JDT: How was neuro-ophthalmology nurtured during your eye residency?
SL: Cogan had a tiny examining room near where I was working. He would show me cases. As my residency was ending, I went to him to get his advice about neuro-ophthalmology fellowships. He said, “Well, Simmons, a neuro-ophthalmologist is someone who other people think is a neuro-ophthalmologist. And people think you are a neuro-ophthalmologist. You don't need a fellowship.”
JDT: Why did Cogan think that?
SL: Because people were sending me private cases to look at even as a resident.
JDT: And what happened next?
SL: Before I had finished the residency, Ephraim Friedman, a very junior faculty member and the fair-haired boy of the Infirmary, called me in and said, “They've just picked me to be the chair of ophthalmology at Boston University. Would you join me?” I hesitated for a nanosecond and then went over to B.U. as the neuro-ophthalmologist!
JDT: Is that when your time at Boston City Hospital began?
SL: Yes, I became director of the B.U. ophthalmology service there and sat on the Executive Committee with Derrick Denny-Brown, chief of the Harvard neurology service there, who had earlier refused me a 1 year neurology position. I remained at B.U. for 18 years.
JDT: When did you begin training neuro-ophthalmology fellows?
SL: I took on a few while I was at B.U.-Michael Cohen, Robert Gise, Jim Coppeto, Alfredo Sadun, Jon Currie. At first I did not think there was a great need for neuro-ophthalmologists and that there were very few places where they should be trained. I did not think I could offer as much as, for example, Bill Hoyt. But there were some who, for logistical reasons, wanted to stay in Boston and so I took them on. Some wonderful people. At the end of their fellowship, I would send them out for a time with Hoyt. Hoyt and Miller Fisher had become part of my superego. I still ask myself, “What would they say about what I'm doing or saying?” I had begun to have more and more contact with Hoyt.
SL: Here and there at meetings. Mutual interests. Correspondence. We even published papers together, on brainstem arteriovenous malformations and the first paper on malignant gliomas of the anterior visual pathway.
I'll tell you about the genesis of that paper on gliomas. At one of the early Walsh meetings, when they were still held at Hopkins, I presented a case of glioblastoma of the chiasm. Walsh attacked me, which is like having a Quaker make war on you. This nice man was saying there is no such thing. Then Hoyt got up and, a little more in character, insisted, “These are not malignancies; they're benign, hamartomatous lesions.” Within 6 months, I had a second case of malignant glioma of the chiasm! I wrote to Hoyt and said, “Ha, ha! It's a real entity.” He wrote back that he'd since seen one. So together we wrote up the three cases as malignancies.
JDT: How did your term at B.U. come to an end?
SL: In 1983 I got a call from Claes Dohlmann, the chief of ophthalmology at the Infirmary, asking me if I knew anyone who might be interested in the neuro-ophthalmology position because Shirley Wray, who occupied it, was moving over to Mass General. I gave him a list and then he said, “How about you?” And so I finally returned in 1984 to where I had done my residency. I've been here now for 22 years.
JDT: Was the transition an easy one?
SL: Well, getting appointed wasn't simple. There was one member of the search committee who was opposed to me. When I was called before the committee, I was sure I'd be asked why I wanted to come to Harvard. I was going to tell them, “I've always wanted to get a Harvard Coop card.” [Editor: to get a card for the Harvard Cooperative Society, which administers the noted store in Harvard Square, you must be a student or faculty member at Harvard.] Anyway, he promptly asked, “Are you the world authority on anything?” I believe he saw his responsibility to be the guardian of science at Harvard. He later made an appointment to come to my lab on a Saturday morning. He spent hours looking over my papers and quizzing me about the research behind them. Apparently he wrote a negative report about me. So they had to call in two witnesses on my behalf-Ed Norton, who came up from Miami, and Norman Geschwind, who was the James Jackson Professor of Neurology at Harvard and had earlier been chief of neurology at B.U.
