Dr. Periman is the Director of Dry Eye Services and Clinical Research at Evergreen Eye Center, located in Seattle as well as Federal Way, Burien, and Auburn, Washington.
1. Please share with us your background.
Seattle, the Emerald City, is nestled in a wild landscape between towering mountains, snow-capped volcanoes, and a glacier-carved sea, and is situated alongside piercingly green forests that are softened by the rains. It’s the perfect urban home for a doctor who grew up in the wilds of Montana as the granddaughter of cattle ranchers, where the land and people infuse a deep sense of place, integrity, and work ethic.
I was 11 before I was old enough to buck a bale of hay, but I knew from an early age that I was destined to be a physician. My Norwegian grandmother, a great healer herself, encouraged my innate curiosity in biology and science. She showed me how to grow my empathic abilities and cultivated my ambitious, independent spirit.
With loans, work-study jobs, and a bit of grit, I melded a 4-year college degree in 3.5 years. After graduating early from Willamette University in Salem, Oregon, I joined Immunex Corporation (now Amgen) and financed my future husband’s way through law school. After 3 years at Immunex, I went back to school at the University of Washington School of Medicine, where I completed a residency in ophthalmology, followed by a cornea and refractive fellowship.
2. What is the focus of your current research?
Understanding the pathophysiology of ocular surface disease (OSD) and relieving the suffering of my patients is the source of my passion. I find great joy in the ability to restore visual function and quality of life to my patients with OSD, and I cherish the communities that strive to learn together and serve the many millions of patients around the world.
Within the ever-expanding world of OSD, I love clinical care, science, and innovation. Despite the influx of new therapies and medicines, the problem we are tackling is complex, nuanced, and pervasive—so our work is far from over. We still need new ways to diagnose and manage OSD, which is why I’m proud to roll up my sleeves and help build new treatments by participating in clinical trials.
Establishing my practice’s clinical trials program was important for other reasons as well. It allows me to offer my patients early access to new therapeutics, devices, and treatments. The hope, healing, and science that come with this access is immeasurable. In the 6 months since I created our clinical trials program, we have completed two new dry eye device trials and are on the short list to be an official trial site for several new OSD therapeutic candidates.
There is marked underrepresentation of female principal investigators in clinical trials. I’m proud to work alongside my incredible team of investigators, who understand that progress is made when all of us support each other in fearlessly pursuing excellence in science.
3. What has your experience been collaborating with industry?
I have a unique perspective on the benefits of collaborating with industry. Prior to medical school, I worked as a molecular biologist in research and development at Immunex, the company that discovered and brought to medicine the important drug Enbrel. Enbrel was one of the first engineered biologics to enter medicine and has improved quality of life for hundreds of thousands of patients with autoimmune diseases.
My time in research and development grounded my deep appreciation for the tremendous investment of time, talent, and resources required to shepherd a new therapeutic from bench to bedside: from discovery to production, from clinical trials to FDA approval, and from patient access to integration into clinical care. The perspective I gained while at Immunex strengthened my appreciation for the commitment that industry brings to developing new therapeutics for our patients and continues to enrich my collaboration with industry.
Although it is easy to balk at the high cost of new medicines, reminding ourselves of the investment and startup costs involved in bringing a new drug to market is logical. The hope that new treatments bring to patients is the heart of innovation. Hidden costs abound in many medical insurance companies, massive insurance carrier and drug store mergers, and pharmacy benefit managers who collude to generate record profits, siphon surpluses off of premiums that should go back to policyholders, control the business of medicine, and limit patient access.
4. In your opinion, how is the role of women in ophthalmology evolving?
I’ll answer this question from the heart. Over my 26-year career, I have been fortunate to witness a gradual shift in the role of women in medicine. A large part of this changing dynamic is due to improved representation. I witnessed a time when women were a novelty in medicine and there were only a few “safe ways” to exist in a world ruled by men: unmarried, unfeminine, and unthreatening. But today, the demographics are different. For the new generation of MD and OD candidates, a near 50/50 male-to-female enrollment is the norm.
