job markets for various specialties vs comprehensive

[FenderB2004]

A lot of people say that you should do a fellowship for better job opportunities...how true is that? Is the job market for cornea or gluacoma that much better than comprehensive (excluding retina and occuloplastics for the moment)?

I don't think there's that much data on this, but my general feeling is that it's not that much better. I certainly don't want to do a fellowship just because I thought the job market was better, but if that's the only way to get a job these days (as some attendings and coresidents imply), I just might have to...

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[LightBox]

A lot of people say that you should do a fellowship for better job opportunities...how true is that? Is the job market for cornea or gluacoma that much better than comprehensive (excluding retina and occuloplastics for the moment)?

I don't think there's that much data on this, but my general feeling is that it's not that much better. I certainly don't want to do a fellowship just because I thought the job market was better, but if that's the only way to get a job these days (as some attendings and coresidents imply), I just might have to...

Very true. You have to think about your job prospects in terms of the "Services" that you can provide patients (and also the "Services" that patients would actually trust you to provide). To be honest, most fellowship-trained Ophthalmologists in private practice practice General Ophthalmology + their specialization. For example, a Cornea person is going to do Cataract surgery + LASIK / transplants. They typically aren't going to perform just Corneal surgery. However, if they somehow get in a situation where they are doing pure refractive....they will quickly consider dropping cataract surgery since refractive is much more profitable.

In summary, fellowship training is definitely worth the extra 1 or 2 years. However, you do have to avoid being "pigeon-holed" into seeing one type of patient just because you are fellowship-trained (e.g. comprehensives dumping "intractable dry eyes" on you while they take all of the cataracts).

 

[Visionary]

I would recommend doing a fellowship...if you want to. Sure, you may be able to make yourself more marketable with fellowship training. For instance, if the area in which you would like to settle seriously needs a glaucoma specialist, you could do a fellowship in glaucoma. Of course, if you don't like glaucoma, that's probably not a good move. Better option is to do a fellowship in something that truly interests you, if you want to focus your practice in that subspecialty. There are far more important factors in your job search (and your revenue potential) than fellowship training.

 

[Myxomatosis123]

From what I have heard/seen, it seems to be about 50/50 in regards to graduating residents going into fellowships/comprehensive. Most things seem to have a pendulum like swing and it seems we are in the "fellowship" side of the swing. I would guess that things might shift back to more comprehensive docs, but who knows.

I did hear from one program director who thought that comprehensive ophthalmologists should be able to care for 80-90% of the population, and then have to refer the rest on.

 

[Visionary]

I did hear from one program director who thought that comprehensive ophthalmologists should be able to care for 80-90% of the population, and then have to refer the rest on.

I'd have to disagree with this statement. That's like saying internists and family practitioners should be able to care for 80-90% of the population and refer the rest. Maybe in the olden days, but modern medicine is too complex and rapidly progressing for that. For instance, I would never recommend that a comprehensive doc routinely follow someone with known retinal pathology. I've seen too many patients with early wet AMD and PDR that was missed, retinal diseases outright misdiagnosed, etc. Without the subspecialty immersion, you are more likely to miss significant pathology--I don't care how good your residency training was. I routinely refer out corneal and lid pathology, strabismus, all but the most straightforward glaucoma, and even some serious uveitis cases. Didn't I learn about all this in residency? Sure, but I don't keep up with the current practice patterns well enough, as my focus is retina. I think those aspects of ophthalmology are better handled by a subspecialist. Fact is that early and accurate diagnosis leads to better outcomes. My opinion. Sure others would disagree.

 

[Hemichordate]

When you do a specific fellowship, how much of your time/training is spent with patients who get referred to that subspecialty and how much of your time is spent looking at patients with other eye conditions? i.e. Do retina fellows work predominantly with retina cases, or do they still get plenty of exposure to patients with glaucoma, cornea problems, etc.?

 

[dantt]

I'd have to disagree with this statement. That's like saying internists and family practitioners should be able to care for 80-90% of the population and refer the rest. Maybe in the olden days, but modern medicine is too complex and rapidly progressing for that. For instance, I would never recommend that a comprehensive doc routinely follow someone with known retinal pathology. I've seen too many patients with early wet AMD and PDR that was missed, retinal diseases outright misdiagnosed, etc. Without the subspecialty immersion, you are more likely to miss significant pathology--I don't care how good your residency training was. I routinely refer out corneal and lid pathology, strabismus, all but the most straightforward glaucoma, and even some serious uveitis cases. Didn't I learn about all this in residency? Sure, but I don't keep up with the current practice patterns well enough, as my focus is retina. I think those aspects of ophthalmology are better handled by a subspecialist. Fact is that early and accurate diagnosis leads to better outcomes. My opinion. Sure others would disagree.

