A Great Conversation With Jonathan Trobe

Great Conversations Section Editors: Meagan D. Seay, DO Rachel Calix, MD A Great Conversation With Jonathan Trobe Rachel A. Calix, MD, Meagan D. Seay, DO, Kathleen B. Digre, MD V alerie Purvin (VP): I am struck by how your early life was so different from most of ours in this country. You were born in Pittsburgh, PA, but then pretty soon after that, you left to live in Europe. How did that happen and what was that like? Jonathan Trobe (JT): I was 4 years old when we left the States. My father was recruited to render services to Holocaust survivors in Europe, so we were sent in 1947 to Vienna. He had been in Europe since 1944, working for the American Jewish Joint Distribution Committee in Lisbon, trying to recruit ships’ captains and ships to get Jews out of Europe. If they got into Spain and then Portugal—those were neutral countries—the Nazis were less likely to get them and send them to the death camps. There were some successes, but of course, a very small number. VP: So postwar Europe right in the thick of it with Holocaust survivors could be pretty grim, but you were just a little kid. Were you spared seeing and hearing about all of that? JT: Completely. I had no idea. VP: Good for your parents. Was your early education in European schools? JT: My parents had already decided that our family would move around and that we kids would then have to go to different school systems, so they put us in the international schools of Europe and later South America. VP: Then your language training was more on the street, so to speak, from living there, not from going to school, I guess. JT: Yes. VP: Which languages did you speak? JT: We were first in Vienna, so that was German. Then Geneva—the French part of Switzerland—so French. Then Rome, Italian. Then Paris, back to French. Then Rio, which was Portuguese, and finally Tel Aviv but I was too old by that time, so I never learned Hebrew! VP: Given that your father was not just active, but so involved in Jewish relief efforts, were you brought up with a lot of Jewish observance and training and education? Departments of Ophthalmology and Neurology (RC), Ochsner Medical Center, New Orleans, Louisiana; and Departments of Ophthalmology and Neurology (MDS, KBD), University of Utah Moran Eye Center, Salt Lake City, Utah. The authors report no conflicts of interest. Address correspondence to Rachel Calix, MD, Ochsner Medical Center, 1514 Jefferson Highway, Jefferson, LA 70121; E-mail: Rachel. [e-mail] 396 JT: Observance, no. Jewish culture, yes. VP: Did you have a Bar Mitzvah? JT: No. My mother said she was allergic to anything religious. She grew up as a socialist. My father’s father was a rabbi but maybe because my father was keen to assimilate, he avoided religious observance. So even though he devoted his career to Jewish social service, there was little observance in our household and I continue that way. VP: Which values from Jewish culture came to bear on your life and your career? JT: I draw an example from the attitude of the Jewish survivors of the Holocaust. When my father was in charge of the displaced persons camps in Europe, he once brought me a playbill from one of the camps. On the cover was written: “Hamlet by William Shakespeare, translated into Yiddish and improved.” VP: It’s a great story. As a child in Europe, were you an avid reader? Was that a part of the seeds for your later career? JT: Yes. VP: What did you read? JT: My father wanted us to read the classics—the old white man classics, European things. He’d suggest that we read them in the original language but that was too hard. Trying to read Stendhal and Balzac and Zola in French? I knew people who did this, but I thought it was good enough that I read them in English. VP: Many of us would have thought that also. Was your father proud of you? JT: Yes, he held back a lot, but I think he was. We didn’t constantly feel as though we hadn’t lived up to expectations. No, I look back on my childhood with very rosy recollections. My mother was a big part. She was an artist, a sculptor, and I got a lot of good stuff from her. VP: Like? JT: She held a salon in our living room. In Vienna, Leonard Bernstein had come to our home wearing a turtleneck. My father scurried around the house to find a suit jacket for him so he could be admitted to Demel, the fancy coffee house in town. VP: But you were not aware of who Leonard Bernstein was. JT: No. VP: Interest in the arts, commitment to the arts, was from your mother. What else came from her? JT: An appreciation of art, although I’m still reaching