Reality check for those interested in ophtho

[hbs]

I am interested in ophtho. However, there are things that bother me and I am not sure what you guys think about these. I think many bright students consider this rout without considering what happens when they get out of residency. I will include the following excerpt from an ophtho department student advisor:
CURRENT TRENDS:
Like many other surgical specialties, there is an over supply of ophthalmologist nationally, particularly in >desirable= urban areas. Also like other surgical specialties, there is a trend towards lower reimbursement for ophthalmic surgery. Starting salaries for ophthalmologists continue to drop, especially in urban areas most heavily impacted by managed care. Optometrists ? are using the political process to attain the right to treat disease in many states. Currently in most states, optometrists are limited to treating allergic eye disease and mild infections. This will undoubtedly change over the coming years, and it is clear that the ultimate goal of organized optometry is to gain complete parity with ophthalmology in the management of both medical and surgical disease. In Oklahoma, a recent law was passed that allows optometrists full surgical laser privileges. It is likely that similar laws will eventually pass throughout the country, so that there will be an even larger over-supply of eye care providers.
Sorry for the long post. However, from what I hear:
1. There is certainly an over supply of ophthalmologists. OK, I realize that aging population will likely increase demand. However to what extent?
2. The optometrists gaining surgical rights is a REAL THREAT to this wonderful field unfortunately! Read the following from the AAO website and you will realize (http://www.aao.org/aao/news/washington/013003_article3.cfm). I do not see a reason why they would not be able to perform simple surgical procedures such as refractive surgery or laser ablation procedures, especially in the current managed care system seeking low costs.
3. Ophthalmologists currently make about $120-130 K starting salary. That is the same as internal med docs. It is the lowest of any surgical subspecialty I have heard of.
4. It is ridiculously hard to match in ophtho. That means it?s harder to go to a program that would set you up with a job or fellowship after you get out. I could pick and choose where I want to go to do a residency in something like medicine or maybe even ED, but I am not sure if I can get into ophtho (based on previous posts from actual applicants).
5. It is not that easy for all residents and fellows to find jobs, especially if they want to stick around popular locations such as in California.
Do I really want to still put in 5 years of my life and work hard on research projects etc for this field with some questions about its future? I am debating that.
I personally think that there are a lot of people who still think ophtho is the field it used to be back in the 80?s. I would really appreciate input especially from the doctors in the forum.
Thanks,
hbs

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[ckyuen]

Sounds like you've made up your mind, ophthalmology is not for you. Choose something else, if you have this much doubt in your mind at such an early stage you will probably be miserable in the field. Also a lot of your comments are financially oriented, so you are right, ophtho is not like it was in the good ole days of 2500 cataract extraction and 1500 yag capsulotomy. expect more like 670 and 230 from medicare, not including facility fees. Believe me you can still do just fine. HMO's in California like Kaiser seem to be eternally looking for ophthalmolgist in great cities, LA, Oakland, Bay area, Sacramento, San Diego. Hours are great, so are salaries.

 

[Mirror Form]

Originally posted by hbs

Like many other surgical specialties, there is an over supply of ophthalmologist nationally, particularly in >desirable= urban areas.

Due to the aging population, ophthalmologists have been predicted to have one of the most severe shortages, along with CT surgeons. Basically, as the boomers get older, no docs are going to be hurting for business in any field.

Originally posted by hbs

Also like other surgical specialties, there is a trend towards lower reimbursement for ophthalmic surgery. Starting salaries for ophthalmologists continue to drop, especially in urban areas most heavily impacted by managed care.

This holds true for medicine in general. No field is safe from this threat!

Originally posted by hbs

2. The optometrists gaining surgical rights is a REAL THREAT to this wonderful field unfortunately! Read the following from the AAO website and you will realize (http://www.aao.org/aao/news/washington/013003_article3.cfm). I do not see a reason why they would not be able to perform simple surgical procedures such as refractive surgery or laser ablation procedures, especially in the current managed care system seeking low costs.

That's what also scares me the most. Who teaches these optometrists to do these surgeries anyway? How do they gain licenses?

Originally posted by hbs

3. Ophthalmologists currently make about $120-130 K starting salary. That is the same as internal med docs. It is the lowest of any surgical subspecialty I have heard of.

Ophthalmologists tend to work less hours then most. Also, their salaries go up to be comparable to most other surgical fields after a few years. So I don't think that making less the first few years in practice is that big of a deal.

Originally posted by hbs

4. It is ridiculously hard to match in ophtho. That means it?s harder to go to a program that would set you up with a job or fellowship after you get out. I could pick and choose where I want to go to do a residency in something like medicine or maybe even ED, but I am not sure if I can get into ophtho (based on previous posts from actual applicants).

According to the avg board scores, ophtho isn't as hard to match into as some other surgical subspecialities, like ENT and uro.

 

[Gleevec]

Im fine with all those qualms brought up personally-- none of the fiscal issues bother me greatly. However, I AM concerned about optometrists taking over surgical volume.

I have no idea what optometrist training is like (aside from prescribing lenses) and the very basic eye disorders.

What kinds of surgery can an optometrist perform though. And if an increasing number of surgeries involve automated lasers, is that just a recipe for for optometrists to take over ophthamologist's turf?

 

[Andrew_Doan]

Originally posted by Gleevec
However, I AM concerned about optometrists taking over surgical volume.

