A Great Conversation With Michael Slavin

Great Conversations Section Editors: Meagan D. Seay, DO Rachel Calix, MD A Great Conversation With Michael Slavin Meagan D. Seay, DO, Rachel A. Calix, MD, Kathleen B. Digre, MD K athleen Digre (KD): Today we have a special treat. We are having a Great Conversation with Michael Slavin (Fig. 1). During his career Michael attained the rank of Associate Professor of Ophthalmology at the State University of New York at Stony Brook and then Professor of Ophthalmology and Neurosciences at Albert Einstein College of Medicine. He has been on Long Island, New York for his entire career. Michael, we’re so glad to have you with us today. Thank you for being with us. Michael Slavin (MS): Thank you for inviting me. KD: I would love to start out if you would tell us a little bit about your background before medical school, even starting in childhood. MS: I was fortunate that my parents decided to purchase an upright piano with the intention of my brother (5 years older than I) taking piano lessons. While he himself quickly lost interest in the whole idea and after 3 years quit, I slowly gained interest while enthusiastically watching his lessons. At age 5, I began taking piano lessons and over only a period of a few years was able to reach a relatively high level of proficiency. Throughout public school, I was already playing local concerts and at age 9, gave a performance of Haydn’s piano concerto in D Major (Hob. XV111/11) with a local orchestra. This was soon after followed by a performance of Mozart’s coronation concerto and Beethoven concerto no. 1. MS: When I was in elementary school, we would have a weekly assembly for all the students of every grade in the school. I would often be called to play a short piano work during these meetings. If any time was left before the end of the assembly, the teacher in charge would say: “Is Van Cliburn here?” After the very first time hearing that, I realized that she was talking about me and calling me Van Cliburn. And then she said, “Will you come up and play the piano?” That was quite a compliment in those times as Van Cliburn was believed to be one of the world’s most famous pianists. Van Cliburn had just won the first prize in Departments of Ophthalmology and Neurology (MDS, KBD), University of Utah Moran Eye Center, Salt Lake City, Utah; and Departments of Ophthalmology and Neurology (RAC), Ochsner Medical Center, New Orleans, Louisiana. M. D. Seay and K. B. 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. The authors report no conflicts of interest. Address correspondence to Meagan D. Seay, DO, 65 Mario Capecchi Dr., Salt Lake City, UT 84132; E-mail: [e-mail] 434 the international Tchaikovsky piano competition in Moscow, which was a monumental event being that it was awarded to an American during the height of the cold war. While I was honored by all of this, it was somewhat stressful to be expected to play a different piece each time almost on a weekly basis! MS: At age 9, I was accepted to be a student at the Juilliard School of Music precollege division, which continued on until the end of high school. The music school activities took place all day Saturday and Thursday afternoon. That occurred concurrently with my regular local public school education. In addition, I would spend several hours a day practicing the piano. I cannot say that my life style was anything but hectic! By age 17, I needed to make a major decision: do I continue on with music and enter the Juilliard Conservatory for college or do I go another route? That nagging dilemma was seriously pitting music against academics for the first time! MS: Although my overall schedule was difficult (especially in high school), I excelled in both arenas. I won many piano awards and competitions. I played with various orchestras, gave a lot of recitals-mostly at Juilliard itselfand most people told me, “This is something you should do as a career.” And in fact, if you asked me when I was 9 or 10, what are you going to be when you grow up? I would say that I was going to be a concert pianist. Same answer at age 16. No alternative (Fig. 2)! KD: Wow. MS: But you know what (?), I did not become a pianist [laughter]. Or at least, it did not become my primary profession. So, what was the conflict there? The conflict was my academics. I was an excellent student. I was accepted to the SP in junior high school (special progress), where you skip a grade or take a very enriched curriculum. MS: Also, after passing a difficult entrance examination, I was accepted to study at Stuyvesant High School, a wellrenowned public college-preparatory specialized high school in New York City. A major problem with going to Stuyvesant for me would have been that it took a bus and a train ride for about an hour each way from my house in Brooklyn. I therefore declined to go to Stuyvesant and wound up going to the local high school where in the end, I was chosen to be the valedictorian. MS: In addition, in high school, I was on the math team, and indeed math and science (chemistry, biology, physics), were my favorite subjects. I thought, “Wow, I would love to be a mathematician.” I really loved, and was good