What percent of patients have serious retinal pathology? What percent of people even see an ophthalmologist until they have a non glasses related eye problem? I think 80-90% is very reasonable.

 

[MR1]

You only see the stuff you are doing the fellowship for. I learned all I want to know about cornea, glaucoma, etc in residency. I only see retina now. Fellowship is too short to do it any other way

 

[90 diopter]

A lot of people say that you should do a fellowship for better job opportunities...how true is that? Is the job market for cornea or gluacoma that much better than comprehensive (excluding retina and occuloplastics for the moment)?

I don't think there's that much data on this, but my general feeling is that it's not that much better. I certainly don't want to do a fellowship just because I thought the job market was better, but if that's the only way to get a job these days (as some attendings and coresidents imply), I just might have to...

Depends on the fellowship. Relatively under-represented specialists that are in demand like glaucoma and pediatrics will allow you the opportunity to pick from a larger geographic area, so if location is important I think a person can build a practice with one of these fellowships very quickly just about anywhere outside of the largest metropolitan areas. If, like me, you prefer smaller towns, you'll have no problem finding a comprehensive ophthalmology job.

You have to consider the downsides of fellowship training. I would go insane if I had to manage trainwreck after trainwreck of patients with pressures in the 50's. Same with treating screaming, unhappy children. Some people enjoy those challenges; I do not.

 

[Visionary]

What percent of patients have serious retinal pathology? What percent of people even see an ophthalmologist until they have a non glasses related eye problem? I think 80-90% is very reasonable.

Hey, I don't have exact numbers to provide you. I'm not an epidemiologist. And I wasn't talking just retina. My point was mainly that "serious" pathology can be missed or misdiagnosed by someone without a lot of experience at it. One of the hardest things about being a comprehensive ophthalmologist (or and internist, for that matter) is knowing when to refer to a specialist.

 

[Visionary]

When you do a specific fellowship, how much of your time/training is spent with patients who get referred to that subspecialty and how much of your time is spent looking at patients with other eye conditions? i.e. Do retina fellows work predominantly with retina cases, or do they still get plenty of exposure to patients with glaucoma, cornea problems, etc.?

For fellowship, it's nearly 100% subspecialty-specific. You'll see other issues occasionally. In practice, it depends on how you're set up. I still see about 10-20% comprehensive, particularly work-ins/walk-ins. I handle some of it myself, but refer a lot of it on.

 

[MstaKing10]

When you do a specific fellowship, how much of your time/training is spent with patients who get referred to that subspecialty and how much of your time is spent looking at patients with other eye conditions? i.e. Do retina fellows work predominantly with retina cases, or do they still get plenty of exposure to patients with glaucoma, cornea problems, etc.?

while the goal of a subspecialist is to focus on their specialty, it is important to draw on general training as well. Most patients with eye disease don't have only one "pure" form of disease. For example, it is not uncommon for me as a retina specialist to be referred a patient for diabetic retinopathy who turns out to also have a diagnoses of glaucoma, iritis, cataract, optic nerve pathology etc. I probably will not end up managing these patients' other diseases but that does not mean that as a retina specialist I stop looking at/focusing on other ocular pathologies. In fact, this can be a major detriment and can lead to misdiagnosis or delay in care. I've certainly seen my share of this happen, when subspecialist put their blinders on and fail to look at the whole eye, heck, the whole body!

In that sense, I think fellows, graduated or in training, continue to get exposure to a wide variety of ocular disease.

 

[Dusn]

I think Glaucoma would definitely improve your job market (especially near large cities with a large african american population). I don't think cornea, at least in most urban areas, will improve your job market much more than comprehensive. Of course you have to like your speciality because if you've got that fellowship name, people are probably be trying to send those difficult patients your way whether you want them or not.

Also, better care is not the only reason to send a patient to a specialist. If a patient is going downhill you should probably send them to a specialist just so that the patient can get a second opinion to reassure them and you that it's not your fault when they go blind and that everything that could possibly be done has been done. It will also take a lot more of your time and more stress to handle the difficult cases yourself than for a specialist to handle it, so you may prefer to send the patient to someone else.

 

[neuronerd12]

This one should be a sticky thread to stay on the top. Helps all, particularly the very few lucky IMGs who will graduate soon to face the job market with or without fellowships. If anybody knows about visa options after graduation, please do share. FMGs are so scarce in Ophth residency, these issues are almost never discussed. For the very few chosen ones (I mean FMGs already in residency), what are the options?

 

[txkiwieyes]

Hi everyone! I'm having a huge internal debate about whether or not to go oculoplastics or comprehensive. I enjoy the challenge of oculoplastic cases, but still can't see myself giving up cataracts or refractive surgery. Any of you with advice for me? I know earlier in this thread people have mentioned that there are alot of sub-specialists who do both comprehensive and their sub-specialty. Are there many oculoplastic surgeons that still do comprehensive ophthalmology as well?

