A Great Conversation With Dr. Valerie Purvin

Dr. Purvin is a clinical professor of Ophthalmol- ogy and Neurology at the Indiana University Medical Center and the former director of the neuro- ophthalmology section of the Midwest Eye Institute

Great Conversations Section Editors: Meagan D. Seay, DO Rachel A. Calix, MD A Great Conversation With Dr. Valerie Purvin Rachel A. Calix, MD, Meagan D. Seay, DO, Kathleen B. Digre, MD R achel Calix (RC): Today, we’re with Dr. Valerie Purvin. Dr. Purvin is a clinical professor of Ophthalmology and Neurology at the Indiana University Medical Center and the former director of the neuroophthalmology section of the Midwest Eye Institute. We’re so thrilled that you could speak with us today. Can you give us a little bit of a background about your life before you went to medical school? Valerie Purvin (VP): Sure. I grew up in New York City, Upper West Side, and went off to college at the University of Wisconsin, Madison, in 1964, at the height of the end the war in Vietnam protests. It was a big center for that, so a lot of us from my high school went there for that reason. I actually started out in pre-med, mainly, no doubt, because my mother had wanted to be a doctor, but she grew up in the Depression. She was a Jewish girl in New York, in the Depression with no money, so it was totally out of the question. So, I think that just got carried forth. My fondest memories, really, of hanging out with her had something to do with medicine, asking, “What does the kidney do?” and having her just talk about it. Medicine was mediated to me in this very nice way, in a loving kind of way. My father was actually an optometrist, which makes it seem like, “Oh, probably that was why you went into neuro-ophthalmology,” but I don’t think so; certainly not consciously. I went away to college and started in pre-med, but very quickly discovered that if you never go to class and don’t really study, taking science classes is probably a mistake. Better off with social science, where you can sometimes, often guess the right answer. VP: So, I quickly changed majors, away from pre-med. Basically, I was just not ready to go to college. I was 16, which is not uncommon in New York. Skipping a couple of years along the way is the New York City public school version of gifted education. So, I was young and just not ready, and the people I was hanging out with were not studying either. Nobody was studying. I did that for 2 years, Departments of Ophthalmology and Neurology (RC), Ochsner Medical Center, Jefferson, Louisiana; and Departments of Ophthalmology and Neurology (MDS, KBD), University of Utah Moran Eye Center, Salt Lake City, Utah. M. D. Seay and K. B. Digre are supported in part by an unrestricted grant from the Research to Prevent Blindness, New York, NY, to the Department of Ophthalmology and Visual Sciences, University of Utah. The authors report no conflicts of interest. Address correspondence to Rachel Calix, MD, 1514 Jefferson Highway, Jefferson, LA 70121; E-mail: [e-mail] e774 and then I dropped out and went to Europe for a year, with 2 girlfriends. We hitchhiked around together for 6 months, then we split up. I did that for a year, which was great. And then when I came back, I was ready, finally, really ready to study. I came back and went to college for a year in New York, then back to Madison where I ended up graduating with a degree in Philosophy. Not with a plan to be a philosopher, but because after changing majors several times, I had accumulated more philosophy courses than in any other subject because it was always the most interesting. So, I ended up with enough credits to graduate with a Bachelor of Philosophy. VP: Then I went back to Europe and studied violin in Paris for half a year and then came back to NY. I come from a musical family. I started playing violin when I was 5, and that’s got its own separate story to it. I was also not ready to commit to violin when I first went to college, but by the time I finished, I was. The next phase of my life I really focused on music, and I practiced really hard. I studied in Paris, then came back to New York and worked as a freelance violinist in New York until I was, finally, really ready to do schoolwork. And then I went back and did pre-med classes at Columbia for 2 years, one year of classes and a year of research while waiting to apply, and then went to medical school. That’s what I did before Medicine. RC: Wow, so you explored a lot of different avenues in that period of time. VP: I did. RC: Do you think you always knew you would come back to medicine or were you really exploring seriously these other things? VP: No, I had no idea that I would end up in medicine. I had no idea you could do that. I had never heard of general studies. I thought that ship had sailed. In fact, the only way I learned about it was 1 of the 2 girls I went to Europe with, her father was a professor of medicine at Washington University, so she knew about those things, and she passed through New York and we reacquainted while she was waiting to go to medical school after having the pre-med work. There was a very influential person in my life, a psychoanalyst in NY, who I also studied religion and philosophy with. He was not as noncommittal as a lot of psychoanalysts are. I came in for my Monday morning session and I said, “Emily is going to be a doctor and I’m so jealous. Help me stop thinking about how lucky Emily is.” And he said, “Why? Would you want to do that?” I said, “Well, yeah of course, but I can’t. I’ll never get in with these lousy grades from my first 2 years of college.” Calix et al: J Neuro-Ophthalmol 2021; 41: e774-e784 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Great Conversations VP: And he said, “Well, that’s not a problem. I have a friend on the admissions committee at Mt. Sinai; I can get you in.” Which of course is not true. I’m sure it wasn’t true then, and it’s not true now. Nobody can do that. But he said, “I can get you in. So, don’t worry about that, but do you want to go?” And it was like the heavens opening up. I said, “Well, of course, absolutely.” He said, “Well, then I think you should do that.” And I did. And I never looked back. I never, ever doubted from that time on that it was the right path for me. I ended up in exactly the right spot. But it wasn’t because I thought that I expected do that. In fact, as pleased as my mother was when she thought I was pre-med at the beginning, there wasn’t really an expectation for me. This was early 60s. The expectation for women, even in an intellectual, artistic family in New York City, the expectation for women was that they would get married and have a family. Guys were expected to have a career but not girls. Whatever you said you were gonna do it was basically ‟That’s nice.” But there wasn’t really an expectation and certainly not a pressure. The joke about the degree was you go to college to get an “MRS” Degree. So there wasn’t any