2024 comprehensive numbers

[mjohnsonets]

Edit to post: 2024 comprehensive numbers
Found more fellows, total 326 now, when I went back to look for specific fellowship numbers.

Not sure if everyone is interested in these kinds of "fun facts" but thought it was interesting and wanted to share.

Every year we try to find every resident that goes to fellowship, which type, etc., just a general part of my job. For 2024 residents, we identified 493 total (this is out of 498 total for 2020 match, military residents are harder to find). We identified 307326 that went into fellowship. We likely missed some too because some fellowships are less visible.

Just using our numbers that's 62% 65% that went to fellowship.

With 186 167 residents not going to fellowship, that's an average of 3.72 3.34 new comprehensive ophthalmologists per state.

Again, we would miscount to the downside too so these are the minimum numbers. As far as we can tell this is the highest proportion who went to fellowship.

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[linevasel]

MsJohnsonets

Any breakdown of the fellowship specialties
Be interesting to see what peopel
are gravitating towards. I'm going to guess.. not uveitis...

 

[PhospholipaseA2]

Very fascinating. As I near the end of my PGY3 year, I feel compelled to do fellowship. One extra year in the grand scheme of my career won’t affect earnings that drastically. However, the extra skills I can pick up both clinically and surgically can pay dividends for patients and diversity of practice for the next two to three decades.

 

[RetinaDude]

Doing a retina fellowship was one of the best career decisions I’ve made.

There’s huge demand for glaucoma and peds, in particular, but almost all sub specialties are needed

 

[Gonio5]

Some fellowship trained ophthalmologists end up doing a lot of comprehensive ophthalmology, especially glaucoma or cornea trained but some oculoplastics or neuro trained. Although there are exceptions, retina and peds tend to stick purely to their sub-specialty.

 

[mjohnsonets]

MsJohnsonets

Any breakdown of the fellowship specialties
Be interesting to see what peopel
are gravitating towards. I'm going to guess.. not uveitis...

Went back to update these numbers and found some fellows not pulled into my original count. Number is 326 fellows now, here's the numbers by fellowship:

100 surgical retina
8 uveitis (one told us going to do surgical retina after)
14 refractive (17 if you include the anterior segment fellows like Vance Thompson/SW Eye)
18 peds
28 oculoplastic (26 out of 27 ASOPRS, missing a couple here because ASOPRS usually fills and multiple 1 year fellows)
3 ocular oncology
4 neuro-ophthalmology (ophthalmology trained only)
12 medical retina with 1 saying they're going to do surgical retina afterward
65 glaucoma
71 cornea

As noted, in an above post, many anterior segment fellows do comp, however, not as expansive as a typical comp doc. The need for comp to go to more rural areas and take care of a wide scope of patients is growing quickly year over year.

 

[linevasel]

I now understand why we have a Glaucoma shortage... and can't recruit plastics....

 

[RetinaDude]

From talking with glaucoma colleagues, they all go into glaucoma fellowships because they enjoy the pathology and patient interactions. When they get into the private world, the reality of paying the bills, and earning an income, hits them. Most glaucoma fellowship trained docs do glaucoma and a lot of cataracts. Glaucoma is time consuming and doesn’t pay well compared to what they can do with cataract volume……and there’s a big need for good cataract surgeons in many communities. As cataract volume goes up, the glaucoma volume usually starts to go down

 

[eyeeye_captain]

Interesting. Pretty sure the number of fellows went up for the COVID classes since their residency surgical volume was down, guess the desire for fellowship is staying up to some extent.

We all know glaucoma is a huge need. I agree that it’s tougher to be productive seeing IOP checks instead of churning through cataract evals, but with OCT/HVF and a level 4 once or twice a year they can do ok. They won’t be doing as many multifocal or EDOF lenses, but torics still make sense in significant glaucoma, and they have a legitimate reason to do more MIGS. The 90 day global is a real pain, but it’s pretty rare that I see anybody babysitting a trab, and tubes aren’t as rough (usually).