JDT: Had Geschwind influenced you?
SL: Absolutely. An extraordinary man. Often wrong, but so stimulating, so provocative. The cognitive functions group at the Boston Veterans Hospital, who were faculty at B.U., included not only Geschwind, but Frank Benson, Edith Kaplan, and Harold Goodglass. For me, it had been like landing in heaven!
JDT: And when you came over to Harvard, you began taking fellows regularly….
SL: Yes, Joe Rizzo was the first. He never left. He has gone on to be a great experimentalist with a terrific imagination. But I do not want to slight any of my fellows. They have all been great.
JDT: As you look back, do you consider the fellows your greatest achievement?
SL: Well, teaching in general-to fellows, to residents, to medical students. There is an old expression: those who can, do; those who can't, teach; those who can't teach, teach teachers. I'd like to think I've given the lie to that expression. Look how many of the former fellows have become extraordinary teachers. Several of the first teaching awards given by the academies of ophthalmology and neurology went to my former fellows Nick Volpe, Alfredo Sadun, and Nancy Newman.
JDT: And now?
SL: I'm still doing it-teaching and seeing patients. I'm still excited by it. I'm excited about that bust in the conference room.
JDT: What bust?
SL: Ephraim Friedman, who sculpted a bust of Cogan, did one of me. The Infirmary's Board of Trustees decided to buy one and put it in the Infirmary auditorium.
JDT: It is the only bust in the auditorium?
JDT: What is special about your teaching?
SL: I'm honest. I acknowledge my shortcomings. I've also tried to be generous. If you have more pieces of the puzzle than the person you are teaching, the next criterion is generosity. What you are trying to do is to give to someone else everything that you have acquired and the means of gaining more. You hope that each one will do even better than you do. The teacher who holds back or is abusive or gruff-I do not see a place for that. And then, be yourself. At meetings, I see people trying to be funny when they aren't funny. They double project with cartoons and then all your attention is taken up with trying to figure out the joke. If you have a good sense of humor, use it. But it doesn't fit everybody.
JDT: Among your academic contributions, what do you value most?
SL: I don't think I've made any great academic contributions.
JDT: But many of your papers are gems of medical writing.
SL: Well, when I started out, I did not write very well. Cogan was helpful there. He was a natural writer. One draft. And I got advice from Stanley Robbins, whose Textbook of Pathology was once the best seller among medical textbooks. He said, “There is no great writing, just great rewriting.” And I think he's right. Also, you learn to write by writing and by reading. I fear that one of the reasons that most writing is not good is that writers aren't reading.
JDT: If you had to pick one of your papers to talk about, it would be….
SL: The one I just published with Jonathan Kim about the superimposition of the age-related depletion of axons on a static optic neuropathy. This applies to people who early in life suffer a vision-limiting optic neuropathy that is stable for decades and then they begin to lose vision. You work them up from top to bottom and find nothing. Why are they losing vision? My theory is that it is like the post-polio syndrome: the tiny depletion of axons with age normally has no impact. But if you start out with 5% of your original complement, then you're in trouble. I think that the first sentence of that paper is one of the best things I've ever written: “The tacit assumption that progression or recurrence of an optic neuropathy results from the same mechanism that inaugurated the disorder has tended to obscure the possibility that in some cases these phenomena might have a pathogenesis independent of the original.”
I'm also fond of an editorial I wrote in the Archives of Ophthalmology entitled “Ischemic Optic Neuropathy. Enigma Variations.” [Editor: Enigma Variations is the title of a musical composition by Elgar.] In that editorial, I quoted two authors. Richard Feynman wrote in 1998: “I believe that to solve any problem that never been solved before, you have to leave the door to the unknown ajar.” Wislawa Szymborska said in his Nobel Lecture in 1996: “This is why I value that little phrase ‘I don't know.’ It's small, but it flies on mighty wings.” The gist is that we don't know what causes ischemic optic neuropathy and knowing will only come with accepting that we do not know.
