Which sub-specialties make the most?

[Perforin]

I was wondering which sub-specialties in Ophtho make the most and least. This is purely a curiosity question, probably won't factor much into any kind of fellowship I may pursue. My guesses, in order from most money to least, would be retina, plastics, cornea, glaucoma, neuro, pathology, pediatric (obviously it depends on how busy you are, so assume a typical practice for each sub-specialty). Does that seem about right?

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[collosalmockery]

I guess retina, oculoplastics and cornea.

 

[WhatNEyeTem]

I was wondering which sub-specialties in Ophtho make the most and least. This is purely a curiosity question, probably won't factor much into any kind of fellowship I may pursue. My guesses, in order from most money to least, would be retina, plastics, cornea, glaucoma, neuro, pathology, pediatric (obviously it depends on how busy you are, so assume a typical practice for each sub-specialty). Does that seem about right?

Highest overall would be: high-volume LASIK

Highest on average would be: retina (mainly high volume medical retina)

Everything depends on what insurance companies/Medicare want to reimburse you. When OCT reimbursements got slashed recently, retina practices took a big hit. It won't take long for insurance companies to also slash other in-office stuff such as FA, focals, PRP, injections etc.

The great thing about high-volume refractive is that you don't depend on insurance companies. The bad thing about it, however, is how many LASIK surgeons can a community really support?

 

[MR1]

In general yes high volume LASIK and retina are the highest paying currently. As far as plastics, I think if you do a lot of cosmetic it can be up there as well. From what I have gathered, cornea and glaucoma don't in general pay that much more than general but the job market is better. Peds and neuro yes are lower paying but from what I have heard there is such a demand for them that you can end up doing okay.

Anecdotal example at my residency the peds folks did considerably better than glc and cornea.

Another thing to add is a general ophtho in a smaller town. I am not talking the sticks, just smaller town middle America. They can easily do better than even well paid retina guys.

 

[Visionary]

Highest overall would be: high-volume LASIK

Highest on average would be: retina (mainly high volume medical retina)

Everything depends on what insurance companies/Medicare want to reimburse you. When OCT reimbursements got slashed recently, retina practices took a big hit. It won't take long for insurance companies to also slash other in-office stuff such as FA, focals, PRP, injections etc.

The great thing about high-volume refractive is that you don't depend on insurance companies. The bad thing about it, however, is how many LASIK surgeons can a community really support?

FYI, injections took a hit at the same time OCT did. CMS won't go after the others you list, because they are low utilization diagnostics/procedures.

To the OPs question, I would agree that a lot depends on the how and where of your practice, as much as your subspecialty. Yes, retina has the highest potential per unit volume, primarily due to imaging and procedures. Of course, I know some retina docs in saturated areas that make less then the comprehensive docs in my practice. High-volume LASIK can bring in a lot, but it's a very cut-throat industry. You won't find many that can hack it. As a generalist, you can do very well with a focus on premium IOLs plus refractive surgery (i.e., glasses-free cataract surgery). Those folks have weathered the drop in LASIK prices quite nicely.

There's no single answer to your question, to be honest. I've always said you should do what interests you. As an ophthalmologist, you should do fine financially (unless you enter a saturated area). If you really want to "kill it," you can set up most any generalist or subspecialty practice with a primary goal of being lucrative. You just have to pick the right location and right angle. Depends on what your priority is....

 

[NeuroOph]

No question retina. Neuro is last by far. In fact, there is no Neuro person who can support themselves doing just Neuro. These people only exist in residencies so that the residency can meet ACGME accredidation. Most Nuero people wind up doing general.

 

[speyeder]

In fact, there is no Neuro person who can support themselves doing just Neuro.

This is probably true 99% of the time. However I know of a couple of neuro-ophthalmologists who do quite well doing neuro only. They don't take insurance, charge out-of-pocket fees for their services, and see 6-10 patients a day. They are located in a large metropolitan area and get referrals from all over. Patients who see them often have been examined by several ophthalmologists without a diagnosis.

 

[sjm5104]

Just curious. How much do average retina guys make these days?

 

[InterviewMe]

This is probably true 99% of the time. However I know of a couple of neuro-ophthalmologists who do quite well doing neuro only. They don't take insurance, charge out-of-pocket fees for their services, and see 6-10 patients a day. They are located in a large metropolitan area and get referrals from all over. Patients who see them often have been examined by several ophthalmologists without a diagnosis.

I have also witnessed this. If you are exceptionally good, you can charge what you want. And honestly, it's worth it.

 

[Visionary]

As far as retina average, estimates will vary, but I'd say between $500k and $600k. There are some in saturated areas who make less and others who make much more. One guy in my area sees over 100 patients per day and probably nets over $1 mil.

 

[sjm5104]

Thank you so much, and wow, I had no idea it was that much more then the general guys. Im only a first year medical student, but ophtho has been emerging as the front runner for me thus far. I understand retina to be the most competitive subspecialty, just exactly how competitive is it. I understand this is an ambiguous question. But are there often students who finish residency and can't find a spot in a retina fellowship?

I apologize for the naive question.

 

[Visionary]

Very competitive, and yes there are some who cannot get a retina fellowship, or at least a decent one. As I stated above, most any subspecialty and even comprehensive can be very lucrative, if you set it up properly and in a good location.

 

[sjm5104]

Thank you very much for your input. I don't really plan on living and practicing in a large metropolitan area. I would love to set up in a more suburban area. perhaps an hour or so outside of a larger city.
thanks again for the input!

 

[WhatNEyeTem]

Very competitive, and yes there are some who cannot get a retina fellowship, or at least a decent one. As I stated above, most any subspecialty and even comprehensive can be very lucrative, if you set it up properly and in a good location.

I agree. Location is probably the most important. If you don't have any competitors, you are going to rake it up. Also, if you practice "true" general ophthalmology, you are not going to feel the need (or be expected from your patients) to refer out PRPs, focals, intravitreal injections, glaucoma lasers, trabs/tubes, K transplants, blephs, ectropion/entropion repair, refractive stuff, etc. In other words, the expectations are somewhat lower in these communities.

Of course, you may not be absolutely the best at doing a DSAEK compared to someone who only does that procedure 10 times a week, but sometimes you are the only option in a community.

Oftentimes, working in a University or highly-specialized setting becomes a "crutch" to some providers, to the point where they refer out everything and never learn things outside of their fields. Yes, the politics of referrals also gets in the way of Ophthalmologists learning/offering more services.

 

[MR1]

I agree. Location is probably the most important. If you don't have any competitors, you are going to rake it up. Also, if you practice "true" general ophthalmology, you are not going to feel the need (or be expected from your patients) to refer out PRPs, focals, intravitreal injections, glaucoma lasers, trabs/tubes, K transplants, blephs, ectropion/entropion repair, refractive stuff, etc. In other words, the expectations are somewhat lower in these communities.

Of course, you may not be absolutely the best at doing a DSAEK compared to someone who only does that procedure 10 times a week, but sometimes you are the only option in a community.

Oftentimes, working in a University or highly-specialized setting becomes a "crutch" to some providers, to the point where they refer out everything and never learn things outside of their fields. Yes, the politics of referrals also gets in the way of Ophthalmologists learning/offering more services.

I don't know though, how can you "really" do all this today. Ophthalmology is so much more vast now than it was not that long ago. Can you really do all this and be good at it or at the very least be doing good for your patients. Even if expectations are lower, it is not like tubes, DSAEK, etc are urgent and patients can't for the most part travel somewhere to get them done. Now maybe you are a comprehensive and you have an interest in glaucoma or cornea or plastics and you do a lot in that field but to do a little in all of them I would wonder if you really are doing your patients a good service here.

I come from a very rural state and the ophtho's did this, one did trabs, one did PK's, one did strab, others did refractive. All as comprehensive docs, but none tried to do it all.

 

[WhatNEyeTem]

I don't know though, how can you "really" do all this today. Ophthalmology is so much more vast now than it was not that long ago. Can you really do all this and be good at it or at the very least be doing good for your patients. Even if expectations are lower, it is not like tubes, DSAEK, etc are urgent and patients can't for the most part travel somewhere to get them done. Now maybe you are a comprehensive and you have an interest in glaucoma or cornea or plastics and you do a lot in that field but to do a little in all of them I would wonder if you really are doing your patients a good service here.

I come from a very rural state and the ophtho's did this, one did trabs, one did PK's, one did strab, others did refractive. All as comprehensive docs, but none tried to do it all.

I guess it's all about how comfortable you are doing certain procedures. In some geographic locations, patients would rather undergo the procedure with a local person rather than travel even 1 hour to someone else/tertiary center.

I believe people confine themselves to one set of procedures more because of the politics of referrals. But if you are the only game in town, then you have more leeway of the procedures you can offer.

 

[tm12]

oops wrong thread

 

[MstaKing10]

I guess it's all about how comfortable you are doing certain procedures. In some geographic locations, patients would rather undergo the procedure with a local person rather than travel even 1 hour to someone else/tertiary center.

I believe people confine themselves to one set of procedures more because of the politics of referrals. But if you are the only game in town, then you have more leeway of the procedures you can offer.

I want to believe you, and for the most part you are probably right. However, still being in fellowship at a tertiary referral center, it is incredible how often we get referrals for 2nd opinions or botched surgeries from docs in the suburbs getting in over their heads or doing the wrong thing. It's not often but often enough. These poor patients end up having to make the one or two hour trip anyways, often several times a week until their problem is fixed. Again, not saying this is the norm, but making a general statement that just because you are the only show in town doesn't mean you should offer any and all services. As you mentioned, it boils down to comfort with procedures and management of their pre and post operative issues.

 

[WhatNEyeTem]

I too was once in a tertiary center doing my fellowship, and one thing that you don't realize when you're training, is that private practice is an entirely different world.

At a tertiary center, the great majority of patients are train-wrecks and/or 2nd/3rd opinions. While in the "real world", most of your patients are bread-and-butter type stuff. It does not take a genius to do a PRP/focal/injection/bleph/filter/strab etc while you are out in practice. Like we agree, it is all about comfort level.

In the "old days", the guys coming out would do real "comprehensive ophthalmology." I think our generation is definitely more timid because it is engrained by tertiary centers that only "specialists" should be handling things.

 

[Andrew_Doan]

There are cataract surgeons who make more than $1 million/year because they are a fast and safe surgeon with amazing business skills.

General ophthalmologists with LASIK/refractive surgery skills can also make more than retina surgeons.

The AAO published average incomes several years ago.

Average comprehensive ophthalmologists make around $340K per year and retina makes about $800K per year.

 

[sjm5104]

So with the understanding of how competitive this field is, I have a natural worry as a medical student that I may not be able to score high enough on boards to be considered. What are some of the things that medical students who do not match can do to still get into the field. Is a research year between school and residency enough to cut the mustard if you don't match the first time?

 

[Visionary]

So with the understanding of how competitive this field is, I have a natural worry as a medical student that I may not be able to score high enough on boards to be considered. What are some of the things that medical students who do not match can do to still get into the field. Is a research year between school and residency enough to cut the mustard if you don't match the first time?

There are only so many things you can do to bolster your CV. Sometimes it just doesn't happen. Sometimes it's persistence. For instance, I know one person who was dead-set on surgical retina. Ended up being the 4th fellowship, but finally made it.

 

[Andrew_Doan]

So with the understanding of how competitive this field is, I have a natural worry as a medical student that I may not be able to score high enough on boards to be considered. What are some of the things that medical students who do not match can do to still get into the field. Is a research year between school and residency enough to cut the mustard if you don't match the first time?

My scores were rather average. I did graduated from Hopkins though and that helped.

The number one question that made me stand out was my eBay business during medical school. Keith Carter, MD at Iowa asked (PD at the time), "How can I get a PlayStation for my kid?!" This was the first question that took up nearly the entire interview!

http://myworld.ebay.com/ebaymotors/medrounds

My advice, be yourself and talk about what you love with passion!

 

[JMK2005]

There are only so many things you can do to bolster your CV. Sometimes it just doesn't happen. Sometimes it's persistence. For instance, I know one person who was dead-set on surgical retina. Ended up being the 4th fellowship, but finally made it.

4 fellowships... so that makes him a comprehensive ophthalmologist?

The persistence and passion is admirable.

 

[RestoreSight]

According to "Eye Health Statistics at a Glance" on the AAO website...

Q: What is the average ophthalmologist income?
A: Average net income: $260,000. [Source: Health Care Group, 2005]

According to the Allied Physician Salary Survey (http://www.alliedphysicians.com/salary-surveys/physicians/) - average retina salary = 469,000

According to the "Medscape Ophthalmology Compensation Report: 2011 Results"

"Despite declining reimbursements, ophthalmology is among the better-paid specialties. Medscape's survey indicates that the median 2010 compensation for ophthalmologists, $248,500, is higher than median earnings for 10 other specialties. What's more, according to the US Bureau of Labor Statistics, as baby boomers age and require treatment for cataracts, glaucoma, and other eye conditions, employment opportunities in ophthalmology are expected to grow 11%-14% during the next few years. As with most medical careers, pay for ophthalmologists increases with experience. Specialization counts, too. Ophthalmologists who specialize in retinal diseases, for example, typically earn more than other ophthalmologists."

Note: Surveys always have potential bias. For example, 3x more men responded than women, and the majority of respondents were between 40-59 years old.

 

[tm12]

I'm not sure how best to quantify this but there are also a lot of fringe benefits that aren't included in these reports. For example, a lot of my friends who are in private practice charge their cell phones, meals, cars, etc to their business.

 

[orbitsurgMD]

I'm not sure how best to quantify this but there are also a lot of fringe benefits that aren't included in these reports. For example, a lot of my friends who are in private practice charge their cell phones, meals, cars, etc to their business.

It isn't as simple as that. Yes, many things that you might have paid for out of pocket with after-tax dollars can be legitimately claimed as expenses of your business entity and therefore paid for with pre-tax dollars. Those aren't "fringe benefits," they are expenses. You can claim un-reimbursed business expenses as an employee as well. In business, when you are the owner, there are no "fringe benefits," only expenses. Everything has to be paid for. Use of your car for business purposes, aside from commuting, is deductible whether you are an owner or an employee. But there are other obligations you have as an owner that you don't have as an employee, such as being taxed at the self-employment tax rate as opposed to the rate under FICA, which is double, given that you pay both the employer and employee contributions.

"Fringe benefits" usually mean things that don't come out of your after-tax money and that also don't count as income: company cars, liberal vacation allowances, educational support, disability insurance, generous pension plans and 401K contributions matching, use of company-owned leisure facilities, generous expense accounts and the like. All of that has to be justified as business-related for the employer to deduct as a business expense.

 

[The Doctor]

I like the spirit of this thread and how we haven't been condemned for asking about potential compensation. The fact is most all of us care about helping people or we wouldn't have gone to medical school, but if you look at other health professions such as nursing they routinely advertise and talk about job security and compensation. We will all have families to support, loans to pay, etc so I think these are very relevant questions and I believe in freedom of information to make our own decisions.

With that said, I will point out that there are many, many specialties and sub-specialties where you can structure your practice to be lucrative if that is a top priority to you. The compensation is good and very comfortable, but I wouldn't choose ophthalmology based on the money. Starting salaries are very low and saturation is an issue around large cities. Other specialties will make more on average including dermatology, rad onc, urology, ENT, ortho, cards, GI, anesthesiology, hem/onc (this is according to the 2010 MGMA report).

Way back early in medical school I collected massive amounts of data on every possible specialty and subspecialty which I arranged in a spreadsheet and ranked - I then tried out each of the best ranked specialties and found out which was the best fit for me personally - ophthalmology. I suspect changing reimbursement will squeeze specialties closer together in terms of compensation in the future, so you are best off choosing what interests you and where you feel like you can have a decent life outside of medicine.

If you still want the numbers, here they are:

Median Salary Data for Ophthalmology according to the MGMA Compensation Report for 2010, based on 2009 data

Ophthalmology - $338,208
Corneal and Refractive Surgery - $386,730
Retina - $578,753
Pediatric - $297,251

 

[tm12]

It isn't as simple as that. Yes, many things that you might have paid for out of pocket with after-tax dollars can be legitimately claimed as expenses of your business entity and therefore paid for with pre-tax dollars. Those aren't "fringe benefits," they are expenses. You can claim un-reimbursed business expenses as an employee as well. In business, when you are the owner, there are no "fringe benefits," only expenses. Everything has to be paid for. Use of your car for business purposes, aside from commuting, is deductible whether you are an owner or an employee. But there are other obligations you have as an owner that you don't have as an employee, such as being taxed at the self-employment tax rate as opposed to the rate under FICA, which is double, given that you pay both the employer and employee contributions.

"Fringe benefits" usually mean things that don't come out of your after-tax money and that also don't count as income: company cars, liberal vacation allowances, educational support, disability insurance, generous pension plans and 401K contributions matching, use of company-owned leisure facilities, generous expense accounts and the like. All of that has to be justified as business-related for the employer to deduct as a business expense.

You are correct. I meant to say I don't think these "business expenses" are reported in those salary surveys.

 

[RestoreSight]

You are correct. I meant to say I don't think these "business expenses" are reported in those salary surveys.

I don't think you quite understand what orbitsurgMD is saying. A fringe benefit is not = to a business expense and your substitution of the two terms is inaccurate. Before med school I worked in finance for a few years and owned a small S corp entity that provided supplemental income. As a business owner (presumably principal shareholder of a corporate entity) you are entitled to a different tax structure than your employees. Legitimate business expenses can be subtracted from your total tax burden "before" you pay taxes annually or quarterly, reducing your total tax liability and sometimes even dropping your company into a lower tax bracket which can save significant income each year. Individual employees receive after-tax income, meaning items such as social security have already been taken from your paycheck before you cash it in. All of the supposed fringe benefits you alluded to (transportation, meetings, travel, equipment for the office, etc) still have to be purchased, but they can be written off your taxes. This is rarely a dollar for dollar transfer as you will pay less in taxes, but it may not equal the total cost of expenses accrued each year.

These surveys do not adjust for different incomes based on location, employment type, tax burden, cost of living, etc. By your logic, a physician living in one of the states with no required state income tax (Alaska, Florida, Nevada, South Dakota, etc) would be receiving a fringe benefit vs a physician in say, California where state income tax is very high. This is obviously not true.

All of the other perks OrbitsurgMD mentioned are closer to true fringe benefits, because they don't really affect your tax burden. There is a gift tax to keep in mind though, and this fine line between fringe benefits and taxable gifts is a prime target for auditors.

 

[tm12]

I don't think you quite understand what orbitsurgMD is saying. A fringe benefit is not = to a business expense and your substitution of the two terms is inaccurate. Before med school I worked in finance for a few years and owned a small S corp entity that provided supplemental income. As a business owner (presumably principal shareholder of a corporate entity) you are entitled to a different tax structure than your employees. Legitimate business expenses can be subtracted from your total tax burden "before" you pay taxes annually or quarterly, reducing your total tax liability and sometimes even dropping your company into a lower tax bracket which can save significant income each year. Individual employees receive after-tax income, meaning items such as social security have already been taken from your paycheck before you cash it in. All of the supposed fringe benefits you alluded to (transportation, meetings, travel, equipment for the office, etc) still have to be purchased, but they can be written off your taxes. This is rarely a dollar for dollar transfer as you will pay less in taxes, but it may not equal the total cost of expenses accrued each year.

These surveys do not adjust for different incomes based on location, employment type, tax burden, cost of living, etc. By your logic, a physician living in one of the states with no required state income tax (Alaska, Florida, Nevada, South Dakota, etc) would be receiving a fringe benefit vs a physician in say, California where state income tax is very high. This is obviously not true.

All of the other perks OrbitsurgMD mentioned are closer to true fringe benefits, because they don't really affect your tax burden. There is a gift tax to keep in mind though, and this fine line between fringe benefits and taxable gifts is a prime target for auditors.

I don't think you understand my point...which is that the incomes reported in the salary surveys do not reflect true compensation.

For example, the reported average ophthalmology salary may be $338,208 but this may not include benefits such as company car and cell phone bills. You would indeed only be taking home $338,208 before taxes. But you get the use of the $50,000 car which is not reported in these salary surveys. Whether these are legitimate business expenses is a completely different issue.

 

[RestoreSight]

I don't think you understand my point...which is that the incomes reported in the salary surveys do not reflect true compensation.

For example, the reported average ophthalmology salary may be $338,208 but this may not include benefits such as company car and cell phone bills. You would indeed only be taking home $338,208 before taxes. But you get the use of the $50,000 car which is not reported in these salary surveys. Whether these are legitimate business expenses is a completely different issue.

What does "the use of the $50,000 car" have to do with salary? A salary is a form of periodic payment from an employer to an employee specified in a contract. Two physicians both making the same salary, but one may just be better at managing money then another and keep more of his earnings. Either way both still have the same salary. In this situation true compensation for both is the same regardless. The point being made is that a fringe benefit is not the same as a business expense. These surveys generally reflect the average salary of physicians in the US, most of whom would describe their salary as their gross, not their net income.

 

[OJOJobsGuy]

Though the Health Care Group is a very well-known, well respected organization, their figures on Ophthalmology compensation are not particularly helpful because they have such low response rates.
For example, here's how many Ophthalmologists responded to their compensation survey according to years:
2010 - 0
2011- 8
2012- 13
2013- 9
2014 - 3
Unfortunately "Googling" ophthalmology compensation isn't especially helpful because it is difficult to determine survey size, whether the data includes salaries from all subspecialties or just general ophthalmology. It's also difficult to ascertain whether production bonuses are or are not included.

According to "Eye Health Statistics at a Glance" on the AAO website...

Q: What is the average ophthalmologist income?
A: Average net income: $260,000. [Source: Health Care Group, 2005]

According to the Allied Physician Salary Survey (http://www.alliedphysicians.com/salary-surveys/physicians/) - average retina salary = 469,000

According to the "Medscape Ophthalmology Compensation Report: 2011 Results"

"Despite declining reimbursements, ophthalmology is among the better-paid specialties. Medscape's survey indicates that the median 2010 compensation for ophthalmologists, $248,500, is higher than median earnings for 10 other specialties. What's more, according to the US Bureau of Labor Statistics, as baby boomers age and require treatment for cataracts, glaucoma, and other eye conditions, employment opportunities in ophthalmology are expected to grow 11%-14% during the next few years. As with most medical careers, pay for ophthalmologists increases with experience. Specialization counts, too. Ophthalmologists who specialize in retinal diseases, for example, typically earn more than other ophthalmologists."

Note: Surveys always have potential bias. For example, 3x more men responded than women, and the majority of respondents were between 40-59 years old.

 

[SphereGlobe]

Does anyone have salary data for oculoplastics? I can't seem to find this anywhere

 

[LightBox]

I always think surveys like this are a joke:

http://www.forbes.com/sites/jacquel...rst-paying-jobs-for-doctors-2/2/#6af2b6937619

They must be polling year 1-3 associates and not anyone mid-career!

 

[pasquals]

I'm very curious about this as well. I'd say it would be Retina but they work longer days and actually might have to come in when on call. Not sure what "per hour pay" would be. It doesn't seem like the rvus for plastics procedures is very high.


Sent from my iPhone using SDN mobile

 

[newby000]

I have no doubt that we won't starve but would be great to know what the starting and mid career salaries are per sub-speciality so that we know what we are worth and bargain for the right price when looking for a job...
From personal communications from someone who just started as a general ophthalmologist in a private setting without a fellowship, in a suburbia about 30 minutes close to a very large city, her starting salary was 220 with bonus depending how much extra money you can bring above their expectations (if they want you to bring in 500K a year and your made 800K, they take the difference and give you a percentage of that). She told me that this plan was for 2 years and her salary was expected to go up after 2 years...

If PGY4s or fellows are reading this, it would be amazing if they can post their findings on the interviews, their offered base salaries and their conditions. I will be posting my findings when applying for jobs)

 

[LightBox]

I would say that "most" run-of-the-mill average general ophthalmologists make around 350-500k mid-career. That is assuming the person is working full-time (not 3 days a week like some people choose). I would say that most "average" retina people make around 450-700k mid-career. The RVUs are very high in retina because you can ram through 60 patients a day with a million tests. I'm not sure about plastics, but I would say closer to the general ophthalmologists.

As reiterated many times on this forum, your true take-home compensation depends on if you own an ASC, optical shops, have optometrists that you profit from, rent out real estate, etc...