for that. I would say to my mother, “I don’t see anything in Calix et al: J Neuro-Ophthalmol 2022; 42: 396-401 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Great Conversations these pictures. Just a bunch of colors.” And she would say, “Someday you’ll understand.” VP: And someday you did. JT: I suppose. I hope to make up for what I don’t yet understand and appreciate. VP: Right, and you plan to live to be quite elderly. Is not that true? JT: We’re physicians. We never know. VP: Back to childhood in Europe. Any particularly vivid memories, either positive or negative from those years? JT: As a child, I was always apprehensive about a move, not down the street, to another country. I had my friends. When we were living in Rome, my father came to announce that “We’re moving to Paris.” Now, most people would say, moving to Paris, that’s great. And I said, “You may be moving to Paris.” We’re staying in Rome. You can put us children in a foster home. We’re not going with you. You may have a life in Paris, but we have our life in Rome.” VP: But of course you went. JT: Of course. When we arrived in Paris, it was raining, and in school I didn’t know anybody. They all had their cliques. I wasn’t part of them. Eventually, we all adjusted and we’re better off for it. VP: But it’s hard to move kids around. I think it depends on the age maybe. It’s like being a military brat. JT: There were a lot of military kids in our international schools. We also had children of diplomats, businessmen, and Fulbright scholars. VP: In your time as the editor of the JNO, you were always supportive of younger colleagues, especially ones from other countries, people submitting papers whose English was not their primary native language. Do you think that comes from your background of having grown up in Europe? JT: Yes. If a paper had something worth telling but the language wasn’t good enough, I would simply rewrite it with the authors. Most authors were happy about that, but there were some ruffled feathers. VP: I do remember the paper that we wrote together, and I had no ruffled feathers. I was grateful, but you wrote a better version than I did. JT: But are not you the Valerie Purvin who is the coauthor of a wonderful book and of many great articles? I did love our collaboration on dural venous sinus thrombosis (1), Archives of Neurology in 1995. VP: You grew up in Europe right through the end of high school, but then came back to the States for Harvard. You must’ve done something to get into Harvard. Did you have spectacular grades or did you talk your way in? JT: They could not turn down somebody whose father had saved Jews, who had lived in umpteen countries, spoke umpteen languages, and could write. I think the interviewers found me relatively sophisticated compared to most American applicants. Also, I was the editor of the school newspaper, president of the class, on student council, and captain of the basketball team. Calix et al: J Neuro-Ophthalmol 2022; 42: 396-401 VP: We could put a title over you that says, “Not a late bloomer.” JT: An overachiever. VP: I didn’t say that, and I would n’t say that. What did you major in college? JT: I moved around. I went from government to biology to English, and then finally to general studies, where you did not need to write a thesis. Harvard was a daunting place. I don’t think that everybody was really better than I was, but I certainly thought that. At my 25th reunion from college, I went to a tell-all session. To my surprise, everybody said, “I thought everybody else was smarter than I was.” VP: It sounds like becoming a doctor wasn’t part of those 4 years? JT: It wasn’t. I was drawn to journalism. In Rome, the Mediterranean Newsweek bureau chief, a frequent guest at our home, had what I thought was an adventurous life— going from place to place, interviewing people, getting stories, meeting deadlines. When we were living in Rio, the South American correspondent for Time magazine had a job that I thought was pretty wonderful. So, in the summer, after my freshman year at Harvard, I went to work for the New York Post, but I had a very difficult time. I had developed herpes keratitis. My eye was painful, and I was very photophobic. We were in a very grimy newsroom, and I spent most of my time carrying text into the composing room. It was hot and noisy. Printer’s ink was everywhere. I edited the horse racing news—not exactly an uplifting start for a would-be journalist. VP: I didn’t even know there was horse racing news. Someone won and someone lost. The rest of them didn’t win, how much is there to say about it? JT: The newspaper offered its readers betting odds and told them how the horses finished—what you might call a narrow creative environment. VP: The best skill or quality that one would bring to journalism is curiosity about the story. Are there other qualities that brought you to it? JT: Journalism is having a nose for news. I have that and I have applied it to neuro-ophthalmology. VP: And it certainly has shown up in your writing and editing. You have a knack for titles. My mentor, Henry Van Dyke, used to say, “If you can just get the title right, the rest will write itself.” I remember “Carotid Endarterectomy ... Who Needs It?” (2) “Seeing but not recognizing.” (3) “Shunt failure without ventriculomegaly proclaimed by ophthalmic findings.” (4) Are you proud of your titles? Did you work to find them or did they come easily to you? JT: I have had fun finding them. VP: When did medicine come into the picture? JT: After my spell at The New York Post. Back in college as an editor of The Harvard Crimson, I rated my talents as average—not enough for a career in journalism. In the meantime, a medical problem dogged me all through my 397 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Great Conversations college years—herpes simplex keratitis. I was drawn into that world. VP: Drawn in as a patient? JT: Yes. I knew nothing about medicine. Nobody in my family was in medicine. I was not a scientist. VP: It’s impressive how far you can get. JT: Yes, I’ve written my way through. VP: Evidently. Take us through .... JT: I applied to medical school because I thought serving people was a good way to spend your life. I always knew that I could interview people and that I could talk to them and that I liked doing that. Then, if you could handle the science, that was a career. VP: But handling science was, in fact, not a problem, was it? JT: It was, especially at the beginning. For example, I had no idea what an organelle was. You probably knew what an organelle was when you started medical school .. VP: A small musical instrument, a small piano. I had similar lack of science background in college. Did you decide early on about ophthalmology? JT: No. When I graduated from medical school, I thought, “I’m going to be an internist.” But when I did a medical internship, I found it hard. I just could not handle multiorgan failure. Also, most of my patients could not even afford bus fare. When I said, “You have to take your thyroid medicine, you have to take your antihypertensives, your seizure medication,” they would say, “I can’t afford them.” And I thought, “I’m not sure I can do this.” I already knew more about ophthalmology because of my own condition. I forgot to mention that I had undergone a corneal transplant between my first and second years of medical school. VP: So, it sounds like the ability to focus on a smaller field—ophthalmology—was appealing. JT: Also, that you could take care of the patient on your own. And look—I ended up in a field where there is much more collaboration than in the rest of ophthalmology! By the way, that fear of internal medicine was based on being young and insecure. VP: That’s the story. That is a theme. So, it was to be ophthalmology, which you did at Wills Eye .. JT: Yes. VP: But headed toward cornea. How far did you pursue that? JT: After my years at Wills, I was drafted into the military, as all doctors of my age were. I had been able to postpone military service until after residency training in ophthalmology. After that, I went into the Air Force and spent 2 years in Washington, DC, at Andrews Air Force Base. There I had a captive audience of patients—military personnel and their dependents. And they were dependent on me. I did several corneal transplants and had good results. I decided to be a corneal fellow. I applied to 2 programs, which were very prestigious: Harvard, where I had been, 398 and the University of Florida, where Herbert Kaufman was the chair of the department, and also an internationally known corneal surgeon. At Harvard, I was told I’d first have to spend a few years in a laboratory working on the tear film. I could not see spending 2 years on the tear film. Then I visited the University of Florida. It was December, but warm. Thom Zimmerman, an old friend from internship, who was in training in ophthalmology, took me out at midnight to play tennis—outdoors! And then I met Kaufman, who had interesting people around him. Kaufman said, “You can come” and so I did. Six months after I got there, they drafted me to direct the ophthalmology program at the veterans affairs (VA) hospital. Our ophthalmology