at, solving Seay et al: J Neuro-Ophthalmol 2023; 43: 434-439 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Great Conversations FIG. 1. Michael Slavin in 2021. math problems (puzzles). On the math team, we would have local competitions in which we were given math problems and were asked to solve it in a limited time period. I enjoyed trying to “beat out” the other kids doing that same task!! Fast forward—Is that not what we love about neuroophthalmology, that is, problem solving? (!) KD: Yes! MS: At age 17, I indeed decided to apply to a standard college, specializing in science, and continuing with my music education through private lessons and study. I attended the Cooper Union, in New York City, and majored in Physics. So, is it possible to do those 2 things at the same time and excel in each? Absolutely not!! I do not think that that is remotely a possibility, because once the college courses start to filter in, most of one’s time is taken up, and music and other activities are forced to take a backseat. Little by little, I saw the time dedicated to music diminishing—although I never gave it up. Rachel Calix (RC): It seems you had these dual, very strong interests in music and academics. Did any of that come from your parents or was most of that internal? MS: I would say that most of that was internal. My open-minded parents wanted me to excel in whatever I pursued. My mother was a typical “backstage” mother and she hoped that I would choose music as my career, because she loved the idea that I would be a “star” and she would be the star’s mother. [laughter] I think my father just thought that I should do whatever would make me happy. KD: Michael, how did you decide to go to medical school, if your interests were math and physics? MS: Although I strongly enjoyed my college education, unfortunately, by the third year of college, the curriculum had become a bit too abstract for my liking (quantum physics, advanced complex variables, etc.) and did not seem to suit me (or deal with reality) as well or as much as I had Seay et al: J Neuro-Ophthalmol 2023; 43: 434-439 expected. I felt that if I indeed decided to continue in science, that I would have most likely pursued a PhD program and eventually wind up becoming a college professor or a researcher. Those ideas however became less appealing to me with time. Then, I heard about and started to think about medicine (which was a very popular destination in those days), which I felt not only included science, but also allowed one to bring one’s own personality into the mix. I also thought that in medicine I would have the ability to do something really special; not only for myself, but perhaps solve other people’s problems. After then, I took an advanced biology and organic chemistry class, both of which further stimulated me more toward the direction of medical school. So, I applied and was accepted to Albert Einstein College of Medicine (Fig. 3). MS: By the way, if I had to give little Michael advice regarding the choice between a childhood passion vs. remaining in academics, I do not think I would do what I did. I think I would say: “Why don’t you give music a try? Put aside a couple of years and see how it goes. If for whatever reason you change your mind at any time, it will not be too late to then proceed with any academic education that you choose.” KD: Right. MS: So, to repeat, I think I would have given music at least a fighting chance. For many years I did think that perhaps I missed out on something. I really felt that way when I heard that 30-year-old pianist Andre-Michel Schub had won the professional Van Cliburn Competition. Schub was a fellow classmate at Juilliard Pre-College when we were both just 9 years old. We were in the same theory classes and we had our own personal “mini-competitions” in class FIG. 2. Michael playing the piano at age 12. 435 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Great Conversations FIG. 3. Michael at Albert Einstein College of Medicine graduation in 1976. performance and in piano performance. And I felt like, “Wow, he stuck to it.” He seems like a pretty bright guy also. So. did I miss out on something? By that time, I was already slowly concocting a long-range plan in the back of my mind that someday, somehow, I would return to give music another serious try. And in fact, that dream actually was realized! KD: When you were at Einstein, were there people who got you involved and thinking about ophthalmology as opposed to something else? MS: Yes, absolutely. I took a six-week ophthalmology elective at Montefiore Hospital, which is part of the Einstein system. Paul Henkind was the Chairman and Professor of Ophthalmology, and specialized in medical retinal disorders. I was lucky enough to be able to spend most of that elective seeing patients with him! Although he was mostly evaluating medical retinal disorders, he would also be referred patients with disorders that ran the full gamut of systemic diseases. It was very exciting to learn how to properly examine fundi and review fundus photos and fluorescein angiograms. I remember my excitement at first seeing findings compatible with hypertensive retinopathy or