I don't want to get into the MD vs OD debate because it has been beaten to death on this forum. I'm flying out to Washington DC in 2 weeks to the AAO Advocacy Day to discuss political issues like the one above. At this point in time, Oklahoma is the only state that allows ODs to perform PRK and minor laser procedures (yag capsulotomies), not LASIK. They snuck the PRK in a bill and then prevented medical boards from suing each other, which essentially prevents further action. The original ruling in OK was that optoms were not allowed to do laser procedures because these procedures were considered surgery. However, because of intense lobbying efforts by ODs at the state and national level, PRK and "minor laser procedures" were allowed in the bill. The main argument in OK was access to care. Because many OK citizens live in rural areas, the big concern was that Eye MDs weren't available. Since then, the AAO has been on high alert about these issues and has faught each new bill very hard. As for doing cataracts, glaucoma surgery, retina lasers, plastics, strabismus, retina surgeries, etc..., I don't think this will happen unless ODs get an MD and then go to surgical residency/fellowship. Even with budget cuts, the public demands a certain level of competency and knowledge.

The AAO has successfully faught each new OD bill in each state as they evolve. The most recent efforts have prevented ODs from performing and teaching ODs to perform laser procedures in the VA system.

In regards to ODs performing "automated laser surgery": it's just as important to know who to cut and who to avoid. Out of OD school, there's not enough pathology seen to pick up problematic patients. Read this debate:

http://forums.studentdoctor.net/showthread.php?s=&threadid=70493

http://forums.studentdoctor.net/showthread.php?s=&threadid=61743


If you're interested in the OD vs MD debates, then read through these posts:

http://forums.studentdoctor.net/showthread.php?s=&threadid=105603

http://forums.studentdoctor.net/showthread.php?s=&threadid=87758

 

[Tony.]

hay Dr. Doan,

when you get back from Washington (AAO Advocacy Day),
will you please post your thoughts and issues on the optometry forum for us?

thankx
Tony

 

[hbs]

My biggest concern with the field is also the ?optometrists taking over? factor. Read the two threads posted by Dr. Doan above and pay attention to the sentiment of the optometrists who post on these threads. I do not know what optometrist learn for 3-4 years, but I can see them being able to learn to handle all major eye problems in this period of time! I just think that it is a matter of who has more lobbying power at this point. OD?s out number Ophthalmologists. I do think that it would be unfair to ophthalmologists to lose surgical rights. It has not happened yet, but it is possible.
hbs

 

[MacGyver]

Just like other specialties, optho has come under assault by non-MDs wanting to infiltrate the realm of medicine.

1) Note that in Oklahoma, it was the MDs THEMSELVES who allowed ODs to get a foothold. The OD schools had to rely on opthos to TRAIN the ODs. Of course, many opthos complied in exchange for $$$$. They were looking to cash out, even if it meant selling their own profession down the river.

2) All it takes is one state to set a precedent, and the chances of other states following suit expand EXPONENTIALLY. Other states look to each other for precedents; the fact that Oklahoma has already established a precedent does not bode well.

3) In spite of #2, I'm impressed by the fact that other states have not yet followed suit. It appears that once Oklahoma changed regulations, opthos finally woke up and started fighting this. Kudos to them.

4) In all fields, MDs for far too long have ignored what other people are trying to do until one or more states change regs. Only THEN do they become involved in the fight. Thats a damn shame, and its a HUGE advantage to the non-MDs fighting to expand scope.

5) If opthos want to stop the trend of ODs expanding scope, then they MUST put more opthos in rural/underserved areas. When state legislatures hear that their citizens must travel 5 hours to find an opthalmologist, it becomes EXTREMELY desirable to buy into the OD argument that access to care should be expanded. This argument is what ultimately will decide the fate of ODs vs MDs. State legislators dont care about the training of MDs vs ODs. They are looking to score political points, and if they are convinced that the public would "benefit" from increased access by allowing ODs expanded practice rights, then usually thats enough to swing hte argument in the ODs favor.

6) Let me emphasize again that EVERY STATE MATTERS! Once a precedent is set, the fight is on for the whole country. Opthos are absolute fools if they think they can sit back and relax because "only" one state has expanded scope rights for ODs. Opthos in Florida have to pay attention to what happens in ALL states, even Alaska and Hawaii.

7) ODs have data backing up their claim that there are no adverse outcomes for ODs doing eye surgery. Thats a HUGE advantage in their favor. Long term, I fear that this, along with #5, will push the argument into the ODs favor. Opthos DESPERATELY need research showing that ODs doing eye surgeries results in more adverse outcomes. If they dont supply this data, then its just a matter of time before ODs expand their scope across the board in all states.

 

[exmike]

Lets face it, the average OD student (no all, just the average) probably could not get into medical school, whereas you have to be a top medical student to become an ophthalmologist. Does it make any sense at all then if the two groups could do the exact the same thing? In addition, you have 4 years of instruction vs. eight years. How could there possibly not be any difference in patient outcomes in regards to surgical procedures by the two groups? I'm not well informed about laser surgery, but my understanding is that calibrating the machine to the patient is the most important part, and perhaps surgical training isnt important. What I wonder though is whether or not ODs would be able to handle more invasive surgical procedures without a surgical background.

On the other hand, podiatrists and orthopods seem to co-exist perfectly fine. Could basic laser procedures be relegated to the world of the OD whereas Ophthos are pushed towards more invasive procedures? The way it looks now it seems like ophtho's will have to do a fellowship to ensure job security in the future. Is this just all a bunch of hand waving or is there something going on.

