people have nurses working in the
• 12:40
  office, and other people have our optometry partners working in the office.
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  And depending on what the flow is and how the office or practice has been set
• 12:50
  up, the patient will then go through various steps along the way: an initial
• 12:55
  assessment, some diagnostic testing, and an assessment by the specialist to
• 12:57
  really look at the condition for which they were referred.
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  And then the day just carries on that way, in the same routine, adjusting to the
• 13:06
  needs of the patient who's sitting in front of you.
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  Sometimes there's time for lunch, sometimes there's not.
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  Most often it's a granola bar. That's not everybody, but in my case, it was
• 13:17
  often just a quick bite here and there. It's a pretty intense, steady day, as
• 13:22
  many of our days are, for many people. But it's very fulfilling.
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  What I found most fulfilling about being where I was at is that there was a nice
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  mix of the clinical work with the academic work, and being able to work with
• 13:35
  learners and faculty as well. And I have always enjoyed patient care.
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  My philosophy has been, I treat my patients the way I would want my parents
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  treated. So it's a very fulfilling mix, intellectually, connection-wise,
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  technically, and in overall satisfaction that you're helping people to the best
• 13:53
  of your ability.
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  JENNIFER: I can hear so much passion in your voice as you describe the different
• 13:59
  scenarios. And I resonate back to a program that we have, the Eye Van, that
• 14:04
  travels through Northern Ontario. We couldn't run that program without our
• 14:08
  partners and the ophthalmologists who take a week out of their clinics and
• 14:12
  travel through Northern Ontario on, I always call it a van, but it's really a
• 14:17
  big transport truck. They become that generalist within their specialty, and
• 14:21
  make those connections and those referrals, and provide that treatment in
• 14:24
  some of our most rural areas here in Ontario.
• 14:27
  DR. AHUJA: I love that. One of the things I would like to share is that with
• 14:32
  Vision Loss Rehab Canada, there is such an important role there, and the
• 14:36
  engagement that we have with our partners across the spectrum is so valuable.
• 14:41
  I really appreciate the fact that we have organizations like yours, because when
• 14:46
  there is vision loss, there's still dignity in that, there's still potential
• 14:51
  in that, there's still opportunity in that.
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  And for someone who's acquired vision loss, it's a complete shift in identity,
• 14:59
  in how they view themselves and what their place is in the world.
• 15:04
  So I just wanted to really acknowledge the work that you do, that your
• 15:08
  organization does, because it is truly such a valuable component of the entire
• 15:13
  spectrum of care.
• 15:14
  JENNIFER: Oh, thank you. We appreciate that. And it is about the whole continuum
• 15:18
  of care. Which conditions do you see most in an ophthalmology caseload, or with
• 15:23
  the patients that come to see you?
• 15:25
  DR. AHUJA: It really depends on the nature of an ophthalmologist's practice.
• 15:29
  There's the day-to-day practice that we have in our clinics, and there's the
• 15:34
  on-call service as well, which is for emergency eye care.
• 15:38
  When you're on call, you are working with a hospital, as an example, and cases
• 15:43
  come through the door, whether it be a retinal detachment, or a sudden rise in
• 15:47
  pressure for someone who's got glaucoma, or there's been a car accident and
• 15:51
  someone's had a trauma to the eye. When you're on call, you see all of those
• 15:57
  things, and that's why the broad training and the depth of training become
• 16:03
  really valuable. In the practice itself, it often depends on how someone has
• 16:08
  focused their practice, and again, location.
• 16:10
  As I mentioned before, if you're in a more rural area, you have that
• 16:16
  comprehensive caseload, where you'll see glaucoma, cataracts, retinal disease,
• 16:19
  macular degeneration as an example, diabetic retinopathy as another example.
• 16:23
  Those fill your days. There's quite a lot of variety.
• 16:27
  The eye is a small organ, yet it is very complex, and there are multiple
• 16:32
  conditions that can happen that need attention and treatment.
• 16:35
  If you are focused in a subspecialty, however, if you're, say, a retina
• 16:39
  specialist, an oculoplastic surgeon or a glaucoma specialist, then while you're
• 16:44
  on call, you'll still be covering the gamut of cases, but in your office it will
• 16:50
  focus more on that area. So a retinal person would see more macular
• 16:55
  degeneration, diabetic retinopathy, some of the inherited diseases.
• 16:58
  All the things that affect the retina will be seen by a retina specialist.
