Cataracts and medical retina?

[MacularStar]

I am nearing the end of my 1st year of ophtho residency and starting to think about fellowship. I love cataract surgery and retina.

How unrealistic is it to do a medical retina fellowship so you can do comprehensive + medical retina?

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[Mirror Form]

I am nearing the end of my 1st year of ophtho residency and starting to think about fellowship. I love cataract surgery and retina.

How unrealistic is it to do a medical retina fellowship so you can do comprehensive + medical retina?

The problem is that comprehensive ophthalmologists won't want to refer to you if you do cataracts.

 

[orbitsurgMD]

I am nearing the end of my 1st year of ophtho residency and starting to think about fellowship. I love cataract surgery and retina.

How unrealistic is it to do a medical retina fellowship so you can do comprehensive + medical retina?

If you are going into private practice and want to do comprehensive ophthalmology, your choice of fellowship, or even doing a fellowship doesn't matter. If you do cataract surgery, you will be seen as either a general or "comprehensive" ophthalmologist. It is true that you will not likely receive referrals from other general ophthalmologists, but that should not affect your ability to receive referrals from other doctors and optometrists. Just don't expect those doctors to know or care much what makes you different from a surgical retina subspecialist. You will also have to have a way of dealing with referrals that actually require a surgical retinologist without upsetting referring doctors or patients who might have seen a referral to you as unnecessary or worse, as a delay to definitive treatment. A busy optometrist who has an emergency patient in his chair wants someone to take the patient straight away and without wondering if you can handle the patient's problem.

"Medical" retina is really a creature of highly specialized academic departments where someone on staff has enough volume in retinal surgery to need a colleague that will see most of the diabetics and AMD and do laser and injections. In the private practice community, that degree of specialization is not common, unless you go to work for a very large retina practice (they exist mostly in large cities, like Detroit and Washington.)

 

[MacularStar]

These are all really good points, especially the delay in care and annoyed patients. I do not plan to practice in a large city, rather a more rural area, and if I did this, probably private practice and in a small group. I realize if I did this Comprehensive docs would not refer to me, but they wouldn't anyway if I did comprehensive alone. I would be relying on the other sources mentioned above and would merely do my own injections, laser, and eval and management of other retina disease, instead of referring to surgical retina. So I wouldn't be running an injection/laser mill (but then there is the question, of whether I would be able to afford the overhead to do this without running a mill.). I am hoping that these patients would see me as their ophtho PCP so would not be annoyed if I referred them again. This might annoy optoms though who also see themselves as this role, however, advanced AMDers and PDR pts would have enough eye pathology to justify the switch over. Unfortunate, but true, in this day in age, it seems that pts have become accustomed to being shuttled around to subspecialists (especially the elderly and advanced diabetics). Orbitsurg, you are right that in order for this to work I would have to have a good relationship with a readily available surgical retina specialist and make the limitations of my scope clear to referring docs. Perhaps part of me is hedging that fewer and fewer things over the next 30 yrs will require surgical intervention in retina and medical tx will expand?

Basically I am in a real bind here in residency where I want to work would not support another full-time retina specialist (medical or surgical). Also, I do not think even the very large jump in salary is worth it to take an additional year of fellowship, and more importantly, the lifestyle of a surgical retina person. I also worry that as our amazing field advances so quickly over the next 30 years things will become even more sub-specialized and I will not be able to offer my patients top notch care in even the most basic procedures/sx without doing a fellowship. After all, if I want to do cataracts, it will require an expensive laser, so why not also do refractive sx with the same laser? So perhaps Cornea is where I should go. But I then I won't be seeing as many retina patients, which are the ones I love. So here we go around in the circle.
Any thoughts on what I should do? Attending , resident, and fellow input highly appreciated =)

 

[Mirror Form]

So I wouldn’t be running an injection/laser mill (but then there is the question, of whether I would be able to afford the overhead to do this without running a mill.).

That's the problem. How are you going to afford a fluorescein angiographer, laser, high rez oct, etc., w/o running a mill?

Most general ophthalmologists are trained to do focal lasers and injections. The problem is the overhead involved with FA's, high rez oct's, and lasers.

 

[Shnurek]

Especially now with the reimbursements for intravitreal injections down by ~25% and OCT reimbursements down and only 1 payment per patient visit not per eye At least FA's still reimburse well and a fundus camera can do them as well as regular retina photos.

