Change of career: ophthalmology or dermatology...

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EtherBunny

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Listen to me, I don't care what you have to do, talk her into doing derm. If she likes operating, she can always do MOHS fellowship. There is no better deal in medicine right now then derm. And she won't have to deal with peanut cataract surgery reimbeursement we get nowdays or having to move to a s**thole to be able to do well financially.
 
I think Derm would likely be a better choice. Derm residency will have much less call responsibility (but will still be significant reading to do after hours). Like mentioned above, she can always do Mohs if she wants to be in a surgical aspect of Derm. Some Mohs surgeons do very impressive reconstruction work and can pretty much close every defect they make. Others just send their difficult repairs out to plastics or ENT, but there is really no shame in that either if you aren't trained/interested in doing them. I think it is more realistic to work a 3-4 day work week and still have a decent salary in Derm once you are out in practice. Additionally, I would recommend having kids during training. This is very easy to do in Derm, and nobody is going to give you crap for missing call. Having them after residency/fellowship will hit your pocket book much harder.
 
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Derm with MOHS. No one knows what the insurance landscape will look like in 10 years. Ophthalmology reimbursement will be closely tied to Medicare rates. Cosmetics and resulting cash payers are much higher in dermatology. Less insurance bullcrap. Lower malpractice insurance. Better (meaning, no) call. She will generally see younger, healthier, patients in dermatology (or if not, see older patients who don't mind paying to look younger - try collecting a refraction fee from these patients is another issue). Derm also gives her the flexibility of concierge (cash) medicine in the future. Sorry to sound mercenary and cynical.
 
guttata said:
Derm with MOHS. No one knows what the insurance landscape will look like in 10 years. Ophthalmology reimbursement will be closely tied to Medicare rates. Cosmetics and resulting cash payers are much higher in dermatology. Less insurance bullcrap. Lower malpractice insurance. Better (meaning, no) call. She will generally see younger, healthier, patients in dermatology (or if not, see older patients who don't mind paying to look younger - try collecting a refraction fee from these patients is another issue). Derm also gives her the flexibility of concierge (cash) medicine in the future. Sorry to sound mercenary and cynical.
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is ophtho really going to blow this much in the future?
 
Ophtho - predictible call, flexibility, good outcomes - check. The OP never mentioned anything about income. There is no doubt derm guys/gals make more money, but I think what you do is as important as how much you get paid for doing it. Personally, derm is pretty boring to me. The landscape in derm is not immune from reimbursement concerns either. They recently cut MOHS reimbursement for all areas outside the head an neck and not everyone likes dermpath or cosmetics. Ophtho always will involve treating blindness which is pretty noble work IMO, and most ophtho docs do pretty well financially. If the goal was to only become rich medicine probably was the wrong field to enter in the first place.
 
I don't get why everyone is assuming derm makes more than ophtho. Even if reimbursement is declining, procedures always bring the most money in medicine. Ophtho has more procedures than derm, therefore more money. And you don't have to live in a ****hole either.

Sdn is biased and thinks any city but LA, NYC, and Chicago is a **** hole. You make twice as much in ophtho if you live anywhere else.
 
EtherBunny said:
Potential income isn't a primary consideration in the career change (principally because we'll be a two physician income household ultimately).

I want her to be happy professionally. It sounds like the attendings on this forum would not recommend that she go into ophthalmology. If differences in income were eliminated from consideration, would you still recommend a career in dermatology over ophthy?

Based on my limited exposure to the field through my rotations in anesthesia residency, I would think that ophthy has a more rewarding daily routine, because essentially everyone deeply cares about their vision (is there a more important sense?). It must feel good as an ophthalmologist to improve the vision of your patients.

For the attendings in the forum, do you still find your work as an ophthalmologist to be fun and meaningful? If issues with compensation are excluded from the equation, would you recommend the field to someone like my wife--i.e., a person with a surgical inclination who wants low acuity patients, great outcomes, and a flexible work schedule with a very tolerable call burden?
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Yes. It's a very rewarding specialty, especially if you do cataract surgery and can make someone go from legally blind to 20/20 overnight with a procedure that takes 5-10 minutes.