JDT: Any regrets about choosing neuro-ophthalmology as a career?
SL: Absolutely none. What I do regret is that it is going to be almost impossible for anyone in the coming generation to have the kind of career that you and I have had.
SL: Accountants are setting the priorities of clinical departments. The non-earners will not get sufficient support. There are departments that redistribute money, but it can only be done to a certain extent. Neuro-ophthalmology's existence is perforce threatened. Maybe neuro-ophthalmology will have to alloy with some gainful enterprise like strabismus or plastics.
Norman Geschwind used to say that the difference between being a clinician and an academician is time. Time to think, to consolidate, to read, to discuss. To be spared 40 patients in the waiting room. Psychiatry is the business of every physician. You cannot give that component when medicine is a quick, chief complaint-oriented experience. Will the patient be correctly diagnosed? Almost certainly. Will the patient get the correct medications, surgery, advice? Almost certainly. Will that fully satisfy the patient's needs? Absolutely not. I think that most patients come to physicians with fears that go unexplored unless they are given time. What was Freud's major contribution to medicine? It is that many patients need an hour with the doctor.
JDT: Despite this apocalyptic view of where neuro-ophthalmology and medicine are going, you are still training fellows at the same rate as you did earlier and they are finding jobs and I think they are practicing the way you taught them to practice.
SL: Well, many of them are doing other things besides neuro-ophthalmology.
JDT: In the 40 plus years of your career, what has changed about neuro-ophthalmology?
SL: I haven't changed my practice at all. Maybe I'm compulsive and stubborn, but I still do the same things. But I've had bosses who have permitted me to do that. It cannot go on much longer.
JDT: So when people come to you and say, “I am considering neuro-ophthalmology as a career,” what do you say?
SL: Go where your heart leads you. You will have to make some accommodations. But everything requires accommodations.
JDT: And what about you. Will you ever retire?
SL: I will tell you something a patient told me recently. She is from rural Maine. I asked her what town she was from, and she said, “I come from far away. It's not the end of the world, but you can see the end of the world from where we live.” At age 73, I do not have a 30 year plan.
A Year with Lessell:
Of all the wonderful things I learned from Simmons Lessell, the most important is that a satisfied soul is borne of a generous spirit.
Mark Borchert, MD
He is equally eager to tell you a joke, discuss why the Red Sox lost the pennant, and quote an obscure journal article that appeared in the German literature. He gets to know each of his fellows in a deeply personal way. By the end of the fellowship, you feel as if you just spent a year with your grandfather. I grew more professionally and personally in that 1 year than in any other year of my life. Although the details are a blur, I remember laughing and loving every day of it.
Dean Cestari, MD
Each working day was constantly spent in Simmons' company (“You go wherever I go; you'll know when I'm happy, you'll know when I'm sad.”). There was the endless personal generosity that he and his wife Irma gave to the fellows and their families, his passion for the critical importance of the clinical history (“If you don't know the diagnosis by the end of the history, you are in diabolical trouble.”), the 16-foot lanes, the limitless supply of stories, jokes, and aphorisms, all accompanied by accurate rendition of appropriate accents-except Australian, which he never mastered. There was the passionate search for that elusive reference (“He who ignores the old German literature will discover many new syndromes.”), trooping to the library just for the fun of looking up who wrote what in the Lancet exactly 100 years ago, matching diagnostic wits with neuroradiologists (“the shadowkings”) or neuropathologists, and always, every day, paying for lunch for his fellows (“When your income is bigger than my tax return, you can buy lunch.”).
Jon Currie, MD
He is not only the smartest man that I have ever met, but also the funniest!
A year ago my (now) wife and I were trying to think who should marry us. Due to his importance in our lives, we asked Simmons, and he agreed. He got ordained in the Universal Life Church online and became the first Jewish reverend!