great disappointment when it appeared that I wasn’t going to be a doctor. Which is why, I think, women used to be better doctors. I think we’re still better doctors, but we used to be even better. Because when women went into medicine, it wasn’t because it was the family business or because you had to choose between law and medicine. We went to medical school because we had a passion to do that. I think nowadays, not quite as much. I think we’re still better but for other reasons now. RC: Once it became known that you were interested in medical school and that you were in fact going to medical school, did your father have any impact on your interest towards ophthalmology? VP: No, not really, because I didn’t start out in that direction. I started out heading toward neurology. I was captured by that. I went to Tulane in New Orleans for medical school where I was totally captured by a neurologist named Dr. Ruth Patterson, who was this enormously charismatic figure. She was a superb clinical neurologist. She was Canadian but had trained at Queen Square in the United Kingdom and brought those clinical skills and style. She walked around with this giant reflex hammer. You would n’t know this, but Kathleen probably does. Queen Square– trained neurologists have not just a little reflex hammer you stick in your pocket, but a 3-feet long, giant black mallet. It’s a mark of the training. But anyway, she was so elegant and a combination of warm when she felt warm and chilly as all get out when she didn’t feel warm, mostly toward residents who didn’t know the answer to something. But she just knew what patients had. She had old-fashioned, pre-MRI, pre-CT-scan, clinical skills. But it’s hard to describe, other than saying she was so charismatic. Generations of medical students, not just female students, went into neurology because of Ruth Patterson. Calix et al: J Neuro-Ophthalmol 2021; 41: e774-e784 VP: And the particular draw was her Wednesday afternoon Neurology Conference. It was an elective. It was just Dr. Patterson and one patient. The Chief Resident would bring in the patient, and it was like a stage. It was like theater. There was her chair and the patient’s chair, or gurney, and she would interview the patient. She would elicit the pertinent history and then she would demonstrate the pertinent findings, and then the chief resident would take the patient out and she would tell us what they had and talk about it. And it was really just like theater. Her focus on the patient was absolute, it was just loving and allencompassing. That person was held by her in that hour. It was remarkable. I took it as an elective as a freshman and then if I had a Wednesday afternoon when I could get out of whatever I was supposed to be doing, I would just go as an auditor. Not for credit, go and just watch, because it was a great, great theater. There was another prominent neurologist on the faculty, Leon Weisberg, who wasn’t an influence in the same way, but he was sort of the opposite in terms of his skill set. VP: Dr. Weisberg was a great teacher in that he could distill the diagnostic process as an algorithm. He thought in algorithms before we had computers that did that. Nowadays, the world is just built that way, but he would say, “This patient has weakness without sensory change, so this is a motor problem. It’s either upper motor neuron or lower motor neuron. The reflexes are down. Therefore, it is lower motor neuron. It’s either this or that ..” He would work through the problem in a logical systematic way and come out with the answer. It was great, it was so easy to understand. Except that he might be wrong. I wouldn’t say he was often wrong, but he wasn’t always right. In contrast, Ruth Patterson couldn’t tell you how she got there and wasn’t interested in explaining the process. She just knew the answer. I remember rounding on a patient in whom she had just diagnosed a cervical cord plaque, and we were about to leave the bedside and a resident said, “Excuse me, Dr. Patterson, why couldn’t this be a brachial plexus lesion?” And she pushed her little half-glasses down her nose and looked at him over them, nailing him with her steely blue eyes, and she said, ‟Well I don’t think that’s very likely, do you? Hmmmm? I don’t think so.” And the resident said, “No, no, I didn’t think so.” VP: She just seduced people into the diagnosis. But she really had no interest in telling you how she got there. I don’t know if she couldn’t or. It’s just not what she did. So, it was interesting to see 2 different teaching styles. But she was certainly the one for me. I’m sure there were people who went into neurology because of Dr. Weisberg, but for me, it was like, “No, I just want to be like Dr. Patterson when I grow up. And if that means being a neurologist, fine, I’ll be a neurologist.” So, I was very quickly pulled into neurology. And then, when you’re a student, if you have a declared interest in something, people think you know the stuff. “Oh, you’re going into Neurology—could you look at e775 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Great Conversations the patient in bed 3? He’s got a stroke.” “Yeah, I’m a thirdyear medical student. How would I know? Sure, I’ll do that.” So, you become an expert quickly. I was sort tracked toward that. So I did neurology residency and was going to leave New Orleans to go to Columbia, it was my chosen place. But instead, I fell in love with somebody, the chief resident, actually who brought that patient in. And he was committed to being on the faculty the next year, as their pediatric neurologist. So, I stayed on. That also has a longer version, but I stayed on in New Orleans so that he could stay there, and so I did my residency in neurology there. A year of internal medicine and 3 years of neurology at Tulane, as well. And then neuro-ophthalmology. Dr. Henry Van Dyk was new; he was the first neuro-ophthalmologist in Louisiana. He came when I was a third-year resident. He came to Louisiana State University (LSU) but we knew he was there, and so we invited him to our Grand Rounds, so we could present a patient. We had a patient with double vision, a young 30-ish woman, and we had no idea what was wrong with her. We just knew that she had double vision, but no idea why or where. VP: Is it the orbit, is it the eyes, the brainstem? We didn’t know, but . wait, we have a visiting neuroophthalmologist now at LSU. Maybe Dr. Van Dyk could come over and we could show him the patient. Maybe he could tell us what she has.” So we did. And he came, and it was like a magic show, it was like, “Nothing up this sleeve, nothing up that sleeve.” He did a cross cover test, which we’d never seen before. He did that and he checked her pupils and he found a Marcus Gunn pupil along with vertical diplopia same on gaze in all directions. He explained why that had to be a skew deviation thus, localizing to the brainstem, the Marcus Gunn pupil was in the optic nerve, 2 totally different