 

[ckyuen]

HBS try to do a phaco and tell me how easy it will be for optoms to take over. It's a very difficult procedure, very unforgiving, and just b/c someone who has practiced for 10 years makes it look easy it's not. Your three years in ophtho is not time spent sitting around, you need that time to learn how to diagnose cases needing treatment and implementing treatment. I think if Optoms did and internship then residency it could be conceivable they gain rights to do what we do. But enough of that debate, that's not what is at issue here. I think you need to spend some time rotating with and optom and ophthalmologist if you are considering the field. I think someone at your level has no way of knowing the difference b/t the two and what is involved in day to day practice. Remember, while lasers can be simple, they can also blind. I've heard of patients with their foveas prp and poor vision b/c the looked at the red laser beam. Also, yags may seem simple until you have the patient return with and rd, or endophthalmitis b/c you released the p acnes hiding back there in the cortical remnants, or the pt has a pressure spike and goes blind.

 

[Andrew_Doan]

Originally posted by ckyuen
Also, yags may seem simple until you have the patient return with and rd, or endophthalmitis b/c you released the p acnes hiding back there in the cortical remnants, or the pt has a pressure spike and goes blind.

I completely agree with ckyuen. Retinal detachments can occur in 1-2% of patients after Yag cap. It's not a trivial procedure. If you do enough procedures, then there will be complications.

http://www.ncbi.nlm.nih.gov/entrez/...ve&db=pubmed&dopt=Abstract&list_uids=14967269

The training of ophthalmologists and optometrists are completely different. ODs will argue that their education is similar, but they don't see enough pathology. Most will see normal individual after normal individual during their clinicals. I think most optometry students see less than a few hundred patients during their clinicals by themselves (I'm not counting "shadowing"). Less than 10% of optometrists pursue a one year residency training program.

In contrast, ophthalmology residents will see over 8,000-10,000 patients during their training with the majority having serious pathology. Mix this in with over 300-500 surgeries as the primary surgeon (Class 1), 500+ surgeries as the assistant (Class 3), and 100-200+ laser procedures, then you will have the ophthalmologist gaining vast amounts of clinical, medical, and surgical experience during residency. This is more experience and training than all optometrists, new grads and those in practice.

 

[Gleevec]

I also think the general public does not appreciate the differences between an OD and an OMD. I myself as a premed did not know the different until my first year of college, so I could completely see how most people would think they both went to med school.

Maybe if people called them "optometrists" and "eye surgeons" the distinction might be clearer?

In any case, these politicians are pandering to their constituencies, so unless the general public understands the difference in training and quality of care, OD representatives are likely to have their way in invading OMD procedures.

 

[chef]

ur complaint of oversupply & turf battles can apply to EVERY specialty!! name me another field that isnt??

 

[Rajshah]

An understandable worry.
People want to know whether the job they choose at the end of residency will be safe.
Things change all the time.
Back in the past (~1970s-80s) Ophthalmology wasn't too popular, and most people wanted to go into mainstream surgery and medical specialities.
Look at it now!! One of the most popular specialities.
Ophths really had a great time when laser surgery came about, but now everyone wants in so supply and demand swing the other way.
So you may say there is an oversupply, but all it takes is a new treatment to come out, and it'll swing again.
Either way Ophth is a lifestyle speciality.
Hope this helps

 

[Andrew_Doan]

Originally posted by Rajshah

Either way Ophth is a lifestyle speciality.

I must admit that I do agree with this statement. However, for those with doubts, please don't apply. This will open spots for individuals who really want to do it. I love this field and would do it for $120K/year... wait. I will be doing it for that much in the military. Money isn't everything. I've said this many times. If you love what you do, then the money is icing on the cake. If you hate what you do, then money becomes a shackle that binds you to the entity that you hate most.

I think we all will be busy in the next 2-3 decades. There's going to be plenty of cataracts, AMD, diabetes, retina problems, and glaucoma to keep us busy, stimulated, and employed.

 

[Elephantitan]

Originally posted by Gleevec
I also think the general public does not appreciate the differences between an OD and an OMD. I myself as a premed did not know the different until my first year of college, so I could completely see how most people would think they both went to med school.
unless the general public understands the difference in training and quality of care, OD representatives are likely to have their way in invading OMD procedures.

I don't know if any of you guys noticed a recent Mastercard commercial, but at the end it said "accepted by orthopedists, neurologists, and optometrists everywhere." It has been changed so it now says ophthalmologists, but it was just another instance of the public not knowing the difference. It's something we'll face forever, but I thought it was an interesting example of the confusion.

 

[Redhawk]

I did notice that commercial. I haven't seen the corrected version, however...

 

[Andrew_Doan]

You all should read this thread:

http://forums.studentdoctor.net/showthread.php?t=115417

 

[I-eye]

http://www.cnn.com/2004/HEALTH/conditions/04/12/vision.impairment.ap/index.html

 

[juddson]

Like these issues in every other specialty (well, not EVERY other specialty), the fact is probably that a large portion of the training an OMD gets is superflous in so much as it consists of training to do procedures that relatively less training can accomplish. In EVERY case that an OD is capable of doing a procedure with similar outcomes to OMD's, the OMD is overqualified to do that procedure - by definition. This will simply lead to greater specialization for OMD's. Besides, who among you wants to toil away your days doing LASIK's? Really? You can't expect to pocket the big coin unless you bring something to the table an OD cannot.

Judd

 

[ckyuen]

Juddson you obviously don't do eye surgery otherwise you wouldn't be saying that. Almost every other procedure any surgeon performs is much more forgiving than phaco. while many are able to make it look easy it is not. people have lost eyes over the procedure.

 

[GeddyLee]

hmmm...what procedure that OD's perform are you eluding to Juddson?

Anyway..it all comes down to clinical decision making. Up to a point, MD's, DO's, PA's, CRNA's, CNP's, and OD's are all equivalent. I mean, I can teach a 5 year old how to recognize and treat a whole host of diseases. Do you really think it's so hard to recognize diabetic retinopathy and shoot laser at it? If a 5 year old can recognize barney and do the barney dance....they can recognize a disease and treat it. But no one is going to suggest that 5 year old be put into medical school.