I feel like as a specialty we’d get a lot more bang for our buck if some of those 71 cornea fellows did a hybrid glaucoma/cornea/complex anterior fellowship. I see very few grafts in the community, and I suspect most are realistically just gaining/honing phaco skills.

I figured the neuro numbers would be bad, but thank you to those 4 folks.

The one year “plastics”/aesthetics fellowships seem to train salespeople instead of surgeons, but to each their own.

Pretty much every subspecialty is lacking if you’re outside of a decent size city, unfortunately.

 

[JinxADC&MD]

Interesting. Pretty sure the number of fellows went up for the COVID classes since their residency surgical volume was down, guess the desire for fellowship is staying up to some extent.

We all know glaucoma is a huge need. I agree that it’s tougher to be productive seeing IOP checks instead of churning through cataract evals, but with OCT/HVF and a level 4 once or twice a year they can do ok. They won’t be doing as many multifocal or EDOF lenses, but torics still make sense in significant glaucoma, and they have a legitimate reason to do more MIGS. The 90 day global is a real pain, but it’s pretty rare that I see anybody babysitting a trab, and tubes aren’t as rough (usually).

I feel like as a specialty we’d get a lot more bang for our buck if some of those 71 cornea fellows did a hybrid glaucoma/cornea/complex anterior fellowship. I see very few grafts in the community, and I suspect most are realistically just gaining/honing phaco skills.

I figured the neuro numbers would be bad, but thank you to those 4 folks.

The one year “plastics”/aesthetics fellowships seem to train salespeople instead of surgeons, but to each their own.

Pretty much every subspecialty is lacking if you’re outside of a decent size city, unfortunately.

Doing a K fellowship to hone in on cataract surgery would usually be a pretty poor use of your time, my K fellowship is on the higher end and I'll only be doing 200 phacos. Either doing an anterior segment where you can do >1000 or just finding a PE attending job that'll drown you with you volume would be a better use of your time imo.

 

[eyeeye_captain]

Doing a K fellowship to hone in on cataract surgery would usually be a pretty poor use of your time, my K fellowship is on the higher end and I'll only be doing 200 phacos. Either doing an anterior segment where you can do >1000 or just finding a PE attending job that'll drown you with you volume would be a better use of your time imo.

I agree with you. I’m honestly curious, what do you think a K fellowship really gives you if you go to the community if it’s not extra cataract/lens/refractive skills? At my residency and fellowship it didn’t seem like the extra training in transplants/SJS/onc etc. really translated to practices outside tertiary referral centers. As a retina person, I legitimately don't know.

 

[mjohnsonets]

From talking with glaucoma colleagues, they all go into glaucoma fellowships because they enjoy the pathology and patient interactions. When they get into the private world, the reality of paying the bills, and earning an income, hits them. Most glaucoma fellowship trained docs do glaucoma and a lot of cataracts. Glaucoma is time consuming and doesn’t pay well compared to what they can do with cataract volume……and there’s a big need for good cataract surgeons in many communities. As cataract volume goes up, the glaucoma volume usually starts to go down

Interesting. Pretty sure the number of fellows went up for the COVID classes since their residency surgical volume was down, guess the desire for fellowship is staying up to some extent.

We all know glaucoma is a huge need. I agree that it’s tougher to be productive seeing IOP checks instead of churning through cataract evals, but with OCT/HVF and a level 4 once or twice a year they can do ok. They won’t be doing as many multifocal or EDOF lenses, but torics still make sense in significant glaucoma, and they have a legitimate reason to do more MIGS. The 90 day global is a real pain, but it’s pretty rare that I see anybody babysitting a trab, and tubes aren’t as rough (usually).

I feel like as a specialty we’d get a lot more bang for our buck if some of those 71 cornea fellows did a hybrid glaucoma/cornea/complex anterior fellowship. I see very few grafts in the community, and I suspect most are realistically just gaining/honing phaco skills.

