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

 

[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.

 

[Bgladney]

The article leaves out how many residents remain with their program after training.

 

[mjohnsonets]

Training wise the numbers today are way better than they were back "in the day". I'd say the idea that training was better back in the day is somewhat pervasive among 55+yo docs. I think the amount of time they worked was more but surgical volumes were much less. There are a couple residencies where every year someone is getting over 400 cataracts in training.

"Rural" is a subjective term. Certainly, hip rural places like Asheville get plenty of attention. I mean more the non-hip areas with lots of geriatric patients - the prime patient age for ophthalmology. It's clear to me rural can be recruited to as long as it's cool rural, not just rural. I will say it is still more of a challenge to get rural due to ophthalmologists tending to have professional level partners as well. I still think some of this can be solved with better incentives and let efficient businesses figure out how to make money treating there.

 

[eyeeye_captain]

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.

Sadly I know I’m not allowed to quote Sgt. Hartman from FMJ’s common courtesy line in regards to him (NSFW if Googling).

I guess the model works if you’ve already gotten your payout, want to give PE 20% of your collections, and just want patients to be seen with minimal interest in the quality of care. I don’t see how you could maintain sanity as an associate with no path to partnership. I suspect the 4.5 day weeks of 9-5 is a fib.

The math doesn’t even math - that practice has 19 cataract surgeons and 27 ODs. Unless they’re getting serious referral volume, there’s no way that ratio generates 40+ cataracts per doc weekly (unless the formula is just see lens, remove lens). If their associate is doing top percentile cataract volume (1600/yr), something seems off.

The leadership voice on PE drives me up the wall. Since you’re in academics, I hope you’re sounding the alarm for your trainees because I’ve been getting horribly bad talking points from residents/fellows I meet at conferences.

 

[eyeeye_captain]

Training wise the numbers today are way better than they were back "in the day". I'd say the idea that training was better back in the day is somewhat pervasive among 55+yo docs. I think the amount of time they worked was more but surgical volumes were much less. There are a couple residencies where every year someone is getting over 400 cataracts in training.

"Rural" is a subjective term. Certainly, hip rural places like Asheville get plenty of attention. I mean more the non-hip areas with lots of geriatric patients - the prime patient age for ophthalmology. It's clear to me rural can be recruited to as long as it's cool rural, not just rural. I will say it is still more of a challenge to get rural due to ophthalmologists tending to have professional level partners as well. I still think some of this can be solved with better incentives and let efficient businesses figure out how to make money treating there.

When I was coming out, 200 was kind of the “wow” number that got people excited. I have no clue what that number was in the 90s, but I can guarantee it was lower. Also, the reason the new grads “can’t manage complications as well” is because they have fewer complications than the old timers because techniques and equipment are better. That’s not even taking into account the fewer cases they’ve done compared to someone 30 years in. I do feel that residency is often hyper focused on cataract surgery, but considering it’s what the majority of graduates will do a ton of, it makes sense.

I don’t doubt that the demand leans toward destination locations of 100k with a larger catchment of ~400k like Asheville. Almost everyone is going to start out at at least age 30 having had to delay gratification for a decade or more - you presumably want some local perks. For less desirable places, the perk may be that somebody or their spouse wants to be close to family. Sometimes it’s niche outdoor stuff like the current ad for Billings, MT.

If you don’t train in Danville or Shreveport or Morgantown or Jackson, you’re probably used to at least something lifestyle-wise outside of work for 4+ years. At least the two new programs at Dartmouth and New Mexico have some outdoorsy stuff, but are otherwise similarly non-cosmopolitan. My experience is that small towners learn to like city amenities more than city folks learn to like the country, at least for full time living. I think the partner angle is real but got a little easier post-COVID with how much has gone remote, although that assumes a partner outside of medicine.

If we hit a full on recession, I could see more new grads or unhappy attendings move farther out than the 1 to maybe 2 hours from a metro to pick up business.

