Skip to main content
  • Summer 2023 Editorial — Grading on a Curve

    This editorial will have a few swerves (unexpected curves) in it. I begin by addressing one of the elephants in the room of senior ophthalmologists (SOs).

    Whether we are an ophthalmologist with a busy private practice, an academic ophthalmologist deeply immersed in scholarly activities, or someone retired or contemplating retirement, the question that sometimes creeps into our mind goes something like this: “Have I had a successful career and life?” We are at an age when we take stock.

    The British poet Rudyard Kipling says we are successes when “you can keep your head when all about you are losing theirs” which is very romantic but not a reliable score card. American essayist Ralph Waldo Emerson recommends measuring our life by the thought that: Success consists of “winning the respect of intelligent people and the affection of children.” I always liked that. Respect from those who are wise and understand and love from those who know you best, seems a fine aspiration.  But as a scientist, I usually seek a more quantitative approach and one with some measures of objectivity.

    Let me begin by saying each of us has had different professional aspirations. Some will have committed themselves to building extensive practices. Others for having tended to the most patients or those most seriously affected with vision threatening diseases. Some have done this with missions to international ports of call where medical expertise is less available. Some of us have attempted to mentor and nurture the careers of others. Some of us have amassed minor fortunes. Others have sought to make new knowledge and to spread this information through publications or teaching.

    So, imagine a curve with the X axis as time and the Y axis as accomplishment of one or another of these objectives. The Y axis might be patients seen, dollars made or offices created. But in this case, I lifted a curve straight out of Pubmed and it lists by year peer-review publications. Obviously, some papers were less important than others, but let’s skip the details and consider the nature of such a curve.

    Editorial image summer-scope-300x186

    Pubmed analysis of peer reviewed papers published per year. Orange arrows correspond to positive Deltas, green arrows are Deltas that have a
    negative derivative. The derivative of the curve shows these as positive values. Psychologists tell us that brief periods of happiness are most correlated with these.

    Figure 1. This curve, at face value, points out the most productive years and even suggests trends. My quantity of publication output varied a bit (and even reveals some years of increased effort corresponding to my attempts to pump up the dossier just before each promotion). But the trend until 2020 was up. This probably reflects less talent and effort and more that collaborations have increased the efficiency of my efforts. And now, in 2023, the curve is heading down. Any curve of accomplishments will eventually decline (with exceptions such as passive income but that’s wealth, not accomplishment). We slow down. We get old. We retire. For some, this may be discouraging. But I take a different view as this further analysis suggests.

    I have asked some of my mentors what were their good years; their glory years; their golden years. By this, I meant the years that made them happiest that validated their professional efforts the most. Invariably, and without differences for what type of accomplishment they were going for, the golden years were those of maximal growth. Stephen Ryan, MD, who built the Doheny Eye Institute, was clear that the first years of the department, when it grew from two to eight faculty members, was the most exciting and fulfilling period. When he got to over 30 faculty members and was directing a well-oiled machine that was well-funded and secure, he was proud, but not as excited. My colleagues in science often described their first grant and their first cluster of publications as the golden years. What they are all alluding to was the period of time when their Delta, positive change over time, was greatest.

    Let’s reexamine the curve in figure 1. The orange arrows are pointing to years 1984, 1990 and 2008, corresponding to such periods. The bumps are small, but a mathematician would describe these as when the derivative of the original curve was most positive. The curves are arcing up. And indeed, psychologists and philosophers have long known that gaining new ground, a positive Delta, is more likely to provide happiness than having more. There is even a term for it: hedonic adaptation.

    Sanjiv Chopra, MBBS, MACP, at Harvard Medical School, tells us that people who win lotteries get happier, but only for a short while. Then the positive Delta either flattens out, or more likely, pitches back into a negative Delta. That is, what goes up, must come down. And that’s when it hurts. Despite still being rich, Chopra’s studies show that lottery winners are NOT happier a year after their numbers came in.

