In this issue, Scope interviews Neil R. Miller, MD, who is the Frank B. Walsh Professor of Neuro-Ophthalmology at the Wilmer Eye Institute, part of Johns Hopkins Medicine. Dr. Miller has published over 500 articles, 93 chapters, and 13 books, including the fourth edition of “Walsh & Hoyt's, Clinical Neuro-Ophthalmology.” It has long been regarded as the bible of neuro-ophthalmology, and the five volumes of the fourth and later editions have influenced the field beyond measure.
See Dr. Miller's slide show.
Dr. Miller has taken great interest in the subspecialty and its practitioners, as evidenced from being a past president of the North American Neuro-Ophthalmology Society (NANOS) and three-time president of the International Neuro-Ophthalmology Society. He has given 44 named lectures around the world, including the Jackson Memorial Lecture at the Academy’s 2001 annual meeting and the Academy’s 2005 William F. Hoyt Lecture. His numerous awards include the Distinguished Service Award from NANOS and the Academy’s Lifetime Achievement Award. Most recently, he has added basic wet bench research to his lengthy opus in clinical research. He even had a cameo in the 2009 Hindi-language action movie, “Kurbaan.”
Alfredo A. Sadun, MD, PhD: Can you start us off with comments about your early life?
Neil R. Miller, MD: I was born in 1945 in Wichita Falls, Texas, where my father was stationed with the Army, but raised mostly in Omaha, Neb., where my father settled in private practice after completing a surgical internship and residency in Chicago and a fellowship in surgical oncology in Boston.
Dr. Sadun: So, you weren’t born and bred as an East Coast elite? And how was it being in the Midwest and being the son of a physician?
Dr. Miller: It saved my life. The summer between high school and college, I developed a very severe headache and fever. My father gave me some type of analgesic, but the headache didn't improve. He suspected there was something serious and took me to the hospital where I was found to have bacterial meningitis. I was treated with hourly intramuscular injections of antibiotics. Fortunately, I made a complete recovery. It is likely that had my father not recognized the seriousness of my condition, I would not have survived!
Dr. Sadun: This was in the early 1950s, when antibiotics were nascent. So, you were also lucky to have not been born a decade or two earlier. When did you decide to become a physician?
Dr. Miller: As my father was a physician and loved being one, I probably always assumed that I would follow in his footsteps. I'm not sure there was a particular moment when I said to myself "I have decided to become a doctor."
Dr. Sadun: Where did you attend college? What was your major?
Dr. Miller: I went to Harvard college where I majored in biochemistry. During my first year, I met another freshman, Harry Quigley, MD. We subsequently became friends and were roommates during college. We then went to the same medical school where we again roomed together, were in the same resident class at Wilmer Eye Institute, joined the Wilmer faculty after our fellowships and have been friends ever since. Of course, Harry has gone on to be recognized as one of the national and international experts in glaucoma.
Dr. Sadun: I’m laughing as I know Harry, and I would consider you two as an odd couple. That aside, you are rather modest in only highlighting his prominence in glaucoma. I refer the readers to my introductory paragraph to reiterate that you are, right now, the world’s most preeminent neuro-ophthalmologist. But back to the chronology. You both went to medical school at Johns Hopkins. What got you into ophthalmology?
Dr. Miller: In those days, A. Edward Maumenee, MD, then the chairman of ophthalmology at the Wilmer Eye Institute, would actively recruit entering first-year medical students who often were from ivy league colleges. This would be known to the current residents who had gone to the same colleges. He would meet with these prospective first year medical students and pitch our field. Maumenee would, tell them how great ophthalmology was, and provide them with funds for summer research. I was one of several students in my class (Harry Quigley, again, was another) who was recruited by Dr. Maumenee, and so I spent a summer doing research in the ocular pathology laboratory at Wilmer under the auspices of William Richard Green, MD. By the time that summer was over, I was hooked, though at the time I assumed I was going to have a career as an ocular pathologist, not as a neuro-ophthalmologist!
Dr. Sadun: Just to remind the readership, before the match program the process of applying for a residency in ophthalmology was a bit wild and very subject to randomness, confusion, capriciousness and serendipity. How was it for you?
Dr. Miller: The application process was straightforward. Each eye department had its own application form. You filled out the hard copy application form and sent it in. You would then be notified if you were invited for an interview with various faculty. Once you visited the program and the interview was finished, you were informed if: 1) you were accepted; 2) you were on a waitlist; and 3) you were not accepted. Being from Omaha, I was interested in a residency position at the University of Iowa; however, the residency had already been filled for several years ahead. Later, Frederick R. Blodi, MD, chairman of the University of Iowa Department of Ophthalmology, asked me why I didn't do my residency in his department. I explained that I didn't even get an interview because the residency positions had all been filled for my year, and several others that I would have had to wait through.
The process was problematic in several ways. One was the hassle and cost of filling out multiple applications. But more importantly, the dilemma was that some programs offered you a position but required you to accept or decline the offer within a day or two, even though you might have to wait many months to hear from other programs. In this way, some programs were able to attract excellent applicants who might have gone to other programs but who didn't want to take a chance of not getting a residency position at all.
Dr. Sadun: Yes, that could be very stressful. Before you started at Wilmer, you had to do an internship. How was that?