As a result, I think there is now enough “safety in numbers” for women in medicine to be our true, authentic selves. The pressures to downplay our abilities, lifestyle, appearance, and words are being replaced by a celebration of skill, individuality, femininity, and authenticity. When a culture of safety is established, when it becomes the norm for all of us to be our authentic selves, and when an ethos of mutual respect and support is established, the entire health care ecosystem benefits, which I believe elevates us all and directly results in better care for our patients.
One ongoing problem is that, while women are better represented in medicine, women in leadership positions are still less common. This reflects a culture and an ecosystem that haven’t taken full measures to assist women at critical life stages or have discouraged women from being assertive and taking up space. Our colleagues in power have an opportunity to create equity as well. Many of them do, but more are needed.
5. What, if any, hurdles do you feel women in health care still face?
There will come a day when health care professionals are celebrated for their healing gifts, no matter their race, gender, or religion. Even midcareer, I continue to face examples of gender bias. Very recently, I was given unsolicited advice from a nonphysician in the ophthalmic space who blurted out, “But you’re just such a busy mom” and “You’re doing too much.” Deep breath. I cordially replied, “I’ve got it, no problem.” He then said, “What does your husband say?” Double take. After a moment of shock, I exclaimed with as much deflective humor as I could possibly muster, “I can’t tell you that! It’s privileged information!”
Anecdotes aside, I think female physicians will have even more hurdles to clear as health care is commoditized by businesses who have lost touch with the art of medicine. As our industry administrators chase operational efficiency, we are losing stewardship of the sacred doctor-patient relationship to spreadsheets and clicks within an electronic health record. The very soul of medicine—time, touch, and human connection—is sacrificed for business. Women are disproportionately affected due to unequal representation in partnership, corporate leadership, and venture capitalist roles.
The call to become a physician and relieve the suffering of patients is not an easy one. Crippling student loans, sleepless nights, sacrifices of family time, ridiculous electronic health record burdens, obstructionist insurance companies, unreasonable noncompete clauses, and unsustainable production pressures—all of these burdens have contributed to physicians having the highest suicide rate of any profession.1 We deliver health care, we heal our patients, and we nurture the sacred doctor-patient relationship. The business of medicine doesn’t happen without doctors.
To women entering the field, I say: Remember who you are. Remember the unique value you bring to the table, and never lose sight of those things. Of course, bills need to be paid by systems, hospitals, and clinics. However, I do not accept that piling on more middle management while denying physicians support staff such as scribes and technicians is a reasonable answer. Watch out for contracts that promise great maternity leave but have unreasonable noncompete clauses. Always leave yourself an escape route. Remember that everything is negotiable, and challenge any claim that the employment contract offered to you is nonnegotiable.
Be willing to walk away—an action that requires resolve, strength, and agency. Culturally, we need to do better in supporting women when such course of action is necessary. The system needs you more than you need it. Patients are discontent with the 8-minute encounter model and are hungry for a more satisfying medical experience. You, the physician, are the key to improved satisfaction with medical care. Connect, heal, and embrace the fulfillment of making a difference in someone’s life. That does not mean sacrificing your evening time to finish charting. Advocate for the support staff needed to practice medicine efficiently, effectively, and safely so that you can enjoy your work and your life.
6. What advice can you offer to young female ophthalmologists who are still in training or just beginning their careers?
It is crucial that young female ophthalmologists seek and cultivate mentors. One activity that brings me great joy is mentorship, and I know that I am not alone in that. When I participate in CEDARS/ASPENS mentorship workshops, I am inspired by the gender balance, ethnic diversity, and intersectionality among my young colleagues. There is a palpable, positive, and powerful sense of equality, and, even better, a powerful sense of equity in the next generation of leaders. Networking is a pathway to connection and community. Community and connection are the antidotes for feelings of isolation and entrapment.