It's very low stress, and you don't deal with sick people on the verge of collapse. Call can be light depending on one's practice situation. I take 6 to 7 weekend calls a year covering our established practice patients only and do not cover any hospitals or emergency rooms. The absolute worst part of my job when I first started was taking hospital call, so I decided after a year to not do that any more.
 
I think compensation and the recent changes and potential future cuts are hard to ignore but ultimately ophthalmology was the only field for me. I like it for the exact reasons your wife is looking for: i enjoy surgery and find it extremely rewarding. I wouldn't say it's "low acuity". It's hard to handle cases that went poorly for whatever reason even if ultimately it was not your fault. I think that's part of being a surgeon though and the majority of cases go very well. Flexibility and call vary with jobs. In the grand scheme of medicine, yes she can achieve both in ophthalmology.

She needs to figure out what kind of "bread and butter" patients she wants to see. Dry eyes, routine eye exams, cataracts, etc or rashes and skin lesions. At least for ophthalmology, most don't operate more than 1 day a week, so the rest is clinic.

Hope that helps. Good luck!
 
If you operate you will get bad outcomes. In ophtho it shouldn't kill the patient but it can blind them. I know the feeling of having to deal with a less than ideal outcome and it sucks. The eye is extremely sensitive and sometimes the operation will look perfect, but patient will still see something strange in their vision or feels something weird in their eye that will drive them and you crazy because they see it or feel it constantly... Every little detail makes a difference. For many patients eyesight is more important to them than their life. So that stress is still there in ophtho.

It does feel good to improve a patient's vision, especially the patients that aren't expecting you to perform miracles for them. Without those patients I would have already quit. But, like in every field, there will also be very unhappy patients who will believe that if anything bad happens it's because you specifically screwed up.

I don't know much about the stresses in derm.
 
I refer you back to post #2.

People that make good money in ophtho (I mean well-established derm money) do very little medicine. They run a business. You have to very business savvy (more then in most other medical fields) to do that. What you told us about your wife, does not sound like she want to run such business. One other major thing is supply/demand. Derms have been very smart by keeping #s of graduates very low thus keeping demand crazy high. There are more ophthos then stray dogs in most places. I am not even talking about optometry issues here. In addition, since medicine is going hospital employed route now, she will likely take hospital ophtho call and will have to come in to see trauma and other eye emergencies. The only thing derms come in in the middle of the night for is probably SJS, may not even have to do that. TALK HER INTO DOING DERM.

P.S. WTH is ophthy? Sorry just never seen abbreviation before. Is this an east coast thing?
 
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EtherBunny said:
LOL. People at my institution always refer to ophthalmology as ophthy--must be an idiosyncracy with my institution. I didn't know that ophtho was more common. Sorry about that.

I think she'll probably end up pursuing derm, but I just don't want her to make another mistake. She already lost several years in her current specialty--years that she can never get back.
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Please keep one thing in mind, even though she wants to pursue derm does not mean she will automatically get it. More then likely she won't be able to switch into derm unless she gets VERY lucky or has departmental connections of some sort at her home institutions. Derm is much harder to match into then ophtho. More then likely she will need to take a year off, do some research, form some connections, etc. Plus having essentially quit with her current speciality maybe a black mark on her application (probably will be). I don't think telling them "I switched out of my current speciality because I want better surgical outcome and better call" will play well in her favor :). I wish you guys best of luck. This certainly WILL NOT be easy.
 
EtherBunny said:
Potential income isn't a primary consideration in the career change (principally because we'll be a two physician income household ultimately).

I want her to be happy professionally. It sounds like the attendings on this forum would not recommend that she go into ophthalmology. If differences in income were eliminated from consideration, would you still recommend a career in dermatology over ophthy?

Based on my limited exposure to the field through my rotations in anesthesia residency, I would think that ophthy has a more rewarding daily routine, because essentially everyone deeply cares about their vision (is there a more important sense?). It must feel good as an ophthalmologist to improve the vision of your patients.