diabetic retinopathy. For the first time I saw a scar because of congenital toxoplasmosis. During that same elective (and again for a second time while doing a neurology clerkship), I met Dr. Herman Barest, a fine ophthalmologist whose major interest was 436 neuro-ophthalmology. He was an extraordinary teacher of neurology and ophthalmology residents, and medical students. He focused on the basics of the neuro-op examination and a thorough development of differential diagnoses. His personality was infectious and one could not help but learn from him. At that time, I also first heard about Dr J. Lawton Smith and I have to say that I was flabbergasted when I started to listen to his tapes! What an educator, what a communicator! How could he talk about the most obscure topics possible, and still make it so interesting (and humorous)!! The two of them made me feel as if the neuro-ophthalmologist were the ultimate problem solver, and the doctor’s doctor. KD: The J. Lawton Smith tapes are in the neuroophthalmology Virtual Educational Library in the NeuroOphthalmology Virtual Educational Library (http://novel. utah.edu). They are all now available online for free in the NOVEL library. MS: Early on in my ophthalmology residency, I met and spent a good deal of time with Dr. Arthur Wolintz, the chief of neuro-ophthalmology in my program at State University of New York, Downstate Medical Center. He was an extremely bright and thoughtful clinician and teacher, and a role model in every way. He believed in evidence-based medicine and had wonderful command of the medical literature. He treated his patients as respectfully as I have ever seen! I grew more and more fascinated by neuro-ophthalmology and by the end of the first year, most of the fellow residents were already primarily consulting me on such cases!! MS: I did a neuro-op fellowship with Joel Glaser at Bascom Palmer Eye Institute. The staff at Bascom Palmer at that time almost constituted the “who’s who” in ophthalmology: Don Gass (medical retina), Doug Anderson (glaucoma) J. Lawton Smith and Joel Glaser among others! J. Lawton Smith happened to be on sabbatical for a good portion of that year, but I was able to get a good amount of exposure anyway and was able to watch him in action. Joel Glaser was the consummate clinician with strong clinical judgment focusing intently on the problem at hand and strongly making use of evidence-based medicine. He had a strong knowledge of the literature and was a superb writer. In addition, he would choose two fellows each year, one ophthalmologist, and one neurologist. That way, the two fellows could learn from each other. My neurology education at the beginning of the fellowship was quite basic. J Lawton Smith was a “celebrity” in neuro-op, and legend has it that when he would give courses at the American Academy of Ophthalmology, there would be people lining the hallways waiting to get in and hear his sessions. After the fellowship, I opted to accept a position in Long Island at what is now Northwell Health. I was one of the first to introduce neuro-ophthalmology as a subspecialty to this area. In addition, my wife and my entire extended family resided there and we both wanted to live nearby. Seay et al: J Neuro-Ophthalmol 2023; 43: 434-439 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Great Conversations FIG. 4. Michael and his wife (Nava) circa 2020. KD: At what point in your career did you meet her and get married? MS: My wife and I both attended college at the Cooper Union. Cooper Union specialized in science and engineering but as well had an art and architecture school. She was studying architecture and I was studying physics and we met in the cafeteria (Fig. 4). KD: That is great. MS: A couple of years later, we married. We have 2 children and 4 grandchildren (aged 7–12). KD: Yes. So where was music in all of this? MS: Well, I did practice the piano, but only sporadically over the years. I played in many chamber music concerts sponsored by The American Academy of Ophthalmology and also ARVO (Association for Research in Vision and Ophthalmology). I played some solo works, and some 2 piano and 1 piano (4 hands) pieces. I played with Dick Sogg, a fellow neuro-ophthalmologist. When I came into neuro-ophthalmology, he was the “piano playing” neuro-ophthalmologist [laughter] and I was the “I-used-to-play-the-piano-neuro-ophthalmologist”. But, slowly and surely, music started to creep back into my life once more. In 1990, I did another fellowship—in genetic diseases and medical retina at Moorfields Eye Hospital in London. At that time in my life and after 10 years of practice, I felt like taking a sabbatical. I thought it would be instructive for me and a great experience for my family. It turned out to be one of the best times of my life. We pulled our kids (9 and 11 years old at the time) out of school. My wife would tutor them in English literature and social studies and I would come home at the end of the day and teach them math and science. Every weekend we would tour around London, England itself and then Scotland, Wales, and Europe. We did this for about 9 months. Best thing you can ever do! Of course, I was not getting paid