Dr. Miller: I have often said that my internship in medicine, which was also at Johns Hopkins, was one of the best years of my life! I had a chance to learn "real" medicine, knowing that I had only one year to do so. We were on call two nights out of every three, and even when we were not on call, we were on the wards until almost midnight! In addition, I was able to spend two months covering the neurology ward, so I got to learn a lot of neurology during the year. As if this were not enough to make it a great year, this was the year that I met Carol Rogues, a dietitian at the hospital, who would become my wife the following year. We're celebrating 50 years of marriage in 2023!
Dr. Sadun: Just to remind the audience: Johns Hopkins was regarded then and, perhaps still now, as the ultimate trial for training in medicine. It was a grind. In fact, it was at Johns Hopkins that Sir William Osler created the term “internship” to reflect the idea that you lived and worked “in” the hospital all the time. When you graduated to “resident,” you still resided there but could leave for short stints. A residency at Wilmer was said to be not only educational, but hard and colorful. What was it like for you?
Dr. Miller: As residents, we were largely autonomous. When we were in clinic, we were pretty much by ourselves. If we didn't know something, we asked a more senior resident. If the senior resident didn't know, he (all men at this time) would ask the chief resident (a former resident who had been away for a fellowship and had then come back for a year to lead the residents). If the chief resident didn't know, he would escort us to Dr. Maumenee or one of the other five or six faculty, introduce us and say something like, "Dr. Maumenee, Dr. Miller would like to discuss a case with you.” It was very, very formal. When we were in the OR, our assistant was likely to be a senior resident or the chief resident, only rarely a faculty member.
Finally, as all patients undergoing surgery (whether cataract removal, retinal reattachment, glaucoma filtering procedure) were admitted the evening before surgery and kept as inpatients for five to seven days, we went on ward rounds every morning at 7 a.m. and every evening at 7 p.m. We also had weekly grand rounds with live patients and intermittent lectures. One of the most important people in my life during my first year of residency was the chief resident, Ron Smith, MD. Ron knew how to not only motivate but to support us. He knew that I was interested in neuro-ophthalmology, so he allowed me to be the "resident expert" in neuro-ophthalmology!
Dr. Sadun: I love hearing that about Ron Smith. He was one of my closest friends, a very kind chairman and always amazing as a supporter. Tell us more about your residency.
Dr. Miller: Every month, one of the first-year residents was designated as the "slide rookie," in charge of making sure that the slides of one of our many guest lecturers was properly set in the slide projector, that the slide projector was working, etc. This was in the days of dual carousels as slide holders. Once when I was slide rookie we had a visiting lecturer, and I was checking the slides on the slide projector. One of them seemed to be stuck in the carousel. I took the top off the carousel to manipulate the slide, then lifted the entire carousel off and flipped it over, having forgotten that the top was still off, whereupon most of the slides fell out! I was so embarrassed that I didn't tell the lecturer. Instead, I just put the slides back in the carousel as best as I could but knowing I hadn’t maintained the proper order. The lecturer started the lecture but as each slide came up, he said, "That's not the right slide!" I finally had to admit my error, and we then waited for 20 minutes or so while he put all the slides back in the correct order!
Dr. Sadun: Ah, yes, those infernal carousel projectors. We all made that same mistake once. It was a version of the childhood game, 52 card pick-up. But for most of us, the spillage was to our own slides. Tell us about your fellowship.
Dr. Miller: Because I was planning to be an eye pathologist, I decided to spend some time at the University of California San Francisco with William Spencer, MD, then one of the leading eye pathologists in the country. When I told my medical school adviser at Johns Hopkins, David Knox, MD, of my plan, he suggested that I spend some time learning more neurology as it related to vision. This could be with Bill Hoyt, who was also at UCSF. It was Dr. Hoyt who with Dr. Walsh had just published "Clinical Neuro-Ophthalmology" as the third edition of the textbook that Dr. Walsh had previously written alone. My time with Dr. Hoyt convinced me that what I really wanted was to be a neuro-ophthalmologist. Accordingly, when I finished the Wilmer residency, I asked Bill Hoyt if he would take me back as a dedicated neuro-ophthalmology fellow, and he agreed. It was a marvelous experience. My co-fellows were Drs. Jack Selhorst and Tom Shults, now both retired. We had a great time together and have remained good friends.
Dr. Sadun: And then what was your first job?
Dr. Miller: After I finished my fellowship, I returned to Wilmer as chief resident, at which time Dr. Maumenee asked me if I would stay on to run the neuro-ophthalmology division. I discussed this with the chairmen of the neurology and neurosurgery departments, and both said that they would give me their full support. I therefore accepted a faculty position and have been at Wilmer ever since!
Dr. Sadun: Not many people have spent their entire careers at one institution, especially having made themselves so renowned. Any regrets in your career in ophthalmology?
Dr. Miller: I sometimes regret not having accepted a chairmanship position. But at the time I was being so considered, my daughter was at an age where a move to another city would have been detrimental to her social and school life. In addition, chairs by then were spending more and more time doing administrative work and less and less time teaching and seeing patients, and I didn't want to give those academic elements up.
Dr. Sadun: And the world was much better for that. You were made for academics, not for administration. Let’s end with a positive. What in your career gave you the greatest satisfaction?
Dr. Miller: Making a difference both individually caring for my patients and on a larger scale through teaching, writing and research.
Chronicles of a Neuro-Ophthalmologist