service was on the same floor as neurology and neurosurgery. The cognitive neurologists invited me to go on rounds and I got swept into that. The more time that I spent there, the more I thought why not neuro-ophthalmology, an interest that had been kindled by Norman Schatz at Wills. VP: I think he had that effect on more than one generation. JT: Yes, he did. I didn’t want to go too far away for fellowship, so when Joel Glaser and Bob Daroff were willing to take me, I was ready to go to Bascom Palmer Eye Institute in Miami. VP: And your memories of that year—that clearly formative year? JT: It was a wonderful year. Joel Glaser was a genius, and Lawton Smith, the great raconteur, was there. And so also was Daroff, who was pathbreaking in ocular motor physiology. And Noble David (5), a true polymath. Bascom Palmer itself was full of great people (6). VP: I think it was referred to in the JNO as the mecca of neuro-ophthalmology. JT Yes, I wrote that! (Figs. 1–3) VP: You interviewed many of these individuals for something called the Legacy section of the JNO. I would recommend to anyone who’s reading this, to spend time reading some of those. You’ve been a physician, a clinician, FIG. 1. My father, Hillel, practicing the flute in Paris, one year after we arrived in Paris, where he was in charge of Jewish emigration out of Europe. Calix et al: J Neuro-Ophthalmol 2022; 42: 396-401 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Great Conversations FIG. 2. My mother Ruth, brother Tom, and me, arriving in Vienna in 1947, where my father was assigned to provide services to Holocaust survivors in the displaced camps of Austria. FIG. 3. In the courtyard by the tennis court in Vanderbilt Hall, the dormitory of Harvard Medical School, in my second year as a medical student. I had probably lost a match to Michael Marmor, MD, who became a famous ophthalmologist and chair at Stanford. Calix et al: J Neuro-Ophthalmol 2022; 42: 396-401 a writer, an editor, a teacher, a mentor. It’s not a competition, you don’t have to pick one, but which are you most proud of? JT: Being a teacher—having trained fellows, medical students, and residents. And taking care of patients. I sometimes wonder if I’ve learned more from them than they have from me. “Oh really, you’re a pilot? Well, what do pilots do?” VP: My mentor, Henry Van Dyke, with whom I did my fellowship, used to come in and we’re ready to have him pronounce about the optic disc, is it pale, temporally, yes or no. And he would start with, “So you’re a pilot, so how did you get into that?” And we’d all roll our eyes and think, “Oh my God, he’s doing it again.” So, I know ... And then flash 4 years later, I was doing that! JT: Yes, one of the reasons I admire you is that you love a good story (Figs. 4–7). VP: What changes have you seen in the field, and specifically neuro-ophthalmology, over these years that you’ve been in the specialty? JT: The single biggest change for me in medicine is the entry of women. Women bring a different mindset, a different consciousness. Medicine becomes more collaborative, more ego free. VP: Certainly, no argument from me. I think we’ve done a pretty good job of being inclusive. What else? JT: New technology. In our field, it’s MRI. I remember when Norman Schatz first said, “You know there’s this thing called MRI?” And I said, “MRI? What’s MRI?” And he said, “Wait, you’ll see.” And then it happened. Now we can’t go back. Some people think that one MRI is worth a 1000 neuro-ophthalmologists. Maybe 500. VP: How about some words of encouragement or enticement for medical students and residents for why they might consider neuro-ophthalmology . JT: Many ophthalmologists think, “Oh, I’m not going into that field because there’s no surgery in it.” Well, there can be, and certainly many ophthalmology-trained people within our field do eye surgery. I have. Many neurologists FIG. 4. Teaching Jeffrey Zink, MD, University of Michigan ophthalmology third year resident, 2004. 