places in space and time. “This is clearly a patient with multiple sclerosis.” This was before the days of MRI. You had to work to get to a diagnosis of MS. He did the work, and it was like a magic act. It was a lot like Dr. Patterson in that way of making it look like theater, but his was a magic act rather than interpersonal drama. RC: Do you think that moment kind of encouraged you towards neuro-ophthalmology? VP: Totally sold. At least, it sold me on doing an elective with him, which was allowed. So, I did that. I spent a month with Dr. Van Dyk. He passed away a few years after that—he died at a really young age, in his early 50s. Kathleen Digre (KD): And he was the chair of ophthalmology at Utah before he went to Tulane. VP: So, there’s a tie I forgot about that. Yeah, that was where he was right before he came to New Orleans. He didn’t write a great deal, he had nowadays what’s probably called a writer’s block or a self-destructive streak. He managed to do all sorts of things to not actually turn in manuscripts when they were supposed to be in. So, he didn’t leave nearly as much of a written record as you would think, but he was in great demand as a lecturer because he was so e776 entertaining. He just made it look fun. When he was a visiting lecturer or at the Academy, his presentations always made it look like fun. And for the entire year that I was his fellow, it was. He made every day fun. It was always worthwhile, worth doing. It was exciting, it was stimulating. He was just great. I have a lot of fond memories of him. Specifically, of how he did that. But I remember him looking into a patient’s fundus with, say a swollen disc, and him saying, “Ooh, ooh, can you just hear the disc crying out? It’s crying for help. Can’t you hear it?” VP: And he would refer to the foveal peak on the island of vision as “the nipple on the tit of vision.” Which, of course, nowadays, you can’t get away with. He said a lot of things we’d get sued for saying now, but he said them, and it was entertaining. It kept you awake. He was always interesting. He used to talk about doing the funduscopic exam and getting “rapture of the deep” as he called it. He said, “I could just look in there forever, so much to look at! Oh, God, isn’t it great?” And after a number of years, I came to appreciate even more what it takes to maintain that level of enthusiasm. Because eventually, whatever is in that fundus, I’ve probably seen it before. And the same thing with the history. We would tell him a patients’ history and then we’d go into the exam room. He always had an entourage of students, residents, me. We would go in there and all we really wanted some was for him to make a pronouncement about the fundus. VP: “Is this disc pale or not?” But he would go in and start with “Well, it says here you set tiles. But what’s up with setting tiles? How’d you get into doing that? Did you go to school to do that?” And we’re all rolling our eyes and like, “God can we just get on with it.” But he always wanted to hear the story. Again, this was old-fashioned clinical medicine, and he just never got tired of hearing it because each story was different. He said it was especially when you already knew the diagnosis, so you could get by without hearing it, but that’s when you really want to listen because you could really learn something. What does optic neuritis sound like? What does papilledema sound like? Years later, I eventually got to a point where I was really tempted to say, “I don’t need to hear the story, I’ve heard it before, do I really have to hear this again?” I didn’t say it really grumpy, but I felt it. I felt more of a pull to just cut to the chase. I appreciated even more how special it was that he could maintain that enthusiasm (Fig. 1). RC: Were there any other major mentors for you throughout your career? VP: Not really. Really there were just 3. Preston McLean was the psychiatrist and philosophy/religion person in New York City. He was a great influence, without whom I wouldn’t be here. I really would not have gone into medicine, and then Ruth Patterson and then Henry Van Dyk. Just 3, and they all died in their early 50s, which was very odd. RC: Those are incredible stories and sound like really influential people, probably to many trainees. What was your first job out of training after you were done there? Calix et al: J Neuro-Ophthalmol 2021; 41: e774-e784 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Great Conversations FIG. 1. In the Louisiana State University Eye Center Library with Henry Van Dyk, on completion of neuro-ophthalmology fellowship. VP: Well, the job that I thought I was going to have that I was prepared myself for doing after my fellowship was at Ochsner Clinic in New Orleans. They needed another neurologist, and they didn’t have a neuro-ophthalmologist. Henry, I used to go with him once a week, half a day clinic there. So, we were staffing neuro-ophthalmology, but they would have been happier having their own person. So, I was going to fill that slot doing mostly neurology with a little extra expertise in neuro-ophthalmology but then the job fell through. Something happened in South America so that all the South American visits stopped for a while, and so there was a freeze on hiring and that job just didn’t exist. There really wasn’t another good alternative in New Orleans, and my then husband also wasn’t happy with his job, so we got out of town. VP: We left and we came to Indiana because we needed a place that wanted a pediatric neurologist and a neuroophthalmologist, same time, same place. Not willing to divvy up. There weren’t many places that needed both of us, and Indianapolis was the most appealing. So, we came here. The problem was that the full-time academic neuroophthalmology job I was hired to do was so different from what I had expected to do while I was training that I was essentially underprepared. There were skills that I had learned at the beginning of my fellowship, like indirect ophthalmoscopy, that I didn’t really try to get good at because I didn’t expect to have that equipment. But suddenly, there I was having to do those exams. I had to figure it out with audience—had to figure out which side of the lens to look through, with the patient and the family and the students and residents from both departments watching. Calix et al: J Neuro-Ophthalmol 2021; 41: e774-e784 Everybody waiting for some pronouncement from me. “Dr. Purvin, what is it?” “I don’t know, I can’t even see the disc. How do I know what it is?” It was so stressful. And I was so busy. The day I arrived they handed me the patient list for the next day. There was a 2 month gap between my predecessor leaving and my arriving, so there was no end of patients and I was way too busy, way too stressed. Learnt a lot. I wouldn’t say fast because it took a couple of years to really get up to speed. I learned ways of temporizing things. I learned to order some sort of a test that wasn’t unreasonable