Choosing between cornea/refractive/anterior segment vs retina

[Eyeball Tickler]

I will be deciding on a fellowship in a year from now and wanted to get thoughts. I have dealt with this dilemma since before residency.

Compensation, surgical satisfaction, variety of procedures, innovation, growth, and independence are important to me and I also want to end up doing what I like. I like most of everything so I was thinking about doing comprehensive or cornea/refractive/anterior segment. By doing this, I want to ideally work in a private practice (one day my own) near but not in a medium-sized metropolis (i.e., Dallas, San Francisco, Seattle, etc.). I want to do very high-volume cataract surgery (including premium, secondary IOLs, MIGS, etc.), refractive procedures, cornea procedures, and run a comprehensive clinic. I know this sounds a lot but I really like all these things.

On the flip-side, I know that it is a completely different part of the eye with different expectations, I also do really like surgical retina (medical is interesting too; I like doing FLs, PRPs and injections). I like vitrectomies and the idea that you can do just about do everything surgical in the eye. I am in awe of some of the retina attendings at my program as they attempt heroic surgeries (although the outcome never really matches the effort that is put in). I like that I will be able to take care of disasters from mine or other surgeon's surgeries.

I've also learned that historically retina compensation (>$500k) is amazing whereas cornea compensation (~$250-300k) not so much. If this was +/-$100k I wouldn't ever consider this a factor in my choice. However, after speaking to a few retina attendings, they have advised that compensation in retina is no longer the same because of reimbursement cuts. They don't consider it to have the same compensation potential it once did. They also feel that the monthly injection model is not something that is sustainable.

I have research experience in both (far more in cornea/refractive than I do in retina). I honestly wish I lived in a world where I could do both because I do find both very interesting despite the stark differences between the two fields. It is so hard to split hairs and try to find the perfect flavor of ophthalmology... a field of study I love endlessly.

Thank you

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[Lazyeye9]

First do what you love, not what you think will get you the most money. Second, a high volume refractive/cataract surgeon will make way more than a retina doctor can. Third, if you like to operate, go into anterior segment. Retina docs don't seem to operate all that much these days, and actually make more money in the clinic.

 

[mjohnsonets]

First do what you love, not what you think will get you the most money. Second, a high volume refractive/cataract surgeon will make way more than a retina doctor can. Third, if you like to operate, go into anterior segment. Retina docs don't seem to operate all that much these days, and actually make more money in the clinic.

Second this.

Fee for service upgrades(femto, premium lenses) are the best way to mitigate the effect of reimbursement cuts. Your comp numbers for cornea are base salary numbers, as Lazyeye9 mentioned, your total comp will be much higher than this if you're high volume and have a good conversion rate. Depending on where you go, you could still do some medical retina if you go the cornea route, but with the cities you listed, most refer to the numerous retina docs around.

 

[Dusn]

My vote is for retina. Most of those cities and even suburbs are saturated and it'll be hard to create a very high volume cataract/refractive practice. I also can't stand selling "premium" IOLs and then dealing with the complaints of glare/halos afterwards but that's just me.

 

[docdoc2012]

It's a question of personality. High volume/refractive vs retina are both surgically intensive but in very different ways.
Retina services for the most part are NOT elective. Patients come to you because they are actively losing vision. You don't have to convince them to get an intervention. They want you to help them and for the most part are cooperative. Retina lifestyle gets a bad rep but in private world for the most part its pretty controlled. The exhaustion in retina comes from sheer volume of patients and initially the intensity of procedures. Yes, injections will likely be on the chopping block - but I think its more along the lines of step therapy - it isn't the procedure code for the injections that is the issue, it is the cost of the drug. But as a retina person you really are the 'surgeon's surgeon' in a way.
My friends who are cataract/refractive, especially in bigger markets seem to always have to be 'on'. They are constantly doing talks or courting their referral sources, dress up to work everyday, have to flash a million dollar smile . They are constantly balancing what is ethical vs. What their practices want. There is a LOT of pressure to convert everyone to premium IOLs. Its a slick salesman operation from start to finish and as the surgeon you have to deliver the final product. It is pressure, but as you can see in a completely different way than retina. You also have to consider that you will have to Co-manage with optoms.
So basically you have to ask yourself - which setting do you feel more comfortable? Are you ok being a salesman?
Retina is definitely more connected medically to the rest of the body, intensive and non-elective surgeries. You are an essential provider and can build a practice wherever you go, but there are no ancillary income streams really. High volume refractive - cash practice with no reliance on insurance, thankful but demanding patients with really no room for bad surgery and, and you HAVE to be a salesman to convert to premium IOLs, and most likely will have to Comanage.