• 17:03
  Similarly, cornea specialists, glaucoma specialists, and oculoplastics, those of
• 17:09
  us who deal with the eyelid, the tissues around the eye, and the things in the
• 17:14
  orbit, the socket where the eyeball sits.
• 17:17
  That's another area of specialty. So you've got your comprehensive aspect,
• 17:20
  which is covered while you're on call, and then depending on your practice,
• 17:24
  you're either comprehensive or more targeted to one or the other.
• 17:28
  JENNIFER: That makes a lot of sense. So now, what would somebody expect in an
• 17:35
  appointment if they were seeing an ophthalmologist for one of those eye
• 17:38
  conditions? They're probably nervous because they have a diagnosis.
• 17:45
  What are those next steps, and what advice do you have for somebody coming in,
• 17:50
  maybe for the first time?
• 17:52
  DR. AHUJA: The first thing I would say to someone coming in for the first time
• 17:57
  is, you can trust the process and the education and training that your
• 18:01
  specialist has. Because we're medical doctors and specialists, we get referrals
• 18:06
  from optometrists, who are our primary eye care partners, family doctors, who
• 18:10
  are our primary health partners for general health, and some nurse
• 18:14
  practitioners as well. So we get information from the person who's
• 18:19
  referring to us. We review everything that's been provided and understand what
• 18:23
  you're seeing us for. And then when you're being assessed, we're targeting our
• 18:29
  questions, examinations and testing to make sure that we are addressing the
• 18:34
  issue that you've been brought to us for.
• 18:37
  At that point, there are a number of people in the team, as I was saying.
• 18:42
  So depending on what stage you are at in the patient flow through the office,
• 18:46
  you may see the receptionist first, to welcome you and check you in.
• 18:50
  Then you may see the technician, and then you'll see myself as the
• 18:53
  ophthalmologist, in my office as an example.
• 18:55
  From there, we'll talk about your experience, what your concerns are, and
• 18:59
  what I see on examination, based on what you've said, and based on the breadth
• 19:04
  of experience and knowledge that I've accumulated over the years, through my
• 19:08
  training as well as experience over whatever time I've been in practice.
• 19:11
  In my case, that's over two decades. And then we'll talk about what the
• 19:16
  implications are of what I'm finding. Some eye conditions progress gradually.
• 19:20
  Others are more urgent, in that you need to do something.
• 19:24
  So we'll have conversations around that, talk about the options, and then make
• 19:29
  plans from there for follow-up, and potentially bringing in other partners:
• 19:33
  referring to a subspecialist, as an example, since I am a comprehensive
• 19:38
  ophthalmologist, or co-managing with optometry if everything is stable and we
• 19:42
  can work together with our partners there.
• 19:44
  So it really is case-dependent, but that's typically what you can expect when
• 19:49
  you go to an office.
• 19:51
  JENNIFER: Thank you for that. We're going to get into timely access and wait
• 19:59
  times in a few minutes, which I know is so critical with some of the advocacy
• 20:03
  we've done around the national eye care strategy.
• 20:05
  Is there a moment in your career that stands out as a reminder of why timely
• 20:10
  access matters so much?
• 20:12
  DR. AHUJA: Yes. I actually had a patient who was having gradual vision loss and
• 20:17
  had been seen several times, but there wasn't anything obvious.
• 20:22
  Their vision started to decrease further, and they were referred to me.
• 20:26
  When I did some testing, because the medical history suggested that some
• 20:31
  testing was required, the lab studies actually showed that the red blood cell
• 20:37
  count was threateningly low. In fact, what was happening is the red blood cells,
• 20:43
  which carry oxygen to the different tissues in the body, including the eyes,
• 20:47
  were so low that the eyes weren't getting enough oxygen.
• 20:52
  So the vision was fluctuating and gradually going down, because the optic
• 20:57
  nerve, which is the cable between the eye and the brain that transmits our
• 21:02
  visual images to help us see, wasn't getting enough blood flow.
• 21:06
  Once we realized that, the person received blood transfusions, in partnership,
• 21:11
  of course, with our medical experts in internal medicine, and the vision
• 21:16
  recovered. But had that access not been there, which came through an on-call
• 21:22
  referral, it would have potentially resulted in permanent vision loss, and
• 21:26
  even worse, potentially loss of life, to be quite frank.
• 21:30
  Not to be dramatic about it, but this person was at risk not only for vision
• 21:36
  loss, but for a heart attack as well as stroke.