Robert Egan, MD
What the Fellows Remember
At least once a week, I would look up an esoteric word in the dictionary, convinced that I had finally found a deficit in his vocabulary, but he would prove me wrong time after time. Toward the end of my fellowship, I finally stumped him with the word, “luthier,” but only because I knew he wasn't a guitar player like me.
Simmons not only invited me to his home for dinner on numerous occasions, he took me on guided fishing trips to the ocean, the local lake, and even to Florida. How many fellowships include a guided trip to Lake Okeechobee to fish for largemouth bass? I must have brought him good luck, because he caught the largest bass of his life on one of those trips. The most indelible image of my year with Simmons is a warm Spring afternoon when he presented me with a brand new fly rod and proceeded to teach me how to cast in the parking lot of the Massachusetts Eye and Ear Infirmary.
Jonathan Kim, MD
As his fellow, I was in his “back pocket.” It was the best year of my educational life. He treated me with great respect and gave me great independence. My desk was in his office and I saw his life from all different angles. I enjoyed getting to know this man not only as a mentor and colleague but as a friend.
Michael Lee, MD
Watching Simmons unerringly tunnel in on what turned out to be the correct diagnosis was always a treat. Even better was the daily word play, which was fields more difficult than producing a differential diagnosis. But best was being mentored by a mensch-generous, honest, straighter than a meridian, approachable but never crossed.
Leonard Levin, MD, PhD
He found the best thing in each of his fellows and made us feel special, like an excellent parent with many different children. He taught me how to write and how to love writing. His command of the English language, both written and spoken, was extraordinary. He is a consummate clinician and an extraordinary wit. He loves and knows all show-tunes, but gets the words wrong!
He is teacher, colleague, father, and best friend.
Nancy Newman, MD
Simmons is one of the few people I've met in medicine who would rather say, “I don't know what it is,” than make up a clever, hand-waving explanation that couldn't possibly be proven or disproven. To hear that statement coming from someone with such vast knowledge and experience was simultaneously humbling and inspirational. Of many lessons I learned during my fellowship, this one about humility in the face of ignorance was perhaps the most profound.
David Newman-Toker, MD
The year I spent with him was the best year of my life. He was unselfish in his time, energy and attention, honest, succinct, and uncompromising in quality and ethics.
The aspect I relish, remember, still glow about, is his treating me with respect, like an equal, while teaching me valuable aspects of the subtlety of the clinical exam. I miss him every day now that I'm on my own.
Susan Pepin, MD
The happiest, most salient moments were discussions on history and music.There were the endless conversations about opera plots and librettos, and the lectures on the origin of a word or the denouement of a particular historic battle. I'll always remember his sayings:
“Do it with alacrity and utmost clarity.”
“It is much easier to be an editor than a writer.”
“There is no such thing as a ‘trace APD.’”
“Say ‘Man, woman, boy, girl.’” (Not gentleman, lady, male female.)
“Affability, Ability, Availability-the 3 A's that lead to success in professional life.”
Misha Pless, MD
The camaraderie with Simmons and other faculty, fellows, and residents at the Massachusetts Eye and Ear Infirmary was extraordinary.
We would help keep his examining room prepared by making sure the Goldmann perimeter was calibrated, that the visual field recording paper was always in stock and positioned properly in the perimeter, and that there were an ample number of cotton applicators with the cotton pulled out to a fine tip to test corneal sensation.
Howard Pomeranz, MD, PhD
After 24 years of working with Simmons, I am still learning from him!
Joseph Rizzo, MD
Simmons loves to laugh and to make others laugh. He had at least two jokes that he would present to his residents and fellows every day. They could be erudite or earthy. Humor was his way of showing his delight in how humans could be humans. Of course, the biggest laughs came from real life. These stories became a bond between mentor and mentee. I've enjoyed recounting these stories ever since.
Alfredo Sadun, MD, PhD
Simmons said when I accepted his offer of a fellowship, his goal was for the fellowship to be the best year of my academic career. It was.
Judith Warner, MD© 2007 Lippincott Williams & Wilkins, Inc.