For the attendings in the forum, do you still find your work as an ophthalmologist to be fun and meaningful? If issues with compensation are excluded from the equation, would you recommend the field to someone like my wife--i.e., a person with a surgical inclination who wants low acuity patients, great outcomes, and a flexible work schedule with a very tolerable call burden?
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If your wife is currently in a surgical field, I think she will like ophtho more than derm. She will still get to operate on a regular basis, although probably less so than other surgical subspecialties. The surgeries in ophtho are intricate, challenging and rewarding and patients usually have good outcomes. It also offers the best lifestyle among the surgical fields, though it is still more demanding than derm during residency.
 
Keep in mind that you're getting a limited cross section of advice on Ophthalmology here. I'd make connections with a few private practice Ophthalmologists and Dermatologists in the area and get their take on everything. I think it's also important to note that she's basically deciding between what people commonly see as the best two income/lifestyle fields in medicine. From my experience people are generally happy in either field. While the advice you're getting on here is pretty negative I have seen far more Ophthalmologists happy that they didn't do Derm than I have wishing they did Derm. If you take income out of the equation I think people with a surgical desire enjoy Ophthalmology a lot more. While she could possibly do Derm and a MOHS fellowship to maybe make her practice a little surgical, Ophthalmology has surgery as a staple of the field. Plus if my friends in Dermatology are to be believed then it's becoming harder to find practice opportunities where you actually get to do a lot of MOHS surgery. And if we're talking anecdotes then I know an Ophthalmologist-mom that works about 3 days per week in my area. I assume that's about as uncommon as part-time MOHS surgeon.


So I'd say get some outside advice and try to see through the grass-as-always-greener advice.

BUT, if she really doesn't care about surgery, can deal with looking at rashes all day, and is basically just wantingto make as much money at a part time job as she can and doesn't care what it is - then Derm is definitely better in terms of money per hours worked.
 
speyeder said:
If your wife is currently in a surgical field, I think she will like ophtho more than derm. She will still get to operate on a regular basis, although probably less so than other surgical subspecialties. The surgeries in ophtho are intricate, challenging and rewarding and patients usually have good outcomes. It also offers the best lifestyle among the surgical fields, though it is still more demanding than derm during residency.
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I dunno if content or interest matters, but if I had to guess your wife is doing neurosurg - hope I'm not way off on this one... ophtho is more of a "neuro" relevant specialty than derm. Just a thought...
 
Derm is boring to me, so Ophtho would definitely be the better choice in my eyes.
 
Listen, I enjoy practicing ophthalmology. I still have a long career ahead of me, but I am not naive about the future.

If your wife would be happy with either field, she should choose dermatology. The writing is on the wall, primary care docs are being gulped up by ACOs at an exponential rate. It is only a matter of time before specialists become part of ACOs. Not sure if you have ever worked for a large institution, but, it is not for everyone.

But, IMO, more importantly, reimbursement rates will be stagnant. Where are we going to get the money to sustain Medicare, especially with an increasingly aging population? How are we going to pay for Obamacare? What do you think will happen to cataract reimbursements when the surgery becomes more efficient and drains more funds from Medicare? Cuts. What do you think will happen when femtolaser becomes more common place? There is going to be a big battle for laser cataract surgery privileges.

Sure, you can maintain your salary by seeing more patients. So, to make the same amount, you see 60 patients a day, instead of 40. You spend 2 minutes with a patient. It's not good medicine. You will run ragged.

I wouldn't necessarily say ophthalmology surgery is low stress. We have good outcomes, but any time you operate, there is a risk. You can be the best surgeon, but if the patient jerks while you are operating, something bad usually happens. Your wife needs to decide whether she enjoys the low acuity more than surgery. No one here can answer that for your wife.

You would be a fool to not consider these reasons. It is not specific to ophthalmology. It applies to all specialties (almost all fields of medicine!) that are highly dependent on insurance reimbursements. So, consider a field where you can go into concierge medicine - where you can value your own worth. It is difficult to do with ophthalmology (perhaps, if she is very lucky, she could become a lasik cowboy) and easier to do with dermatology.