399 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Great Conversations FIG. 5. With my sons Julian (left) and Noah (right) and wife Joan Lowenstein at Comerica Park, downtown Detroit, 2006. The Tigers probably lost. think, “Oh, it’s the eye. I’ll never learn how to examine it.” Maybe not in a month or two, but eventually. Besides, neurologists think more broadly about disease mechanisms than ophthalmologists, which gives them an advantage. I’ve trained over 50 fellows—half ophthalmologists, half neurologists. There are different challenges. You fill in the missing pieces. VP: We skipped over that unusual aspect of your career. Rarely, somebody does both neurology and ophthalmology, and then neuro-ophthalmology, but you took a different route to do ophthalmology, neuro-ophthalmology, and then go back several years later after you were a tenured professor and chose to do a whole neurology residency. I assume you thought that was a good plan, that was worth it, taking the extra 3 years? JT: From the time I started my neuro-ophthalmology fellowship, I thought “I really think I need to do a neurology residency. I feel very uneasy about my lack of neurology,” Daroff said “Don’t do that; you’ll spend most of your time talking to people who have headaches.” And of course, he was right, but I still feel that it was the right thing to do. VP: It certainly puts you in an unusual position, and hence my question about comparing the 2 different FIG. 6. NANOS Dinner 2009 with some former neuro-ophthalmology fellows and Wayne Cornblath, MD (back row, second from left). Front row from left: Maud Jacob, Kara Warden, Shlomo Dotan, Hideki Chuman. Back row: Iris Benbassat Mizrachi, Marie Acierno, Adeela Alizai. 400 FIG. 7. With Klara Landau, MD, Ophthalmology Chair at the University of Zurich (Switzerland) and her husband Ehud, beside the Lake of Zurich, 2012. specialties or specialists and what they bring to the problem because you really have seen it from both sides. JT: Expertise is a funny thing, especially as you get older. Many, many years ago, before I even got into neuroophthalmology, I used to go to the Armed Forces Institute of Pathology for a Friday afternoon pathology session with Dr. David Cogan, who was in the late stages of his career but still sharp. We would show ophthalmic pathology slides and smart people would discuss them. Once I turned to Dr. Cogan, who had not said a word, and I asked, “Dr. Cogan, what do you think?” And he said, “I don’t know the diagnosis.” I pursued him: “Dr. Cogan, if you don’t know, then we don’t know and that makes us feel very uncomfortable.” He said, “I’m sorry. I used to know but now I’m not so sure." VP: What a great story! I’ve been impressed, and again looking back at your CV, at how many papers, especially early on, that you wrote that were on very, very different topics. You didn’t develop a technique and just apply it. They’re all over the place, like higher cortical visual function, third nerve palsy and the pupil, thyroid optic neuropathy, distinguishing skew from a fourth nerve palsy. Do you have words of wisdom for how to do that? JT: I just ask: is this an interesting problem? are there unanswered questions? am I the right person to tackle it? VP: This seems to me, yet again, an aspect of your talent for bringing journalism to medicine. I always thought that being editor of The JNO was the perfect job for you, like a pinnacle. Did it seem like that to you? JT: Absolutely. VP: So, as this field of ours continues to grow, do you have any words of wisdom or advice for people entering? JT: There are plenty of jobs—academic and community— more than ever before. We are in demand! But if you want to become a neuro-ophthalmologist, you must be prepared for a lot of patients in whom you don’t know the answers. You’re Calix et al: J Neuro-Ophthalmol 2022; 42: 396-401 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Great Conversations going to have lots of people with psychogenic illnesses delivered to you in somatic disguises. But the problems are interesting—like puzzles. Be advised that you must learn to be good at interviewing people—at extracting the missing pieces. I am always being told by my trainees, about a patient, that “so and so is a poor historian.” My reply might be, “You know who the historian is? You. You’re the historian.” Kathleen Digre (KD): Jon, I want you to tell us what do you think was the most important successful thing or things in your career? JT: Mentoring trainees and editing writers. VP: Again, your work speaks to that, but what I would consider the generosity of spirit there, the mentoring and teaching, not, “Oh, I published a lot, I wrote 20 books, I published 200 articles,” both of which are true, but editing other people’s works, teaching other people is enormously generous. I would add your innate curiosity. I think kids all start out curious. Why is the sky blue? It gets perverted or damped down. But yours somehow didn’t do that. It grew, it just grew. JT: I have not always been very good about timing my curiosity. It’s a lot easier to be curious when you’re in a position of power. VP: That’s a good point. In recent years, my role at grand rounds for our ophthalmology