 

[Mirror Form]

At least FA's still reimburse well and a fundus camera can do them as well as regular retina photos.

Yep, but you need a skilled photographer and someone who can inject the fluorescein. That's not practical unless you're doing frequent FA's.

Whereas, it's pretty easy to train practically anybody off the street to operate a retcam for fundus photo's.

 

[MacularStar]

yeah, I guess overhead would have to be shared with a surgical retina person, and if they are in the same building I guess we would have to be drowning in retina for it to make sense for the less qualified person to do procedures. Hmm, it is seeming impossible to do both cataracts and medical retina.

 

[MacularStar]

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[Visionary]

Guess I should throw in here, as the private practice med ret guy on this forum. I'll agree, in part, with a lot of what has been stated.

There are really 3 main situations in which you'll find a fellowship-trained (I'll get to why I bolded that later) med ret doc: academia, retina-only group (or solo), or multispecialty group. I'm in the latter. The other 7 docs in my group are comprehensive, though one is fellowship-trained in cosmetic and functional oculoplastics. While I do mostly med ret, I probably average around 20% comprehensive, many through work-ins. However, I do absolutely no surgical comprehensive (e.g., cataracts, refractive, even chalazia). I refer all of that out to my comprehensive colleagues. They, in turn, funnel all of their med ret to me. I have the same relationship with a couple of other subspecialty ophthalmologists in the area. Naturally, other comprehensive docs are leery of referring to me, for fear of losing patients. While I have no intention of stealing such patients, they could decide to simplify things by transferring all of their eye care to our group. The key then, in a case like mine, is to have a large enough internal referral base to keep you busy, and I seem to have that here.

As for the other scenarios, academia is what it is, and if you're headed that direction, you'd probably end up there regardless of the fellowship you decide to pursue. The med ret docs in retina-only groups tend to be surgically-trained but nearing retirement. Retina-only groups typically want the fresh, young docs doing surgery and taking call. I guess a fourth option is employment (e.g., VA, Kaiser), but you really lose the financial advantage of your fellowship training that way.

Building on that last point, if you really are going to spend an extra year specifically studying med ret, I would advise you to essentially drop comprehensive and market yourself as a med ret doc. Not that it's all about money, but the fact is that med ret nets nearly twice per patient as comprehensive. Thus, the more med ret you do, the better you'll do financially. That will also allow you to cover those extra overhead expenses that some above were describing.

Now, at the beginning, I mentioned fellowship-trained med ret docs. If you just can't see yourself letting go of cataract surgery, I'd recommend simply incorporating some bread-and-butter med ret into a comprehensive practice. You can simply tailor it to your comfort level. If you're in a more rural area, you can even develop a co-management relationship with some more distant retina docs. I know some who do that. Anything you aren't comfortable with, you can refer out.

 

[Shnurek]

Yep, but you need a skilled photographer and someone who can inject the fluorescein. That's not practical unless you're doing frequent FA's.

Whereas, it's pretty easy to train practically anybody off the street to operate a retcam for fundus photo's.

I mean I started working as an ophthalmic tech a few months ago and after a day or two I could take good fundus photos while getting them perfect took a few more weeks. As for the FA's my boss (the retinologist) sent me to do phlebotomy courses and now I do the FA's for him as well. Before I was certified, any doc in the practice would inject them and I would take the photos immediately following the injection. Keep in mind though that I am not an average GED technician and they may require 2x-3x longer practice time and may never get it perfect. I also do OCT's but they are easy sauce, I learned in 20 minutes how to do them.

 

[Visionary]

I do not plan to practice in a large city, rather a more rural area, and if I did this, probably private practice and in a small group.

Basically I am in a real bind here in residency where I want to work would not support another full-time retina specialist (medical or surgical).

I'm having trouble reconciling these two statements. Are you already settled on an area? What size town? How many current retina docs? Are you sure it is saturated? If there is established retina, you could potentially go in with a larger comprehensive group and do their med ret and still refer out the surgical cases. There's another med ret guy in my town who is in with comprehensive doc, a glaucoma/cosmetic & functional oculoplastics doc, and two optometrists. He does fairly well. What you need to understand is that many groups without retina would really be open to the idea of keeping med ret (which is 85-90% of retina) in-house. It makes good financial sense. As for the retina surgeons, they will still be your friends, because they need the surgical referrals.