People will read that my post is all about the money. But it is not. It is about the quality of medicine you can practice and how you can practice.
 
jsh1986 said:
Apropos!

http://www.nytimes.com/2013/03/28/h...earing.html?smid=fb-share&_r=0&pagewanted=all
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This is actually a really good article I read and I'm glad you posted it. I think there are several variables that are unknown. We have an aging population with a massive increase in patients over the age of 65 who will be in need of treatment for cataract, AMD, DR, etc. We have a fixed number of new ophthalmologists entering the pipeline with no new residency slots opening up anytime soon and an estimate of between 20-30% of older docs preparing to retire in the next 20 years or so. I may be naively optimistic, but I think supply and demand will ensure a viable future for ophthalmologists despite what the naysayers say on this site. In fact, of the ROAD specialties I think ophthalmology is poised to do very well, better than rads and anesthesia.

Full disclosure, my long time GF is a dermatologist, and she is not nearly as optimistic as some of you on this site. Dermatology pays well, but day-to-day clinic is BORING. Mohs and dermpath are the two primary subspecialties that pay well and she likes neither. She tells me there is actually a fairly high burn-out rate in derm because it is so boring (which I can't verify). Cosmetics and laser procedures are big money items, but a lot of dermatology is skin rashes, biopsies, and acne meds. Consider variety when choosing.
 
RestoreSight said:
This is actually a really good article I read and I'm glad you posted it. I think there are several variables that are unknown. We have an aging population with a massive increase in patients over the age of 65 who will be in need of treatment for cataract, AMD, DR, etc. We have a fixed number of new ophthalmologists entering the pipeline with no new residency slots opening up anytime soon and an estimate of between 20-30% of older docs preparing to retire in the next 20 years or so. I may be naively optimistic, but I think supply and demand will ensure a viable future for ophthalmologists despite what the naysayers say on this site. In fact, of the ROAD specialties I think ophthalmology is poised to do very well, better than rads and anesthesia.

Full disclosure, my long time GF is a dermatologist, and she is not nearly as optimistic as some of you on this site. Dermatology pays well, but day-to-day clinic is BORING. Mohs and dermpath are the two primary subspecialties that pay well and she likes neither. She tells me there is actually a fairly high burn-out rate in derm because it is so boring (which I can't verify). Cosmetics and laser procedures are big money items, but a lot of dermatology is skin rashes, biopsies, and acne meds. Consider variety when choosing.
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She wants to be in a specialty with predictable hours, flexibility, and great outcomes. She wants low acuity. Although she's amenable to call, ideally she wants a career with minimal call burden so she can focus on raising kids. Basically she wants a field that affords excellent balance between personal demands (i.e., family time) and professional commitments.
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This literally describes derm. Hours are less flexible in ophtho then derm due to significantly higher number or real or most of the time perceived emergencies (since no one other then ophtho knows about the eye, everything is an emergency and you have to add patient to your schedule same day). So you (or someone else) kinda have to be there all the time during office hours and provide coverage after hours. It may be for your practice only, ER or UC depending on the arrangement. If a PCP calls you and wants you to see a stye the same day he is not comfortable managing, guess what, you seeing them the same day. If you don't, referral goes somewhere else next time. Yes, you can be part time in some big practice, kind of a mommy track so to speak, but don't bet on making any kind of good money. In terms of being boring, EVERYTHING becomes boring after a while. I have friends in all kinds of specialties. One of them is a pediatric cardiothoracic surgeon (how cool is that???). Even he tells me he job is a job and after several hundred cases it is just another heart transplant. Same thing goes for all specialties.

I know grass is always greener; we will ALL have plenty of patients to take care of but I do feel that derm will fare better financially in the future for several reasons: 1. Less dependence on insurance and cosmetic component; ophtho also has this component but to a lesser degree; 2. high demand for derm in most areas (have you tried to make an appointment with a dermatologist lately?); 3. True practice flexibility with your schedule and call (most hospitals do not have a derm call panel but they sure have or trying to have an ophtho call panel).

Personally, I do not have any career regrets.I love cataract surgery, it is the most elegant and life changing procedure in medicine. I do feel our services have been devalued and still being devalued because we are such an easy target for CMS cuts. Stay tuned for more.
 