 

[mjohnsonets]

My experience is that small towners learn to like city amenities more than city folks learn to like the country, at least for full time living.

This is very true. I tell many of my rural clients struggling to recruit that from a statistics standpoint, the opportunity is just down. Most people will not live in an area smaller than where they grew up, unless it's niched like Montana or Asheville. Like you said, the transition from rural to urban happens way more often than the transition from urban to rural. A little over half the country lives in the 52 largest metro areas, for reference, Tucson is currently 52nd. Translate that to where graduating ophthalmologists grew up and if your area is smaller than those 52 metros, you are likely dealing with at most half of them from the start. Then on top of that, most are going to where they have some sort of connection.

 

[Slide]

Sadly I know I’m not allowed to quote Sgt. Hartman from FMJ’s common courtesy line in regards to him (NSFW if Googling).

I guess the model works if you’ve already gotten your payout, want to give PE 20% of your collections, and just want patients to be seen with minimal interest in the quality of care. I don’t see how you could maintain sanity as an associate with no path to partnership. I suspect the 4.5 day weeks of 9-5 is a fib.

The math doesn’t even math - that practice has 19 cataract surgeons and 27 ODs. Unless they’re getting serious referral volume, there’s no way that ratio generates 40+ cataracts per doc weekly (unless the formula is just see lens, remove lens). If their associate is doing top percentile cataract volume (1600/yr), something seems off.

The leadership voice on PE drives me up the wall. Since you’re in academics, I hope you’re sounding the alarm for your trainees because I’ve been getting horribly bad talking points from residents/fellows I meet at conferences.

Oh yeah they absolutely know how I feel and I share experiences of friends and colleagues that have been run raw by PE. If I weren't in academics I'd seriously consider my membership with at least ASRS due to how much they are PE-captured at this point. I get how much the grind leads to burnout and reimbursements have been constantly dropping but this isn't the way.

 

[eyeeye_captain]

A little over half the country lives in the 52 largest metro areas, for reference, Tucson is currently 52nd.

Interesting stat with Tucson around 1.1M. Do you have a ballpark percentage of your clients that fall outside the top 52?

Thinking back on everyone I trained with from medical school through fellowship, I only know 3 in a metro under 200k. All 3 fall under family or outdoors.

If I weren't in academics I'd seriously consider my membership with at least ASRS due to how much they are PE-captured at this point.

Yeah, those meetings are getting pretty annoying with such a vocal minority holding the podium hostage. Unfortunately a lot of new grads are going to have to keep playing ball if they want to be in certain markets.

 

[mjohnsonets]

Interesting stat with Tucson around 1.1M. Do you have a ballpark percentage of your clients that fall outside the top 52?

I'd say about 50% are outside of these metros. If you include close, as in 1 hour of them, it probably drops to 30-40% outside these metros.

I think the larger metros will start to really feel like they have limited job options if M&A starts to pick back up. From a recruitment standpoint, I've told PE groups that buying up practices in rural areas might be great from a cash flow/earnings perspective, but it becomes extremely hard and costly to recruit to. It seems like the rural buying has been parsed back in favor of expanding within established metros and new ones. If I was a PE group, this is what I would do because l know people have to be there for different reasons, which will keep a steady stream of candidates.

 

[percyeye]

Being an Optometrist in the rural Midwest and trying to get patients in to see any sort of specialist whether it be Glaucoma, Uveitis, Peds, Cornea etc has become unbearable even in the mid-sized cities hours away taking 4-6 months. Neuro-Ophthalmology might as well put up a clinic on the moon, and I know for them it is like that everywhere in the country. Retina overall is still somewhat hanging in there on referral time. But I'm thinking of pro-creating more children just to make sure at least one of them can go into Glaucoma and then come back to this area.

 

[eyeeye_captain]

I'd say about 50% are outside of these metros. If you include close, as in 1 hour of them, it probably drops to 30-40% outside these metros.