a penny during all this time. So, as you can see, maybe finance was not my best suit either. [laughter] I picked neuro-ophthalmology [laughter] Seay et al: J Neuro-Ophthalmol 2023; 43: 434-439 and then I actually took off a year at no pay, and selffinanced. By the time I came back it was like, I better start working again. [laughter] You own a home and there is a mortgage. And my wife obviously took a leave as well. KD: Did you seek out that opportunity or is that something that presented itself to you and you said you just had to do it? MS: I wanted to cement my role as an overall diagnostician of visual loss by becoming well skilled in macula and retinal diseases. I also saw many interesting retinal genetic diseases that hardly anyone trained in the US gets to see. KD: Right. Did you just inch back into music? Because to compete in the Van Cliburn competition is a great feat. That is amazing! So, you have to tell us a story. MS: I basically started taking piano lessons again at age 63. I would say that within a year, my technique and musicality had come roaring back. I was as good as ever quickly. In fact, I entered my first piano concerto competition again in Chicago in 2013 (playing Beethoven Piano Concerto no. 3) and I won first prize! The prize was awarded to me officially by Mark-Andre Hamelin, one of my piano heroes. Of course, a little bit of success makes you try even harder for the next bit of success. I wound up practicing 3 to 4 hours a day. That is not easy of course, and it also started to feel a bit like a “job.” In fact, it is a job and I am still doing it. Still enjoying it (Figs. 5 and 6)! KD: Wow. But you were also working in neuroophthalmology at the time. MS: At the beginning of my come back to music, yes and then eventually I slowed down and stopped and was concentrating entirely on music. Fortunately, my wife was picking up at her work, so she was a great support. If you are going to go into a field like music, one better give careful consideration of how you are going to support and feed your family. [laughter] KD: But it is going to feed your soul! MS: It feeds my soul. Well, this is what life is all about, is it not? So, overall, I am very happy, because I feel fulfilled in my former medical career and now the music career (Figs. 5 FIG. 5. Michael playing piano with the Fort Worth Symphony in 2016. 437 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Great Conversations FIG. 6. A fan’s sketch of Michael playing in the finals of the Paris international piano competition. and 6). I am not done yet, by the way. After winning second prize in the Van Cliburn Competition back in 2016, I again won second prize in its 2022 edition. I was the second to oldest contestant. (Age 71.) And I plan to play there again in 4 years and compete for first prize. Meanwhile, I have some concerts scheduled. I have one in Milan this fall and several local events. Hopefully, I keep setting goals for myself, which means I am able to keep practicing. It is still fun. As long as it is fun, you do it. If not, I will have to look for a third enterprise!! Not sure I have one! I do attempt to teach my grandchildren math and music, but in the end, they are not entirely interested in being taught by their grandfather. [laughter]. KD: They will someday look back on it and say, “Oh, are we grateful that our grandfather taught us that math?” KD: Can you share a couple of your favorite performances for our readers? MS: Yes. Two of my favorites are Chopin Ballade no. 1 (https://youtu.be/Ww38yG7_Lr4) and Chopin Scherzo no. 2 (https://youtu.be/42hhwe915Q0). MS: Not only was I very satisfied with my medical career from a patient standpoint, but I was also able to contribute many diverse articles to the medical literature. KD: What is your favorite paper that you wrote? MS: One of my first papers that I wrote with Joel Glaser was on Orbital Myositis before the actual condition was better understood.1 It was initially under the rubric of inflammatory orbital disease. There are 3 other papers that I still recall today, and think that they are very important. The first is asymptomatic physiologic hyperdeviation (HD) in peripheral gaze.2 In that article, I examined random volunteers (medical students, hospital employees, etc.) and measured their ocular alignment using the Maddox rod test. I found that 77% of the 61 patients showed an HD of at 438 least 2 prism diopters (PD) (range 2–10 PD). The HD was mostly observed in the fields consistent with the pattern of overacting inferior obliques. No HD was observed in primary gaze and Bielschowsky head tilt test was negative. This “normal” and likely physiologic occurrence must be carefully considered to prevent the clinician from making a false diagnosis of skew deviation, muscle paresis, orbital restriction, ocular myasthenia, etc. In a similar vein, I found HD associated with otherwise isolated unilateral abducens palsy.3 In 14 of 17 patients examined by me, an HD measured with Maddox rod was noted ranging from 4 to 16 PD (mean 8.2 PD). In most cases, the HD was maximal in the direction of the paretic lateral rectus. In 10 cases, an HD was also noted in primary gaze. When the sixth