EtherBunny said:
The potential boredom in derm is something that she's concerned about. On the otther hand, she doesn't want to be in an "exciting" specialty but have a relatively poor lifestyle.

The future demand for ophthalmology should be enormous. I can't imagine why ophthalmologists 10 years from now would struggle financially.
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Well, cataract surgery used to pay $3800/eye in late 80's. Up until this January, it was around $650. It was cut again 10% in January of this year before 2% sequester cut.
 
EtherBunny said:
The potential boredom in derm is something that she's concerned about. On the otther hand, she doesn't want to be in an "exciting" specialty but have a relatively poor lifestyle.

The future demand for ophthalmology should be enormous. I can't imagine why ophthalmologists 10 years from now would struggle financially.
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Medicare pays for for the majority of cataract surgery. The demand is going up, there's only so much money to go around.

Derm has more opportunity for cash paying patients.

If you take money out of the equation, ophthamology wins in my opinion.
 
In an article that came out today from Medscape on Physician Burnout, ophthalmology was ranked as the 3rd lowest specialty in terms of percentage of physician experiencing burnout, behind 1 pathology and 2 psychiatry - so essentially we have the lowest burnout rate of the "real" doctors (zing!)
 
Eyefixer said:
I know grass is always greener; we will ALL have plenty of patients to take care of but I do feel that derm will fare better financially in the future for several reasons: 1. Less dependence on insurance and cosmetic component; ophtho also has this component but to a lesser degree; 2. high demand for derm in most areas (have you tried to make an appointment with a dermatologist lately?); 3. True practice flexibility with your schedule and call (most hospitals do not have a derm call panel but they sure have or trying to have an ophtho call panel).
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I agree with points 2 and 3, but I don't think they necessarily translates into better pay. Honestly though if the OP's wife is really looking for the most flexibility in a field I think those two points make derm the winner. There is such a big waitlist for derm everywhere that you can set your schedule at 3 days per week and now you'll have patients lined up on those days. You won't be losing them to another doc, because they're booked up too. If she really wants to do surgery and isn't interested in derm though, my opinion is that she's going to be miserable doing derm. Everyone on here keeps saying "a job is a job after a while" and that is true, but as someone who switched from a $70,000/yr, 40 hour per week job I can tell you that if you hate it the money won't matter and you'll be miserable. So she's going to have to decide which one is king: liking the job or an extremely flexible work schedule. But honestly if she hates derm why would doing that be better than quitting medicine altogether?

Everyone seems to agree with your point #1 about derm, but I don't agree completely. Derm may end up with less dependence on insurance due to the cosmetic components, but you know everyone is trying to up-sell premium IOLs for the same reason so Ophthalmology does have some similarities there. And the big cosmetic derm stuff: laser peels, tattoo removal, etc can be done by basically any physician. If you guys don't think some savvy family medicine docs are going to be opening up cosmetic centers once the APNs and PAs encroach further on their territory, I think you're wrong. And please don't tell me patients are going to be checking which board-certification the doctor doing their skin resurfacing has, because you know most of the time they don't know you're not the same thing as an Optometrist.

Anyway, all that to say that I think the insurance-proof claims of a dermatology practice are way overblown. They aren't as invulnerable as everyone thinks, just like Ophthalmologists don't make $1,000,000 per year like everyone thinks. This ain't the 80s folks. Plus if Medicare dies I'll bet you my IRA that people will be paying cash for cataracts before they'll be paying to get skin smoothed. And we'll be there to provide it - probably cheaper and more efficiently than we did with Medicare anyway.
 
Everyone on here keeps saying "a job is a job after a while"

Everyone seems to agree with your point #1 about derm
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May be your own statements can glue you in a little? Especially since you are talking about PRACTICING ophthalmologists :)

Anyway, all that to say that I think the insurance-proof claims of a dermatology practice are way overblown.
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Care to provide some references to these statements? Or is this just a feeling you have?
 
ophthope said:
1. So she's going to have to decide which one is king: liking the job or an extremely flexible work schedule.

2. And the big cosmetic derm stuff: laser peels, tattoo removal, etc can be done by basically any physician. If you guys don't think some savvy family medicine docs are going to be opening up cosmetic centers once the APNs and PAs encroach further on their territory, I think you're wrong.