Any difference in rates of preference for comp versus specialist? I’ve seen plenty of ads for “comp with a special interest in xyz”, so that kind of muddies the waters.

What are the new comp grads saying they’re comfortable doing? I know a lot is personal/program dependent. I’d guess phaco/MIGS/premiums are mostly covered and some are ok with injections. Any lid work? Any interest in covering hospital/trauma call?

 

[mjohnsonets]

Any difference in rates of preference for comp versus specialist? I’ve seen plenty of ads for “comp with a special interest in xyz”, so that kind of muddies the waters.

What are the new comp grads saying they’re comfortable doing? I know a lot is personal/program dependent. I’d guess phaco/MIGS/premiums are mostly covered and some are ok with injections. Any lid work? Any interest in covering hospital/trauma call?

I'd say outside of metros, practices are more likely to accept what they can get. I know for me, I don't want to see someone whose cornea/glaucoma not apply to a comprehensive position because it's too comprehensive. Having someone doing some comprehensive here and maybe not doing additional injections in the practice is better than waiting for someone to do everything you want.

New grads are generally telling me cataracts (varying levels of premium exp in training, all want continued mentorship), MIGS, medical retina including injections, willing to do lids to fill time. I've put these in order of average interest. Very few willing to see peds and I'd say there is a specific, unsolicited request for no hospital call with 25% of the residents I interview. This means there are likely many more who feel that way and just don't say it. For most areas it really comes down to what the local market does. For instance if you're going to Chicago, you're probably going to have some hospital call. Reno, you're going to. However, if you want Vegas, it's basically non-existent there, they send patients to LA. LA, call goes to academic centers, same in San Diego.

 

[RetinaDude]

Peds ophthalmology must really be hurting. There’s already a shortage and few people want to do the fellowships anymore. For the most part, compared to retina and/or a premium cataract practice, the reimbursement for peds is low. Also, the possible liability of taking care of kids, as a surgical specialist, is higher when you consider some states let them sue all the way through the age of 18.

 

[eyeeye_captain]

Agree on peds, tough market. If they get stuck doing ROP it’s even worse. I had a NICU reach out when I started at my current spot and that was a polite but hard no in response.

I’m surprised only 25% are explicitly saying no hospital call - I agree the number has to be substantially higher. Maybe hospital groups in Chicago and Reno should try to hire a unicorn like Dr. Czyz: Article

Bless the soul of anyone who has the strength to make hospital/trauma call their entire job. I bet there’s a market for it. The ophthalmology groups would probably chip in to make it happen.

 

[mjohnsonets]

Agree on peds, tough market. If they get stuck doing ROP it’s even worse. I had a NICU reach out when I started at my current spot and that was a polite but hard no in response.

I’m surprised only 25% are explicitly saying no hospital call - I agree the number has to be substantially higher. Maybe hospital groups in Chicago and Reno should try to hire a unicorn like Dr. Czyz: Article

Bless the soul of anyone who has the strength to make hospital/trauma call their entire job. I bet there’s a market for it. The ophthalmology groups would probably chip in to make it happen.

It's getting substantially harder to recruit peds into private practices, most are going academic or hospital. The liability to 18 is bad, but a lot of people tell me it's some of the medicaid parents that make it a real pain to practice peds. Low reimbursement/pay obviously top of the list though.

The hospital groups are losing some power to do have call due to the low numbers of doctors. Like I said, it's mostly regional. With such a patchwork of laws, regs, and standards, I gave up trying to make sense of it years ago. I can say in the 10 years I've been doing this, there are many practices that used to take hospital call and have been able to get off of it, so it seems this trend is only moving in one direction. I know there are many more lurkers on SDN, so I do want to say that in private practice, I've never had a private practice doc who had to take hospital call say it actually made a dent in their lifestyle. I don't know everyone, but for the most part (outside of retina), it seems like middle of the night patients might happen once every other year. I've always been surprised by that. Otherwise, a quick phone call, and they're on the schedule next day. If you're just starting out, hospital call is a good way to build your practice faster.