It takes years of training to learn to make appropriate decisions. It takes years of training to know how to interprate the results of the latest Bausch&Lomb sponsored "research." It takes years of training to know how to decide when someone if feeding you a bunch of bull-hockey, and when they are onto something. You average PA probably believes everything he/she reads or hears from your favorite fortune 500 pharmaceutical giant. Not because they are gullible, but because they don't have the background to analyze it critically.

Hell...nobody believes LASIK requires a 4 year degree + 4 years of med school + 4 years of residency. It's just not hard. But let's not be idiots and act like LASIK certification should be offered a la welding at the local community college. Nor should OD's be doing either...surgery is surgery, and you should be trained as a physician and as a surgeon in order to do it....otherwise, you'll mess somebody up that you shouldn't have.

Phaco is hard...so I'm told. But you could still teach it to a child! I mean get real people. Just because in theory an OD or a PA, or a highschool graduate, or a child, or a monkey, or whatever CAN learn to the technical skill to do it, doesn't mean they will ever learn when to do, or (more importantly) when not to do the procedure. It doesn't mean they could ever learn to recognize and treat the complications. And because they don't have the broad based clinical background of the MD/DO, they would probably end up being completely incompetent, even thought they mastered the technical skill.

Oh...contrary to popular belief..."making coin" isn't every ophthalmologist's greatest ambition. And any of you nim-rods who want to be LASIK cowboys and make "the coin"....just stay away from OPH....or at least be truthful at your interviews. Go be boob job cowboys....you'll do much better. Seriously. Women will pay whatever you charge. People can always just wear contacts. There's only one way to make boobs bigger.

Interviewer (from cleveland clinic): So applicant, why ophthalmology?.....
Applicant (looking very sharp): I wanna do LASIK and make big bucks.
Interviewer: Your in! Like swimwear.

The only way any of you will ever make big bucks is just sheer luck. You can't expect to train for a job and make big bucks. Nobody gets rich from working a job! Now, if you get lucky and you somehow inherit a booming practice doing half the lasik in town...you'll do quite well. But don't kid yourself into dreaming of that bright shiny G-V just yet. And doing neurosurgery vs. OPH vs. optometry vs. orthopedics is not going to guarantee you anything, other than that you'll hate your life because you followed the illusion of money that just doesn't exist.

Probably 70% of the 100 richest people in the world were either born that way, or lucked into it. The rest worked hard and put an original idea into action and made big on it. A couple probably started in the mailroom at a major corportation and worked up to being the CEO. I bet none of them became ophthalmologists. So, enough talk about big bucks...you gotta get original to make the serious dough.

And as far as all of this sky-is-falling malarkey....well guess what...IT IS!!! Ophthalmology has an incredibly dismal future. Nine out of ten physicians say so. Those same nine also say that family practice is the wave of the future and believe herbal remedies for cancer really do work. I hope you all decide against ophthalmology...because if you are making your career choice based on whether or not OPH will pay the big bucks, then you deserve to catch a venereal disease...with ocular involvement.

 

[chef]

hmmm...what procedure that OD's perform are you eluding to Juddson?

Anyway..it all comes down to clinical decision making. Up to a point, MD's, DO's, PA's, CRNA's, CNP's, and OD's are all equivalent. I mean, I can teach a 5 year old how to recognize and treat a whole host of diseases. Do you really think it's so hard to recognize diabetic retinopathy and shoot laser at it? If a 5 year old can recognize barney and do the barney dance....they can recognize a disease and treat it. But no one is going to suggest that 5 year old be put into medical school.

It takes years of training to learn to make appropriate decisions. It takes years of training to know how to interprate the results of the latest Bausch&Lomb sponsored "research." It takes years of training to know how to decide when someone if feeding you a bunch of bull-hockey, and when they are onto something. You average PA probably believes everything he/she reads or hears from your favorite fortune 500 pharmaceutical giant. Not because they are gullible, but because they don't have the background to analyze it critically.

Hell...nobody believes LASIK requires a 4 year degree + 4 years of med school + 4 years of residency. It's just not hard. But let's not be idiots and act like LASIK certification should be offered a la welding at the local community college. Nor should OD's be doing either...surgery is surgery, and you should be trained as a physician and as a surgeon in order to do it....otherwise, you'll mess somebody up that you shouldn't have.

Phaco is hard...so I'm told. But you could still teach it to a child! I mean get real people. Just because in theory an OD or a PA, or a highschool graduate, or a child, or a monkey, or whatever CAN learn to the technical skill to do it, doesn't mean they will ever learn when to do, or (more importantly) when not to do the procedure. It doesn't mean they could ever learn to recognize and treat the complications. And because they don't have the broad based clinical background of the MD/DO, they would probably end up being completely incompetent, even thought they mastered the technical skill.

Oh...contrary to popular belief..."making coin" isn't every ophthalmologist's greatest ambition. And any of you nim-rods who want to be LASIK cowboys and make "the coin"....just stay away from OPH....or at least be truthful at your interviews. Go be boob job cowboys....you'll do much better. Seriously. Women will pay whatever you charge. People can always just wear contacts. There's only one way to make boobs bigger.

Interviewer (from cleveland clinic): So applicant, why ophthalmology?.....
Applicant (looking very sharp): I wanna do LASIK and make big bucks.
Interviewer: Your in! Like swimwear.

