Ronald M. Burde, MD, retired this year as the Editor-in-Chief of the Journal of Neuro-Ophthalmology. He had inherited the journal in 1994 from its founding editor, J. Lawton Smith, MD.
Born in the Bronx, NY, and brought up in Connecticut, he attended the Massachusetts Institute of Technology (BS, 1960) and Jefferson Medical College (MD, 1964). He completed his ophthalmology residency at Washington University in 1968, and, after a 2-year neuro-ophthalmology and glaucoma fellowship there, took over the neuro-ophthalmology service with the support of Andrew J. Gay, MD. After building the service to international renown, he left in 1988 for New York City to become chair of the Department of Ophthalmology, Albert Einstein College of Medicine. This fall he retired from that position, having secured major endowment for the program and compiled an enviable roster of academic honors. The following excerpts are drawn from an interview conducted at his home on May 16, 2001.
JDT: As you look back, what do you consider your finest achievement?
RMB: The well-trained residents and fellows who have worked with me and gone out into the world. I've tried to teach them a mixture of science and humanism. You have to have science, but if you don't feel something for the patient and make the patient feel better, you're just a good doctor, not a great physician.
JDT: How have medicine and ophthalmology changed since you started?
RMB: Less teaching, more unnecessary surgery, overtesting and increasing charges—40 cataracts per day. That is commerce, not medicine.
JDT: Do you see that changing?
RMB: Yes, we're passing through a dismal era. The time will come when the money will run out and we'll go back to doing what we were trained to do—prevent and treat disease, not chase dollars.
JDT: How is that change going to happen?
RMB: A single key payor system or a socialized system will evolve. Involved professional societies—ophthalmology, optometry, opticianry—will work together to create a delivery system the public can afford.
JDT: Don't prepaid health plans already do that?
RMB: Yes, but health planners including academic physicians will have to decide how much and what type of eye care is necessary and enforce the rules.
JDT: Will doctors accept that kind of dictatorship?
RMB: Yes, when their income falls enough. It is and it will even more.
JDT: What about academic medical centers? Are they in danger?
RMB: The danger is that the education of doctors is being marginalized—especially in small urban centers, where there simply isn't enough money to allow time off for teaching.
JDT: Why was so much more teaching possible in the good old days?
RMB: Medical wages and salaries were so much lower then. In the '60s, hospitals paid less than 50 cents per hour to the custodians and laundry workers. I received $2,200 for an entire year as an intern and $3,300 as an early resident. Now salary costs alone make the delivery of good care unaffordable.
JDT: Speaking of those days, what made you into an ophthalmologist?
RMB: I went to a big public high school in Bridgeport, Connecticut, where a low percentage of students went on to graduate from college. I was always quite adept at math and science. My father wanted to be an aeronautical engineer. Like most immigrant boys at that time, he did not have funding to afford schooling. So he made his career in business. But I knew my father wanted me to be the aeronautical engineer he couldn't become. With encouragement from him and my high school principal, I was accepted at Massachusetts Institute of Technology (MIT).
JDT: What happened at MIT?
RMB: At 11 o'clock one night near the end of my first year, I was struggling over some technical drawings of a Japanese fighter plane. I said to myself, “if you have to do this for the rest of your life, you'll be crazy.”
JDT: So you got out of aeronautical engineering?
RMB: Yes, after some searching, I settled on “quantitative biology.” Graduation at MIT required the writing of a thesis. At this point, I was fortunate to meet J. Y. Lettvin, MD, PhD, a boarded neuropsychiatrist. He eventually invited me to join his laboratory. Good science was the result.
JDT: What happened when you met Jerry Lettvin?
RMB: I walked into his lab, a desperate third-year student, looking for a thesis advisor. Sitting around this genius were the likes of Pitts and McCollough. People were exchanging ideas on life as well as science. That laboratory group changed my life by providing a rich milieu in which I could begin intellectual growth. This is where Sharon comes in. We had been dating since high school and her dad was an ophthalmologist. Going through my father-in-law's books I found a copy of Polyak. I became intrigued by the ratio—1:1 of midget bipolar cells to single cell receptor. So I went back to see Dr. Lettvin and on the basis of that small obsession of mine, he invited me to join his laboratory for a senior thesis.
JDT: You had never done anything like this before. How did you know what to do?
RMB: I stumbled a lot, but Lettvin's hand and others were there to help. Jerry was always presenting questions that could be answered and one day he announced that Dr. Axelrod and I would demonstrate how cockroaches smell. After working for a month, the day had arrived and we had not been successful. I suggested that we cut the tip off one of the hair cells on the antennae. Jerry took a big, long drag on his short Camel and all of the sound amplifiers hooked to the cockroach antenna went off. We had developed a new system for studying smell in cockroaches.
JDT: So you were off on a career in basic science.
RMB: No, I went to medical school.
RMB: I wanted to combine service with science. Jerry wanted me to get a PhD in neurophysiology from Humberto Maturana, PhD, in Chile. Sharon and I were getting married, and Jerry sent two of his buddies to convince my parents and my future in-laws to let me go off to Chile. I went off to Jefferson Medical College (Philadelphia) instead.
JDT: And at Jefferson?