• 21:39
  JENNIFER: What a very impactful moment. Definitely.
• 21:42
  We're going to talk a little bit now about access, and I think the timeliness in
• 21:47
  your example of the most impactful surgical moment for you there is really
• 21:53
  critical. Where do you think wait times have the biggest outcome on somebody's
• 21:59
  health, and why?
• 22:00
  DR. AHUJA: When it comes to wait times, I think of it from the perspective of
• 22:05
  impact, because there are different types of impact when it comes to vision
• 22:10
  loss. There's the biological impact. For example, you can have an anatomical
• 22:15
  issue, like a retinal detachment. If it's not repaired immediately, you can have
• 22:19
  permanent vision loss. Similarly with glaucoma: if someone's pressure has
• 22:24
  suddenly spiked and you don't correct it, you're going to have permanent vision
• 22:29
  loss. So that's a physiological, biological, anatomical impact of wait
• 22:34
  times that are beyond what's ideal. The other side of it is the functional
• 22:39
  impact. For example, when people develop cataracts, for the most part, it's not
• 22:45
  something like a retinal detachment or a sudden increase in pressure like
• 22:49
  glaucoma, where you need to treat it immediately.
• 22:51
  Oftentimes people are diagnosed with cataracts, and we follow it along as
• 22:56
  ophthalmologists in partnership with our optometry colleagues.
• 22:58
  Once it gets to a point where it's affecting vision and affecting the ability
• 23:03
  to do things well, then that's an impact that becomes important as well.
• 23:08
  So when you're looking at wait times for the emergent cases, where there's an
• 23:13
  anatomical shift that can cause permanent vision loss, wait times that are long
• 23:18
  can have devastating consequences. Now, the benefit that we have is the on-call
• 23:23
  service that ophthalmology provides at hospitals, so that if someone has
• 23:27
  something like that, they can go to the emergency department.
• 23:31
  We get a referral directly from the emergency doctor, and then we take it from
• 23:36
  there and do what we need to do. Not all cases can have restored sight, but
• 23:41
  depending on the nature of the case, we can at least assess it and do what we
• 23:47
  can. From a functional standpoint, cataracts, like I said, can develop slowly
• 23:51
  over time, so the wait times are a little more tolerable.
• 23:54
  I say that very guardedly, though, because when vision gets worse, you're at
• 23:58
  increased risk of falls, as an example. You can become less functional at work.
• 24:03
  You can become dangerous at work. So we need to be able to address those wait
• 24:08
  times. There's no question about it. But I do see a difference in terms of where
• 24:13
  we need to make sure that it's tight, and we're lucky we have that with our
• 24:19
  on-call services for the more emergent cases, so that we can then try to address
• 24:24
  the other issue, where we can keep people functioning as well as possible from a
• 24:28
  vision standpoint, in terms of decreasing risks of falls and all the other
• 24:33
  safety issues, and maintaining their engagement in the surrounding world that
• 24:37
  they're in, so they can enjoy it as best as they can.
• 24:42
  JENNIFER: Yeah, it sounds like triaging: looking at the cases that are the most
• 24:47
  emergent and critical, which are the most important ones to get early, quick
• 24:52
  access to, but also really monitoring and understanding where vision is starting
• 24:57
  to impact daily living, which increases somebody's access need as well.
• 25:03
  DR. AHUJA: And I'm certainly not minimizing that second category.
• 25:06
  Ideally, everybody gets care as quickly as possible: right person, right
• 25:09
  provider, right time. But in the reality that we live in, that's how we need to
• 25:14
  look at it at this point, until we figure out how to make the system function
• 25:19
  more effectively that way, to meet the needs.
• 25:21
  JENNIFER: No, I think that makes a lot of sense. So we've talked about wait
• 25:28
  times. If we flip to the word access, do you see a difference across Canada
• 25:36
  between an urban centre and a rural or remote area, in access to ophthalmology?
• 25:41
  DR. AHUJA: There are differences. At the Canadian Ophthalmological Society, some
• 25:45
  of our members have done studies looking at the geographic distribution of
• 25:50
  ophthalmologists relative to the population.
• 25:53
  We do see that a good percentage of patients are within a certain distance of
• 25:58
  ophthalmologists, which is reassuring, but some of these distances are far, and
• 26:04
  so travel can become an issue. In a lot of these rural centres, we don't have a
• 26:10
  large number of ophthalmologists, so there are fewer providers there.