The only way any of you will ever make big bucks is just sheer luck. You can't expect to train for a job and make big bucks. Nobody gets rich from working a job! Now, if you get lucky and you somehow inherit a booming practice doing half the lasik in town...you'll do quite well. But don't kid yourself into dreaming of that bright shiny G-V just yet. And doing neurosurgery vs. OPH vs. optometry vs. orthopedics is not going to guarantee you anything, other than that you'll hate your life because you followed the illusion of money that just doesn't exist.

Probably 70% of the 100 richest people in the world were either born that way, or lucked into it. The rest worked hard and put an original idea into action and made big on it. A couple probably started in the mailroom at a major corportation and worked up to being the CEO. I bet none of them became ophthalmologists. So, enough talk about big bucks...you gotta get original to make the serious dough.

And as far as all of this sky-is-falling malarkey....well guess what...IT IS!!! Ophthalmology has an incredibly dismal future. Nine out of ten physicians say so. Those same nine also say that family practice is the wave of the future and believe herbal remedies for cancer really do work. I hope you all decide against ophthalmology...because if you are making your career choice based on whether or not OPH will pay the big bucks, then you deserve to catch a venereal disease...with ocular involvement.

AMEN BROTHA!!!!!

 

[Gleevec]

lol brilliant post GeddyLee

 

[Koji Kabuto]

It's funny that if someone posts enough times, you can really get a sense about what they are like. (Kinda like with Icewoman!)

GeddyLee, I have followed your posts on this board for about a year now. In that time, the overall Gestalt that I have is that I just don't like you. You claim to be a normal, average Joe, but you seem kinda creepy to me. You give off this holier-than-thou attitude and you often pass judgement on others. You have this sense of entitlement that you deserve Ophthalmology more than many other applicants out there who matched ("I have more research and pubs than these people in my class who matched," "I have better grades and board scores than these jokers who matched," and "I have altruistic motives for going into Ophtho not like these lying lasik cowboy wannabees" and so on...) To me, you seem like a bitter, bitter guy. As you know, the match is not all about numbers. They also involve a lot of intangibles one of which is a sense of "do I wanna work with this guy for 3 years?" I feel that if on these interviews, if some of the personality that you show here comes out, then the answer to that question is "No."

Am I the only one on this board who feels this way? Likely not. But I'm maybe the only one who will admit it and burn up all my Karma points along with it. I was content to sit back and continue to lurk on this board, but what finally set me off was this latest diatribe of yours. Specifically, it was when you, in my opinion, unfairly singled out the Cleveland Clinic as a program that likes to train the money grubbing lasik cowboys. I was a fellow applicant for the Ophthalmology match this year. I also interviewed at the Cleveland Clinic. On the contrary, they were stressing how they wanted to train future academicians. I'm sure it probably scared off some applicants about how gung-ho they were about wanting this, but at least they were honest in saying what they preferred, which is a direct opposite from what you alluded to in your post. Heck, I wish I could have matched there but it wasn't in the cards. I feel that they are continuing to improve an already awesome department, and it would have been nice to be a part of something on its way up. I actually matched at a program ranked higher than Cleveland Clinic on the USNews and I am extremely happy with my match, but I can admit that I ranked the Cleveland Clinic higher. I won't say which program it is that I matched to because I do not want any voodoo dolls coming my way.

I know I'm probably gonna get flamed for this post to no end, but I just couldn't help myself.

 

[Andrew_Doan]

Thanks for all your posts. I feel the same frustrations when people think ophthalmology is "easy" or not "medically relevant". This is one reason why I started archiving the morning rounds cases at Iowa and presenting some of the cases on this forum. Ophthalmology is, in fact, not easy and very difficult. I'll be presenting this case later, but here is one example. Early ICE syndrome can look like a pigmented mass in the angle. The patient was sent to us for further evaluation and "surgical intervention" if needed. If one doesn't pick up the subtle findings in ICE syndrome, then this woman could have undergone a biopsy or, worse, a larger iridocyclectomy. If you're not a surgeon, then you'll ask... what's the big deal? Cutting out a sector of the iris and ciliary body is fairly "easy" and "routine".

First off, it's technically difficult. Second, the risks of surgery are real and serious. The patient could: bleed and develop glaucoma, develop corneal blood staining from the hyphema, develop an eye threatening endophthalmitis, develop sympathetic ophthalmia and go blind, develop a retinal detachment requiring further surgery, lose vision because of her procedure, or even die or have a stroke because of the stress of being in the OR. The risks I've listed may occur even in the most perfect surgical scenario and if the surgeon did everything perfectly. These risks are natural consequences of performing surgery on the eye, which essentially is controlled trauma.

The point of this case is to emphasize that the patient did not need surgery or a biopsy. She had a unilateral syndrome called ICE syndrome. ICE is diagnosed clinically and managed initially like other glaucomas. While it is important to know how to cut, it is equally important to know when not to cut. This is why it's difficult to be a surgeon, and those without enough training should not do surgery, nor do they understand why residency is essential for surgical training.

 

[ckyuen]

Some people may be very gifted and have the great hands and excellent depth perception and a wonderful ability to work under magnification and convert what you are doing to the appropriate measurements at different magnifications. for these people they may find eye surgery easy for the other 99% of us it is extremely technically challenging. To find out where you are on your first capsulorhexis measure your pulse, no change? you may be in the one percent to find out start making your grooves, keep going deeper one phaco needle depth, deeper, two, deeper three. the tips about a millimeter long. how thick is the lens in ap dimension? you definitely need to know b/c I'll tell you the posterior capsule is only 4 microns thick and about as strong as a piece of wet toilet paper. your phacotip is akin to a jack hammer with a diamond blade in its destructive ability. If your pulse is still normal you are probably in the one percent. But hold on you haven't removed the pieces yet and experienced the joy of having the phaco surge ( the post cap acts like a trampoline and shoots towards your jackhammer, I mean phaco tip) if you haven't broke capsule yet and your attending has not once gotten anxious, told you to come out of the eye, used an explitive or two, grabbed the instruments, or most importantly your pulse is still normal you are one of the few. I on the other hand am with the majority. And there can't be another resident who plays more video games than I do http://abcnews.go.com/wire/Living/ap20040406_2079.html. three hours a week is nothing I've done 5x as much in a single day.

