A woman of vision

Tel Aviv medical center ophthalmology department head Prof. Anat Loewenstein has never regretted her decision to concentrate on retinal diseases.

anat loewenstein 224 (photo credit: Judy Siegel-Itzkovich)
anat loewenstein 224
(photo credit: Judy Siegel-Itzkovich)
Out of 20 ophthalmology departments in Israel's hospitals, only four are chaired by women - and one of them is Prof. Anat Loewenstein of Tel Aviv Sourasky Medical Center (better known by its original name, Ichilov Hospital). But Loewenstein is even more rare: A specialist in retinal disorders, she is among the world's top 50 experts in age-related macular degeneration (AMD) - a so-far-incurable cause of blindness that affects tens of millions of people over 50 around the world. Born in Tel Aviv 49 years ago, the pixie-faced, diminutive ophthalmologist always wanted to be a doctor because almost everybody in the family was one, and because of her desire to help people, especially the elderly. "My mother is still a cardiologist who does screening at Sourasky; my late father was a dentist; my brother is a surgeon at Soroka University Medical Center in Soroka; an aunt and uncle were doctors, and my grandmother was a nurse; a medical career was never a question for me," says Loewenthal in an interview with The Jerusalem Post. SHE STUDIED medicine at Tel Aviv University's Sackler Medical Faculty as part of the Israel Defense Forces academic program (Atuda), even though in those days the IDF didn't cover the costs of such studies. Today, she serves as deputy dean of that medical faculty. After graduating in 1983, she trained at the Rabin Medical Center and spent four years as an IDF physician. Then, the army didn't pay tuition for university studies of those who joined the Atuda. "It was difficult at first, as my fellow graduates had already completed their army service and went to work outside in medicine. But in the end, all of us who took the IDF academic path caught up with those who hadn't. One gets a lot of experience as a military physician," she adds. Today, there is such a severe shortage of military physicians that it has reduced the quality of care for soldiers. Loewenstein says the IDF is doing its best to cultivate a new cadre of medical students, but it isn't easy because of outside attractions. "For my specialty, I had thought of obstetrics, but I chose ophthalmology," she explains, "because I saw I could help patients, especially older ones, quickly and definitively." She says she could never have achieved what she has without her husband, mother and mother-in-law. Her husband, a lawyer and businessman, has been very supportive. "As I had to go to the US for two years of post-doctoral work in ophthalmology at Johns Hopkins University in Baltimore, he had to be willing. There aren't many men willing to drop everything and put their careers on hold so their wives can go abroad," she says with a smile. As the busy parents of three - a 24-year-old daughter (a student of law and Chinese) and 21-year-old twin boys who are in the army - they depended on their mothers, as well as the babyminder, who were always there to fill in. "I had a lot of help. I never missed work because a child was sick." But none of their children wants to be a physician, she says with a shrug. "They know what a big investment of time and energy medicine demands. The boys are influenced by my husband and his interests." MEDICINE IS increasingly becoming a "women's occupation" in the Western world, as half of medical students are females. The brightest men who might have gone to medical school seem to find it easier and more financially rewarding to go into business, computers and other fields that demand less training and and fewer long, irregular hours and low pay during the earlier stages of their careers. Medicine is not easier for women than for men, notes Loewenstein, especially a surgical specialty like hers. But there will continue to be more men in senior administrative positions. "You want to do everything very well. I also spend a great deal of time and effort reading about the latest developments in my field." Sourasky's ophthalmology department, which she has headed for eight-and-a-half years, has 19 inpatient beds and a large number of daily outpatient-clinic patients and is staffed by 85, including 35 physicians. Eye departments have significantly reduced the number of inpatient cases over the years, as more procedures can be done in the clinic or day hospital on an ambulatory basis. "Most patients prefer to return home the same day. It saves a lot of public money. We do hospitalize patients, for example, who have difficulty coping after surgery, or those who need to get eye drops every hour." Her hospital, run by director-general Prof. Gabi Barbash, offers very good conditions for medical school graduates, awards prizes and other incentives, and promotes research, she says. "As department chairman, I don't interfere in the professional decisions of doctors who work under me. We have leading experts in each field of ophthalmology." She is an expert in retinal diseases - involving the tissue at the back of the eye on which images are focused, not the cornea (the transparent covering on the outside of the front of the eye). But she says she is exposed to everything from cataract transplants to glaucoma, genetic disorders and treatment of diabetics to Lasik surgery and eye cancers. It was not difficult for her to be elected department chairman, says Loewenstein. There was a tender, with four or five doctors competing. "I was very advanced academically, but at 40, I was younger. As the years pass, the 'youth problem' fixes itself. A woman has to be willing to work very hard," she says, adding that it was never difficult getting lower-ranking male doctors to follow her instructions or give her respect. But