• 26:14
  So travel does become a barrier sometimes, if people can't make it to a larger
• 26:19
  centre. And then also, when they do come and you're able to provide care, the
• 26:25
  follow-up of care becomes a concern as well.
• 26:28
  So there are differences. With the Canadian Ophthalmological Society, and as
• 26:32
  we're doing through the Vision Health Coalition, a primary priority is
• 26:35
  increasing access to care. That's where we're trying to leverage different
• 26:40
  technologies, exploring how we can have collaborations amongst our professional
• 26:43
  colleagues along the spectrum, all the way from prevention through to rehab, and
• 26:48
  what we can do to help people get the best care at the right time, regardless of
• 26:55
  whether they're urban or rural. But there are some challenges, for sure.
• 27:00
  There are differences.
• 27:01
  JENNIFER: So now I'm going to give you a little magic wand, Nina.
• 27:07
  If you could wave your magic wand, what would it take to reduce wait times
• 27:14
  across Canada?
• 27:15
  DR. AHUJA: I would say number one is to optimize our existing resources by
• 27:20
  really having integrated care pathways that are developed in partnership between
• 27:26
  optometry and ophthalmology, so that we can make sure the limited financial
• 27:32
  resources are used most effectively, in the best interest of our patients.
• 27:38
  I know that we have a common goal there, so I'm very hopeful and optimistic that
• 27:44
  we will get to be working together on that.
• 27:47
  I think prevention is huge. I think that's where Fighting Blindness Canada is
• 27:52
  very important. We've got so many things that we can be doing to increase
• 27:58
  research, to understand the contributing factors to eye disease that we can
• 28:03
  prevent, or that we can educate people on.
• 28:05
  So that is also something that is very valuable.
• 28:09
  And the third thing is to have a commitment from the government to really
• 28:15
  look at what resources are being allocated, and how more can be allocated
• 28:19
  as well. Because vision is important. There are huge economic losses associated
• 28:23
  with vision loss. Some data shows that for every dollar invested in eye care,
• 28:28
  you're getting $3 back in terms of productivity and return.
• 28:33
  So if we look at those three aspects, we can really try to use our resources as
• 28:39
  effectively and efficiently as possible, so that we can have more care, more
• 28:44
  programs and more initiatives to really bring care to everyone in a way that's
• 28:50
  going to benefit them, so that vision is preserved, optimized and enhanced as
• 28:55
  best as possible for the population.
• 28:57
  JENNIFER: I love that. Thank you for that. Maybe this is another area where
• 29:05
  there's been a lot of advancement, around treatment and innovation.
• 29:09
  What do you see as the most exciting, or what are you most encouraged about,
• 29:16
  related to some of the major eye conditions that are affecting Canadians
• 29:21
  today?
• 29:22
  DR. AHUJA: Well, I think there are many things happening right now, but the one
• 29:26
  that I'll highlight is that we know that over the age of 55, macular
• 29:30
  degeneration is one of the leading causes of vision loss, and there are a lot of
• 29:36
  really exciting developments in that area.
• 29:39
  We do have injectable therapies, as an example, to treat wet macular
• 29:42
  degeneration. If it's caught early enough, sometimes you can preserve the sight.
• 29:47
  Sometimes you can even get a little bit of improvement.
• 29:50
  So that's really encouraging, especially since we know that that's the most
• 29:54
  common cause of vision loss in that age group, and we've got many people
• 29:59
  increasingly over the age of 55. I'm almost there too.
• 30:03
  But anyway, you've got your injectable therapies as one modality.
• 30:10
  The other thing that's really exciting is gene therapy, where they're
• 30:15
  discovering that there are certain ways to deliver healthy genes that otherwise
• 30:19
  are causing inherited eye disease. And that's again in the retinal space.
• 30:24
  So the research in that area is really expanding, which is again very, very
• 30:30
  exciting. So where you have those categories of irreversible vision loss,
• 30:34
  there are developments happening that are really coming to the forefront to make
• 30:39
  a real difference for people. And then in surgical spaces, with cataract
• 30:43
  surgery, we've now got very small incisions, whereas before they used to be
• 30:48
  very large, which would impact recovery time, healing, and time off work for
• 30:52
  those people who are still working. And with glaucoma, as an example, we've got
• 30:56
  treatments that are not very invasive, and yet very effective.