 

[Visionary]

Are there many oculoplastic surgeons that still do comprehensive ophthalmology as well?

Yes, most definitely.

 

[bucknut101]

Hi everyone! I'm having a huge internal debate about whether or not to go oculoplastics or comprehensive. I enjoy the challenge of oculoplastic cases, but still can't see myself giving up cataracts or refractive surgery. Any of you with advice for me? I know earlier in this thread people have mentioned that there are alot of sub-specialists who do both comprehensive and their sub-specialty. Are there many oculoplastic surgeons that still do comprehensive ophthalmology as well?

One of the guys in my group does neuro/orbit/plastics and still does cataract surgery and a little comprehensive as well. It takes him an hour to do a phaco but he still insists on doing them for some reason. Keep in mind if you do a plastics fellowship you will likely go 2 years without doing any cataract surgery at all.

 

[guttata]

Yes, most definitely.

Most of the ASOPRS fellowship trained oculoplastics surgeon I know do not practice comprehensive ophthalmology. You will rely on oculoplastics referrals from your comprehensive colleagues.

It depends on what you want to do. You could do a one year plastics (cosmetic) fellowship and practice both plastics (mainly cosmetic) and comprehensive. You could go into practice after residency and still do some plastics without a fellowship.

But, if you want to do the difficult/complex orbital cases, you need to go the ASOPRS route. If that happens, your practice will be mainly plastics based (just like 2 year surgical retina guys are retina based). Sure, you will hear about the uncommon retina guy who does cataract surgery. But, be assured, he will never get any referrals from any cataract surgeon.

That being said, location makes a big difference. If you are in a rural area, you probably could 'do it all' because there's no politics involved.

 

[Hemichordate]

If you're an attending and want to learn or get certified in a new surgical technique, do you just shadow other attendings and then practice with supervision? Or is there a different, more expedited process? I'm wondering because if you go into a sub-specialty and "forgot" a lot of the techniques you learned during residency, if would be a real pain to have to go through that entire training process again.

 

[LightBox]

You can do whatever you want (cataracts, plastics, LASIK, glaucoma, peds, etc) when you are out on your own. However, as others have stated: (1) It will be hard to stay facile in all types of ophthalmic surgery...to the point of actually being able to do a good job for your patients and (2) no one is going to refer to you if you are "stealing" their bread-and-butter procedures (e.g. cataracts and LASIK). Again, this is more true of highly-competitive, urban areas than rural, underserved areas. Most plastics people that I know don't want to deal with intraocular surgery anymore and would rather just do cosmetic, cash-paying procedures.

 

[Visionary]

Most of the ASOPRS fellowship trained oculoplastics surgeon I know do not practice comprehensive ophthalmology. You will rely on oculoplastics referrals from your comprehensive colleagues.

It depends on what you want to do. You could do a one year plastics (cosmetic) fellowship and practice both plastics (mainly cosmetic) and comprehensive. You could go into practice after residency and still do some plastics without a fellowship.

But, if you want to do the difficult/complex orbital cases, you need to go the ASOPRS route. If that happens, your practice will be mainly plastics based (just like 2 year surgical retina guys are retina based). Sure, you will hear about the uncommon retina guy who does cataract surgery. But, be assured, he will never get any referrals from any cataract surgeon.

That being said, location makes a big difference. If you are in a rural area, you probably could 'do it all' because there's no politics involved.

True. I should have clarified. I wasn't really talking about the ASOPRS-trained (very few fellowships) or non-ASOPRS folks who trained to do complex reconstruction. If you have invested the training in that, you should focus on it. I was talking more about the folks from the more modest plastics fellowships who do blephs, brows, ptosis, BOTOX, etc. Of course, there's nothing to stop an ASOPRS-trained doc from doing general with a plastics focus. Seems like a waste of training, though.

 

[orbitsurgMD]

Most plastics subspecialists do blephs, brows, entropion and ectropion as a core part of their surgical practice. Lacrimal, orbit, oncology are also there, but are not the most frequent types of cases. Unusual cases, exenterations, combined specialty skull-base surgeries, large reconstructions, reanimation procedures are even much less common and are generally confined to major city university eye centers.

 

[Merlin0082]

Obviously it depends on which fellowship you do, but overall, what would you guys say about the difference in compensation between general and specialized ophthalmologists?

 

[doctortom]

Obviously it depends on which fellowship you do, but overall, what would you guys say about the difference in compensation between general and specialized ophthalmologists?