 

[CECFellow2018]

I'm a cataract/refractive surgeon who bought a practice this year and am solo with and OD. As someone who is happy to assist patients when they want premium IOLs or refractive surgery; I've never felt the need to be a salesman or encourage anyone into anything. I simply do what I believe to be ethical. I listen to what a patient wants, I explain to them their options and I execute to the best of my ability.

I wouldn't consider yourself a salesman as a refractive cataract surgeon. "It's a slick salesman operation from start to finish" is a pretty ignorant way to describe the specialty.

 

[docdoc2012]

I'm a cataract/refractive surgeon who bought a practice this year and am solo with and OD. As someone who is happy to assist patients when they want premium IOLs or refractive surgery; I've never felt the need to be a salesman or encourage anyone into anything. I simply do what I believe to be ethical. I listen to what a patient wants, I explain to them their options and I execute to the best of my ability.

I wouldn't consider yourself a salesman as a refractive cataract surgeon. "It's a slick salesman operation from start to finish" is a pretty ignorant way to describe the specialty.

ignorant? really?
you went solo with an OD. obviously that's a different practice model than the high volume refractive person working in a big city, not seeing patients pre or post op, having an entire staff dedicated to just having IOL talks with people, being trained on how to present the options without looking pushy but still encouraging them towards the premium option. There are entire talks from high volume guys at IOL dinners talking about how a patient visit to a practice is an 'experience' from start to finish, how information about femto for example is reinforced and presented in a subtle way from start to finish. trying to say that this does not happen, that you do not have to employ sales tactics to increase conversion rates is being willfully ignorant. This isn't a unique situation - this is pretty common. The OP was specifically talking about high volume practices.

If you are practicing in an ethical way in a solo practice with one OD you trust, that is great. But to say that the above doesn't happen in high volume practices is just wrong.

 

[hello lady!]

I'm a cataract/refractive surgeon who bought a practice this year and am solo with and OD. As someone who is happy to assist patients when they want premium IOLs or refractive surgery; I've never felt the need to be a salesman or encourage anyone into anything. I simply do what I believe to be ethical. I listen to what a patient wants, I explain to them their options and I execute to the best of my ability.

I wouldn't consider yourself a salesman as a refractive cataract surgeon. "It's a slick salesman operation from start to finish" is a pretty ignorant way to describe the specialty.

One could probably convert a very large chunk their cataracts to premium depending how this "explanation" happens. The physician has a lot of power in the room. Power + huge financial conflict of interest can yield some really murky ethical areas, even for those who think they're staying on the right side of the line.

 

[CECFellow2018]

Entertaining responses....so you feel that you have enough knowledge of every high volume practice to know what happens behind closed doors. Don't understand how you can make blanket statements about an entire specialty.

I can speak on behalf of what I know. My "conversion rates" are low and I don't have a number because I literally don't pay attention to them. I'm comfortable with the income we generate and don't practice refractive cataract to print out cash. I enjoy it. I have no financial interest in anything.
I'm incredibly comfortable with my transparent conversations with patients regarding their options and whether or not they should pursue. My goal is to save people money.

You're correct in saying I'm not high volume at this point; given I just started and will hit around 500 cases this year; so your blanket statements are referring to place where thousands of cases are being complete. However, with that said, I trained at a place your describing - and the surgeons were not "slick salesmen". They were greats surgeons who were honest and transparent with patients.

Given the environment, making BLANKET statements about groups of people is definitely ignorant. I'm sorry to hear you've convinced yourself that anyone who enjoys surgery and provided people minimal dependence on glasses when they ask for it and are good candidates are money hungry salespeople.

 

[MstaKing10]

Retina docs (of which I am one) see the bad apples and admittedly have a bias. When we see the umpteenth referal for an unhappy multifocal patient due to a horrendous pucker or AMD or whatever that was missed pre op you get jaded. Clearly not all cataract docs are money hungry but there’s enough out there that it gives the field a bad name. May be a regional thing but there’s plenty of that going around.

Back to the original point which is a very good one, Retina docs take care of people who need surgery or risk blindness. Refractive docs have a much different mind set. Just the way it is. Both improve people’s quality of life so nothing wrong with either, but I find the personalities in these fields are quite different.

In terms of compensation, I’ve seen way more refractive docs take a hit during this pandemic then retina docs. And if the economy slows so will their practices. People will continue to need retina services no matter what. I’m not sure what figures some on this thread are looking at but retina docs certainly have the potential to make as much if not more than their refractive colleagues. And this income is more insulated from major changes in the economy than their refractive counterparts.