to get which would buy a day or 2, and then I could look it up or call Henry in New Orleans or figure something out, and then move on. VP: But it was just so hard. I remember thinking early on when I would do hospital consults and I would get to the bottom of the page where I would write Impression, I wanted to write, “Will present to staff in AM,” and then realized that staff isn’t coming in the AM. It’s just me, and there’s no help coming. It was very, very hard. And then, as if it wasn’t already hard enough, I had another child—my third. And so, my advice to young women? VP: Yeah, don’t do that. Don’t do what I did. I generally don’t give advice to people because I just don’t feel equipped like, “Oh, it was so great. What I did was just such great choices.” It worked out, and I got really good at doing this because I had to. But starting out in a place with a senior colleague or being part time would be such an easier way to do it. Then, I think you maybe wouldn’t get to the same place, but the place you’d get to would be fine. RC: How long did you feel like you kept reaching out to Dr. Van Dyk? Was it a certain number of years and then you said, “No, I’ve got this; I don’t need help?” VP: Well, I think I would have but sadly he died just a few years later. So I became an adult pretty quick. RC: Any other advice to people just starting their careers in neuro-ophthalmology? VP: Well, I mean, there’s the obvious stuff that people give advice about: how to pay the overhead, how to get a job, do a second fellowship, or be a residency program director. There’s ways to do that. But I was lucky to have a position where I didn’t have to do anything except neuroophthalmology. Although the first few years I was still staffing some general neurology, including the in-patient service 3 months a year. During those months, I had my regular neuro-ophthalmology clinic plus a general neurology ward to staff first thing in the morning and last thing in the evening. The months from hell. I did that for 5 years, and then after I had my third child, I decided that I could be part time. Being part time just got me out of doing those 3 brutal months of neurology staffing; otherwise, I was still doing the same work, although with a sizable pay cut. I think my main advice to colleagues, especially women, starting out is to not be reluctant to ask for help. VP: I had a housekeeper who came during the day to take care of the kids, but I never had her make supper and I e777 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Great Conversations never had her go grocery shopping. Because, to me, that would have been like saying, “Oh, I can’t, I can’t cook dinner.” But I said, “I can do it, I can do it. Let me at it, I can do this.” So, I strongly urge people to look deeper at that need, at the reluctance to say, “I can’t.” It’s not even I can’t, it’s ‟I don’t want to do this, it’s I’m not doing this.” I never asked for help, and I always thought people should read my mind. “Well, of course, I need help. Don’t I look like I need help? What do you think?” Yes, I needed help. But I think everyone always thinks I know what I’m doing. I didn’t know anything of what I was doing. Don’t be afraid to ask for help is one. Oh, and the other thing that I did do, and for this one I’m willing to give advice because I actually did this is for women to be unpleasant, early on. So that you don’t have to do it later. My experience in the ophthalmology department, where my office was at the medical school, was that when something was in short supply, like office or clinic space or technician time, they would take it away from me because I was a girl and girls don’t mind. I shared an office with the other female faculty member, and they had us share an office. “That’s okay, Elaine and Valerie will have fun in the office together.” “No, we won’t! I want my own office.” So I learned to be so unpleasant that they would do it to somebody else. So that next time they needed to take away a resident or some clinic space, they would do it to someone else. Because you’re going to have to deal with me, and it’s not going to be fun. And that helped. Try to lose the idea of wanting people to like you. Don’t do that. It helped that being in the Midwest but being from New York, people always thought I was much more upset than I was. I remember complaining that a spinal fluid specimen I had sent to the lab wasn’t resulted yet 3 hours later. Soon after explaining to the tech why the fluid needed to be processed promptly, I got a call back from the head of pathology saying “Dr. Purvin, we heard you were very upset.” I said, “I wasn’t very upset, I just want my spinal fluid done right.” VP: Another time, early on, one of my patients had their scan bumped for an emergency. I called radiology to complain. My point was “Do not do that because I’m going to be in your face about it.” And that approach worked for me. Maybe other people don’t need that advice, but it helped me. I kept the clarity that I wasn’t trying to win a popularity contest. After a while, I didn’t have to do it anymore. People just knew to screw over somebody else. KD: Right. I have a question. I think your career is so interesting that you worked at that Midwest Eye Clinic and a university, balancing academics and a more private practice type thing. Tell us how that worked because that’s pretty unusual. VP: It was special. I was full time at the university for the first 4 years, then I went part time for the reasons stated, to get out of doing the neurology staffing. Then, the ophthalmology department took a nosedive. Internal politics: the chairman stepped down, the Dean was angry e778 at the department about financial issues and sort of hung us out to dry by not appointing a search committee for some time. Three other faculty members were leaving the department to join a growing subspecialty ophthalmology clinic here in town called Midwest Eye Institute. The hospital where the group was located (Methodist Hospital of Indiana) had committed to expanding a few sections and ophthalmology was one; neuroscience was another. They basically made me an offer I couldn’t refuse. My colleagues said, “We’re going to join Midwest Eye Institute and we’d like you to join us.” I said, “Yeah, that’s nice, thanks, but the natural home of a neuro-ophthalmologist is in a university.” That was much truer then. I think now there’s more flexibility. But at that time, you didn’t just hang out your shingle and announce “I’m a neuro-ophthalmologist, come see me in my little private office.” So, I felt that I needed to be at the university. I basically said no thanks. And they said, “No, no, we think we can work it out so it’s good for you, so it works for you.” And I said no a few more times. VP: ‟Just come over and look at the place. Let us tour you around, meet the CEO of the hospital and the neurosurgery chief and let us show you around.” “Fine, fine.” They were persistent. “Okay I’ll