• 31:00
  So we're seeing growth, development and research in all of these areas.
• 31:04
  Those are just a few examples.
• 31:06
  JENNIFER: So this one's always a hard question, because we don't know what we
• 31:11
  don't know today. But if you were to look five years in advance, what do you
• 31:17
  think eye care would look like that it doesn't look like today?
• 31:22
  DR. AHUJA: I'm very hopeful that eye care is going to be optimizing technology,
• 31:27
  expertise and efficiencies, so that patients are able to access care no matter
• 31:32
  where they are, and preserve and maintain their vision longer than we've been
• 31:37
  able to so far. To get a little more specific on that, we know that there are
• 31:43
  technologies that allow us to do remote access to care, such as
• 31:47
  teleophthalmology. Artificial intelligence is coming into the space, and that's
• 31:50
  going to be allowing for diagnostics. That is going to be a very efficient use
• 31:56
  of resources once we've validated a lot of the algorithms.
• 31:59
  Initially, it's going to be a lot of extra work, I think, because while it can
• 32:04
  do a lot to help identify diseases, we need to make sure that it's accurate, and
• 32:09
  so there's a lot of expertise that needs to be involved in that validation.
• 32:14
  But remote access to care through teleophthalmology, as an example, and AI
• 32:17
  algorithms, and how we can use them to optimize care, allow us to care for more
• 32:22
  patients once we have that optimization and efficiency in place and everything's
• 32:26
  been validated. And then the integration of care, where we're really optimizing
• 32:30
  the expertise along the continuum, again, from prevention: What's the research
• 32:34
  coming out? How can we inform and educate people in terms of maintaining and
• 32:38
  preserving their vision? How can optometry, how can we increase access to
• 32:43
  routine eye exams for children all the way through to seniors, and how can we
• 32:47
  optimize resources so all of that can be funded?
• 32:50
  And then with ophthalmology, how can we leverage the expertise that we have in
• 32:54
  the medical and surgical space to really be able to preserve vision where we
• 32:59
  can, and then restore vision where we can, and hopefully have more tools?
• 33:03
  And then from there into the vision rehabilitation and low vision space, with
• 33:08
  organizations like yours, where we can really help people still be productive
• 33:12
  and contributing in ways that are meaningful to them, while potentially
• 33:16
  having to deal with this challenge. So I see this lovely tapestry of care, where
• 33:21
  all of us are doing our parts, and yet we're all intertwined in ways that it
• 33:28
  just flows. That's what I would love to see.
• 33:31
  JENNIFER: I think that's a great five-year view of what eye care looks like, and
• 33:36
  I think we're going to get there with this national eye care strategy.
• 33:40
  At least I hope so. You and I had the privilege of doing a lot of advocacy work
• 33:48
  together, and we both had the opportunity to present at the Senate.
• 33:52
  What did that process teach you about health policy and how it really gets made?
• 33:57
  DR. AHUJA: That was a fascinating experience for me.
• 33:59
  I so enjoyed that, and I felt so honoured to be a part of that process with COS
• 34:06
  and working with all of our partners. I was able to get involved, learn
• 34:11
  everything, get engaged, and help bring it across the finish line with our
• 34:17
  entire coalition. What was not seen, though, in those moments, is the years of
• 34:22
  work and effort that were put in by my colleagues at the COS, colleagues at the
• 34:28
  Canadian Association of Optometrists, yourself, and all the organizations that
• 34:32
  are involved in the coalition. So the lessons from that experience for me were a
• 34:38
  few. One: introducing health policy or making a change is a long process.
• 34:44
  It requires patience. It requires diligence, coordination, collaboration and
• 34:47
  communication. It's very much an integrated process that you need to be
• 34:53
  committed to, to be able to bring it to a point where it can be passed through
• 35:00
  the finish line. There were champions within government.
• 35:04
  Judy Sgro, she was the MP who brought this forward as a private member's bill.
• 35:11
  So fortunate to have that voice being lent to this cause.
• 35:14
  And then Senator Ravalia, he was in the Senate.
• 35:17
  He was really pushing it and supporting it as well.
• 35:21
  So that, to me, became part of that collaborative piece, where you need to
• 35:26
  have the key stakeholders who are believing in this mission and believing in
• 35:30
  the vision working together, and then key people who are in and around those
• 35:36
  decision-making tables to really bring voice and lend voice to this.