There are some unique locations like Eugene, OR where the practices share call for everyone, hospitals and practices. The docs there end up on call ~2 weeks/year, and it's somewhat busy I'm told. However, that 2 weeks is the only call you have, whether it's for your personal practice or hospital. For me personally, this kind of system sounds exciting and balanced.

 

[TheLesPaul]

It's getting substantially harder to recruit peds into private practices, most are going academic or hospital. The liability to 18 is bad, but a lot of people tell me it's some of the medicaid parents that make it a real pain to practice peds. Low reimbursement/pay obviously top of the list though.

The hospital groups are losing some power to do have call due to the low numbers of doctors. Like I said, it's mostly regional. With such a patchwork of laws, regs, and standards, I gave up trying to make sense of it years ago. I can say in the 10 years I've been doing this, there are many practices that used to take hospital call and have been able to get off of it, so it seems this trend is only moving in one direction. I know there are many more lurkers on SDN, so I do want to say that in private practice, I've never had a private practice doc who had to take hospital call say it actually made a dent in their lifestyle. I don't know everyone, but for the most part (outside of retina), it seems like middle of the night patients might happen once every other year. I've always been surprised by that. Otherwise, a quick phone call, and they're on the schedule next day. If you're just starting out, hospital call is a good way to build your practice faster.

There are some unique locations like Eugene, OR where the practices share call for everyone, hospitals and practices. The docs there end up on call ~2 weeks/year, and it's somewhat busy I'm told. However, that 2 weeks is the only call you have, whether it's for your personal practice or hospital. For me personally, this kind of system sounds exciting and balanced.

I'm oculoplastics and hospital call is definitely a burden. I take a week at a time. There is no other oculoplastic surgeon in my conglomerate hospital chain despite being in a busy NYC-adjacent area. As such, when a patient presents to a hospital to which I have no connection other than the fact that it was purchased by the mothership for which I am on staff, it is transferred to me. This includes general ophthalmic conditions when I am on call, or any oculoplastic issue even when I am not on call.

As it is private practice I have some say in how and when I see these or whether to send to my clinic but it is definitely a burden. Middle of the night patients happen commonly. We do get paid (not enough) and I bite bullet and do it because who else will? But I can see getting burnt out of it after some time.

There is a "private practice" coverage system that is available amongst the community docs but #1 they are not going to resuture my dehisced blephs nor will I inject their endophthalmitic eyes, #2 I have a concierge practice, I don't want my patients farmed out to someone else.

 

[RetinaDude]

I get emails from recruiters (mostly locums) trying to recruit for hospital call coverage because Level One trauma centers have to have all surgical specialties covered (ophthalmology included). Many offer schedules of seven straight days of 24 hour call coverage. I cannot imagine doing that at a regional center where everything from the surrounding area is referred to you and all the local ophthalmologists are not part of the coverage.
Plus, no residents to help with the care. Seems it could create chaos in a busy clinic schedule.
Our community has call set up where it is shared among the general ophthalmologists, and is paid. It’s mostly younger ophthalmologists since the local groups usually let older docs get out of call once they stop operating and/or reach a certain age. We in retina are not part of the regional general ophthalmology call group since we are available to the entire region of ODs and the multitude of ophthalmology groups.

 

[mjohnsonets]

I get emails from recruiters (mostly locums) trying to recruit for hospital call coverage because Level One trauma centers have to have all surgical specialties covered (ophthalmology included). Many offer schedules of seven straight days of 24 hour call coverage. I cannot imagine doing that at a regional center where everything from the surrounding area is referred to you and all the local ophthalmologists are not part of the coverage.
Plus, no residents to help with the care. Seems it could create chaos in a busy clinic schedule.
Our community has call set up where it is shared among the general ophthalmologists, and is paid. It’s mostly younger ophthalmologists since the local groups usually let older docs get out of call once they stop operating and/or reach a certain age. We in retina are not part of the regional general ophthalmology call group since we are available to the entire region of ODs and the multitude of ophthalmology groups.