For women new to motherhood, the kindness and consideration that is completely necessary during pregnancy, delivery, and post-partum phases are not something to be begged for nor hoped for, but rather normalized, expected, and celebrated. I believe that the bitter and derogatory “How was your vacation?” comments made to my female co-residents returning from maternity leave are being replaced by a better understanding of what equitable opportunity and collegiality really mean. Equality is second best to equity. Many of our male colleagues understand this and jump at the chance to offer support and assistance. Many of our young colleagues understand that these phases of a young female physician’s life are more than just necessary and important but are also natural and worthy.
I applaud the welcoming accommodations that large professional organizations have recently adopted, such as comfortable and private areas to nurse or pump breast milk. Smaller conferences are starting to offer child care. All of these efforts help create equitable access and are important strides for women in health care.
7. Can you propose a unique or creative idea that may help women in ophthalmic practices?
Three words: community, connection, collaboration. Women in ophthalmic practices, particularly those dominated by men, benefit from supportive relationships not only with other women in the field but also with men who genuinely wish to see gender equity. Our male colleagues are important advocates who can help us advance effectively and harmoniously. In a similar and equally important way, I remember to express my gratitude to my spouse and children for their incredible support to do this work in OSD that I love.
Creative networking to build important relationships with other women in the field provides multiple crucial levels of support throughout a career. I believe these are of paramount importance to prevent feelings of loneliness, powerlessness, and isolation. There are multiple ways to connect, create community, and collaborate with other women and those who support us. I highly recommend attending smaller meetings such as MillennialEYE Live, Women in Ophthalmology, and Cornea360 as well as leadership and networking events such as those hosted by Ophthalmic World Leaders. Surround yourself with positive, progressive people by attending these events. The positive vibe will sustain you long after. Don’t have time for a meeting? No problem—there is always a brightening dose of positivity in the tweets from these groups.
Additionally, hunt for private supportive groups online. (Ask me about one very special private group in particular the next time you see me.) Look for private interest groups in your favorite subspecialty (eg, keratoconus, glaucoma, retina, etc.). There are many examples of synergistic business partnerships that have formed through these wonderful online communities.
As a physician who has recovered from major surgeries and injuries, I’m decidedly stronger for the incredible and loving communities of other physicians who have encountered major medical problems. My friends and colleagues in CEDARS/ASPENS are another source of inspiration and strength. OSDocs on Facebook is a collegial group of clinicians, clinical scientists, and their key staff members from around the world who are interested in OSD. Being a part of these is like having a cherished network, a friend group, and a collegial journal club in my own back pocket. Again, the three c’s: community, connection, and collaboration.
In summary, you are not alone. There are many individuals who are ready to help you take flight and who will delight in seeing you soar.
1. Periman LM. Tear film and corneal disorders. In: Narang P, Trattler WB, eds. Optimizing Suboptimal Results Following Cataract Surgery. Thieme; 2018.
2. Periman LM. TFOS DEWSII distilled. Ophthalmology Management. 2017-2018.
3. O’Dell LE, Periman LM, Sullivan AG, Halleran CC, Harthan JS, Hom MM. An evaluation of cosmetic wear habits correlated to ocular surface disease symptoms. Invest Opthalmol Vis Sci. 2017;58.
4. O’Dell L, Sullivan AG, Periman LM. When beauty talk turns ugly. Advanced Ocular Care. February 2017.
5. O’Dell L, Sullivan AG, Periman LM. Beauty does not have to hurt: ocular surface disease exacerbated by chemicals hiding in plain sight. Advanced Ocular Care. July/August 2016.
6. Periman LM, O’Dell L. When beauty doesn’t blink. Ophthalmology Management. August 2016.
7.Periman LM. DED surveys: reality vs perception. Ophthalmology Management. August 2016.
8. O’Dell L, Sullivan AG, Periman LM. Suﬀering for beauty: harmful ingredients and trends in cosmetics. Advanced Ocular Care. September 2016.