Also, I do not think even the very large jump in salary is worth it to take an additional year of fellowship, and more importantly, the lifestyle of a surgical retina person.

Med ret has the best ROI of any fellowship--one year to nearly double your income potential. My lifestyle is nothing like a retina surgeon. Pretty much 8:30-5, 4.5 days per week, with Q7week practice call.

I also worry that as our amazing field advances so quickly over the next 30 years things will become even more sub-specialized and I will not be able to offer my patients top notch care in even the most basic procedures/sx without doing a fellowship.

That's a risk with any medical field. We are essentially in a gate-keeper (primary care) to specialist model.

After all, if I want to do cataracts, it will require an expensive laser, so why not also do refractive sx with the same laser?

"Laser" cataract surgery will never take off. Too expensive without significant benefit over modern phaco. Heck, the currently available cataract lasers don't even do refractive!

So perhaps Cornea is where I should go. But I then I won’t be seeing as many retina patients, which are the ones I love. So here we go around in the circle. Any thoughts on what I should do? Attending , resident, and fellow input highly appreciated =)

Vacillating between extremes of cornea and retina tells me you aren't really sure what you like. They are VERY different subspecialties. Seeing as you're a 1st year, perhaps you just need to allow a little more time for your path to crystallize.

 

[MR1]

Now, at the beginning, I mentioned fellowship-trained med ret docs. If you just can't see yourself letting go of cataract surgery, I'd recommend simply incorporating some bread-and-butter med ret into a comprehensive practice. You can simply tailor it to your comfort level. If you're in a more rural area, you can even develop a co-management relationship with some more distant retina docs. I know some who do that. Anything you aren't comfortable with, you can refer out.

Agree with this 100%.

Only other thing is if you are dead set on a particular town, you may have to tailor yourself to that place, ie do a fellowship needed there or not do one at all.

 

[MacularStar]

First, thank you for responding Visionary I was hoping you would chime in.

I'm having trouble reconciling these two statements. Are you already settled on an area? What size town? How many current retina docs? Are you sure it is saturated? If there is established retina, you could potentially go in with a larger comprehensive group and do their med ret and still refer out the surgical cases.

Here's my deal: For family reasons my spouse and I know that we want to live in a particular area, mostly its rural, but we have our eye on the largest city within this area which has 100,000 people. There are already 5 highly trained retina people there. The math doesn't work out, I know, I think some might have satellite offices or something or work part time? Need to do more research. The point is they are saturated. Some are also my med school mentors so I love them. It is true that one possibility would be to try to join them or replace the one who wants to retire. Although if it really comes down to it we may just have to live someplace else and my family is starting to express more flexibility as they see me agonize.

There's another med ret guy in my town who is in with comprehensive doc, a glaucoma/cosmetic & functional oculoplastics doc, and two optometrists. He does fairly well. What you need to understand is that many groups without retina would really be open to the idea of keeping med ret (which is 85-90% of retina) in-house. It makes good financial sense. As for the retina surgeons, they will still be your friends, because they need the surgical referrals.

Yes, this is exactly what I imagined. Lots is probably people skills/relationships, but the overall theory works. Keep med retina in a group practice and feed the surgical retina so they can stock their OR days and help you out when you need them.

Med ret has the best ROI of any fellowship--one year to nearly double your income potential. My lifestyle is nothing like a retina surgeon. Pretty much 8:30-5, 4.5 days per week, with Q7week practice call.

This is interesting and very appealing. Wouldn't mind having your life. Its always about the money (especially when people say its not), but I would be foolish to choose a fellowship based on current reimbursement. Anything can change at this point in time. It is helpful to know that though, at least for a few years I'll be able to pay my loans.


"Laser" cataract surgery will never take off. Too expensive without significant benefit over modern phaco. Heck, the currently available cataract lasers don't even do refractive!

I hope so! Spend way too much time struggling with capsulorhexis to have it taken over by a computer!

Vacillating between extremes of cornea and retina tells me you aren't really sure what you like. They are VERY different subspecialties. Seeing as you're a 1st year, perhaps you just need to allow a little more time for your path to crystallize.