patients who are not used to having women doctors as the department chief "sometimes think I am a secretary or nurse. But this never bothered me." In most Israeli hospitals, department chairmen remain at the helm "for life," or until retirement age. The system of rotation has never caught on here, partly due to opposition from the Israel Medical Association and medical specialty associations. "I am for rotation of department heads. In some US hospitals, every two years doctors take on a different responsibility." As for relationships with patients, Loewenstein - having spent two years in the US and often gone there to attend and speak at conferences - notes that "there is a lot of respect given to patients there. We must do this more in Israel - regard the patient as your mother or father. This is our job. When I smile and say 'Good morning,' too often patients seem surprised." As a municipal/government-owned hospital, Sourasky is not allowed to offer private medical services (Sharap) to compensate higher-ranking physicians for longer hours. As a result, many leave the hospital in the afternoon and work in health fund or private clinics to earn more. "I think the Sharap system is very good, and you can see that it has succeeded in Jerusalem's hospitals. Doctors remain in the hospital all day, and senior physicians do consultations and surgery after regular hours, sharing the money with the hospital, which provides facilities. It's better for patients when doctors are on hand for many hours." AN INCREASE in eye diseases was inevitable with the ageing of the population, notes Loewenstein, who sees "like an eagle" at a distance but wears reading glasses. "Thirty percent of the population over 50 have some degree of AMD, and many don't know. AMD wasn't well known until quite recently, as there was no treatment, so there was nothing to talk about. But now there is more hope." It is a bit more common in women than men, in light-skinned and light-eyed people than dark-skinned and dark-eyed people, and much more common in smokers and in individuals with a family history of AMD. "Over 30 genes have been identified as having a link to the disease, and if there is a genetic link and you smoke, the risk can be 40 times higher." The macula - the "M" in AMD - is the center point of the retina, the delicate tissue that lines the back of the eye and sends visual signals to the brain. That tiny "bull's eye" is composed of millions of light-sensing cells that help produce central vision. A painless disease, AMD gradually destroys sharp central vision. In the US alone, where there is keen awareness of AMD among the Baby Boomers, there are more than 10 million such patients. The leading cause of blindness in middle-aged and elderly people, AMD affects one in four Israelis over 65, with 5,000 new cases diagnosed each year. In some people, AMD progresses so slowly that it will have little effect on their vision as they age. But in others the disease progresses faster, and may lead to a loss of vision in one or both eyes. About nine in 10 AMD patients suffer from the "dry" type, in which the macula becomes diseased, leading to a slow breakdown of the light-sensing cells and a gradual loss of central vision. The "wet" type occurs in the rest, but is responsible for 90 percent of all blindness from the disease. As the condition of dry-AMD patients deteriorates, angiogenesis (the growth of new blood vessels) may occur. These new capillaries have thin walls and often leak blood and other fluid under the macula, resulting in wet AMD, triggering rapid damage and causing the loss of central vision in a short time. Until recently, photodynamic therapy (PDT) - an expensive light therapy - was used to treat AMD. Costing some NIS 8,000 to NIS 12,000, it was provided by the health funds only to AMD patients with the advanced and irreversible "classic" form of the disorder. About 40% of AMD sufferers with the early stage of the disease will eventually become "classic" cases. But Loewenstein notes that PDT is rarely used now, as a handful of medications are much better. "Until 10 years ago, there was nothing that helped. PDT was the first breakthrough to stop the decline in vision, but it was not enough. Drugs that work against the proliferation (angiogenesis) of blood vessels in the retina are much preferable," she says. These, called Lucentis and Avastin, are injected into the eye. "It is not painful; no one has dropped out because of pain. We have to see patients once a month and decide whether to inject or not. Lucentis is not in the basket of health services. Avastin is not in the basket for AMD - it is provided by the insurers for colon cancer - so most patients pay NIS 500 monthly for the drugs, except for one health fund's supplementary health insurance policy that covers the cost. Avastin is from the same family of drugs as Lucentis. We don't know yet if it is less good or the same. Every month, the AMD patient comes to our clinic, and we decide if he or she needs needs the shot. The average is seven shots a year, but we want to reduce the frequency." While hearing problems have been improved with advanced technology such as cochlear implants and advanced hearing aids, Loewenstein says the eye is "much more complicated. It takes light energy and processes it. You can't transfer this energy directly to the brain for interpretation. There is a chance that embryonic stem cells could eventually be used to repair tissues in the eye, but it is now very experimental." The Sourasky ophthalmologist has no regrets about going into the relatively narrow field of retinal disease. "People advised me years ago to go into corneal diseases, but I decided to focus on the retina, and I'm not sorry. There has been so much progress in this area; we had nothing to give patients before. They are so grateful!