Discussed before

http://forums.studentdoctor.net/showthread.php?p=11615158

 

[e4e]

Very interesting discussion! I have just started my residency in Ophth and I'm an FMG. My questions to my colleagues:
1. I plan on going for a surgical retina fellowship (depending on the visa issues) after residency. I understand that a retina trained surgeon can also do catarcats and other general procedures and there's nothing that can really stop them.But do they get patients that way? And also, wouldn't it be unethical for a retina surgeon to compete with comprehensive for cataract surgery? It would definitely result in an extremely bitter if not hostile professional environment. Wouldn't it?
2. Can we really say that surgical retina and plastics are the only two 'future proof' fellowships at this moment? Considering the constant pushing and the lobbying by the optoms, I am afraid we may eventually lose cataracts, lasers, lasiks and intravits to the optoms in the next ten years or so. Where will the comprehensive and medical ophth stand then? Surgica rtina and plastics being most tecnically challenging and training intensive, I don't see them going into the hands of optoms in the foreseeable future. Do you agree? Don't start another flame war; we've had enough going on already!

 

[Dusn]

Very interesting discussion! I have just started my residency in Ophth and I'm an FMG. My questions to my colleagues:
1. I plan on going for a surgical retina fellowship (depending on the visa issues) after residency. I understand that a retina trained surgeon can also do catarcats and other general procedures and there's nothing that can really stop them.But do they get patients that way? And also, wouldn't it be unethical for a retina surgeon to compete with comprehensive for cataract surgery? It would definitely result in an extremely bitter if not hostile professional environment. Wouldn't it?
2. Can we really say that surgical retina and plastics are the only two 'future proof' fellowships at this moment? Considering the constant pushing and the lobbying by the optoms, I am afraid we may eventually lose cataracts, lasers, lasiks and intravits to the optoms in the next ten years or so. Where will the comprehensive and medical ophth stand then? Surgica rtina and plastics being most tecnically challenging and training intensive, I don't see them going into the hands of optoms in the foreseeable future. Do you agree? Don't start another flame war; we've had enough going on already!

1. Yes. I don't know any retina surgeons doing cataracts except in the military.
2. I don't think we need to worry about cataracts, unless they become much much easier to do. Cataract surgery was one of the hardest and most stressful things I've had to learn in my entire life. Once you've gotten it down it's easy to forget how hard it was early on. Not to mention that it takes attendings with some serious guts to train residents; there's no way these attendings are going to put their career and malpractice on the line to train anyone but an ophthalmologist. Also, I think that if and when optoms realize how much surgery (and it's aftermath) can suck when things go wrong very few of them would want to operate in the first place; they didn't choose this life for a reason.

 

[Zorro12]

1. If you are doing cataract surgery you would be hard pressed to get any referrals from general oph, unless you were the only Retina guy within 100 miles.
2. You don't think the ODs could find an OMD to train cataract surgeons if tomorrow OD were allowed to start operating? You are crazy. The conversation would be something like this: Dr. X, this is optometry school Y. We want you to train our ODs to do cataract surgery. How does 500K a year, benefits, no clinic, no call, and we supply the patients sound? We'll send the moving truck tomorrow.

 

[Shnurek]

2. You don't think the ODs could find an OMD to train cataract surgeons if tomorrow OD were allowed to start operating? You are crazy. The conversation would be something like this: Dr. X, this is optometry school Y. We want you to train our ODs to do cataract surgery. How does 500K a year, benefits, no clinic, no call, and we supply the patients sound? We'll send the moving truck tomorrow.

Exactly like Omni Eye Care in my area. Optometrists own it and employ ophthalmologists. I'm sure the optoms tell the ophthos to teach them a few tricks. And now especially with the LenSX system gaining popularity and that article (http://www.revophth.com/content/c/33272/) about letting optoms do part of the surgery, it may be a real possibility in the next few decades.

 

[jsh1986]

god shnurek you are annoying please go away

 

[cubsrule4e]

god shnurek you are annoying please go away

Welcome to the ophtho forum! What Shnurek dreams are made of

 

[rocketbooster]

Welcome to the ophtho forum! What Shnurek dreams are made of

hey I'm glad he's here! I learned from his posts and then posts from residents/physicians following his replies that optometry doesn't threaten ophtho at all. I was a noob and thought otherwise before. No wonder he was so excited when I even brought it up because he said it's nice to hear a compliment every now and then. Gotta take them in on that rare occasion from noobs like me haha.

Shnurek, if I become an ophthalmologist, you can come work for me. The corneal specialist that did my LASIK had a nice 1-2 punch with the optometrist that worked for him. The optometrist did all the free LASIK screening and then the ophthalmologist did all the surgeries and brought in the $$ for everyone performing like 20 LASIKS per afternoon twice a week.

 

[Shnurek]

hey I'm glad he's here! I learned from his posts and then posts from residents/physicians following his replies that optometry doesn't threaten ophtho at all. I was a noob and thought otherwise before. No wonder he was so excited when I even brought it up because he said it's nice to hear a compliment every now and then. Gotta take them in on that rare occasion from noobs like me haha.