go look.” And they basically did make me an offer I couldn’t refuse. They just kept upping the ante, “We’ll give you this, we’ll give you that; space, time, support for research and teaching” And I said that I didn’t want to work full time because at that point, I had 3 small children. The CEO said, ‟We don’t care how many days a week you work. We just want to know that when you’re not here at Methodist Hospital, you’re not across town seeing patients at St Vincent’s Hospital. If a patient wants to see you, they have to come see you here.” And I said, ‟That’s fine, I can absolutely guarantee that I’m not going around town doing consults at different hospitals.” VP: So, I took a chance, and they were absolutely good to their word. They provided everything that they had promised me—support for the academic work, for fellowship salary, for travel, it was all there, and it was so productive. And the group grew, now up to 20 ophthalmologists; all subspecialized, nobody does general ophthalmology. The department had a few skimpy years then recovered and then some years later did something similar. And then recovered again. So, I’ve seen several life cycles in that department. The good thing was that when I jumped off and took that leap of faith to join Midwest Eye Institute, at that point there wasn’t a neuro-ophthalmologist at the university to take my place. So, the residents continued to rotate with me, 5 minutes away. Then Bob Yee came as chairman the next year, and he was very kind and very gracious to continue that arrangement (Fig. 2). VP: I continued to have the residents 3 days a week, and he had them 2 days. He absolutely didn’t have to do that, but he did, he was very generous. So, I had all the pluses really of both sides. Maybe it’s not a plus to everybody, but Calix et al: J Neuro-Ophthalmol 2021; 41: e774-e784 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Great Conversations FIG. 2. Bob Yee, Valerie Purvin, and Aki Kawasaki celebrating Aki completing her fellowship year. it was to me. I had the residents and students and sometimes a fellow, but I didn’t have to have a chairman and I didn’t have to have a dean. And my group and the hospital were very supportive. So, I did that for a really long time. And the other thing that worked out well happened because I was aware that it might not last. My position felt somewhat fragile because it required financial support from the hospital and my group and a foundation that all contributed to pay my salary, so that I didn’t have to do anything except straight neuroophthalmology. But I was aware that at some point, I might need to get back into the world of academics. And I didn’t want to be coming from private practice and be asked, “What have you done for the past · number of years?” and say, “I’ve seen a lot of patients” to be told, “That’s nice. Next.” So I made a more conscious effort to always be publishing something; not giant prospective studies but just keep turning some stuff out, to just keep at it, writing about what I saw and had collected (Figs. 3 and 4). VP: And so I did that, I wrote more than I did when I was full time at the university, oddly. Then, it turned out I didn’t need to leave. But by that time, I was in that habit of writing and teaching. So, it worked out really well. It kept me here. In a way, I was victim of that success of having this really special opportunity, this special support that most people don’t have. It was a fluke. I was lucky. And I’m still here. Eventually, I could have left, especially after the kids went off to college, but by then, it was like my orbit had decayed. I had so many connections here. I realized it when I had major surgery 10 years ago for scoliosis, leftover from having had polio as a child. During my recovery, all these people came to help me; all these friends and colleagues, and string quartet people and group therapy people; there were all these people. You practically had to take a number to bring me lasagna, line up at the door to bring food or Chinese takeout. VP: That was when I was at the stage when I might have left. I had thought “Okay, I’m probably going to move. Calix et al: J Neuro-Ophthalmol 2021; 41: e774-e784 FIG. 3. Bob Yee, colleague and Chair of the IU Ophthalmology Department, with Valerie Purvin. Where to? Because now I can.” And at that point, I realized I really had a life here. So I didn’t go. There are more glamourous places to live, but it is my home and it’s been very good to me. It’s been great for having a career and a family. KD: I think another thing that people would love to hear about is tell us about your music background. You went to Paris to study violin, and you started at age 5, but tell us what you’ve done throughout your whole career with music because think about North American Neuro-Ophthalmology Society (NANOS) and you’re often playing the violin FIG. 4. Aki Kawasaki, initially medical student, then resident, then fellow and ultimately colleague and friend. With Valerie Purvin. e779 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Great Conversations FIG. 5. Playing violin-piano sonatas with Dick Sogg. with Dick Sogg. So, tell us about how that all happened in your life (Fig. 5). VP: Yeah, that’s harder. Well, I can do this, it’s a challenge to tell an abbreviated version of this part. So, as I said the family I grew up in was musical, but my older brother was actually a child prodigy at the piano, and he was the star of the family. He went to Juilliard, and some of the people he played with there are now household names, like Itzhak Perlman and Pinchas Zukerman. So, I grew up hearing those people, they played music in our house all the time. So, my concept of what was like to be a real violinist was that. I thought, “Well, it’s not me, I don’t do that.” So I had a fairly low opinion of my own skill level, and it wasn’t up for reassessment ‘til I went away to Madison, where I showed up to audition for the orchestra, at my mother’s insistence. Every week, we would talk and every week she’d say, “So did you try out for the symphony?” “No, not yet.” “Really? You should do that.” “Yeah, yeah, I know.” And I finally did, and they made me concert master of the orchestra and gave me a fellowship, and I started getting playing gigs. It turned out that by normal standards, not the little slice of the world that I grew up in, I was actually very good. VP: I played a lot of jobs in Wisconsin, doing community orchestras and church jobs and opera. That was fun, but then I was stuck with these 2 different views of myself. I guess this would be an impostor syndrome thing in that the world seemed to think I was so good, but I knew I really wasn’t. So I would make up reasons for the disparity. “Well, I do have facility. I’m fast, I can sight-read anything, I learn stuff quickly, but I lack depth. I’m not a Real Violinist.” I think medical school, as an intellectual version of that disparity, is a great opportunity. Because