With level 1 trauma certs requiring all surgical specialties and how much that certification is apparently worth to hospitals, I think we'll see a real squeeze higher on pay or heavy lobbying action from hospital groups. Only issue is this could draw in more ophthalmologists if they can give them schedules that are somehow favorable and remove them from community care.

 

[Slide]

Agree on peds, tough market. If they get stuck doing ROP it’s even worse. I had a NICU reach out when I started at my current spot and that was a polite but hard no in response.

I’m surprised only 25% are explicitly saying no hospital call - I agree the number has to be substantially higher. Maybe hospital groups in Chicago and Reno should try to hire a unicorn like Dr. Czyz: Article

Bless the soul of anyone who has the strength to make hospital/trauma call their entire job. I bet there’s a market for it. The ophthalmology groups would probably chip in to make it happen.

ROP sucks but these days you can now at least make it worth your time. More screeners are now requesting a stipend with 100% indemnity in addition to billing patients - I do as well but its paltry compared to some of the private practice offers I've seen. I've realized that if you do ROP, you have all the power because without you, the reimbursement level drops significantly without a ROP screener, enough to maim the NICU to a point where services are extremely limited. When I was asking around, I saw asking rates as high as an extra 100-150K a year for screening, not including treatment.

I get emails from recruiters (mostly locums) trying to recruit for hospital call coverage because Level One trauma centers have to have all surgical specialties covered (ophthalmology included). Many offer schedules of seven straight days of 24 hour call coverage. I cannot imagine doing that at a regional center where everything from the surrounding area is referred to you and all the local ophthalmologists are not part of the coverage.
Plus, no residents to help with the care. Seems it could create chaos in a busy clinic schedule.
Our community has call set up where it is shared among the general ophthalmologists, and is paid. It’s mostly younger ophthalmologists since the local groups usually let older docs get out of call once they stop operating and/or reach a certain age. We in retina are not part of the regional general ophthalmology call group since we are available to the entire region of ODs and the multitude of ophthalmology groups.

One of my colleagues is in a city-wide call group for their local hospital, and apparently the group gets paid very well for their services. However, without a resident, it can be very tough since there's lots of trauma. Level 1 centers really need to pony up the cash and pay if they want to be certified - I do think the hospitals have taken ophthalmology coverage for granted in years past and don't understand how difficult it is to take call while running a busy practice.

 

[RetinaDude]

I never thought about the difficulty some ROP units might be having recruiting/retaining peds ophth and/or retina to do their screening and treatment. Two areas, Level 1 trauma and ROP where hospitals actually need our services and we have the power balance

 

[eyeeye_captain]

There’s a current listing out of Rome, GA asking for q2 call at a regional Level 2. I’ve only ever covered Level 1’s thanks to training, so I don’t know how much better that would be, but it sounds awful.

If you can get $100-150k with indemnity, maybe ROP is tolerable as long as the NICU doesn’t keep sick kids and you also don’t have to treat. My neck still has PTSD from those long laser sessions. If you consider it as 0.1 FTE, that has you at the equivalent of $1M+ compensation at least. The billing is relatively negligible as it’s just a bunch of level 2 visits despite taking longer than most level 4’s.

Outside of the possible legal stuff, the logistics are probably a nightmare in the community. You really need 2+ screeners since some kids will need weekly exams and vacation is a thing. The charge nurses have to make sure their crew is actually doing the drops and getting exam kits and equipment ready before you get there. You need social work help to make sure parents actually bring the kid to clinic when discharged. You may have to deal with whatever your state’s family services department. Your staff has to be efficient getting a potentially sick kid in and out fast. You have to make your other patients think you’re torturing a child. I’m glad we still have folks willing to bite the bullet and help out.