 

[ckyuen]

Oh also keep in mind while doing the procedure pushing down to hard by a couple of millimeters or pulling up to hard by a couple of millimeters throws you completely out of focus, and opens your wound destroying your closed system flattening your ac bringing you ever closer to killing of those few remaining endothelial cells and dooming your patient to a PK. Remember there are a lot of people who finish an opthalmology residency and don't operate well,.

 

[Andrew_Doan]

But hold on you haven't removed the pieces yet and experienced the joy of having the phaco surge ( the post cap acts like a trampoline and shoots towards your jackhammer, I mean phaco tip) if you haven't broke capsule yet and your attending has not once gotten anxious, told you to come out of the eye, used an explitive or two, grabbed the instruments, or most importantly your pulse is still normal you are one of the few.

The above narrative is true for each "routine" case; however, there are many diseases that make cataract surgery a nightmare: pseudoexfoliation, neovascular glaucoma, small pupil, trauma, diabetes, dense cataract, prior surgery, posterior capsule adhesions, etc... Not only do we have to master the routine cases, we must also know how to handle hundreds of other variables that make a routine case into something horrible.

My first 25 cases went beautifully. My 26th case had a posterior capsule adhesion. I pulled a little too much during the irrigation/aspiration phase and instantly there was a posterior capsular tear. Luckily it wasn't a great problem because the lens was already removed, and we placed in a sulcus lens after an anterior vitrectomy. Had this occurred during phacoemulsification, then the retina docs would have had to go fishing for the lens fragments.

My pulse still race during the key steps of each surgery. I envy the coolness of my attendings who hold a knife under high magnification, and it appears like they are using a robotic arm to control the cutting. It's awesome!

 

[Mirror Form]

It's funny that if someone posts enough times, you can really get a sense about what they are like. (Kinda like with Icewoman!)

GeddyLee, I have followed your posts on this board for about a year now. In that time, the overall Gestalt that I have is that I just don't like you. You claim to be a normal, average Joe, but you seem kinda creepy to me. You give off this holier-than-thou attitude and you often pass judgement on others. You have this sense of entitlement that you deserve Ophthalmology more than many other applicants out there who matched ("I have more research and pubs than these people in my class who matched," "I have better grades and board scores than these jokers who matched," and "I have altruistic motives for going into Ophtho not like these lying lasik cowboy wannabees" and so on...) To me, you seem like a bitter, bitter guy. As you know, the match is not all about numbers. They also involve a lot of intangibles one of which is a sense of "do I wanna work with this guy for 3 years?" I feel that if on these interviews, if some of the personality that you show here comes out, then the answer to that question is "No."

Am I the only one on this board who feels this way? Likely not. But I'm maybe the only one who will admit it and burn up all my Karma points along with it. I was content to sit back and continue to lurk on this board, but what finally set me off was this latest diatribe of yours. Specifically, it was when you, in my opinion, unfairly singled out the Cleveland Clinic as a program that likes to train the money grubbing lasik cowboys. I was a fellow applicant for the Ophthalmology match this year. I also interviewed at the Cleveland Clinic. On the contrary, they were stressing how they wanted to train future academicians. I'm sure it probably scared off some applicants about how gung-ho they were about wanting this, but at least they were honest in saying what they preferred, which is a direct opposite from what you alluded to in your post. Heck, I wish I could have matched there but it wasn't in the cards. I feel that they are continuing to improve an already awesome department, and it would have been nice to be a part of something on its way up. I actually matched at a program ranked higher than Cleveland Clinic on the USNews and I am extremely happy with my match, but I can admit that I ranked the Cleveland Clinic higher. I won't say which program it is that I matched to because I do not want any voodoo dolls coming my way.

I know I'm probably gonna get flamed for this post to no end, but I just couldn't help myself.

That was out of line. If you want to flame people go to the Everyone forum.

 

[Eyesore]

Andrew and ckyuen,

Do you guys learn how to chop? Or have you already? If not yet, then wait till you guys do. It adds a whole new dimension to performing cataract surgery. When you get used to it, it makes the case much faster, safer, and requires much less phaco time. It also looks more elegant and all in all is a whole lot more fun to do!

However, it also takes a bit of getting used to. The transition from divide and conquer to chopping is quite significant. When you first start out, you lose track of where your 2nd instrument is at times. This makes your attending very nervous. It also takes a while to get used to controlling both instruments at the same time in that tiny space. Chopping also requires more control of your phaco pedal, as well as better scope management. So you have both hands and both feet all working together at once. I'm not aware of many video games that require this.

Overall, it is more exciting and fun to do, and in my opinion, it is safer for the patient. So once you get comfortable with it, you wouldn't want to go back to divide and conquer again.

 

[Andrew_Doan]

Andrew and ckyuen,

Do you guys learn how to chop? Or have you already? If not yet, then wait till you guys do. It adds a whole new dimension to performing cataract surgery. When you get used to it, it makes the case much faster, safer, and requires much less phaco time. It also looks more elegant and all in all is a whole lot more fun to do!