after you go through the whole process of medical school it’s hard to maintain wild fantasies about how brilliant you are. You either are, or you are not. Wherever you are, in certain skill sets that you have, that’s where you are. It’s the same thing with the violin. After grappling with these 2 differing views of myself, I realized that the only way to know how good I e780 could be was to actually practice. So I did. That’s what I did after college. I practiced really hard. I practiced absolutely religiously 4 hours a day, basic stuff, plus playing jobs when I went back to New York. VP: And I took lessons and I actually ended up being lots better than I thought I was going to be. I was really pleased with how good I got. I came to terms with the reality of it. After all that I knew my strengths and my weaknesses. It was so great that I did that work, went through that process, but I never expected to have a career in music. Playing jobs in New York was really biding time til I was ready to do something that I really wanted to do. I was good at it; I got plenty of jobs, it wasn’t that I didn’t work enough. But most freelance jobs don’t offer a lot of self-expression. Medicine is so great for letting you really be yourself, whatever your Self is. So many selves can all find a way to shape the work the way you want it to be. But for freelance music, for a string player at least, you’re usually in an orchestra with 30 other people playing the same part. If the audience can hear you, it means you made a mistake. VP: I wanted a job where my own voice was going to be heard. So, when I went to medical school, I came right out of having been at the top of my game really, musically. I continued to play regularly during my first 2 years of medical school. I would spend each evening studying, like 2 hours studying, and then I’d take a break and practice for half an hour, and then repeat the process. It felt like the flow reversed: stuffing information in for 2 hours and then playing the violin and stuff would come out. It felt like a eustachian tube, equalizing the pressure on either side of the membrane. It was such a huge relief. It furnished the perfect antidote to studying. VP: Medical school also helped for performance, although I’ve never been all that interested in performing. I think it helps to do medicine and to have the stakes be so clearly different. Like if you make a mistake at work as a doctor, someone could die or go blind. Make a mistake on the violin—I went for this high C and I missed it—Fine, so you’ll hit it next time. So what? The stakes are just not that high. It doesn’t feel like that when you’re in that world because everything hinges on it. And maybe to really hit that high note, you have to feel like everything in the universe is depending on it and then you nail it. VP: But anyway, it’s actually helped my playing. In some ways, my playing got better when there was less pressure on it; when it was truly just for fun. During the 10 years, I was in New Orleans I had a pianist whom I played sonatas with regularly. Then, when I moved here to Indiana, I found, really quickly, 3 other string players, and I’ve been in basically the same quartet. We’ve occasionally changed a member, but we’ve continued to play every week for all these years. Now we play with masks. It’s been a wonderful balance to a career in medicine (Fig. 6). RC: What do you feel like your biggest successes have been, either professional or personal, over the years? Calix et al: J Neuro-Ophthalmol 2021; 41: e774-e784 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Great Conversations FIG. 6. Piano trios with Joel Glaser and Dick Sogg (not shown: Norman Schatz official page turner). VP: That’s hard. I think eventually I got really good at being in a room with a patient. I haven’t thought about this for years really, but it’s like what Dr. Patterson used to do with that one-on-one time. And it wasn’t like I kept working with that in mind, I mean that was an early seed for that tree. I hadn’t even thought about that connection until you asked that. But in a sense, I really did get there. And I think that’s the part that you can’t teach in a lecture or in writing. The only way for students or residents to learn that is being in that room. And so, I think what I learned, what I discovered, was there’s much more flexibility to how to do that, how you can be with a patient. It’s not Marcus Welby or Dr. Kildare. It’s however you want it to. There’s many different ways to do that. So I feel like I found what worked for me and what I was good at, and it seemed to work for patients. I’m mostly retired now, but I still staff a clinic for the residents. It doesn’t amount to much, but I do that and I do some medical legal work and second opinion things and lecture for the residents. But the bulk of the work, which was my private practice, I’ve stopped doing that. VP: It was 5 years ago when I retired. I gave a 6-month lead time for everyone, for my partners, for patients. During that 6 months, I had a lot of patients who were return visits. I would explain that I wouldn’t be there for their 6-month visit, that they would be seeing someone else, and that we would help arrange that for them. A lot of patients would cry—“No, you can’t go!” One woman literally sat on the floor, holding my leg, saying “No, no, don’t go!” I’m like, “Okay, you have to get up now, [laughter] this is really not okay.” I did get better at the process. I learned to save it for the end of the visit. “Okay, we’re going to go across the hall now, and as we go, let me just tell you what’s going to happen.” Because it was just too painful. But it was good to have that validation from patients who seemed to feel that I had helped them a lot. KD: Of course. VP: I think that’s the main thing. And I ended up publishing a fair amount and that was nice. I’m proud of that and lecturing a bunch of places. But I think what came to mind when you asked that question really was being a Calix et al: J Neuro-Ophthalmol 2021; 41: e774-e784 clinician and how to do that and how to teach it, because I also feel like I got good at that. Not just that everybody left the room feeling better, but to explain to a student or resident what they had just seen. And I see Kathleen nodding here, because she knows exactly what I mean. Because often there’s the patient in the chair and then there’s the concerned spouse in your side vision, in the other chair over there. And so, after a while, you get better at picking up “Okay, there’s an issue there.” The wife is shaking her head, looking dubious. So, flashing on that, picking that stuff up quickly, and addressing it. Or with the patient, “Wait, what was that face? I just said we’re going to get an MRI, is that not okay for you? What did that face mean?” “I’m thinking, if I were you, I might be discouraged. I waited all this time, I thought I was going to get an answer today and now you’re being told, “You need to come