Does anyone foresee surgery in ophthalmology becoming obsolete?

[gregoryhouse]

Do you guys who are practicing in Ophthalmology right now ever see cataract or other ocular surgery becoming less common in the near future? It seems like even in retina with the advent of injections that the need for surgery is becoming less common. I think there will always be a need for surgery but do you guys think the number of cases will diminish eventually as technology and treatments advance? And what would the practice of Ophthalmology look like if cataracts and other common surgeries end up being taken over by alternative treatments?

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[MstaKing10]

At least for retina: injections can't treat retina detachments, macular holes or puckers, retina tears, non clearing vit heme, retained lenas material, dislocated lenses etc etc etc. As technology advances the field will change for the better but I don't see surgery becoming obsolete, at least not in my lifetime

 

[Slide]

Do you guys who are practicing in Ophthalmology right now ever see cataract or other ocular surgery becoming less common in the near future? It seems like even in retina with the advent of injections that the need for surgery is becoming less common. I think there will always be a need for surgery but do you guys think the number of cases will diminish eventually as technology and treatments advance? And what would the practice of Ophthalmology look like if cataracts and other common surgeries end up being taken over by alternative treatments?

From a retina standpoint, some of the riskier indications may be obsolete (such as macular translocation) due to new injections, and some of the softer indications for vitrectomy can be managed medically now, but the number of surgically-appropriate cases will probably stay static because most of the indications cannot be treated medically. If anything, with all the advances in vitrectomy, you can make an argument for being more aggressive surgically. Reimbursement, is a different story: it pays more to be in clinic so for ophthalmologists (esp retina) who have to keep costs in mind, we're being pushed more towards trying to stay in clinic.

For ophthalmologists in general, I don't see the need for surgery decreasing. Advancements will change how we do some surgeries and make them less invasive but I do not feel it will threaten the number of cases. For cataract surgery, I cannot see alternative treatments replacing phaco anytime soon.

This is a side note from the original point but I feel the bigger issue is that there are ophthalmologists are graduating without great surgical experience, and not getting enough broad microsurgical training throughout residency. The biggest gripe I hear from residents is that they don't get to operate enough so they have to pick up how to do other surgeries after residency, which is tougher than as a resident. You always have to learn newer techniques as surgery advances and improves over time, but you need to have a solid foundation to work upon in order to do that, and the latter is what I'm concerned about in regards to general resident training.

 

[DrZeke]

This is a side note from the original point but I feel the bigger issue is that there are ophthalmologists are graduating without great surgical experience, and not getting enough broad microsurgical training throughout residency. The biggest gripe I hear from residents is that they don't get to operate enough so they have to pick up how to do other surgeries after residency, which is tougher than as a resident. You always have to learn newer techniques as surgery advances and improves over time, but you need to have a solid foundation to work upon in order to do that, and the latter is what I'm concerned about in regards to general resident training.

I agree wholeheartedly with this. I think there are a lot of residencies out there that just aren't as well-rounded as they claim to be. Sometimes you'll even pass through a residency when they won't have good representation of a sub-specialty, so you will be undereducated in a particular area. Like there may be a 1-3 year period where there is no glaucoma faculty that you get to rotate with but everyone before or after you got a strong foundation in glaucoma.

You can study and teach yourself a lot about the management of certain conditions, but there is definitely an art to managing certain diseases. And not everything is as simple as "if it's wet inject" or "just lower the pressure". I think that's a huge motivator to do fellowship. Personally I always knew I wanted to do fellowship but I think it can be demoralizing to feel like you don't have a choice. Particularly if you want to become surgically competent in an area.

And i know this is a taboo topic but I have heard rumors of people having to fudge numbers for logs.... has anyone heard of this ?


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[MstaKing10]

I agree wholeheartedly with this. I think there are a lot of residencies out there that just aren't as well-rounded as they claim to be. Sometimes you'll even pass through a residency when they won't have good representation of a sub-specialty, so you will be undereducated in a particular area. Like there may be a 1-3 year period where there is no glaucoma faculty that you get to rotate with but everyone before or after you got a strong foundation in glaucoma.