9. Periman LM. Getting beyond the surface in ocular surface disease. Ophthalmology Times. September 2016.
10. O’Dell L, Sullivan AG, Periman LM. Uncover patient lifestyle habits that lead to OSD. Optometry Times. October 2016.
11. Periman LM. Clues to DTS may lurk on meds list. Ophthalmology Management. March 2015.
12. Periman LM. Dry eyes since DEWS. Ophthalmology Management. August 2015.
13. Periman LM. From chronic dry eye to LipiFlow and premium IOL. Ophthalmology Management. August 2015.
14. Periman LM. IPL as a treatment for DED. Sjogren’s Syndrome Foundation. 2015;33(9):6-8.
15. Periman LM. Testing for Sjogren’s Syndrome expands dry eye protocol. EyeWorld. 2014.
16. Periman LM, Ambrosio R Jr, Harrison DA, Wilson SE. Correlation of pupil sizes measured with a mesopic infrared pupillometer and a photopic topographer. J Refract Surg. 2003;19(5):555-559.
17. Galeana CS, Smith R, Maloney RK, et al. Postoperative complications. In: Galeana CS, ed. LASIK/LASEK: The New Horizons in Quality of Vision. Highlights of Ophthalmology International; 2003.
18. Periman LM, Sires BS. Floppy eyelid syndrome—a modified surgical technique. Ophthalmol Plast Reconstr Surg. 2002;18(5):370-372.
19. Periman LM, Harrison DA, Kim J. Fungal keratitis after photorefractive keratectomy: delayed diagnosis and treatment in a co-managed setting. J Refract Surg. 2003;19(3):1-3.
20. Harrison DA, Periman LM. Diﬀuse lamellar keratitis associated with recurrent corneal erosions after laser in situ keratomileusis. J Refract Surg. 2001;17(4):463-465.
21. Periman LM, Sires BS. Full-thickness skin grafting of eyelids in a generalized morpheme patient on thalidomide. Arch Ophthalmol. 2000;118(1):135-136.
22. Periman LM, Alexander G, Sage EH, Porter P. SPARC, a protein of extracellular matrix modification and angiogenesis, demonstrates increased expression in infiltrating ductal breast carcinoma. J Invest Med. 1995;54:278.
23. Kaynard AH, Periman LM, Simard J, Melner MH. Ovarian 3 beta-hydroxysteroid dehydrogenase and sulfated glycoprotein-2 gene expression are diﬀerentially regulated by induction of ovulation, pseudopregnancy and luteolysis in the mature rat. Endocrinology. 1992;130(4):192-200.
24. Simard J, Melner MH, Breton N, et al. Characterization of macaque 3 beta-hydroxy-5-ene steroid dehydrogenase/delta 5-4 isomerase: structure and expression in steroidogenic and peripheral tissues in primate. Mol Cell Endocrinol. 1991;75(2):101-110.
PROFESSIONAL SOCIETY MEMBERSHIPS
• American Academy of Ophthalmology (AAO)
• Association for Research in Vision and Ophthalmology (ARVO)
• American Society of Cataract and Refractive Surgery (ASCRS)
• CEDARS/ASPENS Society
• Ophthalmic World Leaders (OWL)
• Women in Ophthalmology (WIO)
• Washington Academy of Eye Physicians & Surgeons (WAEPS)
HONORS AND AWARDS
• Janet M. Glasgow Memorial Achievement Citation | 1997
• Georgianna Kirby Award | 1997
• Alpha Omega Alpha (AOA) | 1996
• Western Student Medical Research Committee Award for Excellence | 1995
• Rex and Arlene Garrison Oncology Fellowship | 1994
• Terry Spies Memorial Scholarship | 1989
EDITORIAL BOARD positions
• Journal of Dry Eye and Ocular Surface Disease
• Ophthalmology Management
1. Anderson P. Doctors’ suicide rate highest of any profession. WebMD. May 8, 2018. www.webmd.com/mental-health/news/20180508/doctors-suicide-rate-highest-of-any-profession#1.