I figured the neuro numbers would be bad, but thank you to those 4 folks.

The one year “plastics”/aesthetics fellowships seem to train salespeople instead of surgeons, but to each their own.

Pretty much every subspecialty is lacking if you’re outside of a decent size city, unfortunately.

Both points made here align with what I'm hearing and interviewing.

The issue with glaucoma for young glaucoma docs seems to be call related and not getting covered up long term with glaucoma. At least these are their stated fears. From my perspective, it probably isn't fun watching your refractive colleague make more money, have happier patients, and not having to chase any real emergencies. The incentive structures all point towards cataracts and I know quite a few glaucoma surgeons in the first 5 years of practice that have given up doing tubes and trabs. Every year there are even 1 or 2 fellows who do not want to do them coming out of fellowship.

As for cornea fellows, there are quite a few every year that tell me they did it mostly for more refractive training. It also does help with getting into saturated metro areas. I have been encouraging residents wanting more refractive focus to do one of the private practice fellowship for a more real world practice experience and higher volumes.

As a note on neuro, there are some neuro fellows who are neurology trained. We don't tend to track and chase those as much because they're harder to put into private practices.

 

[JinxADC&MD]

I agree with you. I’m honestly curious, what do you think a K fellowship really gives you if you go to the community if it’s not extra cataract/lens/refractive skills? At my residency and fellowship it didn’t seem like the extra training in transplants/SJS/onc etc. really translated to practices outside tertiary referral centers. As a retina person, I legitimately don't know.

Great question, I wondered the same thing and actually started a thread last year asking what is the point of a K fellowship lol. I'm going to a K fellowship that has a heavy refractive component to it because that's what interests me the most. I fully understand that in PP, you don't see the same level of pathology as an academic institution but I think i would become so bored if all I did was cataract surgery. My comp attendings (in a major city) are seriously considering retiring early cause they are tired of seeing cataracts and blepharitis only. If I can at least throw in some DSAEK, PKPs, and refractive procedures into the mix that would provide me more long-term satisfaction.

 

[Slide]

This thread is a bit depressing to hear because it's making me worried for the future - there's only so many cataracts to go around and these more serious glaucoma and cornea issues aren't going away by themselves. It's extremely difficult to find a cornea specialist that handles the complex corneal pathology that gets referred out typically.

 

[TheLesPaul]

incentives are going to incentivize. if we want more PK or trab surgeons we will have to increase the reimbursement for those procedures either on a payor level or practice level

 

[RetinaDude]

This thread is a bit depressing to hear because it's making me worried for the future - there's only so many cataracts to go around and these more serious glaucoma and cornea issues aren't going away by themselves. It's extremely difficult to find a cornea specialist that handles the complex corneal pathology that gets referred out typically.

The 65 and older population is one of the fastest growing and will increase the need for our services. Unfortunately, I read some place else that ophthalmology will not be able to keep up since there are more docs retiring than finishing residency. This means even more available cataracts and fewer docs to take care of them. In turn, as these docs are flooded with cataracts, even fewer will want to take care of complex corneal or glaucoma pathology. It is a vicious cycle.

 

[eyeeye_captain]

incentives are going to incentivize. if we want more PK or trab surgeons we will have to increase the reimbursement for those procedures either on a payor level or practice level

I looked up the CMS data for a trab, tube, DSAEK, PK, RD repair, and routine cataract.

Of those, the best reimbursement was the RD by a hair, and that’s just short of 2.5x a cataract. The worst was a trab at 2x, and that’s going to easily have the worst global period.

Considering we keep getting cuts, it’s going to have to be the practices subsidizing the care to some extent. If young glaucoma docs are giving up incisional surgery and want 4 day weeks like Matt has said previously, things are only going to get worse.

 

[mjohnsonets]

The 65 and older population is one of the fastest growing and will increase the need for our services. Unfortunately, I read some place else that ophthalmology will not be able to keep up since there are more docs retiring than finishing residency. This means even more available cataracts and fewer docs to take care of them. In turn, as these docs are flooded with cataracts, even fewer will want to take care of complex corneal or glaucoma pathology. It is a vicious cycle.

Managing the Upcoming Provider Shortage

www.reviewofophthalmology.com

John Pinto estimated there were about 550 ophthalmologists retiring every year as of 2022, the number is likely accelerating. We have added a couple new residencies and the ITO program is now consistently making new BE ophthalmologists each year. Issue is though that an experience doc is likely to see more patients and do more surgery than a new one so it's not necessarily a 1:1 replacement when it happens.

As time goes on it will be necessary to co-manage routine cases. It's an efficient model, necessary in rural areas, and helpful in urban areas for keeping practices reasonably profitable.

 

[percyeye]

Managing the Upcoming Provider Shortage

www.reviewofophthalmology.com

John Pinto estimated there were about 550 ophthalmologists retiring every year as of 2022, the number is likely accelerating. We have added a couple new residencies and the ITO program is now consistently making new BE ophthalmologists each year. Issue is though that an experience doc is likely to see more patients and do more surgery than a new one so it's not necessarily a 1:1 replacement when it happens.

As time goes on it will be necessary to co-manage routine cases. It's an efficient model, necessary in rural areas, and helpful in urban areas for keeping practices reasonably profitable.

I'd say the number graduating is a problem, but also distribution. If 60% of graduates go to the same 3% areas of the country that also causes a major shortage.

 

[mjohnsonets]

I'd say the number graduating is a problem, but also distribution. If 60% of graduates go to the same 3% areas of the country that also causes a major shortage.

I feel eventually market forces will help this a little. It will be so much money, lifestyle, and autonomy that some will start to actively make the decision to go outside metros. PE groups seem to have calmed down buying rural (hard to recruit to and learned the hard way) and as they gain market share in metro areas, this will be another nudge for more entrepreneurial docs to head rural.

I'm not saying this will cure the problem by any means but combining it with a heavily co-managed model could save a few more years.

 

[eyeeye_captain]

That article may hurt some young folks’ feelings, but it’s true that the focus on work/life balance hurts the incoming/outgoing balance. I’m not going to hate on anybody for prioritizing being a person instead of a doctor, but it does change the math when the pendulum swings from the days of “working too hard” to going part time right out of the gate.

(The irony is not lost on me that the chair of one of the most laid back residencies in the country is the one in the article bemoaning this, too. I would have expected Stein or UTSW or something.)

The theoretical answer is to just train more people. I suspect every program I was with from medical school through fellowship could add a resident - they all talked about it. The demand is definitely there when you look at the Match numbers.

 

[eyeeye_captain]

The rural problem kind of needs to be defined. How small and how far from a “city” are we talking? How big is the city?

When you look at the numbers, the top 10 metros in America have larger populations than around 30 states. Metro NYC has ~34x the population of Wyoming. We all agree there is a distribution problem, but at least some of it makes sense.

For reference, I looked at my hometown’s situation a few months back when my mother gave my contact info to a retina doc with a satellite in the area to try to bring me back home. I don’t think most would call it desirable but it has a multi-county catchment of maybe up to 300k, nice outdoors stuff, and the closest metro is a little under 1.5 hours to downtown/an airport with 500k people. As far as I can tell/Google, that 300k is being managed by 4 or 5 comp docs and 2 or 3 visiting retina docs with no other subspecialty care until you hit the “city” or another one maybe an hour farther away. For a comp doc who’s from the region, that seems like a possible gold mine.

Note how I said from the region, and this ties back to the population stuff. There are exceptions, but many people practice near family or where they trained or both. Nothing against them, but places like West Virginia and Mississippi probably aren’t having an easy time recruiting, even in their bigger locales.

 

[linevasel]

That article reads like it was ghost written by Optometry... That whole, "physicians should do what only physicians can do" is how every scope battle starts and ends.

Before you know it, the physician extenders scope expands and physician reimbursement drops, while med tuition and student loan burden is ever increasing.

PAs should do injections. Retina docs should do vitrectomies and fluoresceins. I am speechless.

 

[eyeeye_captain]

I originally skimmed the first part of the article and thought I was done - clearly I missed a lot at the bottom. Jeez, the last half is awful. So sorry about that hate mail you used to get Dr. Grayson. After selling to PE in 2017, you gave us gems like this:

- “Their time should be spent fixing detachments, doing vitrectomies, analyzing fluoresceins.” Just banging out nothing but FAs and detachment surgeries? Tell me you maybe sorta kinda learned some retina in the 90s without having to tell me. That expensive PA to just do my injections is going to quit within a month while only saving me maybe 15 productive minutes a day in clinic.
- “My optometrists see the patients first, and they’re top-notch. We don’t miss stuff. I’m proud of our model. I think we do a great job.”
If you don't take a temperature, you can't find a fever. (Love getting to use a House of God quote on willful ignorance in a PE mill.)
- “In our practice model, the ophthalmologist actually has minimal interaction with patients, aside from meeting them and saying, ‘Hi, do you have any questions? Let’s go do your cataract.’” Hope you never have a complication after giving the patient so many warm and fuzzies, and that your army of overworked ODs didn’t somehow miss something preop. Non-surgeons understandably don’t think like surgeons. I’d bet a dollar they’re taught to think like salespeople and get more premium lenses.
- “I can go in, see 100 patients, then go to the OR and do 60 cases, and still be done at a reasonable hour.” Maybe, but that sounds awful even for a workaholic like me. I doubt you have the time to have your OD show you that OCT of a preop ERM like you claim.
- “In fact, if you try to train more residents, you’re doing them a disservice, because they can’t be trained as well today… As a result, there’s been a decline in patients going to clinics, which means residents don’t get to do as many cases during their training. I can see the difference in the new residents coming out.“ If you’re telling me you got better training 30+ years ago, I’m going to strongly disagree considering how the field has rapidly changed. This came out in 2022, with the COVID classes, so nice cherry picking. Everywhere I’ve heard of has been getting higher numbers over the years as techniques get more efficient.
- “In this climate we still need academic centers to manage the special, unusual cases, but not for routine care,” Translation: residents can see my train wrecks so I can keep churning.

Specialists should only do their specialty and manage disasters and surgical patients. Yeah, uh, that actually makes you significantly less efficient. Also, outside of high volume cataract and some plastics, surgery loses you money. In retina, a whole lot. I will, however, agree that if we pigeonhole specialists into these cases, access to care goes up, which is admirable. Painful, but admirable, although I highly doubt this guy is doing much incisional glaucoma.

How laughable is the suggestion that we should just start sending people to other countries to get their care?

I’ll stay away from anecdotes about our OD colleagues who absolutely provide value, but outside of the basic basics they should probably have a quick trigger to refer.

 

[RetinaDude]

Great responses!

 

[Slide]

Managing the Upcoming Provider Shortage

www.reviewofophthalmology.com

John Pinto estimated there were about 550 ophthalmologists retiring every year as of 2022, the number is likely accelerating. We have added a couple new residencies and the ITO program is now consistently making new BE ophthalmologists each year. Issue is though that an experience doc is likely to see more patients and do more surgery than a new one so it's not necessarily a 1:1 replacement when it happens.

As time goes on it will be necessary to co-manage routine cases. It's an efficient model, necessary in rural areas, and helpful in urban areas for keeping practices reasonably profitable.

Good god this article is horrible. I'm heartened that at someone of us can quickly sniff out the BS in these articles. But not surprising since I've seen more and more articles from our field leaders tout the virtues of PE despite being captured by them. Dr. Grayson sounds like your typical boomer physician who still practices in a 90s/early 2000s mindset, claims to be a god-like surgeon but does stuff like implant a MF IOL in patient who has geographic atrophy and then dumps it on someone else while refusing to refund the IOL premium.