• 35:40
  It was fascinating. The other thing I would say is I was really happy to see the
• 35:46
  due diligence that was put forward in both the House and the Senate.
• 35:52
  They were really looking at the legislation to make sure that it was
• 35:57
  robust and well thought out, and that there was something really substantial
• 36:04
  behind it. So to me, that's reassuring: when it comes to bringing about change
• 36:10
  in government, it is a thoughtful process that we can, again, have trust in.
• 36:15
  JENNIFER: Yeah, I agree. That really resonated with me as well.
• 36:18
  So COS represents over a thousand ophthalmologists across the country.
• 36:22
  How do you build consensus among so many practices and perspectives, while
• 36:27
  advocating with one voice?
• 36:29
  DR. AHUJA: The best place to start, from my perspective, is: what is the
• 36:33
  ultimate common goal? That common goal and shared perspective is that we want to
• 36:39
  deliver the best quality of care to all Canadians.
• 36:42
  And with that, what does that then require?
• 36:45
  That requires excellent standards of care.
• 36:48
  That requires us to be accountable for the care we provide.
• 36:53
  That requires systems that are there to ensure that we're regulated, that the
• 36:58
  standards are being met, and that there are checks and balances within the
• 37:03
  system. Recognizing that people have different perspectives, though, and
• 37:07
  different practice styles, and we've got many changes happening within the world
• 37:11
  of ophthalmology that will bring us forward in many respects.
• 37:14
  Not everybody agrees on how things should be done, even though we have that
• 37:19
  common goal. So my approach has always been, let's focus on what the ultimate
• 37:24
  is, and then whatever differences we have, let's learn from each other and
• 37:28
  understand what the perspectives are. What are the lessons you've learned from
• 37:31
  your experience? What are the lessons the other person has learned from their
• 37:35
  experience? What do I bring to the table from my experience?
• 37:38
  As you mentioned earlier, I've got an academic lens, I've got a leadership lens,
• 37:42
  I've got a clinical lens. Other people have an entrepreneurial lens in the
• 37:46
  ophthalmology space. Those are the experiences we bring from the totality of
• 37:51
  experience that each one of us has. And so if you're open to asking questions
• 37:56
  and seeing, okay, now what is common within that, that can benefit that
• 38:00
  ultimate goal, that becomes a process by which we can then come forward with a
• 38:05
  united voice.
• 38:06
  JENNIFER: With the implementation of the National Strategy for Eye Care, and it
• 38:09
  being tabled in June, what happens next? What do you believe the government
• 38:14
  needs to do so that Canadians feel the benefits of this national strategy?
• 38:19
  DR. AHUJA: I think the most valuable thing that the government can do is really
• 38:23
  put support behind this effort, so that the national strategy is actually
• 38:28
  implemented. I agree with you that if it is tabled as a document, that's an
• 38:33
  amazing first step, but it does nothing until it goes through to implementation.
• 38:38
  So our joint ask is to request funding so we can establish a National Vision
• 38:45
  Health Steering Committee, which can basically oversee the various parts of the
• 38:50
  strategy and help ensure that things are implemented, because there are so many
• 38:55
  different elements to the strategy itself.
• 38:57
  We've got the various priorities, from access through to data collection and so
• 39:03
  on. So I think that would be the big thing.
• 39:08
  And also the recognition that vision matters.
• 39:11
  We are often taking our vision for granted, and until you have a problem with
• 39:16
  your sight, you don't realize just how precious it is.
• 39:19
  So I think supporting implementation of this strategy is the biggest thing that
• 39:24
  the government can do.
• 39:25
  JENNIFER: Yeah, I agree. And I think without having that accountability,
• 39:29
  sometimes strategies like this just stay on a bookshelf, and that's not what we
• 39:35
  want the National Strategy for Eye Care to be.
• 39:38
  I think you laid out a really important point there at the end: we want people
• 39:45
  to be aware that their vision matters, not just when something goes wrong, but
• 39:50
  to be proactive. So prevention, and making sure that people get out and get
• 39:55
  their eyes tested on a regular basis, is so critical as well.
• 39:59
  DR. AHUJA: Yes, I agree 100%.
• 40:01
  JENNIFER: So you've written and spoken a lot about stress, resilience and
• 40:05
  respect in leadership and in medicine. How do those ideas shape the way that you
• 40:12
  lead COS, and even run your own clinic?