nerve palsy resolved, the concurrent HD markedly diminished or entirely resolved. The third article that I am very proud of is the use of the prism dissociation test in detecting unilateral functional visual loss.4 In such cases, a small vertical prism is used to create vertical diplopia. The patient (who states that 1 eye sees poorly) will often admit to seeing double and even comment on the clarity of the image that he supposedly does not see. A little cajoling is needed from the examiner, but at least in my hands, the test worked like a charm. KD: Those papers are so good. KD: How do you spend your free time? If you are not practicing, spending time with family, what are you doing? MS: Okay. You mean I have some extra time left over? [laughter]. MS: I enjoy reading and mainly the topics are music biographies or contract bridge. I should mention that I am an avid bridge player and now since Covid, enjoy playing bridge exclusively online. In bridge, the player attempts to solve small puzzles hidden within each hand. I also spend quite a bit of time listening to various classical performances on YouTube. Otherwise, there is babysitting for my grandchildren, and that is quite gratifying! I go to business meetings with my wife and she comes with me to all my concerts, which are often abroad. We almost always add a generous amount of vacation time to all of these ventures So, for instance, I am going to be playing in Milan, in September. Having visited Italy numerous times, we decided that this time we will add a 10-day vacation and visit Croatia. When I played in Munich, we took a side trip to Prague. MDS (Meagan D. Seay): Where do your grandchildren live? MS: I am blessed. I have 4 of them, 3 from my daughter. They live about 8 to 10 minutes east in Roslyn, Long Island, while my son and 1 granddaughter live about 20 minutes west in Port Washington (Fig. 7). MDS: That is great. KD: What do you miss most about neuroophthalmology? Seay et al: J Neuro-Ophthalmol 2023; 43: 434-439 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Great Conversations FIG. 7. Michael’s wife and grandchildren (from left to right: Zoe, Jake, Nava, Dylan and Brooke). MS: I loved teaching residents (ophthalmology and neurology) and medical students. My teaching techniques were very simple. I tried to keep the room lights on, the atmosphere relaxed, and the dialogue flowing. The Socratic method was in full display. I hardly ever used prepared slides or power point, and did not quote many references. I just used a black (white) board. I would present a simple case and go through a logical thought process with them to arrive at a differential diagnosis. An example was an abducens palsy, in which I would insist that they start thinking about the location of the lesion going from front to back—that is, could it be orbital, could it be myoneural junction, and then could it be the sixth nerve in all of its locations (cavernous sinus etc.)? I swear that if I, myself, did not use that same strategy that I would have forgotten to include and would have overlooked multiple cases of ocular myasthenia. Seay et al: J Neuro-Ophthalmol 2023; 43: 434-439 KD: If you were trying to influence someone to go into neuro-ophthalmology, what would you tell them? MS: I would tell them how satisfying it is to attempt to solve these very difficult clinical dilemmas. How you will come up with diagnoses that have previously eluded others. How doing the latter will favorably affect so many patients in a positive way! How you can contribute to the medical literature forever! Would I suggest first going through an ophthalmology residency or a neurology residency on the road to neuro-ophthalmology? That is somewhat difficult to say. I was an ophthalmology resident and it was somewhat frustrating for me. After all, ophthalmology is a surgical subspeciality and a lot of the residency deals with learning surgical techniques, not relevant to a neuro-op career. However, you become adept at refraction, and how to properly examine an eye to rule out corneal irregular astigmatism, cataract, optic nerve changes, and macular and retinal disease. You also learn about strabismus, amblyopia, and how that is different from other ocular motor diseases. Unfortunately, there is a world of neurology that you will need to learn, but slowly I was able to do that! However, the neurologist seeking to do neuroophthalmology has to become quite proficient at examination of the eye, and that will take quite a bit of time as well. RC: Interesting. Thank you. KD: Well, thank you Michael! We really enjoyed this Great Conversation! MS: Thank you for inviting me! REFERENCES 1. Slavin ML, Glaser J. Idiopathic orbital myositis: report of six cases. Arch Ophthalmol. 1982;100:1261–1265. 2. Slavin ML, Potash SD, Rubin SE. Asymptomatic physiologic hyperdeviation in peripheral gaze. Ophthalmology. 1988;95:778–781. 3. Slavin ML. Hyperdeviation associated with isolated unilateral abducens palsy. Ophthalmology. 1989;96:512–516. 4. Slavin ML. The prism dissociation test in detecting unilateral functional visual loss. J Clin Neuroophthalmol. 1990;10:127–130. 439 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited.