Fellowships

[tennik]

When a person does a one year fellowship like cornea do they typically hope to do only cornea in practice? I would think that outside of large academic settings there are few places that can support a cornea specialist.

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[Andrew_Doan]

Many fellowship trained ophthalmologists practice BOTH their fellowship specialty and general ophthalmology. One exception is retina.

For instance, as an ocular pathologist, I plan to practice both ocular path and general ophthalmology.

 

[tennik]

So do you do a fellowship like cornea because you didn't get enough cases in cornea during your residency, or do you do the fellowship because it makes you more marketable for hire?

 

[Andrew_Doan]

So do you do a fellowship like cornea because you didn't get enough cases in cornea during your residency, or do you do the fellowship because it makes you more marketable for hire?

Many residencies don't train their residents to do corneal transplants, for example. There are no RRC reqirements for corneal procedures. Thus, if one desires to do corneal transplants and other corneal procedures (DLEK), then it is highly advisable to do a cornea fellowship where one will perform numerous corneal surgeries.

I can do a corneal transplant if needed (emergency situation) or simple case, but I will not feel comfortable doing corneal transplants on a regular basis given than I've only done 4 corneal transplants and assisted on 20+ cases. The post-operative care for corneal transplants requires extensive experience; thus, I wouldn't want to manage these cases without a cornea fellowship.

 

[tennik]

Do some programs cover specialties like retina from a gereralists perspective in order to protect the retina cases for the specialists (i.e. if you don't get good exposure to retina in residency and don't do a fellowship, you will have to refer more cases to a retina doctor)?

 

[Andrew_Doan]

Do some programs cover specialties like retina from a gereralists perspective in order to protect the retina cases for the specialists (i.e. if you don't get good exposure to retina in residency and don't do a fellowship, you will have to refer more cases to a retina doctor)?

It's not a matter of protecting the retina docs. It requires at least one year of surgical retina to be good at posterior pole surgery. During residency, residents at Iowa, for example, do 20 weeks of retina. The first 10 weeks is for clinical retina and to learn some laser surgery. The second 10 weeks is more surgical where we do mainly laser surgery and scleral buckle procedures for retinal detachments. I did some tap and injects for endophthalmitis and pneumatics for tears/superior detachments. However, there's simply not enough time during ophthalmology residency to master all the surgical techniques in retina. Retina cases are difficult if you don't get enough training. Thus, this is why ophthalmologists complete a retina fellowship.

Could I do a buckle? I could, but without more surgical cases, I'd feel more comfortable sending my patients to a retina specialist. On the other hand, membrane peels, posterior pole surgeries, and macular hole repairs are beyond my scope of practice.

 

[mdkurt]

Do some programs cover specialties like retina from a gereralists perspective in order to protect the retina cases for the specialists (i.e. if you don't get good exposure to retina in residency and don't do a fellowship, you will have to refer more cases to a retina doctor)?

Programs cover retina to the extent that you should be able to handle non-incisional issues without difficulty. This usually excludes intravitreal kenalog. Many general ophthalmologists feel comfortable handling medical retina, but will hand over severe diabetic macular edema, proliferative AMD, etc. Buckles used to be well within the realm of the general ophthalmologist, but as retina specialists become more prevalent fewer generalists are willing to bring that pain upon themselves.

 

[tennik]

I have talked to general docs who wish they had done a fellowship so they could operate with "cooler toys." Seems logical that a doc like this could just sit in on 20+ cases with a cornea specialist etc. and then use the the "cool toy" themselves. In the same light, what do general docs do when new products come out - how do they learn the new techniques?

 

[Andrew_Doan]

I have talked to general docs who wish they had done a fellowship so they could operate with "cooler toys." Seems logical that a doc like this could just sit in on 20+ cases with a cornea specialist etc. and then use the the "cool toy" themselves. In the same light, what do general docs do when new products come out - how do they learn the new techniques?

The good thing about intraocular and ocular surgery is that surgeons can build on fundamental surgical steps. So when new techniques are developed, surgeons either work with other surgeons who can teach them or attend courses to learn these new techniques. You're right that a physician can sit in on 20+ cases with a cornea specialist, but the physician who is learning must also generate cases. Who is going to refer patients to the general ophthalmologist who just learned a new corneal surgery? The general ophthalmologist is better off staying away from the more difficult sub-specialty cases.

It's not about the 'cool toys', because any toy becomes mundane with time. It's about finding out what makes you happy in regards to type of patient, type of surgeries, and variety of pathology.

 

[Retinamark]

Do some programs cover specialties like retina from a gereralists perspective in order to protect the retina cases for the specialists (i.e. if you don't get good exposure to retina in residency and don't do a fellowship, you will have to refer more cases to a retina doctor)?

It's also about surgical experience. If you had a retinal detachment, who would you want doing the surgery
- a general ophthalmologist who does 5 - 10 per year
- a retina specialist who has done 2 years of retina fellowships and does 200 or more cases per year?

The first operation is always your best chance to get it right - this applies not only to detachments, but corneal transplants, trabeculectomies etc.

In general, the more you do something, the better you get at it.

 

[tennik]

But often patient's go to a general ophthalmologist and that doc decides who does the surgery. You are right that the patient will choose the retina doc, but they don't choose from a menu.

 

[Andrew_Doan]

But often patient's go to a general ophthalmologist and that doc decides who does the surgery. You are right that the patient will choose the retina doc, but they don't choose from a menu.

Most general ophthalmologists (there are always exceptions) know what is beyond their scope of practice. If a surgeon has extensive experience in cornea transplants without doing a cornea fellowship, then the surgeon is probably pretty good if their practice is focused on doing transplants.

Your comment above is valid; however, it perplexes me how patients do not do research before going to their doctor. Many do not know, for instance, the difference between their optometrist vs ophthalmologist.

Also, patients rarely do extensive research about their medical problem or surgery. On the other hand, if an individual shops for a new car or home, then how much research is done for these types of endeavors?

You're incorrect that patients cannot choose from menu.

A little research and knowledge will guide them to the menu items they want or need.

 

[Yogi Bear]

Many fellowship trained ophthalmologists practice BOTH their fellowship specialty and general ophthalmology. One exception is retina.

For instance, as an ocular pathologist, I plan to practice both ocular path and general ophthalmology.

hey, how's it going? i remember u mentioned awhile back u were looking into neuroopth. are u still planning to do that? seems as though u're going to sunny cali.

 

[ttt0079]

While we're on the topic of fellowship, Dr. Doan, how do most residents choose a field? When do you have to decide to prepare aggresively for the fellowship match? It seems that most of the residents at my institution are going to either cornea or retina. Are these two fields going to be saturated in a few years? I am personally very interested in glaucoma, but have been quite discouraged since all the cornea/retinal-oriented residents seem to consider glaucoma a second-rate field lacking any advances. Is that true? Thanks.

 

[Andrew_Doan]

Don't worry about what is saturated or not. Concentrate on the things you enjoy, and it'll all work out! If you go into retina for the money and you are miserable, then do you think you'll be an effective retina surgeon?

Follow your interests and success will continue.