back for another test.” “Well, yeah, yeah, that’s what I was thinking.” “Okay, well, let’s talk about that.” VP: So that’s what I mean by being in the moment. How to do that stuff with the patient, and then to be conscious of it enough to explain it to a student. Or even adjusting interpersonal space. Of course, now it’s different; we can’t do that now [due to the pandemic] But in past times, when you wanted to get closer to a patient, like when you pick up that they’re getting nervous or they’re getting sad, you could scoot your chair over. It helps to have chairs on wheels. Kind of scoot over and be closer because you need to do that, and other times, you might want to pull back. I assume that patients are anxious about the process of being a patient, maybe they aren’t all. But I start with the assumption that they are, and that they’re afraid. That’s probably informed by my experience of being sick as a child, of being hospitalized for polio at age 6. So, I think that’s my concept of being a patient. I figure everybody’s scared, anxious, and so my effort is that anything we can do to diminish that is going to be good, except for certain diseases in certain patients. Like glaucoma, which is not something I treat, but ‟It’s going to be okay.” “Really? Good, because I don’t want to take this medicine that’s expensive and keep coming. She said it was going to be okay.” VP: So for some patients, you really want to put the fear of God in them. “People go blind from this.” Pseudotumor is the most common for us. For those patients you want them to be kind of scared. So, you judge, “How scared is this person?” You want them just the right amount so that they’ll be compliant, not fall off the edge on either side. So that’s the kind of stuff that I would always talk to residents or students about, consciously “Did you see what happened in the room? Did you notice this? Did you hear that?” And that theme came to be more interesting to me over the years than grading the relative afferent pupillary defect or the degree of disc edema. “Is it a plus 2 or a 3? I honestly don’t care.” It’s important. I understand why it’s important. And e781 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Great Conversations I learned all that stuff, but I think there’s something about doing it for a long time that affects people in different ways. RC: It’s interesting to hear about how Dr. Patterson really influenced you with her style and developing those instincts over time and trying to teach the trainees to work at developing those instincts, I think it’s really interesting and really good. VP: It’s important. And I worry that they don’t get enough of that. The only way to get that really is by example. They’ll imitate their mentors. I was in group therapy for a number of years and I learned a lot of things there that applied to being with patients. Like when a patient would say something complimentary, like, “Well, my doctor says if you can’t help me, no one can.” or “He says you’re the smartest person he knows.” And I think most of us, many of us, get flustered hearing that. “Well, let’s move on to something else.” But that doesn’t capture the moment, you don’t get to feel it. I learned to just say what I’m feeling. “Oh, that’s so touching, so sweet. Thank you.” That’s all. Then you move on. It requires an awareness of who is this about? Is this about me? Or is it about the patient? Learning to be aware of that difference and learning to control it. VP: Another example: When I don’t know the answer for a case I’m likely to be irritable. “Well, did you bring your scan with you?” “No.” “Did you not receive a letter explaining how important it was to bring your scan.” I came to understand that I only doing that because I don’t know what they have. If I knew what they had I’d be saying, “Oh, it’s okay, we deal with that all the time, we’ll send for it. No problem.” So that’s about my own discomfort at not knowing the answer. There’s this reflex thing to try to shift it to somebody else. “Well, maybe if they had sent me the records, I would know.” The worst is shifting blame onto the patient. We ask them, “Did you use the artificial tears 11 times a day?” They say, “Well, maybe just 10.” We say, “Well, there you are.” This can be done in body language—to imply that it’s their fault that they’re not better, not MY fault. That stuff came to be more interesting. And I developed more awareness from dealing with it in the setting of group therapy. I felt good toward the end about melding that work into my clinical practice. RC: Absolutely. So now, I don’t know that you have much free time, but what have you been doing in your free time? VP: Well, now I have almost nothing but. And that’s the irony. Now I have a lot of free time. I was so overworked for so long. But anyway, I did stuff the hard way, always. So, when I first retired, I thought I had overworked so much for so long that I would never run a risk of feeling either guilty or bored that I’m not doing enough. “Shouldn’t I be doing whatever?” Like, “No, no, I did that, I did all that.” So now I could go for a pedicure every day and it would n’t be excessive. Now it’s my turn. I believed that, and it was true at the beginning, it’s a little less so now. I guess it changes over time. What I do now, pretty much every day, is I practice the violin, and I study Italian. e782 VP: I’m always trying to learn Italian. I bought a house in Italy 3 years ago and renovated it. And now I can’t be there. I don’t expect sympathy for this from anybody, but the fact is since the quarantine, I haven’t travelled and that leaves out a lot for me. Besides Italy, I have grandchildren. My kids are bicoastal, I have 2 daughters on the East coast, a son on the West coast, 4 grandchildren on the East coast, and I’ve not seen them this past year. Nor have I gotten to Italy in the past year. I’ve been kind of stuck; stuck is not the right word because it’s been okay. I’ve just been here and it took me quite a while, a surprisingly long time, to get up to speed on this; to develop a rhythm and a routine for how to do this. But now I have. Each day I do some Italian, some violin, I do an exercise class online, and Italian lessons online. I play quartets twice a week now. I read a lot of books. I have a book club. And I staff clinic for the residents twice a month. I review articles for journals. I do some consultation work—second opinions on cases in which somebody’s done the hard part already and I can come in and explain it or sometimes clean it up, so that’s fun. When the weather is nicer I work in the yard. I talk too much to my cats. Does that answer what I do? RC: Oh, absolutely, thank you. It seems like you had such a natural progression through your career, despite pursuing all of these other interests, a natural progression to neuro-ophthalmology because of these incredible mentors. What would you say to someone if you were trying to influence them into pursuing