However, it also takes a bit of getting used to. The transition from divide and conquer to chopping is quite significant. When you first start out, you lose track of where your 2nd instrument is at times. This makes your attending very nervous. It also takes a while to get used to controlling both instruments at the same time in that tiny space. Chopping also requires more control of your phaco pedal, as well as better scope management. So you have both hands and both feet all working together at once. I'm not aware of many video games that require this.

Overall, it is more exciting and fun to do, and in my opinion, it is safer for the patient. So once you get comfortable with it, you wouldn't want to go back to divide and conquer again.

Thanks for the advice!

I've done some stop-n-chop. Our volume of cataract of surgery jumps from 15-30 our second year to over 120-150 our third year. I'll have more opportunity to learn new techniques after I master the divide-n-conquer technique!

Dr. Oetting at the VA does an awesome job teaching us at the U and VA. He tries to expose us to as many techniques and surgical challenges as much as possible.

 

[GeddyLee]

Koji Kabuto...

Actually my point with the Cleveland Clinic comment was that no one would be stupid enough to tell an institution that aims to train academic ophthalmologists that they wanted to become private LASIK surgeons. On the contrary, I'm sure almost everyone who interviewed there who plans on doing private practice would have lied and said "academics".

Cleveland Clinic is an astoundingly fine program, which I'm 100% certain would be horrified if one of their graduates opened a 2-for-1 Lasik factory. I was using this to illustrate the irony of the situation.

Anyway, as for you not liking me, or anyone else for that matter, I've got bigger problems than anonymous bulletin boards posters not being savvy on me. But I think everyone's point of view should be welcome, so long as it doesn't aim to hurt anyone's feelings

 

[Andrew_Doan]

But I think everyone's point of view should be welcome, so long as it doesn't aim to hurt anyone's feelings

Well stated! What are you doing in July?

 

[chef]

sweeet i can write "PS2 & XBOX" on my resume & optho application w/ pride now!!!! woooooooooooooot

Some people may be very gifted and have the great hands and excellent depth perception and a wonderful ability to work under magnification and convert what you are doing to the appropriate measurements at different magnifications. for these people they may find eye surgery easy for the other 99% of us it is extremely technically challenging. To find out where you are on your first capsulorhexis measure your pulse, no change? you may be in the one percent to find out start making your grooves, keep going deeper one phaco needle depth, deeper, two, deeper three. the tips about a millimeter long. how thick is the lens in ap dimension? you definitely need to know b/c I'll tell you the posterior capsule is only 4 microns thick and about as strong as a piece of wet toilet paper. your phacotip is akin to a jack hammer with a diamond blade in its destructive ability. If your pulse is still normal you are probably in the one percent. But hold on you haven't removed the pieces yet and experienced the joy of having the phaco surge ( the post cap acts like a trampoline and shoots towards your jackhammer, I mean phaco tip) if you haven't broke capsule yet and your attending has not once gotten anxious, told you to come out of the eye, used an explitive or two, grabbed the instruments, or most importantly your pulse is still normal you are one of the few. I on the other hand am with the majority. And there can't be another resident who plays more video games than I do http://abcnews.go.com/wire/Living/ap20040406_2079.html. three hours a week is nothing I've done 5x as much in a single day.

 

[ckyuen]

Steel Battalion for the XBox does just kidding. I watched our third years chop and it looks so elegant and beautiful, I can't wait to learn it. Thanks for the encouragement.

 

[GeddyLee]

Dr. Doan...
I'll be doing a preliminary medicine year starting in July. I'm going to try to set up a research fellowship for 2005, and have this as a "selling point". I'll apply to OPH, during the coming round of applications. I considered sitting out a year in order to really improve my application, but since I got a lot of positive feedback, and learned that I just missed matching at 4 of my 10 programs, I've decided it will be worthwhile to give it another try this year. What do you think?

Anyway...I haven't decided on whether or not I'll pursue a backup plan...nothing else is really striking my fancy. I'm doing a general surgery rotation right now, which is super cool, but I just can't hack the 90 hour weeks for long. Anesthesia looked promising for a while, but it doesn't really float my boat either. So maybe I'll be an eternal OPH applicant, or hopefully someone will be nice enough to give me a spot. I think although not much on my application will change, I'll have proven committment to OPH, and I'll also have my Step II scores, which were pretty good and should prove that I'm capable of mastering clinical knowledge. And I've go a whole new lot of LOR's in the works too.

ANyway...that's what I'm doing! Right now I'm trying to plough through this surgery rotation...it's brutal!

GEddy

 

[Andrew_Doan]

Dr. Doan...
I'll be doing a preliminary medicine year starting in July. I'm going to try to set up a research fellowship for 2005, and have this as a "selling point". I'll apply to OPH, during the coming round of applications. I considered sitting out a year in order to really improve my application, but since I got a lot of positive feedback, and learned that I just missed matching at 4 of my 10 programs, I've decided it will be worthwhile to give it another try this year. What do you think?

I like that plan! Good luck!

 

[BeefyRedEye]

Good luck Geddy! I'm sure you will do very well in the match next year!

 

[MacGyver]

I have to agree with juddson here. If in fact there are studies showing that clinical outcomes between optometrists and opthos are equivalent for the same procedure, then that procedure is going bye-bye from the world of opthos and will be taken over by the Borg (i.e. optometry).

Government bureucrats WILL NOT PAY opthos 50% more to do the same procedure that an optometrist does at equivalent clinical outcomes. Thats just not going to happen, no matter how long you scream and cry about it.

If opthos really want to stem back the tide of invading optometrists, then they need to put out studies showing they provide superior medical care. Otherwise, all is lost and this ranting about how optometrists arent trained enough to handle these clinical situations is MOOT.