3. And please don't tell me patients are going to be checking which board-certification the doctor doing their skin resurfacing has, because you know most of the time they don't know you're not the same thing as an Optometrist.

4. Anyway, all that to say that I think the insurance-proof claims of a dermatology practice are way overblown. They aren't as invulnerable as everyone thinks, just like Ophthalmologists don't make $1,000,000 per year like everyone thinks. This ain't the 80s folks. Plus if Medicare dies I'll bet you my IRA that people will be paying cash for cataracts before they'll be paying to get skin smoothed. And we'll be there to provide it - probably cheaper and more efficiently than we did with Medicare anyway.
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To the first point you made, I think ophtho offers a flexible work schedule too. Early on you may have to cover more call or see less desirable patients, but most mid-career ophtho docs can set their schedule to a 4-5 day work week, 40 hrs, and many cherry pick their patients depending on their practice scope. That's pretty good in comparison to most other fields in medicine

I don't think there has been a big movement for family practice docs to start doing the procedures you mentioned. I know of one family doc I rotated with 3rd year that does botox, but there is incredible push-back on this.

Derm is one of the few specialities where patients are pretty knowledgeable and many specifically ask for references and google their docs. The reason? If you can afford expensive cosmetic procedures out of pocket you tend to be better educated and, lets face it, appearance and beauty is big business and VERY important to that demographic of patients. Dermatology also has significantly better branding than ophtho vs optometry. You see ads on TV all the time about "dermatology tested" or "dermatologist recommended." There is no confusion on patients part about what a dermatologist is. Most patients that pay out of pocket for expensive laser, peels, cosmetics, botox will not allow a family practice doc to perform this procedure, let alone a PA.

Derm is also pretty insulated from changes in medicare and insurance issues, at least if your practice is focused on cosmetics. Either you have a cadillac insurance coverage that will pay for everything or it will be out of pocket. There are almost no CPT codes for most beauty-associated procedures. the Mohs guys may make less because of recent code changes to non-head/neck surgeries, but still they are in HIGH demand. Derm has succeeded in their market and have a pretty deep moat for protection or encroachment from other specialities. Their biggest threat is probably plastic surgeons. Ophtho does have oculoplastic specialists, but I don't think they have the same branding.

It will be tough to covert cataract to a cash business. The average low to middle-class American can't afford to pay out of pocket for the procedure and its so debilitating insurance really has to cover it. What is more likely is if medicare reimbursements get too low ophtho docs will stop seeing medicare patients all-together, then expect a reaction..
 
Congrats! I'm a little jealous.... which means I think she made the right decision.
 
Since the original point of this thread basically concluded, I was wondering if there were any other specialties about which you guys could have a similar debate. Instead of Derm vs. Ophtho, maybe ENT and your speculation of both fields moving into the future. Any thoughts?
 
I'll take that as a very positive thing. Thanks!
 
Feed Me said:
Since the original point of this thread basically concluded, I was wondering if there were any other specialties about which you guys could have a similar debate. Instead of Derm vs. Ophtho, maybe ENT and your speculation of both fields moving into the future. Any thoughts?
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I considered ENT. It's not a bad specialty.
 
Eyefixer said:
Nope. Derm is pretty much it.
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Translation: a lot of people would trade their left nut for Derm. In other words--who cares if you find it "boring"--do it anyway. The rest of your life will thank you.

peace
 
Eyefixer said:
Well, cataract surgery used to pay $3800/eye in late 80's. Up until this January, it was around $650. It was cut again 10% in January of this year before 2% sequester cut.
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Yeah, but wasn't this because the surgery took an hour or more back then? And the technology advanced such that the surgery now takes 20-25% of the time?
 
I have heard of $2800 per eye back in the day, but not $3800. Those days, mostly extra-cap with sutures, postoperative suture cutting, many repeat refractions, higher risk of vitreous loss, CME and so on. Early phaco wasn't easy or fun and demanded much more skill than now to get optimum results, and also required sutures until better scleral tunnel and clear-cornea techniques caught on.
 
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