You can study and teach yourself a lot about the management of certain conditions, but there is definitely an art to managing certain diseases. And not everything is as simple as "if it's wet inject" or "just lower the pressure". I think that's a huge motivator to do fellowship. Personally I always knew I wanted to do fellowship but I think it can be demoralizing to feel like you don't have a choice. Particularly if you want to become surgically competent in an area.

And i know this is a taboo topic but I have heard rumors of people having to fudge numbers for logs.... has anyone heard of this ?


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Is this a new trend or has this always been an issue? What percentage of residencies do you think fall into this poor training category? Fudging numbers would be very innapropriate.

It's really incumbent upon you to stay up to date and teach yourself the latest techniques and medical management. A decade after graduating residency techniques and management standards will change, and 2 decades later in the prime of your career things may be vastly different. Residency lays the foundation but without continued learning this will only take you so far.

 

[DrZeke]

Is this a new trend or has this always been an issue? What percentage of residencies do you think fall into this poor training category? Fudging numbers would be very innapropriate.

It's really incumbent upon you to stay up to date and teach yourself the latest techniques and medical management. A decade after graduating residency techniques and management standards will change, and 2 decades later in the prime of your career things may be vastly different. Residency lays the foundation but without continued learning this will only take you so far.

Unclear...probably several of the low-middle tier ones that don't have great numbers or strong representation in every sub-specialty without a plan for subsidizing that education.


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[Slide]

Is this a new trend or has this always been an issue? What percentage of residencies do you think fall into this poor training category? Fudging numbers would be very innapropriate.

It's really incumbent upon you to stay up to date and teach yourself the latest techniques and medical management. A decade after graduating residency techniques and management standards will change, and 2 decades later in the prime of your career things may be vastly different. Residency lays the foundation but without continued learning this will only take you so far.

I don't know if it's always been the case but it's the case for the past several years. Depending on your criteria, I would say anywhere from 10-15%.

I didn't think this was the case until fellowship. As a resident, all the residents in my program and in nearby programs were pretty competent in phacoemulsification, lasers, LASIK, and some glaucoma and plastics surgeries. But here in fellowship, I know attendings less than 10 years out who don't operate...at all. I feel bad for the residents because all they learn to really do is phaco, which is great and all, but it also limits what you can do. Even if you're an avid learner during residency and keep up with the latest techniques out there, it doesn't mean **** if you don't feel comfortable with the microscope and take 10 minutes putting in a suture.

The issue with logging numbers to meet requirements is that it's an honor system, and the criteria to log primaries is very nebulous from program to program. Most non-phaco cases are poached by fellows and attendings. Its also probably no secret that the more academic, "prestigious" residencies work this way and essentially force residents to do fellowships.

 

[LightBox]

Every Ophthalmologist should really be worrying about whether Optometrists will be doing the "common surgeries" soon:

https://www.flsenate.gov/Session/Bill/2017/1168/BillText/Filed/HTML

I'm not trying to incite a flame war, but this is a real deal threat. Optometry in Florida wants to be able to dictate what does and does not constitute the "scope of optometric practice" without oversight. There are too many silent people in Ophthalmology while Optometry continues to whittle away and undermine all of the years of intensive training that we have undertaken. If you care at all about your future, everyone should be donating to your local Ophtho PAC/society and also to AAO's Surgical Scope fund. I don't even live in Florida, but I have contributed to the Florida Society of Ophthalmology's "FOCUS" fund to prevent granting of surgical privileges to Optometry. I don't want to see our fellow Ophthalmologists competing with and our patients being operated on by "Certified Optometrists in Ophthalmic Surgery" anywhere.

Lastly, and very importantly, you absolutely must contact all of your delegates opposing these bills. They actually will listen to you especially if you live in their district.

 

[DrZeke]

We have seen some horror stories in my state. There are many wonderful optoms out there, there are also those treating scleritis with oral steroids for 4 months whiIe the patient has a history of deep tissue infections and actively had a large non healing wound during the duration of treatment that ultimately ended up requiring hospital admission. I mean there's a reason we are able to practice what we do... we went to medical school. I pride myself on the knowledge gained in med school and enjoy being a team player for my hospital consults.

I went to AAO mid year forum and I recommend to everyone. My program only sponsors like 1 resident per year and our state society won't help us pay for the meeting. It's a shame because it's kind of pricey. Seems worth it tho...


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