 

[Andrew_Doan]

I have to agree with juddson here. If in fact there are studies showing that clinical outcomes between optometrists and opthos are equivalent for the same procedure, then that procedure is going bye-bye from the world of opthos and will be taken over by the Borg (i.e. optometry).

What studies? Which procedures? We're not talking about yag capsulotomies or punctal plugs here. We're referring to glaucoma filtering surgeries, cataract extractions, and other invasive surgeries.

Spend more time doing a literature seach on optometry and surgical outcomes before posting a view here. Your point of view is not founded by any sound clinical trial because optometrists aren't allowed to perform surgical procedures except in OK, which is very limited and restricted to minor lid bumps and PRK (not LASIK). There aren't any clinical trials because optometrists are not allowed to perform surgery.

 

[ckyuen]

Well put Andrew. I don't think such an ignorant post should even be dignified with a response. I was thinking what the same thing you wrote and I was about to post when I decided why bother.

 

[Eyesore]

Do pencil push-ups count as surgery?

 

[MacGyver]

What studies? Which procedures? We're not talking about yag capsulotomies or punctal plugs here. We're referring to glaucoma filtering surgeries, cataract extractions, and other invasive surgeries.

Spend more time doing a literature seach on optometry and surgical outcomes before posting a view here. Your point of view is not founded by any sound clinical trial because optometrists aren't allowed to perform surgical procedures except in OK, which is very limited and restricted to minor lid bumps and PRK (not LASIK). There aren't any clinical trials because optometrists are not allowed to perform surgery.

NO NO NO.....you have totally misinterpreted my post.

What I'm saying is that for procedures that optoms CAN ALREADY DO, such as PRK, that there will eventually be data regarding optom vs optho performance on shared procedures. If the research shows no difference in outcomes, then long term PRK is going to be taken over by optoms.

Give me one good reason why state legislatures would not change the laws to allow optoms to do PRK when they have data in other states showing no difference in outcomes? Opthos dont have a leg to stand on once those studies come out.

You are probably one of the docs who says "let the optoms do the small stuff, we dont care." As I have said before with CRNAs vs MDAs, thats a very short sighted and myopic viewpoint. Essentially, this concession type of attitude will result in increased scope for optoms, and reduced market share for opthos.

Of course by the time that reaches fruition, you will already have made your millions and retired. This same scenario is taking place in almost every specialty. Too many current docs dont give a **** about the future of the profession--they are just looking to cash out.

My point is that its entirely irresponsible for docs to just concede bread and butter stuff to midlevels and other providers.

 

[Redhawk]

You are probably one of the docs who says "let the optoms do the small stuff, we dont care."

I don't think you've read enough of Dr. Doan's posts.

 

[MacGyver]

I don't think you've read enough of Dr. Doan's posts.

I've read enough to know that he's not really concerned about the ODs in OK because they "only" do PRKs.

 

[Mirror Form]

That was out of line. If you want to flame people go to the Everyone forum.

After receiving lots of negative karma about this post, I formally retract this statement. The ophtho forum is as good a place to flame people as any. And oh yeah, geddy lee sucks.

 

[Gleevec]

I've read enough to know that he's not really concerned about the ODs in OK because they "only" do PRKs.

No MacGyver you really dont read enough of Dr. Doan's posts. Also reread his comment that you misquote: "Your point of view is not founded by any sound clinical trial because optometrists aren't allowed to perform surgical procedures except in OK, which is very limited and restricted to minor lid bumps and PRK (not LASIK)." At no point does he say he is not concerned about OK, and he never says they "only" do PRKs (at least in a sense that PRKs are trivial). So you're really just putting words in his mouth now.

He never said he approved of the OK deal, in fact in other threads he vehemently opposes it. Please get your facts straight before posting in the future. Thanks.

 

[Andrew_Doan]

I've read enough to know that he's not really concerned about the ODs in OK because they "only" do PRKs.

You are truly arguing with a database of ignorance.

I'm currently in Washington D.C. at the AAO advocacy meeting to meet with policy makers about optometry and procedures. I do care about OK, but the optoms in OK snuck in a law that allowed them to perform laser procedures and a clause preventing medical boards from suing each other. Since then the AAO has faught with local ophthalmology societies to prevent similar bills from being passed in other states. We lossed the battle in OK because we were apathetic.

My point is that if ODs cannot do surgeries then there cannot be data to demonstrate outcomes. ODs aren't surgeons.

The current optometry data for laser procedures are not published and unfounded. For instance, optometrists claim that 10,000 lasers procedures have been done without complications. This cannot be true because the rate of retinal detachment occurs 1-2% of the time even in the most ideal conditions. WIth 10,000 lasers there has to be at least 100-200 retinal detachments statistically. Also, laser can cause problems that require emergent surgical intervention in the OR. I don't want non-surgeons doing procedures resulting in problems that they can't rectify.

FYI, I do care about the future of ophthalmology. I don't care about making millions. I plan to be an academic. I will be working for the US military. Thus, my fundamental political interests are based on my concern for patients and maintaining high standards for my field.

 

[MacGyver]

We lossed the battle in OK because we were apathetic.

Exactly, and now that Oklahoma has established a precedent, it will be MUCH HARDER for opthos to argue against similar privileges being doled out in other states.

I'm sure ODs in OK are busy right now compiling data about how their PRK procedures are no worse than those being done by opthos. I hope the opthos have competing data arguing against that, because if they dont, opthos are going to lose the battle.

Opthos spend way too much time making irrelevant arguments about how ODs are not "trained" to deal with PRK, instead of actually fighting the most important aspect of this which is clinical outcomes data.

Do you have data showing PRK performed by ODs to be worse than MDs?