• 40:16
  DR. AHUJA: For me, one of the fundamental principles in my work in leadership,
• 40:21
  and in the leadership model that I've developed, is really recognizing that
• 40:26
  everybody views the world through their own lens.
• 40:30
  We all have experiences in our lives, and each experience in our life leaves a
• 40:35
  crack on a windshield. I often speak of that analogy.
• 40:40
  The lens through which you view that windshield is going to impact how you view
• 40:46
  the world, how you receive it, and how you interact with it.
• 40:50
  So my approach to leadership at the COS, and in general, really respects that,
• 40:56
  because while we may not agree, it's worth hearing another person's perspective.
• 41:01
  Everybody learns something from their experience, and if we're able to bring
• 41:06
  that experience to the table, we can develop solutions to challenges, or
• 41:12
  initiatives and opportunities that really have more depth, richness and
• 41:16
  comprehensiveness, if we're allowing people who have different viewpoints to
• 41:20
  add to the conversation. So I'm not one to shy away from conflict.
• 41:25
  That, I have to admit, has been an evolution, because generally I'm a
• 41:32
  non-conflict person. But I've learned to appreciate conflict, because it's very
• 41:36
  easy to agree with people, but it's very difficult to be open to hearing
• 41:42
  perspectives, and being receptive to those perspectives, when you're in
• 41:46
  disagreement. And yet sometimes I think that's when some of the most powerful
• 41:51
  insights come.
• 41:52
  JENNIFER: I love that. And I think that's one of the leading areas where, when
• 41:58
  we talked a few minutes ago about bringing the voices and perspectives of over a
• 42:03
  thousand ophthalmologists together, really leaning into that leadership and
• 42:07
  understanding where people are coming from, I'm sure, is building on the success
• 42:12
  that you're having at COS. If we talk a little bit about well-being, we know
• 42:18
  that the work that you do in ophthalmology, and in leadership as well,
• 42:24
  can be stressful and overwhelming. Is there a connection between a surgeon's own
• 42:31
  well-being and the quality of care that patients receive?
• 42:35
  DR. AHUJA: I would say that there is a connection between a surgeon and the care
• 42:42
  they deliver from an interaction standpoint, not from a quality of care
• 42:48
  standpoint. There are exceptions as well, so don't quote me on that directly as
• 42:53
  a blanket statement for 100% of people. But there are a couple of things that
• 42:59
  contribute to why I said what I said, that it's more often an interaction thing
• 43:04
  than a quality of care thing. Number one, our training is rigorous.
• 43:09
  Medical school is not easy. Residency is not easy.
• 43:12
  There are times when you're up 24 hours and then another 24 hours.
• 43:18
  That was not an uncommon experience. You are pressed and pressured.
• 43:23
  Your stamina is developed within an environment that is contained, in a space
• 43:29
  where you've got experts around you as your preceptors and supervisors.
• 43:33
  You're doing procedures, you're dealing with difficult cases, you're seeing the
• 43:36
  gamut, you're getting the feedback, you're dealing with trauma.
• 43:39
  You're dealing with the ups and downs and the emotional highs and lows of what
• 43:44
  it is to deal with someone with severe vision loss, or someone who's had a
• 43:49
  trauma where, unfortunately, the sequence of events is such that the eye needs
• 43:54
  to be removed. You are dealing with the most high-stakes, high-intensity moments
• 43:58
  in a sheltered space, to develop that capacity over an extended period.
• 44:03
  You're looking at at least nine years in an accredited space.
• 44:08
  So you can have the confidence that if you're faltering, the people there will
• 44:14
  be able to teach you and guide you through those moments.
• 44:18
  So that's number one: you have confidence in your training, and you build up the
• 44:23
  capacity for resilience in your training as well.
• 44:26
  Number two, we are all held accountable. There are accrediting bodies that we
• 44:31
  need to be approved and certified by before we can even get out there.
• 44:36
  And then in day-to-day practice, we have the regulatory bodies, where patients
• 44:43
  can put forward complaints if there's a concern, and those concerns are taken
• 44:47
  very seriously. That is an accountability piece that becomes very central to
• 44:52
  ensuring that we maintain our education, that we maintain our skills, and that
• 44:55
  we maintain personal checks and balances, to ask: Are we meeting the standards
• 44:59
  that we've been trained to meet? Are we safe in providing the care?
• 45:04
  And can we maintain that patient trust? So even where the stress can become
• 45:09
  very, very high, and you can be pulled in different directions, we've been
• 45:13
  through so much that it becomes part of who you are.