    Buddhist philosophy addresses this a lot. It contends that pursuing anything external is fruitless. Sadness, misery and a life of discontent are the only possible consequence of successes along the way. Look at figure 1 again and look at the green arrows at years 1997 and 2022. Buddha advocated the renouncement of all gains, not just material ones. A family, with a loving wife and happy children, produces attachments and when, inevitably, things go wrong with these attachments, then pain and sadness follow. The positive derivatives must be followed by negative derivatives. Buddha understood hedonic adaptation. That much is true. But I can’t ascribe to a life of non-commitment. There is value in things and ideas, and personal relationships are too beautiful to miss out on even if they give me attachment. So, I guess I can’t be a good Buddhist. But I don’t have to be.

    There remains another mathematical trick that we might consider using. And we are at that stage in life when such a trick reveals the deeper truth that we need. When we are young, then the direct measurement of our objective is most worthwhile. Keeping score keeps us on the right track. In mid-life, it’s more appropriate to often look at the derivative of the curve and smell the flowers of our positive derivatives. As well, we should appreciate that the unhappiness we might feel when we suffer a business setback, a health challenge or a minor failure, is appropriate but temporary and just require patience and resolve. We look further to the future and reassure ourselves that a positive Delta is around the corner.

    But, at the end of our careers, positive Deltas are harder to come by. And some people see this as a very gloomy thing. I think that’s wrong. So, I quote the greatest scientist of our century. Albert Einstein redefined physics. He made, arguably, the three greatest discoveries of the 20th century. He showed a deep understanding of the universe and for this received an astounding acclaim by his peers, the collection of amazing Nobel Laureates in physics who came to Einstein whenever they discovered something important to get his approval and validation. They certainly qualified as Emerson’s intelligent friends. On the side of love of family, Einstein was not so fortunate. But he had friends whom he loved and who loved him. His closest friend was Michele Besso, a mathematician who had even helped Einstein with some math problems early in Einstein’s career. In 1955, at 81, Besso died. Einstein wrote this letter to Besso’s sister.

    “Now he has again preceded me a little in parting from this strange world. This has no importance. For people like us who believe in physics, the separation between past, present and future has only the importance of an admittedly tenacious illusion,” Einstein wrote. Einstein died almost exactly one month after his friend on April 18, 1955.

    What did Einstein mean? For the most part, Einstein was alluding to time. Some physicists have thought that Einstein was alluding to the relativistic logic of time dilation, etc. But Besso’s sister wasn’t interested in that and the context was that Einstein was writing a letter of condolences and was being sensitive to her needs. I think Einstein was alluding to the idea that time has too much meaning to us humans who are enslaved to time as we go about our business; that time dominates our views of whether we are happy or sad based on recent gains and losses; that in this case, time makes us aware of what was and is no longer which drives the feelings of loss and grief. It is very human to worry about change for that evolved as a survival selection advantage. But, I think that what Einstein was telling us was that we should sometimes look at things without accounting for the pressing issue of time. He might have added, as he often did, that you can generate the future from the past so emphasizing the dividing line of past from future isn’t necessary.

    So seen this way, the accomplishments of his great friend, Besso, and Besso’s life, including his beautiful relationships, stand on their own; that these things, if not eternal, at least are not ephemeral either. Einstein was telling Besso’s sister to take the integral of her life with Besso. Einstein was dying (from a bleeding abdominal aneurysm) and probably wrote this letter while taking the integral of the curve of his life as well.

    Now we can reexamine the curve of our lives and concentrate not only on the highs and lows, and not even on the many Deltas that brought us moments of joy and anguish. We can now look at the integral under the curve, and thus the totality of it. If we have lived well, we will have left our mark: On the patients we’ve seen and whom we alleviated some anxiety over their vision. On the colleagues we’ve encouraged and mentored. On our body of scholarly work that hopefully shapes the future understanding and discoveries in our fields. On our students, formal and informally taught. On our spouses and children and grandchildren who shared with us rich, emotional lives. In these and in many other ways, we are very fortunate if we’ve left footprints in the sands of time.

    So, in fact, our lives are graded on a curve. And whether we fixate on the standard curve, the derivative of that curve or the integral, makes all the difference.