Shnurek, if I become an ophthalmologist, you can come work for me. The corneal specialist that did my LASIK had a nice 1-2 punch with the optometrist that worked for him. The optometrist did all the free LASIK screening and then the ophthalmologist did all the surgeries and brought in the $$ for everyone performing like 20 LASIKS per afternoon twice a week.

Sounds awesome let's keep in touch. Or you can work for me depending on who pays their student/practice loans off first Partnering is probably the best option.

 

[Visionary]

In the real world, most ophthalmologists and optometrists work well together. It's our organizations and their agendas that don't mix.

 

[mydodger]

hey I'm glad he's here! I learned from his posts and then posts from residents/physicians following his replies that optometry doesn't threaten ophtho at all. I was a noob and thought otherwise before. No wonder he was so excited when I even brought it up because he said it's nice to hear a compliment every now and then. Gotta take them in on that rare occasion from noobs like me haha.

Shnurek, if I become an ophthalmologist, you can come work for me. The corneal specialist that did my LASIK had a nice 1-2 punch with the optometrist that worked for him. The optometrist did all the free LASIK screening and then the ophthalmologist did all the surgeries and brought in the $$ for everyone performing like 20 LASIKS per afternoon twice a week.

Didn't the number of LASIK procedures being performed drop dramatically in recent years due to the economy? Might not be a realistic practice setting for much longer. And I'd be glad to hear from someone that "Optometry doesn't threaten Ophtho" but that's not the feeling I get in my conversations with some physicians.

I'm sure Shnurek would be a fine partner but he may steal your identity and start doing blephs or something.

Exactly like Omni Eye Care in my area. Optometrists own it and employ ophthalmologists. I'm sure the optoms tell the ophthos to teach them a few tricks. And now especially with the LenSX system gaining popularity and that article (http://www.revophth.com/content/c/33272/) about letting optoms do part of the surgery, it may be a real possibility in the next few decades.

Data on femtosecond isn't good enough yet - in fact it pretty much offers no benefit over phaco right now and is actually a lot slower. The benefit of femto right now seems to be pure marketing - i.e. "Oh I want that new laser cataract surgery." Allowing optometrists to do part of the procedure might make it faster, but the only reason you need an extra person to make it faster is because currently the technology is not as good as just doing phacoemulsification. I find the fact that people are even buying these machines right now pretty sketch. Anyway I don't see how a technology that is currently slower and requires additional providers while offering zero to extremely minimal benefits over conventional phaco is better in any way. If the technology improves we may be having a different conversation some years down the road, but I just don't see this being beneficial right now. Hopefully it doesn't become purely economically motivated where everyone will have to buy a freaking femtosecond because of patient demand based purely on marketing.

 

[Shnurek]

I'm sure Shnurek would be a fine partner but he may steal your identity and start doing blephs or something.

 

[e4e]

Can you maintain volume of practice by doing just surgical retina, without cataracts, diabetes and AMD and without being severely restricted geographically at the same time? Most of the breaks can be lasered and followed up by comprehensives or medicals; you don't need retina surgeon to do that. Yes, you can get a lot of patients in big city referal centers, but how can you survive outside? Very few mess up with phaco these days and unless another newer cataract surgery technique replaces phaco entirely, putting the current phaco surgeons through another painful learning curve (and providing bulk volume of practice to retina surgeons for some time), how many detachments could you possibly get in practice?

 

[orbitsurgMD]

Patient "demand" might not mean much when demand really means only the choice where they will go to use their ever more tenuous Medicare benefit. If f.s. cataract surgery is a money loser unless combined with an enhanced lens or LRI, I can see a two-tier service arising, one where you get the femtosecond yag procedure only when you are buying an enhanced lens or keratotomy procedure as well, but not otherwise. Except for LRI, there is no other billable procedure for which the extra costs of these very expensive devices could be offset.

 

[MR1]

Can you maintain volume of practice by doing just surgical retina, without cataracts, diabetes and AMD and without being severely restricted geographically at the same time? Most of the breaks can be lasered and followed up by comprehensives or medicals; you don't need retina surgeon to do that. Yes, you can get a lot of patients in big city referal centers, but how can you survive outside? Very few mess up with phaco these days and unless another newer cataract surgery technique replaces phaco entirely, putting the current phaco surgeons through another painful learning curve (and providing bulk volume of practice to retina surgeons for some time), how many detachments could you possibly get in practice?

Are you only talking about incisional surgery volume or clinical procedure volume?

If you are talking incisional surgery only, there is a lot more to retina than dropped lens and RD's. What about VMT, macular holes, ERM, TRD, VH are the main ones. Then you still have endopthalmitis, subluxed cataracts needing PPL, CME\DME resistant to treatment needing PPV.

Granted you can't be in middle of no where America. You need a certain population and referral base but you don't have to be in a massive town for this. I have heard before that you need about 5 busy ophtho's to support one retina specialist. So no small town America but not super urban either.