department has been my willingness to say, “Wait, what’s that little blue or that little red thing? What’s that white spot? That thing over there, is it an artery or a vein?” So now at this stage, when you’ve had all that career, what else would you like to do? JT: I have an interest in doing a radio show or podcast on health, to interview people on hot topics. The title might be something like, “Is it good for your health, or is it bad for your health?” It’s very hard to get people to say that something is not good for you, and that’s the challenge. In medical reporting, too often we get the public relations view. KD: What do you do when you’re not a neuroophthalmologist or teaching residents, or writing papers, or guiding your fellows? JT: I read, I listen to music, I play tennis. VP: What do you read? JT: I read more nonfiction than fiction. History. Steve Newman shares books with me. I read what he sends me! VP: Some of us also watch TV. It’s streaming, not just movies, but series where you could binge, watch an entire 3 seasons, which I confess to having done some of, just so I could have something to talk to my children about. Do you do any of that? JT: Yes, with great avidity. I love “limited series.” The Crown. The Drop Out. The Bridge. My wife Joan and I go for British, French, Scandinavian. The more Nordic, the better—gnomes and ogres, dark woods, raining all the time, deep snow. Bodies carved up and left under bridges. Rachel Calix (RC): Having trained over 50 fellows, what is your take on training providers in neuro-ophthalmology? Did you find a style that was especially successful? Calix et al: J Neuro-Ophthalmol 2022; 42: 396-401 JT: Many fellows who come to us are very skilled in ophthalmology or neurology, but not great at asking the second question, the follow-up question. They can ask “when did your problem start?” But what’s next? The other important task for us trainers is to fill in the missing background. For ophthalmologists, it is understanding the nervous system and thinking like a neurologist. For neurologists, it is getting up close and personal with the fine points of the eye. Ophthalmologists must be immersed in the care of neurologic patients. That means being on the ward, going to the bedside. If you’re phobic about going into the intensive care unit (ICU), we’ve got to get you into the ICU more. I had to overcome that fear. It is scary when there are lines everywhere, and the patient has an altered mental status. The examination of the diplopic patient needs attention. It is muffed all the time. RC: And on the flip side of that, with neurology-trained neuro-ophthalmologists, what do you think is the best way for them to fill in the blanks? Is it time at the slit lamp, rotating through clinics, reading a textbook? JT: You know the Oslerian dictum! if you are seeing patients without reading, then you are sailing an uncharted sea. But if you are reading and not seeing patients, you’re not going to sea at all. So, if you are a neurology-trained person and you are trying to do neuro-ophthalmology, you must get comfort with the indirect ophthalmoscope, the 78, and the 90. And the slit lamp—handling it over and over and over again with supervision. We cannot have you learn about Fuchs dystrophy from looking at pictures. A final point, fellows of all stripes cannot get enough neuroradiology. We hold a 2-h conference every Friday in which faculty, fellows, and rotating residents and medical students must participate—and present cases we’ve examined in that week. Our neuroradiologists take turns leading those conferences. We learn from them. They learn from us. ACKNOWLEDGMENTS Drs. Seay and Digre are supported in part by an Unrestricted Grant from Research to Prevent Blindness, New York, NY, to the Department of Ophthalmology & Visual Sciences, University of Utah. REFERENCES 1. Purvin VA, Trobe JD, Kosmorsky G. Neuro-ophthalmic features of cerebral venous obstruction. Arch Neurol. 1995;52:880–885. 2. Trobe JD. Carotid endarterectomy. Who needs it? Ophthalmology. 1987;94:725–730. 3. Trobe JR, Bauer RM. Seeing but not recognizing. Surv Ophthalmol. 1986;30:328–336. 4. Katz DM, Trobe JD, Muraszko KM, Dauser RC. Shunt failure without ventriculomegaly proclaimed by ophthalmic findings. J Neurosurg. 1994;81:721–725. 5. Available at: https://www.legacy.com/us/obituaries/ timesunion/name/noble-david-obituary?id=19843598. Accessed May 1, 2022. 6. Glaser JS. The golden age of neuro-ophthalmology at the Bascom palmer eye Institute, J Neuroophthalmol. 2002;22:222–227. 401 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited.