Let me provide another viewpoint since this thread seems fairly one-sided. In academics you have more specialists usually, so you tend to be pressured more to do a fellowship as a resident. You have to actually ask comprehensive docs for their viewpoint to hear both sides of the story. Here's why comprehensive is still a great choice. I'll breakdown each fellowship option. The good thing about ophtho is that it has many fellowship options, but the bad thing is most of them are not worth doing. So to sum up what I'm going to post below, retina and plastics are the only fellowships worth doing since they add a lot to your residency training, job market, and future services you can offer your practice. The rest of the fellowships don't and aren't worth doing, IMO. The problem with retina+plastics is that you cannot do cataract surgery and general ophtho due to referral patterns, thus those are only viable options if you like either more individually than comprehensive. I'll break down each fellowship now:
Retina - definitely worth doing, but then no comprehensive in practice
Plastics - definitely worth doing, but then no comprehensive in practice
Uveitis - waste. Doesn't add anything surgically. Ppl only do it to make themselves more competitive for another fellowship or IMGs trying to get into residency. Doesn't help in prvt practice job market or future income.
Neuro - waste. Doesn't add anything surgically. Can't practice neuro only in private practice and have to stick to academics. In prvt practice you'll be doing more general than neuro, and the more time you spend on neuro, the less money you'll make. Some do it to make themselves more competitive for plastics.
Peds - can do strabismus which is cool, but most ppl can't stand working with kids all day. Nothing's more intolerable than peds ophtho IMO. Also financially they make less than comprehensive. There's a reason why Bascom often has an umatched peds spot.
Onc/pathology - very rarely used in prvt practice. Probably have to work in academics. Therefore less money. Not good for prvt practice.
Cornea - supposedly adds refractive and transplants. Refractive is very cutthroat and is done by cornea and comprehensive in most areas. Refractive isn't good when economy is down. If you have a refractive factory, then you're that 1% and it paid off but you don't need a fellowship to get there. Transplants are interesting, but they are low volume in prvt practice. If you suddenly couldn't rely on cataract surgery anymore, transplants would not be a viable option to fall back on because even the most busy cornea transplant docs only do a few per month. The job market is bad, even worse than comprehensive possibly, definitely not better. It doesn't pay more than comprehensive unless you do high volume refractive, but that's extremely hard to break into and you see comprehensive docs doing it anyway. Cornea specialists will try to argue only they should be doing refractive surgery (not because of the surgery is hard but for the preop + postop care). If you go to one of these refractive factories run by a cornea specialist, they have optometrists doing all the pre and postop care anyway. So that argument is a bunch of garbage. Also, if you look at the average surgical numbers for cornea fellowships, they don't even do that much refractive. They spend most of the year learning transplants. So, in the end, doesn't seem that worth it and there's a reason there are always dozens of cornea spots unmatched each year.
Glaucoma - has a better job market. Does add glaucoma surgery. Some comprehensive docs do some glaucoma surgery, but it usually is express shunts and maybe trabs. Glaucoma specialists will argue comps often do the wrong surgery or XYZ was the better option, but if you actually look at the studies, often the research doesn't say which is better and that specialist's opinion is anecdotal and you'll hear another glaucoma specialist say the opposite. However, you need to look beyond just doing the glaucoma surgery. Even though it's cool, you're going to spend 30 minutes doing the surgery on the pt and then managing the postop complications forever. Unfortunately, glaucoma surgery has the highest rate of complications of any ophtho surgery, highest rate of post-op endophthalmitis, and you can spend a lot of time (paying you little since it's postop care) addressing bleb leaks, blebitis, failed surgeries, etc. And in the end, the pt never notices improved in their QOL. Initially they are likely seeing worse due to inflammation, and will still never improve their VF and only see it progressively worsen. Also, you need to see what type of pts are referred to glaucoma specialists. Most glaucoma pts are actually managed by comprehensive docs, while the end-stage advanced glaucoma pts are the ones sent to the specialist. Personally, I don't think I'd enjoy a practice full of pts who are nearly blind and can do very little about it. It's definitely a noble thing to do, but from a financial standpoint, it doesn't pay off, and if you don't like chronic disease that you can't improve, then shouldn't do it. So better job market, doesn't pay more, and are referred a bunch of end-stage pts who you can never improve but hopefully slow down losing their last pinhole of vision. These days, glaucoma is also a lot more competitive than it was. Ten years ago you only had ppl applying who liked glaucoma, but now you have a bunch of ppl applying in addition for the better job market. You can argue you don't have to practice glaucoma longterm if you really don't like all those ultra advanced glaucoma pts, but then why did you do the fellowship to begin with?
So, in summary, retina and plastics are great fellowships since they add a lot, but if you like cataract surgery + variety more, then you should do comprehensive. There will be always be a job market for it because, like I said, doing most of the fellowships doesn't add much. If we suddenly lost cataract surgery, every specialist would suffer just as much as comprehensive except for retina and plastics. Glaucoma would survive to some extent, but they also rely on a lot of cataract surgery. There's a reason the most competitive fellowships are now #1 plastics, #2 retina, and 3# glaucoma. If you don't like managing a lot of end-stage glaucoma, then glaucoma isn't a good option either. If you actually do job searches, there are a lot of comprehensive jobs out of there. But also, many ppl only want to live in the center of big coastal cities, so the job market is tighter and a fellowship can help land a job. IMO, this is a big reason why you see 65% of residents doing fellowships now, but truthfully, only those competitive 3 I mentioned are the only fellowships that will significantly improve your job market (maybe peds too? but also most ppl couldn't do peds just for a better location). However, I see a good number who don't even practice their fellowship anymore and just do general. So they wasted that year and missed out on $150,000-200,000 attending pay, 1 year closer to making partner (and once you do you can count on your salary to double), and likely had to move to a random place for 1 year for fellowship before finally being able to settle down. And if you have a family, that's a lot to miss out on. If you truly prefer one of the top 2-3 I mentioned, are single or can land the fellowship in the same city your family wants to live in, then sure go for it. If it's not one of those top 2-3, the positives doesn't seem to outweigh the negatives.