 

[LightBox]

As I've mentioned before, I know lots of greedy retinal specialists who basically commit Medicare fraud with their overtesting and overtreating of patients. Again, the difference being the patients are none the wiser since there is no subjective visual feedback the patients can give regarding their "retinal care" unlike in the anterior segment / refractive field. Many of the largest government punishments are against unsavory retinal specialists.

South Florida Eye Doctor Gets 17 Years for Medicare Fraud

Dr. Salomon Melgen, a retinal specialist in Palm Beach County, Florida, was sentenced Thursday to 17 years in prison and ordered to pay $42,6 million on charges he bilked Medicare out of $73 million over two decades.

www.courthousenews.com

So let's all agree that there are just bad apples in all fields. Retina specialists are not holier than thou.

 

[docdoc2012]

This literally isn't even a discussion about bad apples or who is more unethical.

It's a question of how your typical practice will look like in a retina vs. high volume cataract/refractive practice.

Apparently saying you have to have salesman qualities to be a high volume refractive person really hit a nerve.

Nowhere in my post did I say this is the norm for all cataract/refractive surgeons in all practice settings. I didnt even say the surgeons are the 'slick salesman' - I said it's this type of operation, and a surgeon you are expected to deliver the final product in this operation - basically be on point. The practices are structured so that by the time the pt even gets to your chair, they're already kinda wanting the 'premium' product.

Are we really pretending that this is not the case? That these practices don't have entire sales strategies centered around IOL conversions? Why is this such a big deal to accept? If you as a surgeon have to chosen to center your skills around an out-of-pocket procedural set, this is part of the equation. Accept it and move on.

It is important for the OP to know this. Because remember OP, cataract surgery is the first ophthalmic surgery most of us fall in love with. As to whether you will choose high volume cataract surgery or not - the salesman part of it is a HUGE sticking point to many. To be a good retina surgeon you have to have good ant seg skills to begin with So many retina people turn away from ant seg because they don't want to have to deal with premium iol issues in the real world - either because they don't feel comfortable with the concept or don't have that natural quality with people

this should factor into your equation .

 

[ophtho838]

I don't think the vast majority of ant seg/cataract docs have to put on their salesman hat 24/7. I feel like the 'questionably ethical salesman' tactic is specific to those high-volume cataract surgeons with high conversion rates (which is what OP is asking about), so yes, you have to be comfortable selling these IOLs if that's what you aspire to. Just look at the websites of high-volume premium IOL surgeons - they are essentially billboards.

Back to OP's original question: retina and ant seg are very different. Of course, do what you love, but don't base your decision on the 10% of cool things you might see in each specialty; think about the 90% of bread and butter stuff you'll be dealing with for most of your day. For comp/ant seg, that's cataracts and dry eye. For retina, that's DR and AMD. What can you see yourself doing day in and day out?

Also, keep in mind that every resident loves cataract surgery... but that's just because they haven't done a vitrectomy yet.

 

[dantt]

This literally isn't even a discussion about bad apples or who is more unethical.

It's a question of how your typical practice will look like in a retina vs. high volume cataract/refractive practice.

Apparently saying you have to have salesman qualities to be a high volume refractive person really hit a nerve.

Nowhere in my post did I say this is the norm for all cataract/refractive surgeons in all practice settings. I didnt even say the surgeons are the 'slick salesman' - I said it's this type of operation, and a surgeon you are expected to deliver the final product in this operation - basically be on point. The practices are structured so that by the time the pt even gets to your chair, they're already kinda wanting the 'premium' product.

Are we really pretending that this is not the case? That these practices don't have entire sales strategies centered around IOL conversions? Why is this such a big deal to accept? If you as a surgeon have to chosen to center your skills around an out-of-pocket procedural set, this is part of the equation. Accept it and move on.

It is important for the OP to know this. Because remember OP, cataract surgery is the first ophthalmic surgery most of us fall in love with. As to whether you will choose high volume cataract surgery or not - the salesman part of it is a HUGE sticking point to many. To be a good retina surgeon you have to have good ant seg skills to begin with So many retina people turn away from ant seg because they don't want to have to deal with premium iol issues in the real world - either because they don't feel comfortable with the concept or don't have that natural quality with people

this should factor into your equation .

The practice owner(s) and sometimes doctors set the culture of the practice. I know many refractive surgeons whose patients come to them looking for a specific type of expertise and service; no "selling" needed. I know others who's counselors are payed on commission and are authorized to offer "discounts" to "close the deal."