• 45:16
  That level of excellence and commitment to patient care becomes who you are.
• 45:21
  That's why, no matter how stressed you are, I don't believe it translates into
• 45:25
  the quality of care. That said, sometimes, depending on how well you manage your
• 45:29
  stress, you may not have the best bedside manner, and that is actually part of
• 45:34
  quality of care. But when it comes to the technical aspects, I think for the
• 45:38
  most part, we're good to go. It's those interpersonal skills, how you
• 45:41
  communicate with people and the rest of it, that we don't get training in, and
• 45:46
  that's why that is sometimes a weak point.
• 45:49
  That led to me going into the leadership space and doing all the work that I do
• 45:53
  now.
• 45:54
  JENNIFER: I love how you've done that as a full circle again.
• 45:57
  You've shown another example of where you've witnessed different areas, and then
• 46:02
  invested your own time and your own expertise in learning an area that is so
• 46:07
  important. I would say it's very important in ophthalmology, but it's very
• 46:13
  important in any type of clinical leadership role, like you've described
• 46:17
  there. So one of my favourite questions that I want to ask you now is, if you
• 46:25
  had 30 seconds with the next Minister of Health, what is one thing about the
• 46:30
  National Strategy for Eye Care that you would want them to understand?
• 46:35
  DR. AHUJA: Vision is important. The strategy must be implemented.
• 46:37
  We're here to support you however we can.
• 46:40
  Just let us know what we can do. That's what I would say.
• 46:45
  JENNIFER: Wow. Very impactful. It's a great opportunity.
• 46:47
  DR. AHUJA: Yeah, it is. It's as simple as that.
• 46:52
  JENNIFER: Very good. So this series is launching on World Sight Day, October
• 46:57
  8th. What does that day mean for you and for COS?
• 47:01
  DR. AHUJA: That day, to me, is really about celebrating vision as the gift that
• 47:06
  it is. When I take off my glasses, the world is a blur, and that started in
• 47:14
  childhood. So I recognize and appreciate the gift that vision really is.
• 47:18
  It's what allows me to do what I do, and I feel very blessed for that.
• 47:23
  So to me, it's representative of that. And I think for the organization, it's a
• 47:28
  recommitment to an ongoing commitment to really protect vision for Canadians,
• 47:33
  and to bring the best of care that we can to all Canadians through the work that
• 47:39
  we do.
• 47:40
  JENNIFER: Beautiful. And my last question for you is, what is the moment or
• 47:45
  story that reminds you of why this work matters, even on the hard days?
• 47:50
  DR. AHUJA: I once had a patient who came into my office for a post-op check from
• 47:55
  cataract surgery, and she was crying. She was a lovely Italian woman, I think in
• 48:00
  her 80s, if I remember correctly, and she didn't speak English.
• 48:03
  Her daughter was with her, and I immediately was worried.
• 48:06
  I thought, my goodness, she's in a lot of pain, or something's happening.
• 48:10
  What's happening? So when her daughter translated, she said to me that she's
• 48:16
  crying because she's so happy. She saw her family portrait for the first time in
• 48:23
  20 years because of her surgery. So those are the moments that make the really
• 48:29
  tough times worthwhile.
• 48:30
  [Theme music begins and plays to the end]
• 48:31
  JENNIFER: Absolutely. Well, thank you so much, Nina, for being here today, and
• 48:36
  to our listeners for tuning in to Perspectives, a VLRC podcast.
• 48:41
  Today's takeaway, I think, is an important one.
• 48:44
  The national eye care strategy is critical.
• 48:46
  We've got to move it from implementation into what really matters for Canadians.
• 48:51
  And the other piece that you really highlighted is timely access: as
• 48:57
  somebody's vision changes, that referral to specialists is so critical.
• 49:03
  You can learn more about the Canadian Ophthalmological Society at cos-sco.ca,
• 49:10
  and about VLRC's work at visionlossrehab.ca.
• 49:13
  If you're listening and enjoying this series, follow or subscribe wherever
• 49:18
  you're listening. It really helps us find more people in these conversations.
• 49:23
  Join us next week as we turn the lens on to VLRC, where we'll discuss vision
• 49:30
  rehabilitation, habilitation, independent living, and Vision Loss Canada's
• 49:33
  survey report. Until then, this has been Perspectives, a VLRC podcast.
• 49:39
  Thanks for listening.