You are right and I realize that they are very different. Retina is my favorite sub specialty by far and it is what I am best at. The part about family, location, and saturation is a major stumbling block, the part about giving up cataracts, is also a major downside. Comprehensive plus bread and butter med retina is an option, but would be limited to above mentioned probs with equipment/staff. At this point I think the entire eye is fascinating and I could be happy doing any specialty within ophtho (except for maybe peds.) Cornea was more a solution to the above problems, rather than something I'm inherently drawn to, so maybe I am answering my own question about that.

Thank you for your comments everyone, keep them coming!

 

[MstaKing10]

Some of the attendings in my fellowship consistently did their own cataracts. This was a large group (>50 ophthalmologists) and so the volume was greater than many places but nonetheless, this was standard for them. One of them would do 2-3 each OR day, some just cataracts without vitrectomy. As a surgical retina fellow I have done well over 100 cataracts.

I realize this is quite a unique situation but just throwing it out there as a possibility in the right setting.

 

[Visionary]

Some of the attendings in my fellowship consistently did their own cataracts. This was a large group (>50 ophthalmologists) and so the volume was greater than many places but nonetheless, this was standard for them. One of them would do 2-3 each OR day, some just cataracts without vitrectomy. As a surgical retina fellow I have done well over 100 cataracts.

I realize this is quite a unique situation but just throwing it out there as a possibility in the right setting.

I'm going to wager that most of the docs in your department are subspecialists, so that arrangement probably works okay. In the real world, where the comprehensive docs far outnumber the subspecialists, the boundaries are typically more strict.

 

[Visionary]

Here's my deal: For family reasons my spouse and I know that we want to live in a particular area, mostly its rural, but we have our eye on the largest city within this area which has 100,000 people. There are already 5 highly trained retina people there. The math doesn't work out, I know, I think some might have satellite offices or something or work part time? Need to do more research. The point is they are saturated. Some are also my med school mentors so I love them. It is true that one possibility would be to try to join them or replace the one who wants to retire. Although if it really comes down to it we may just have to live someplace else and my family is starting to express more flexibility as they see me agonize.

You need to determine the catchment area for the town you're considering. City population usually isn't an accurate reflection. For instance, the "city" in which I work has a population of around 250k, but there are 13 retina docs (two of us are medical). That math doesn't work either, until you consider the surrounding area, which boosts the catchment population to nearly 1.5 mil. As a subspecialist, you don't necessarily have to travel to tap that market. You just need to solidify referral sources.

Yes, this is exactly what I imagined. Lots is probably people skills/relationships, but the overall theory works. Keep med retina in a group practice and feed the surgical retina so they can stock their OR days and help you out when you need them.

The lure for the group will be the revenue potential you bring to the table. That will help with practice overhead, which makes them more money without affecting their comprehensive volume.

This is interesting and very appealing. Wouldn't mind having your life. Its always about the money (especially when people say its not), but I would be foolish to choose a fellowship based on current reimbursement. Anything can change at this point in time. It is helpful to know that though, at least for a few years I'll be able to pay my loans.

Don't get me wrong. Whenever you talk about spending 12+ years after high school (believe it or not, I did 18), there should be a payoff. Unless you feel a particular calling, you don't want to spend extra years (i.e., fellowship) without an improvement in income potential. As you correctly state, the reimbursement climate is always subject to change. We already took a hit with consult fees, intravitreal injections, and OCTs. It's clearly not going to get better.

I hope so! Spend way too much time struggling with capsulorhexis to have it taken over by a computer!

You are right and I realize that they are very different. Retina is my favorite sub specialty by far and it is what I am best at. The part about family, location, and saturation is a major stumbling block, the part about giving up cataracts, is also a major downside. Comprehensive plus bread and butter med retina is an option, but would be limited to above mentioned probs with equipment/staff. At this point I think the entire eye is fascinating and I could be happy doing any specialty within ophtho (except for maybe peds.) Cornea was more a solution to the above problems, rather than something I'm inherently drawn to, so maybe I am answering my own question about that.

You're still a 1st year, so cataract surgery is still new and exciting. Wait until you've done a hundred or so cataracts. Once you're comfortable and the newness has worn off, it may not seem so attractive. For me, after about 40 cases, cataract surgery became a procedure of extremes. If things were going well, I was bored. If things went south, it simply sucked. Others may have a different opinion, of course. I find that I much prefer the intellectual aspect of being a diagnostician in clinic. Also, retinal pathology has always been a draw for me. That's one of the things I love about medicine: you have the opportunity to tailor your path.