Now clinical procedure volume, there are tons of focal,PRP,retinopexies, intravitreal to do. Most comprehensive dont' laser anything, some just do PRP and maybe retinopexies. There is plenty to go around though.

Patient "demand" might not mean much when demand really means only the choice where they will go to use their ever more tenuous Medicare benefit. If f.s. cataract surgery is a money loser unless combined with an enhanced lens or LRI, I can see a two-tier service arising, one where you get the femtosecond yag procedure only when you are buying an enhanced lens or keratotomy procedure as well, but not otherwise. Except for LRI, there is no other billable procedure for which the extra costs of these very expensive devices could be offset.

I have often thought the femtosecond would set up a two-tiered cataract surgery system

 

[WhatNEyeTem]

The reason why retina peeps can stay busy is because, for the most part, they are dealing with chronic diseases that can be controlled, but usually not "cured." In other words, it benefits Retina physicians that their patients never truly are "free" of their AMD, DME, RVO, etc...because this leads to an infinite number of follow-up visits until death. At each of these visits, they can do a slew of diagnostic tests and a little laser here and an intravitreal there to help with maintenance. Perhaps in the future, glaucoma management will be similar if they develop an injectable drug that needs to be delivered every 6 weeks. A similar analogy in Oculoplastics is BoTox, which I am sure Allergan is happy only lasts ~3 months per injection.

In contrast, patients after cataract surgery or LASIK don't usually need that much follow-up. So though these therapies end in "cures" and good results in the vast majority of patients, they do not generate follow-up visits. And what do insurance companies and the government think of procedures, like cataract surgery, that perform so well --> of course they should be reimbursed less! Sadistically, Ophthalmologists would do better if the cataracts grew back every 6 months or so

 

[e4e]

Are you only talking about incisional surgery volume or clinical procedure volume?

If you are talking incisional surgery only, there is a lot more to retina than dropped lens and RD's. What about VMT, macular holes, ERM, TRD, VH are the main ones. Then you still have endopthalmitis, subluxed cataracts needing PPL, CME\DME resistant to treatment needing PPV.

Granted you can't be in middle of no where America. You need a certain population and referral base but you don't have to be in a massive town for this. I have heard before that you need about 5 busy ophtho's to support one retina specialist. So no small town America but not super urban either.

Now clinical procedure volume, there are tons of focal,PRP,retinopexies, intravitreal to do. Most comprehensive dont' laser anything, some just do PRP and maybe retinopexies. There is plenty to go around though.



I have often thought the femtosecond would set up a two-tiered cataract surgery system

I am talking about total clinical practice volume, not just incisional surgery. Realistically, how many macular holes/trauma/TRD can you possibly get every year? Even vitreous hemorrage is not that common; besides, most don't need surgery any way. Yes, PRP and other lasers (and AMD of course) can indeed provide a bulk volume to your practice, but then again isn't it the job of medical retinologist?

 

[e4e]

The reason why retina peeps can stay busy is because, for the most part, they are dealing with chronic diseases that can be controlled, but usually not "cured." In other words, it benefits Retina physicians that their patients never truly are "free" of their AMD, DME, RVO, etc...because this leads to an infinite number of follow-up visits until death. At each of these visits, they can do a slew of diagnostic tests and a little laser here and an intravitreal there to help with maintenance. Perhaps in the future, glaucoma management will be similar if they develop an injectable drug that needs to be delivered every 6 weeks. A similar analogy in Oculoplastics is BoTox, which I am sure Allergan is happy only lasts ~3 months per injection.

In contrast, patients after cataract surgery or LASIK don't usually need that much follow-up. So though these therapies end in "cures" and good results in the vast majority of patients, they do not generate follow-up visits. And what do insurance companies and the government think of procedures, like cataract surgery, that perform so well --> of course they should be reimbursed less! Sadistically, Ophthalmologists would do better if the cataracts grew back every 6 months or so

Agreed mostly! But I don't buy the botox analogy. As long as there is desire for everlasting youth and beauty and a whole bunch of 50 or 60 somethings trying desperately to look like 20 something and willing to pay anything to get that, there will be botox and plastics people will be keeping busy. Thanks to glossy covers and red carpets! On the other hand, until the glossy covers and ramp walks uphold a beautifully lasered retina as something very youthful and trendy, retinal lasers will never be something to dream for by aging population or by anyone for that purpose. Come on, how can you say to someone something like, oh you look so beautiful because you have such good looking retina that is so beautifully lasered!!??? May be I change my mind eventually at the end of my residency favoring plastics over retina. Hollywood, here I come!

 

[WhatNEyeTem]

Every surgical retinal specialist spends the majority of their time in the office.

Office visits is where the $$$ is at for retina specialists because they can streamline processes and have many, many patients undergo the same testing throughout the day.