neuro-ophthalmology? VP: What’s interesting is I left out this really important piece. I think I got so caught up with the individuals, the personalities involved, but I left out the part about the field itself. I usually tell people is it’s one of the last bastions of old-fashioned clinical medicine, where we know what people have from the story and a little bit of exam. And that’s what we do. And what drew me to it was that. What I loved about neurology from the beginning was that it brought order to chaos. Somebody comes to the emergency room who can’t walk for example. Well, there’s maybe 6 possibilities. Why can’t they walk? It could be weakness, it could be pain, could be this or that. You listen, you go through those. VP: So, for the ER person it’s like, “Well, I don’t know, we couldn’t get him up. He just didn’t walk. Call neurology.” And then as the neurologist, you can figure out is it spinal cord, is it brain, toxic, metabolic. Where is this? That’s what I mean by bringing order to the chaos, to the confusion. Well, what I discovered is neuro-ophthalmology does the same thing for both ophthalmology and neurology. What starts with, “He says he can’t see but the eye looks fine.” We can figure that out. What starts out as a puzzle and a mystery, we can bring order to it. And what I usually say is on a good day we can do that. The magic doesn’t always work, but it often does. Neuro-ophthalmology is a great field if you like that process of problem solving. One of my kids, my son, is very much into problem solving. Calix et al: J Neuro-Ophthalmol 2021; 41: e774-e784 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Great Conversations VP: I recognize that trait when I see it in him. That process of moving from, “I don’t get this,” to “Aha, now I get it!” But I found that got harder to do over the years. The way I learned everything was by starting out confused. But it’s so uncomfortable to be at that point of not knowing—the anxiety that goes with “I don’t get it.” I think eventually I didn’t want to sit with that anxiety any more. It was like climbing the mountain, I just wanted to enjoy the view. I didn’t want to be that confused or that anxious anymore. I just wanted to enjoy knowing what I know. More than ever I admire Henry Van Dyk’s ability to still be excited after all that time. There are people in our field who maintain that curiosity, that willingness to be on that cutting edge—not like in technology but the cutting edge of, “I don’t understand this, can I shine a light in this dark spot?” There are people who continue to do that even after many years. VP: David Cogan is one who comes to mind. He’s passed away now, but in his later years, he was really elderly and still so much wondering about stuff and still thinking about it and figuring it out and exploring. I mean it was impressive by any measure, but I’m more impressed now that I realize I just don’t have the energy to be that confused any more. For me, it feels like anxiety, that’s how I experience it. Maybe, other people don’t experience it that way, so it’s not as much of an accomplishment to continue to do it. What I tell residents about our field is that it has drawbacks, some practical drawbacks in terms of finding a job, earning a living, that stuff. I think many of us don’t try to recruit people into our field, and we should be doing that. But I tend to see it from the opposite side. If you put up some roadblocks, like “You’ll never get a job, you won’t do surgery,” the people who still make it through are like, “Yeah, I know but, boy, this is so great, I just want to do this.” That’s who we want. And they do it and they love it. And there are these people every year, there’s people who find it and are captured by the same thing that captured us, and they should be doing it. VP: And I know there are reasons to not do neuroophthalmology from both specialties. I was on the NANOS board when we did a study of why residents didn’t go into neuro-ophthalmology. It was so interesting. For neurologists, it was being put off by the complexity of the eye, learning the anatomy, the exam, the optics, all that stuff was daunting. For ophthalmologists, it was not getting to do surgery, which is totally understandable, as most of them went into ophthalmology to do microsurgery. And to tell them, “Oh that part? No, no, you won’t be doing that part.” That’s not okay. So, it’s already a smaller group. But if you don’t try to make it sound too great—if you just show it, do it, and let them judge. Because just over time, Calix et al: J Neuro-Ophthalmol 2021; 41: e774-e784 FIG. 7. Jon Trobe with Valerie Purvin at a NANOS meeting. there’ll be people coming through who just think it’s fabulous. Okay, I know the disadvantages, but I just want to do that (Fig. 7). RC: So, we just need to identify those people and encourage them and nurture them? VP: Well, yes, they’ll identify themselves. I think the department needs to allow and encourage exposure to our field. This was sometimes a point of friction between me and the Neurology department. Neuro-ophthalmology was never a requirement for the neurology residents in my program. It is, of course, for the ophthalmology department— it’s a board requirement. So how much varies, but our residents do 2 months of full-time neuro-ophthalmology during their second year. For neurology residents, it’s always been an elective, and they have very little elective time. I have faulted the department for not making it a requirement. VP: I think many more people would be attracted to the field if they got closer to it. There’s a way of getting close to it that only happens when you’re seeing patients in the clinic with a neuro-ophthalmologist. You cannot get it from a lecture, or a book, or a podcast, or a YouTube video. So, we should be encouraging that. RC: Well, were there any other topics that you had thought about that you wanted to mention? e783 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Great Conversations VP: I don’t think so. And it’s a treat, I didn’t start out by saying, but this is such a treat to be asked to do this and to do it. So, being asked was a huge treat, but the experience of doing it has been just like the world’s best first date or something. Let me tell you all the adorable stories that I can think of. RC: I’m so glad you’ve enjoyed it, and I’m sure I can speak for Kathleen and Meagan, this has been such an enjoyable conversation. MS: Yeah, it was great. e784 VP: Thank you so much for doing this. KD: We can’t thank you enough for sharing such wonderful stories, and because these are the kinds of conversations that help us understand who we are and where we’re going and how people make it, and it’s really great. And it’s a pleasure to see you, oh my goodness, I miss seeing you so much. VP: Yeah, this one’s a treat. Kathleen, great to see you again. Calix et al: J Neuro-Ophthalmol 2021; 41: e774-e784 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited.