Hi guys.I hear all the time that the future of ophtho doesn't look so good in any way you see it (ODs,medicare etc.). I had the thought of applying to ophtho but when it comes to $$ things don't look good(starting salaries etc). Is there still hope? What is the average income in private practice?? Loans are a significant factor...as you all know. Thanks!

if you're pickin ophtho based on money then go into neurosurg or ortho...you need to be more concerned with finding what you love...because you have to wake up everyday of your life doing it. We all have or had loans and picked ophtho (as do family med people with loans...who average the lower salary scales in medicine). So you're probably not going to find many people on here that can feel sorry for your loans...you don't wantto know how much I owe in loans. Good luck finding a field you love! In my opinion Ophtho is amazing for HUNDREDS of reasons

I know that all of us owe a lot and for sure I'm not picking any specialty based on money, but you have to admit that it does play a role. Ophtho is a very interesting and rewarding field. The thing is that many attendings discourage people from going into ophtho these days because it's getting harder and harder to find a job. I really don't know if this is true or not.Thanks!

I understand your concern but in the end, you have to pick a field you enjoy doing daily since it can be a thirty plus year commitment. Generalists and family docs can pay off their loans...so no doubt ophtho can too! Good luck figuring out if peds cards or ophtho is best for you! In the end I think you will ""just know" what is right for you. Best of luck

Hi guys.I hear all the time that the future of ophtho doesn't look so good in any way you see it (ODs,medicare etc.). I had the thought of applying to ophtho but when it comes to $$ things don't look good(starting salaries etc). Is there still hope? What is the average income in private practice?? Loans are a significant factor...as you all know. Thanks!

There will always be a need for ophthalmologists. Whether the need will extend to having them on the same terms in the future as in the past is another matter.

Issues of money are not insignificant in this field as the costs of opening and operating an office are on the higher side compared to many other specialties (maybe radiologists owning their own centers excepted). Recent estimates of costs of equipping a small basic office for one ophthalmologist at $300,000.

There has been a history of high-priced buy-ins in ophtho, much higher than is typical of other specialties, and as reimbursements have fallen, especially for cataract, there have been disagreements as concerns price relative to net receipts. A lot of older doctors wishing to sell are finding younger associates unable and unwilling to pay the old-style buy-in price. The lower salaries are an indicator of lower reimbursement and higher practice costs, which in a rational world should have the effect of lowering buy-in price, but that has not happened uniformly in many places.

The thing is that many attendings discourage people from going into ophtho these days because it's getting harder and harder to find a job. I really don't know if this is true or not.Thanks!

That depends on where you look. You might have trouble getting in on the market in LA, but in less urban areas there may not be another ophthalmologist for miles and miles. I recently read that of the 77 counties in Oklahoma, only 18 of them have ophthalmologists. So under served areas do exist.

I c that if you after it you might succeed anyway. From what I found especially surgical specialties are no more that well paid as they used to be.At least ophtho has the best possible lifestyle compared lets say to general surgery.

Issues of money are not insignificant in this field as the costs of opening and operating an office are on the higher side compared to many other specialties (maybe radiologists owning their own centers excepted). Recent estimates of costs of equipping a small basic office for one ophthalmologist at $300,000.



Can you please outline where that $300000 comes from because I helped a local young ophthalmologist with a cold startup and it was a LOT less than $300000.

Can you please outline where that $300000 comes from because I helped a local young ophthalmologist with a cold startup and it was a LOT less than $300000.

I can easily see how it would be 300k if you wanted to be able to do things like visuals fields, OCT's, pay for technicians, secretary, EMR, SLT, yag etc. Also keep in mind that location is a big factor. Costs on personel and the office will be very variable.

I can easily see how it would be 300k if you wanted to be able to do things like visuals fields, OCT's, pay for technicians, secretary, EMR, SLT, yag etc. Also keep in mind that location is a big factor. Costs on personel and the office will be very variable.

See, that's just crazy.

When you are in a cold startup situation, you should spend as little as humanly possible on things that do not make you money.

EMR is an incredible waste for a cold start up. most of those systems are in the multiple tens of thousands of dollars and require multiple workstations/licenses/service contracts to maintain. It's completely unneeded for a cold start up. Would it be nice? Sure....but start with paper charts. The only thing electronic should be insurance billing, and most of the electronic clearing houses will provde you with the software for free and charge as little as $0.50 per claim.

SLT and Yag? How much of that does a cold start up do in a month? What better arrangement could you come up with? Perhaps you could lease from another practitioner one day a month and just bring the few patients that you have over to their practice for those procedures. Same thing with OCT, Gdx, HRT. Lease one one day a month or have a portable one brought to your office and schedule all of your patients on one day to have those tests performed instead of spending $40000 on a new one.

Technicians....how many do you need when you are starting off? Start off small by doing more things yourself. Yes, you may have to lower yourself to performing your own visual accuities, pupil assessments and Goldmanns but it will save you at least $25000 per year per technician. Don't waste money on an autorefractor. Do retinoscopy. Don't waste money on an NCT. Do Goldmann yourself. As time goes on and you become more busy, you can invest in these devices but initially, only spend money on things that MAKE you money and an NCT isn't going to do it.

Costs of personnel.....you need one full timer and one part timer for most cold startups. Ideally, the part timer should have a somewhat flexible schedule in case the full timer needs to be out. Staffing is by far and away the biggest headache in running any sort of practice.

I helped an ophthalmolgist open cold for just under $70000 after a failed partnership attempt. Everything was leased and/or used. He had a refurbished retinal camera and visual field machine. (These things generate revenue and many patients need these tests) But...he was up and running and (most importantly) in the black very fast. That's the key. Cash flow is king in any new startup. Don't tie up all your cash flow into things like EMR and OCTs.

See, that's just crazy.

When you are in a cold startup situation, you should spend as little as humanly possible on things that do not make you money.

EMR is an incredible waste for a cold start up. most of those systems are in the multiple tens of thousands of dollars and require multiple workstations/licenses/service contracts to maintain. It's completely unneeded for a cold start up. Would it be nice? Sure....but start with paper charts. The only thing electronic should be insurance billing, and most of the electronic clearing houses will provde you with the software for free and charge as little as $0.50 per claim.

SLT and Yag? How much of that does a cold start up do in a month? What better arrangement could you come up with? Perhaps you could lease from another practitioner one day a month and just bring the few patients that you have over to their practice for those procedures. Same thing with OCT, Gdx, HRT. Lease one one day a month or have a portable one brought to your office and schedule all of your patients on one day to have those tests performed instead of spending $40000 on a new one.

Technicians....how many do you need when you are starting off? Start off small by doing more things yourself. Yes, you may have to lower yourself to performing your own visual accuities, pupil assessments and Goldmanns but it will save you at least $25000 per year per technician. Don't waste money on an autorefractor. Do retinoscopy. Don't waste money on an NCT. Do Goldmann yourself. As time goes on and you become more busy, you can invest in these devices but initially, only spend money on things that MAKE you money and an NCT isn't going to do it.

Costs of personnel.....you need one full timer and one part timer for most cold startups. Ideally, the part timer should have a somewhat flexible schedule in case the full timer needs to be out. Staffing is by far and away the biggest headache in running any sort of practice.

I helped an ophthalmolgist open cold for just under $70000 after a failed partnership attempt. Everything was leased and/or used. He had a refurbished retinal camera and visual field machine. (These things generate revenue and many patients need these tests) But...he was up and running and (most importantly) in the black very fast. That's the key. Cash flow is king in any new startup. Don't tie up all your cash flow into things like EMR and OCTs.

Well I'd agree it's smart to try and conserve as much money as possible when initially starting up, but those extra costs are basically going to be mandatory for what I'd consider a practice I want to be a part of. So you can avoid them early on, but the start up cost is still going to end up huge, regardless of whether you buy the expensive stuff during your first year or your second year. The costs will still eventually come. And if you never get busy enough to afford an OCT and a yag then it's time to change towns!

Not to distract from the thread hijack on practice startup costs. . .

. . .but if you're worried about ophtho going forward I think you're over-reacting. Now, if you are worried about the state of healthcare and medicine in general, then there are some legitimate concerns. It's hard to know what is coming in the future with regards to things like single-payer centralized healthcare, more bureaucratic headaches like P4P B.S., etc. Still, I don't see ophtho as being any more or less likely to do well than most other surgical subspecialties. Anesthesiologists deal with CRNAs, primary care competes with NPs and PAs, etc. It's always something. Rest assured that if something like radiology is making a lot of money now, they could easily be the next target for a reimbursement cut. So do what you want to do. Except FP, because that will NEVER make any money. ;)

Well I'd agree it's smart to try and conserve as much money as possible when initially starting up, but those extra costs are basically going to be mandatory for what I'd consider a practice I want to be a part of.

But see, if you're considering a cold startup, you have to get out of the "resident" mentality and put on your "business man" hat.

When you are a resident, you are likely at a teaching hospital and you likely have access to every fancy, high tech piece of gadgetry out there. That's fun and exciting and yes, it would be nice to be part of a practice that has all of that but it's just not feasible for a cold start up.


So you can avoid them early on, but the start up cost is still going to end up huge, regardless of whether you buy the expensive stuff during your first year or your second year. The costs will still eventually come. And if you never get busy enough to afford an OCT and a yag then it's time to change towns!

Respectfully, I think that that is an unwise way of looking at it. Yes, the costs will eventually come, but the costs will come at a time when your practice is more established and not only are you more likely to be able to afford the expense, you will have the established patient population make much more efficient (and lucrative) use of your technology. You may even have some of your other equipment paid off freeing up more cash flow.

To say that you're just going to equip your cold startup with things like OCTs and EMR is like saying "I"m going to put in the Viking Range, and exotic jacuzzi in my starter home." It just makes you more house poor. When starting up cold, the key to the game is cash flow. Take little bites, my friend. Little bites. :thumbup: Starting a practice is a marathon, not a sprint.

But see, if you're considering a cold startup, you have to get out of the "resident" mentality and put on your "business man" hat.

When you are a resident, you are likely at a teaching hospital and you likely have access to every fancy, high tech piece of gadgetry out there. That's fun and exciting and yes, it would be nice to be part of a practice that has all of that but it's just not feasible for a cold start up.



Respectfully, I think that that is an unwise way of looking at it. Yes, the costs will eventually come, but the costs will come at a time when your practice is more established and not only are you more likely to be able to afford the expense, you will have the established patient population make much more efficient (and lucrative) use of your technology. You may even have some of your other equipment paid off freeing up more cash flow.

To say that you're just going to equip your cold startup with things like OCTs and EMR is like saying "I"m going to put in the Viking Range, and exotic jacuzzi in my starter home." It just makes you more house poor. When starting up cold, the key to the game is cash flow. Take little bites, my friend. Little bites. :thumbup: Starting a practice is a marathon, not a sprint.


Well I guess we'll have to agree to disagree on a lot of those points. Much of the technology does make money in the form of increasing effiency along with being directly billable.

You're going to be pretty inefficient if you have to use a contact lens to check for CSME in all of your diabetics when you could just do something that's billable (OCT, although it doesn't bill for much) instead. Likewise, you're going to want an IOL master to effeciently pre-op people for cataract surgery, and you're going to want an SLT and YAG otherwise you'll lose a large amount of potential revenue, especially from the SLT. I'll agree an EMR could wait for awhile, but I think most of us will eventually want that as well.

Saving on costs when you first start up is definitely the way to go. But all the same concerns about business and reimbursement are still going to be there as you have to keep buying and upgrading/maintaining your equipment.

And if you establish your practice with all technology needed what is the mean income/year?Just curious cause recently an ophtho friend told me that he faces reduction in his income, making around 250k a year from 350k he used to make. Is that range the usual or not?

Can you please outline where that $300000 comes from because I helped a local young ophthalmologist with a cold startup and it was a LOT less than $300000.

That $300K figure came from a major ophthalmology "throwaway" magazine.
They get their revenues from ads from suppliers and manufacturers, (so like DeBeers and their ideas about what you should spend on diamonds, the companies are only too ready to suggest what you should budget for an office.) But it is worth considering for discussion purposes.


A lot depends on how well the cash flow flows.

A conservative first year operating budget will be $160,000, and that includes nothing for compensation for the doctor. You might save $10,000 if you have not matured your malpractice, but the other costs will not change that much. Staff costs, hiring help with setting up billing, even if you process the submissions yourself, is the biggest component. If you need to lease space, much will depend on the quality and availability of medical office inventory. If you need to pay for build-out, most conservative estimates figure $75 per square foot. (Ever price a commercial-grade air conditioner?) Getting a decent contribution from the landlord is essential, if you go that way. Triple-net leases need to consider real estate taxes, building insurance and maintenance fees and utilities. Then there is equipment, some of which can be had cheaply on the used market, but some of which will have to be bought new. No, you don't need an IOL-Master to start, but a decent A-scan with Praeger shell and up-to-date software, $5000, a Tono-Pen, $2000, if you can get one used, $3000 new. Then there are the little things like credit card machines, a phone system, yellow pages ad fees, hospital staff dues, professional dues, and so on. So even if you forgo the OCT, IOL master and other "nice-to-have" items, you will still need to have enough equipment and staff with facilities to offer competitive service to patients going to your office.

A YAG laser is nice to have. I would make that a priority over an IOL master or an HRT (it is a lot cheaper, for one thing) only because you only need to have an emergency patient with an angle-closure attack once after working hours to appreciate how much of a nuisance not having one can be. I would rather buy a top-of-the line $25K perimeter with a SWAP capability and evaluate borderline glaucoma cases that way before buying an OCT, HRT or GDx (which I would get, but maybe not right away). An OCT right now will set you back $60K. Unless you are doing retina, where I think an OCT is now essential, that amounts to $1500/month, every month. Could you justify that in a general practice? Probably not during the first year.

I am sure that with a small, make-do office and very basic equipment, you could launch on less than $100K, but that requires availability of things like suitable office space that doesn't need construction and enough patient flow to generate income so you can buy the extra things you will need without too much delay.

You're going to be pretty inefficient if you have to use a contact lens to check for CSME in all of your diabetics when you could just do something that's billable (OCT, although it doesn't bill for much) instead.


Just a minor point, but CSME is a clinical diagnosis made by ophthalmoscopy. The diagnosis is not made by FA nor is it made by OCT.

That $300K figure came from a major ophthalmology "throwaway" magazine.
They get their revenues from ads from suppliers and manufacturers, (so like DeBeers and their ideas about what you should spend on diamonds, the companies are only too ready to suggest what you should budget for an office.) But it is worth considering for discussion purposes.

Yes, those types of journals drive me crazy. Nothing more than advertisers trying to convince you that unless your practice has every piece of equipment that their company makes then you will go bust. :rolleyes:


A lot depends on how well the cash flow flows.

A conservative first year operating budget will be $160,000, and that includes nothing for compensation for the doctor.

You should always include as part of your business plan 2 years of a small salary for the owner doctor. I mean, you have to eat, right? Even if it's only $30000 per year, budget at least that.


You might save $10,000 if you have not matured your malpractice, but the other costs will not change that much. Staff costs, hiring help with setting up billing, even if you process the submissions yourself, is the biggest component.

Unfortunately, staff costs and staff issues are the biggest headache in any business, not just in health care.


If you need to lease space, much will depend on the quality and availability of medical office inventory. If you need to pay for build-out, most conservative estimates figure $75 per square foot. (Ever price a commercial-grade air conditioner?)

I practice in CT, which is not known for being a haven of cheap real estate and $75 per square foot is far far too high. We are in the process of completing a huge move of our office to a much fancier, larger, high end location and our buildout was under $40 per square foot. As far as a commercial grade air conditioner, you should not be putting things like that into a building. That is for the owner to do. You don't spend a bunch of money upgrading THEIR building. If you need to modify the interior space to suit your needs then you may have some expenses for duct work and plumbing but the actual unit itself should always be part of that scenario. To be honest with you, I've never heard of anyone paying for those types of capital improvements to a building that isn't owner occupied.


Getting a decent contribution from the landlord is essential, if you go that way. Triple-net leases need to consider real estate taxes, building insurance and maintenance fees and utilities.

All true


Then there is equipment, some of which can be had cheaply on the used market, but some of which will have to be bought new. No, you don't need an IOL-Master to start, but a decent A-scan with Praeger shell and up-to-date software, $5000, a Tono-Pen, $2000, if you can get one used, $3000 new. Then there are the little things like credit card machines, a phone system, yellow pages ad fees, hospital staff dues, professional dues, and so on. So even if you forgo the OCT, IOL master and other "nice-to-have" items, you will still need to have enough equipment and staff with facilities to offer competitive service to patients going to your office.

This is all basically true but patients aren't going to notice the difference between an IOL master and an A-scan with Prager shell. So again, when you're starting out, cash flow is key. Don't blow a bunch of money an OCT or YAG that is going to sit idle most of the time during the start up phases. Most start up businesses (of all types) fail because they are undercapitalized to get themselves through the initial lean period of a start up. Another way to look at that is to say that they are overextended. Don't contribute to that over extension by spending tens of thousands of dollars on equipment that will be rarely used initially. Unless you are 100% sure that you are going to be heavily booked right from the word "go" then it's best to take it slow and easy.


A YAG laser is nice to have. I would make that a priority over an IOL master or an HRT (it is a lot cheaper, for one thing) only because you only need to have an emergency patient with an angle-closure attack once after working hours to appreciate how much of a nuisance not having one can be. I would rather buy a top-of-the line $25K perimeter with a SWAP capability and evaluate borderline glaucoma cases that way before buying an OCT, HRT or GDx (which I would get, but maybe not right away).

A good visual field machine is a wise investment. In my area, visual field testing pays approximately $100 and there are many many diagnoses in which visual fields are indicated. That is the type of machine that can be used many times a day. The issue of an angle closure patient is legitimate but how often does that occur? You are likely better off saving the money and just having an arrangement with some friendly competition that is outside of your patient draw area and just making an arrangement to use theirs for a per use fee rather than putting one in a cold start up.


An OCT right now will set you back $60K. Unless you are doing retina, where I think an OCT is now essential, that amounts to $1500/month, every month. Could you justify that in a general practice? Probably not during the first year.


See, I thought they were down to $40000. If it's $60000, that's even MORE reason to forego it.


I am sure that with a small, make-do office and very basic equipment, you could launch on less than $100K, but that requires availability of things like suitable office space that doesn't need construction and enough patient flow to generate income so you can buy the extra things you will need without too much delay.

Suitable office space for a cold start up may just be a waiting room, one exam room, one "other" room for photography and visual fields and an office for the doctor. Even an office for the doctor may be unneeded if the exam room is large enough. Right now, my desk is in my main exam room. Once we complete our move, I'll have a separate office but for now, it works just fine.

Again, people desirous of starting cold need to get out of "resident" mode and into "business man" mode. I agree, it's nice to have all the fancy high tech gadgetry and instrumentation but it rarely adds anything to a cold start up.

I also think that a cold start up is an often times overlooked option for new doctors. Far too many people try to do the "partnership" route and end up just getting taken advantage of by tired old doctors. I tried that many times myself. Been there, done that. Talking to the physicians of all disciplines that I refer to who are of my age group, they all report similar experiences in medicince as I had in optometry. On some level, that made me feel better and others worse.

I understand that many people graduating school are in very large amounts of debt and maybe hesitant to jump into the deep end of a cold start up. But if planned for reasonably well, it's a very very viable option for people and it shouldn't be overlooked.