Future of Ophthalmology & Optometry

[Kemien]

Hello,

I am an MS3 currently debating between ophthalmology and other surgical subspecialties. One thing that has me very concerned is the invasion of Ophthalmology by Optometry. We're seeing currently attacks on ophthalmology in multiple states (Florida, Alaska, California, Georgia, North Carolina and Maryland) where optometrists are lobbying big time to become surgeons. I find it pathetic that this is even being considered but I don't want to start another ophthalmology vs optometry debate. Rather my question is to people in the field; how big of a threat does this pose to ophthalmology? Could it make ophthalmology obsolete or severely cripple it (like what interventional cardiology did to cardiac surgery)? Is this threat considerable enough to factor it in my career decision?

Thank you.

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[KHE]

Don't know but as an optometrist for 17 years, I think the bigger "threat" to ophthalmology other than the constant attacks on reimbursements by CMS would be drops that treat cataracts and/or retinal conditions. Lucentis in drop form, in other words.

 

[Trefoil]

I would caution against worrying about optometrists as many subspecialies of medicine have mid level providers that will try to advance their scope (CNAs, Nurse Practioners, etc.) Similarly, all specialties have reimbursement cuts. Today, I was told that cardiology has faced a more competitive market for the same reason. Ophthalmology may have been hit disproportionately because of how commonly cataract surgery is performed.

I think you ultimately need to choose what you enjoy. Other surgical fields are generally more demanding and less clinic based than ophthalmology. If you love clinic, then consider ophthalmology a contender. If you hate clinic, you should probably steer away from ophthalmology and ENT. ENT is another great option for someone who enjoys the OR and clinic.

 

[peter2013]

Cardiothoracic surgery is obsolete? That's new to me.

In regards to optometry: Increasing the scope of practice for optometrists could become a financial issue for ophthalmologists, but it's one that hasn't come to fruition for the last 30 years. If optometrists do get rights to perform laser procedures such as LASIK or intravitreal injections, this could decrease procedural volume for ophthalmologists. If history is your guide, you could make an argument that this won't be an issue for years to come. If you look at history a little differently (that they have gained the rights to prescribe drops, then systemic medications), then you could make an argument that surgical privileges could eventually happen.

In regards to drops to cure cataracts or retinal diseases: Drops for cataracts are arguably closer to becoming a reality (with lanosterol) than drops for treating retinal pathology such as AMD or DME. If drops to treat/delay cataracts pass clinical trials, this could greatly decrease procedural volumes for ophthalmologists.

In regards to Medicare/RUC: I think this is the biggest problem for both ophthalmologists and optometrists. While both groups are focused on fighting against each other, they should be working more on lobbying to improve compensation. Both groups are competing against giant hospitals for reimbursement changes and are losing the fight.

In regards to innovation: This is the greatest potential for ophthalmology. New procedures and/or more efficient procedures tend to be the most lucrative (ex: cataract surgery advances in the 80s and 90s, and intravitreal injections in the 2000s). A ton of research is being done on stem cell therapies, gene therapy, new pharmaceuticals and the eye is the perfect place to test these new therapies because the eye is an immune-privileged, the volumes are small and treatments are easily monitored. I expect innovations to continue, which will help ophthalmologists financially.

Overall, if you're looking to make a lot of money without any risk, ophthalmology may not be the best risk/benefit calculation. If you want to pursue ophthalmology because eyes are beautiful, helping people with their vision is rewarding, you like the balance of clinic/surgery and the patients are terrific, then it's worth these hypothetical financial risks. Who knows, new innovations may make these concerns obsolete. Additionally, if we will become a single payer system in the near future (hopefully not!), then all bets are off.

 

[ophthope]

I doubt lanosterol will have a significant impact on surgical volume. It would be nice to have something to offer those patients that are extremely anxious about surgery so that maybe they can do something to improve their visual acuity, but I highly doubt it will be a miracle cataract reversal agent.

If Optometrists actually start to do any significant amount of surgery, there will almost certainly be a war that starts. I guarantee you that every major city will have a "Did your "eye surgeon" go to medical school, or just optometry school? GET YOUR SURGERY BY A REAL SURGEON COME SEE US AT [Insert practice name here]". Most Ophthalmologists don't have an extremely high surgical volume already and if the pool is diluted further by more providers then nobody wins - NOBODY will be as experienced at surgery at many fewer patients will have the benefit of a surgeon who does the same surgery 10-15 times per week. The whole issue is absurd. Frankly, you could train anyone to do cataract surgery. I'm sure with a little teaching I could cath and stent your freakin' LAD. You can train anyone to do any procedure. The issue is whether or not we SHOULD and that tends to be lost in these debates.

As peter2013 mentions above the real problem is that while we are young in our careers, our forefathers in Ophthalmology AND Optometry have wasted all of this time fighting each other instead of embracing each others' strengths and working together. Meanwhile, reimbursement is being gutted, new OD grads have to work in a Sam's Club to barely pay off their loans, the public is being given data and sensational news that makes retina docs looks like money grubbers for using lucentis when the real problem is with the pharamaceutical industry and the FDA who won't provide cheap single use avastin or approve multi-dose vials for usage, etc. Took us like what, over a decade to get collagen crosslinking approved when it was pretty obviously the best thing for patients for a while?

And yet we wasted all this time arguing about whether or not someone is not trained to do surgery can actually do it. ODs are stupid for fighting this battle and for oversaturating their field, and MDs are stupid for not working closer with ODs in the first place generations ago since it would have been better for our patients.

I wouldn't let it play heavily into your decision on choosing a specialty. Do what you like the most, and if you don't like anything in particular then pick a specialty that has good hours. For me, I'm not sure what else I would really have done. Derm was really boring.

If you just want to get into medicine and pay off loans and get out then pick a short residency with high early earning potential and the possibility of shift work - like Emergency Medicine or Anesthesiology. If you want out then live cheap and only do a shift per week.

If you want to reverse blindness, have patients that hug you and cry for what you've been able to do for them, etc... well I guess keep hanging around here.

 

[kid Icarus 3]

I agree with the above post regarding miracle cataract drops. I feel it will be a long time to #1) prove they work effectively for age-related cataracts in the general population and #2) convince people to put steroids in their eye for who knows how long rather than have a quick surgical intervention with nearly immediate results that will likely need no further treatment. Even if drops work it is unknown if people will need to continue to use them for the rest of their lives. There are a lot of questions yet to be answered.