RMB: I quickly ran into difficulty with laboratory attendance especially in histology. Students were mandated by the Commonwealth of Pennsylvania to spend a certain amount of time in the laboratories, but I got the work done in half the time allotted, so I would go off to the library to study. The Dean called me in to his office. He told me that there was no legitimate excuse for skipping lab time. This is where my second mentor came in—Al Sedar, PhD, an electron microscopist. Working for him in my second year, I second-authored (with him) two papers that still stand as classics on succinic dehydrogenase systems in bacteria (J Cell Biol 1965;24:285–295;J Cell Biol 1965;27:53–66).
JDT: Didn't that kind of success make you feel comfortable as a basic scientist?
RMB: Yes, but I still felt the tug of service. And my father-in-law was an ophthalmologist and a great role model. By this time our first child was born. I applied for an ophthalmology residency.
JDT: Did you have any idea at that time that you'd end up in neuro-ophthalmology?
RMB: Not really. In retrospect, I was influenced by an exciting exposure to neurology and neuro-ophthalmology rounds in medical school and internship at Jefferson.
JDT: How did you choose your ophthalmology residency?
RMB: I was ready to go back to Connecticut—to Yale, but I also applied to Washington University (in St. Louis).
JDT: Why consider Wash U, in the middle of the country?
RMB: It had a great reputation for having smart residents. My father-in-law urged me to apply there.
JDT: Did you apply anywhere else?
RMB: No. I met Mort Smith, MD, who was spending 2 years in Washington, DC, at the AFIP (Armed Forced Institute of Pathology) between the end of his third and beginning of his chief residency year at Wash U. He was interviewing candidates for the ophthalmology residency at Wash U. He offered me a position and I took it.
JDT: Without first going to St. Louis?
JDT: The power of Mort Smith. What was it like as a resident in St. Louis in those years (1965–1968)?
RMB: Exciting, nurturing, dynamic. Dr. Becker (Bernard Becker, MD, Chair of Ophthalmology)—the third mentor in my life—set standards of excellence I have tried to emulate all my life.
JDT: How did you get in neuro-ophthalmology?
RMB: As a first-year resident, I went on field trips to southern Missouri to examine rural, indigent patients. On the first one of those trips, I went with a senior resident who had written a paper on paradoxical pupillary responses with Andrew Gay, MD (then head of the neuro-ophthalmology section at Wash U). He asked me to look at it, and I ended up rewriting the paper. Andy was impressed enough to offer me an opportunity to co-edit an edition of International Ophthalmology Clinics (1967;7) dealing with neuro-ophthalmology. The next thing I knew I was a fellow in neuro-ophthalmology under Andy. Then I spent another year in St. Louis as a glaucoma fellow. Halfway through that year, Andy came to tell me that he was leaving to go into private practice in Maine. Becker and Gay asked me to take over the neuro-ophthalmology service and I accepted.
JDT: Did you accomplish any science while you were in St. Louis?
RMB: Yes. Dr. Becker always found a way to support our work on establishing the anatomy of the pupillary pathways in rats, cats, and monkeys (Brain Res 1982;249:379, Brain Res 1982;261:303, Brain Res 1983;101:930). He was my intellectual father. He encouraged us to be eclectic and independent in our scientific interests.
JDT: And you weren't hounded to see more patients?
RMB: No, that pressure did not start until the late '80s, but even so, we (Bill Hart, Terry Klingle, and I) vastly increased the clinical volume of the neuro-ophthalmology service
JDT: Did you have neuro-ophthalmology fellows?
RMB: Yes, over the years, I've trained 36 clinical fellows: William Pilchard, Evadne Titer, Carl Ellenberger, Joel Karp, John Perlmutter, William Hart, Marc Goldberg, Walter Warren, Michael Henry, Tom Slamovits, Lenore Breene, Terry Klingele, Jan Winkelman, Lyn Sedwick, Greg Kosmorsky, Tom Mizen, Marc Levy, Rodney Kellen, Satoshi Kashii, Esriel Killer, Dennis Matzkin, Caryn Pearlstein, Michael Shaffer, Rochelle Zak, Shmuel Friedland, Harriet Lester, and Michael Altman. There have been six research fellows: Joe Parelman, Ron Kurnick, Cynthia Smith, Carl Rosen, Richard Bazarian, and Frank Parisi. I also count three “special fellows”: Gillian Roper-Hall, Judith Stein, and Irina Klyatis.
JDT: What made you decide to become a department chair?
RMB: I had always wanted to run my own program. I couldn't resist the offer to come back to the East Coast, to an urban but underserved area, to a program previously run by my old friend Paul Henkind (Chair, Department of Ophthalmology, Albert Einstein College of Medicine, until 1988).
JDT: How do you feel about that experience?
RMB: Good. As I said earlier, I feel I've accomplished some goals, but the battles have been tough.
JDT: As you look back, which part of your career are you going to remember most?
RMB: The book (Burde, Savino, and Trobe:Clinical Decisions in Neuro-ophthalmology, 1st ed., 1986; 2nd ed., 1993. Philadelphia: Mosby). I'm not just saying this for you and Peter (Savino). When we started making up the decision trees, it nearly drove me mad. Turning everything upside down, going from symptoms and signs to conditions instead of the usual way, from conditions to their symptoms and signs. In the early 1980s, few other writers were presenting material in a learning tree format. I remember the arguments the three of us had—your telling me that no one else in the sane world approached patients the way I did. But we all survived the experience, and we're even closer for having done so. The book changed the way we thought about neuro-ophthalmic patients. Decision trees are the best way I know of to bring science into the service of patient care. You know, being a true physician, not just a good doctor.