In contrast, doing a retina surgery takes time and does not generate as much revenue per hour. Just think how many focals you can do in the same amount of time it takes to do one RD repair (also include the time to travel to the ASC/hospital and turnaround time).

 

[mydodger]

So there's been a lot of discussion, but here's a big question: Is there still a good market for comprehensive ophthalmologists? Are comprehensive docs just not making much money? I still see quite a few 4 day per week comprehensive offices - are they just barely making any profit?

And why aren't comprehensive docs doing injections, PRPs, ALT/SLT, etc? I mean all the residents I've met say they have done plenty of all of those procedures. If we're trained to do it why aren't we doing it?

 

[LightBox]

So there's been a lot of discussion, but here's a big question: Is there still a good market for comprehensive ophthalmologists? Are comprehensive docs just not making much money? I still see quite a few 4 day per week comprehensive offices - are they just barely making any profit?

And why aren't comprehensive docs doing injections, PRPs, ALT/SLT, etc? I mean all the residents I've met say they have done plenty of all of those procedures. If we're trained to do it why aren't we doing it?

I think a ton of comprehensives (maybe too many) are doing ALT/SLT for the wrong patients. They especially market the SLT as the "cold laser" that can effectively halt all types of glaucoma. So they SLT over and over again that advanced glaucoma African American patient...and eventually end up referring the patient to a glaucoma specialist for a filter when they are already end-stage. It's all about RVUs.

I think retinal lasers are more protected because, in general, you probably need SD-OCT and fluorescein angiography capabilities to effectively manage medical retina patients. Many comprehensive practices don't want to invest in this equipment if they are only seeing a few true medical retina patients a week. There's also the liability issue, especially if there is a retina specialist across the street. Actually, I think that one of the benefits of practicing in a rural location is that it is more acceptable to practice a broader range of services. Of course, this is a double-edged sword since it is difficult to keep up-to-date in multiple subspecialties. But then again, most patients will choose the guy-across-the-street rather than drive 30 miles to the nearest specialist.

Comprehensives can make good money. But you definitely have to supplement the income with premium lenses, refractive surgery, and optical. Also, if you haven't noticed, there are a lot of providers out there (of every sort) that make a killing by committing <let me be blunt> quasi-FRAUD. e.g. SLT'ing every other visit; YAG every post-op cataract; getting OCT/VF/punctal plugging every patient; telling their glaucoma suspects that they have to return every 2 months otherwise they will go blind, etc...

 

[MR1]

I am talking about total clinical practice volume, not just incisional surgery. Realistically, how many macular holes/trauma/TRD can you possibly get every year? Even vitreous hemorrage is not that common; besides, most don't need surgery any way. Yes, PRP and other lasers (and AMD of course) can indeed provide a bulk volume to your practice, but then again isn't it the job of medical retinologist?

Granted I am at a large tertiary referral center in fellowship but I'd say I do about 2 Mac holes, 2-3 ERM, 3 TRDs, 1 trauma, and 4 VH each month. Between me and the staff I work with now we see about 160 patients a week and do about 8-10 cases a week.

TRD and VH just depend we're you are. I am not in diabetes land but still get a lot. If you are in TX you will be up to your eyeballs with diabetes! By the way VH is fairly common.

Lastly like said by others. Retina is busy in clinic. We do prob 10-20 lasers a week. Yes medical retina folks do this but how many of those do you think are out there? Not many. Most "retina" are surgical trained. Theres not a lot of medical retina fellowships.

I have yet to hear of a non busy retina doc. Where I am there are 2-3 openings and the load is so great every doc is super busy and needs help.

 

[Visionary]

Granted I am at a large tertiary referral center in fellowship but I'd say I do about 2 Mac holes, 2-3 ERM, 3 TRDs, 1 trauma, and 4 VH each month. Between me and the staff I work with now we see about 160 patients a week and do about 8-10 cases a week.

TRD and VH just depend we're you are. I am not in diabetes land but still get a lot. If you are in TX you will be up to your eyeballs with diabetes! By the way VH is fairly common.

Lastly like said by others. Retina is busy in clinic. We do prob 10-20 lasers a week. Yes medical retina folks do this but how many of those do you think are out there? Not many. Most "retina" are surgical trained. Theres not a lot of medical retina fellowships.

I have yet to hear of a non busy retina doc. Where I am there are 2-3 openings and the load is so great every doc is super busy and needs help.

You'll probably never see the degree of pathology in practice that you are in fellowship. Of course, that's why you're in fellowship! Yes, there are not a lot of medical retina fellowships, because most merged with surgical when vitrectomy took off. Fact is that currently ~90% of retina is medical. The busier VR docs around here do 5-6 cases/wk, most of which are ERM peels. There just aren't as many dropped lenses, post-cataract RDs and endophthalmitis anymore. VR docs around the country have been talking about the drop in surgical volume. Some are trying to come up with more ways to get into the OR, such as drug implants, but none of it is really taking off. When Ocriplasmin is released, I think you'll see another, likely small, drop in surgery. Unless you are really busy or really efficient, the OR is still a money loser in retina.

 

[Visionary]

I think retinal lasers are more protected because, in general, you probably need SD-OCT and fluorescein angiography capabilities to effectively manage medical retina patients. Many comprehensive practices don't want to invest in this equipment if they are only seeing a few true medical retina patients a week. There's also the liability issue, especially if there is a retina specialist across the street. Actually, I think that one of the benefits of practicing in a rural location is that it is more acceptable to practice a broader range of services. Of course, this is a double-edged sword since it is difficult to keep up-to-date in multiple subspecialties. But then again, most patients will choose the guy-across-the-street rather than drive 30 miles to the nearest specialist.

Agree. In a rural area, where it's a 2+ hour drive to retina, you'll find a lot more comprehensive docs doing medical retina or at least co-managing care with distant retina docs. In my town the couple comprehensive docs doing medical retina are pretty fringe. You're taking a chance, when there are a lot of retina docs in the same area.

 

[e4e]

So there's been a lot of discussion, but here's a big question: Is there still a good market for comprehensive ophthalmologists? Are comprehensive docs just not making much money? I still see quite a few 4 day per week comprehensive offices - are they just barely making any profit?

And why aren't comprehensive docs doing injections, PRPs, ALT/SLT, etc? I mean all the residents I've met say they have done plenty of all of those procedures. If we're trained to do it why aren't we doing it?

I will most likely go into comprehensive because I have visa issues. My only concern with comprehensive at this moment is the political push towards universal coverage. Everybody wants the best health care for free; nobody wants to pay for it! If you ask them to pay for it or to work longer hours in return or to pay more in taxes, they will start rioting in the streets. The French have free health care and they work 35 hours per week! During the slump the French Govt wanted to make ‘Monday’ a working day and the French people started rioting in Paris because normally they work only 4 days a week and now they even want another half day off from that (no joke, this is fact). Seriously, how dumb is that?
Let us just look at the facts. Universal coverage is utopian and impossible to provide for its people even by the richest nation on the planet! Period. This is not my opinion, many research have proven that time and time again. But we are heading in that direction in this country. One more fact (I didn’t come up with this, this is research data), any country pays roughly about two thirds of its total expenditure on health care in staff payments. In the next decade or so, increasingly more and more responsibilities will inevitably go to ‘cheaper’ (not necessarily inferior) alternatives like PA/MA/SA/ Nurse Practitioners/Optoms etc. and the major volume will be taken away from the comprehensives and all other primary cares in the future. Any legislature today is just a piece of paper that can be replaced by another one tomorrow. Anything that is not too training intensive, will struggle to survive in the future. On the other hand, anything that is too training intensive doesn’t constitute the bulk volume of any practice. Probably a handful of orbit surgeons and retina people doing complex RDs/GRTs will still do pretty well, but what about the rest? This is not scare mongering, if this universal coverage plan really does what it intends to do, we are doomed! Please prove me wrong somebody, never in my life I have wanted to be proven wrong this badly.

 

[MR1]

You'll probably never see the degree of pathology in practice that you are in fellowship. Of course, that's why you're in fellowship! Yes, there are not a lot of medical retina fellowships, because most merged with surgical when vitrectomy took off. Fact is that currently ~90% of retina is medical. The busier VR docs around here do 5-6 cases/wk, most of which are ERM peels. There just aren't as many dropped lenses, post-cataract RDs and endophthalmitis anymore. VR docs around the country have been talking about the drop in surgical volume. Some are trying to come up with more ways to get into the OR, such as drug implants, but none of it is really taking off. When Ocriplasmin is released, I think you'll see another, likely small, drop in surgery. Unless you are really busy or really efficient, the OR is still a money loser in retina.

Oh unfortuantely I know this is true, but I do enjoy the pathology for now. Have you ever heard of a non-busy retina doc outside of NY,SF,etc?

Even if we do less surgery in the future, we still will be in clinic enough and like you said I agree 90% is non-surgical and is where we make the money anyway.

 

[rocketbooster]

Oh unfortuantely I know this is true, but I do enjoy the pathology for now. Have you ever heard of a non-busy retina doc outside of NY,SF,etc?

Even if we do less surgery in the future, we still will be in clinic enough and like you said I agree 90% is non-surgical and is where we make the money anyway.

This is what scares me about going into ophtho.

Which fellowship specialty(s) will not have foreseeable drop in surgeries in the future?
I want to go into an ophtho since it's a surgical subspecialty. If it's going to be 90% clinical, I'd rather do something else. So, are any fellowship specialties not heading down this direction?