Cutthroat Market Compared To Other Specialties?

[corneainterviewseason]

I'm still in training, but my sense in talking with practicing ophthalmologists in a few different cities (desirable locations) is that the market is pretty cut-throat. Given the over-saturation in these areas, I've been told it has become more cut-throat recently with stiffer competition and intense pressure to "keep up with the Joneses", having the lastest and greatest piece of technology, etc... Some that have recently started out lament how difficult it is to join a smaller practice (2-3 physicians) and compete with mega-groups spending millions on advertising every year. Some personal friends have left for less desirable locations.

Am I just oblivious to this happening in other specialities? Or does our high rate of elective procedures, or premium lenses, encourage this sort of behavior? I love ophthalmology and what I have chosen to do, but if I had one complaint it is how much of a business ophthalmology has become. Anybody have friends in other specialties that complain of this sort of thing? I'm hoping it exists elsewhere, for some reason that would make me feel less frustrated.

---

Members don't see this ad.

 

[DrZeke]

I originally wrote "fellowship?" But based on your name it appears you are going to do cornea. I understand your post better now...

I'm also in training and I have gotten a similar impression of comprehensive ophthalmology and wondered the same.

Sent from my iPhone using SDN mobile app

 

[corneainterviewseason]

You're correct. The people I've heard talk most about this are anterior segment surgeons.

 

[LightBox]

Like anything financially worthwhile in Life, Ophthalmology in private practice is competitive. But I wouldn't say "cutthroat". If you do a good job, are a good surgeon, and are pleasant, then you will do just fine. Everything is relative. Sure, the big dawgs are probably making 7 figures while the small pups are making lower/mid 6 figures. But to be honest, the level of happiness between the two groups is probably relatively similar.

 

[Bgladney]

Wouldn't say it is "cutthroat" out there on the whole. In the metro areas like NYC, LA, etc, it is difficult.

Major Metros....250 cataracts per year might be a fairly busy practice. An hour outside of a metro, 250 would be a starting volume for someone.

If you are looking to be in Orange County or something, you should have lower expectations or you will be extremely disappointed.

 

[Dusn]

I try to discourage my residents from going into cornea. I think you pretty much described the business situation accurately there. When I look at the typical retina, uveitis, or glaucoma clinic - most of the patients on the clinic schedule would go blind if they weren't seen and treated. When I look at the typical cornea clinic schedule (outside of some academics) I really wonder whether I could cancel the entire clinic and almost all of the patients would be completely fine. After seeing so many unhappy patients with multifocal IOLs I'm also not a fan of what they do there. It's an oversaturated sub speciality and they do little that comprehensive can't do.

Sorry to sound harsh to the cornea specialist out there but I wanted to be pretty straightforward to the residents here considering cornea.

 

[DrZeke]

I try to discourage my residents from going into cornea. I think you pretty much described the business situation accurately there. When I look at the typical retina, uveitis, or glaucoma clinic - most of the patients on the clinic schedule would go blind if they weren't seen and treated. When I look at the typical cornea clinic schedule (outside of some academics) I really wonder whether I could cancel the entire clinic and almost all of the patients would be completely fine. After seeing so many unhappy patients with multifocal IOLs I'm also not a fan of what they do there. It's an oversaturated sub speciality and they do little that comprehensive can't do.

Sorry to sound harsh to the cornea specialist out there but I wanted to be pretty straightforward to the residents here considering cornea.

After attending meetings, interacting with renowned cornea specialists who are even more specialized within cornea, I still have some of these impressions too. Is there a cornea specialist who can speak to this or say otherwise?




Sent from my iPhone using SDN mobile app

 

[Slide]

I try to discourage my residents from going into cornea. I think you pretty much described the business situation accurately there. When I look at the typical retina, uveitis, or glaucoma clinic - most of the patients on the clinic schedule would go blind if they weren't seen and treated. When I look at the typical cornea clinic schedule (outside of some academics) I really wonder whether I could cancel the entire clinic and almost all of the patients would be completely fine. After seeing so many unhappy patients with multifocal IOLs I'm also not a fan of what they do there. It's an oversaturated sub speciality and they do little that comprehensive can't do.

Sorry to sound harsh to the cornea specialist out there but I wanted to be pretty straightforward to the residents here considering cornea.

Slightly unrelated to the topic at hand but one story a colleague told me about one of his friends who was starting his cornea fellowship was that he was told this introductory quote:

"Congratulations, welcome to the worst specialty in ophthalmology but we're happy to have you!"

Before the pitchforks come out, the phrase was in reference to the typical patient population he was going to treat - namely, patients with high expectations and needs. I am in no way dissing on cornea specialists and fellows/applicants - it just seems that in the private practice world, unless you have a concierge-like practice where you can not deal with insurance/government reimbursement, it seems like an ever-evolving rat race (having the new femtosecond/ORA technology, 20/20 refractive packages, etc.) that your patients are making you participate in. Fits probably some people but definitely not for me. Then again, in retina having to deal with noncompliant patients with unrealistic expectations after surgery can also be just as painful.

To OP: yes you are right, it's very competitive and cut throat in major metropolitan areas. If you don't have connections or a friend/family member that can hook you up, finding a job is difficult, and even if so, the pay may not be great even after your first few years. Even for specialists, you may need to have some niche thing in your field in order to find a nice job in a major metropolitan area. If you're willing to go in higher need areas, you'll be rewarded handsomely.

 

[Eyefixer]

I've been posting about this on here for many years. This is not just limited to cornea. I am a senior partner in a large medical group in ultra competitive area and I sit on physician compensation committee for all specialities. Ophthalmology reimbursement is miserable. MGMA wRVU values are on par with Peds. Even family medicine is higher. This will likely continue to get worse as they keep cutting reimbursement for surgical procedures. The only way you are going to be able to make any kind of real money in ophthalmology in the future is by being an entrepreneur- surgery center, optical revenue, premium lenses, employing other doctors, etc. If you are not that type, DO NOT go into ophthalmology. You will be paid peanuts for your work by insurances.


Sent from my iPhone using SDN mobile

 

[EyeOweYou]

I've been posting about this on here for many years. This is not just limited to cornea. I am a senior partner in a large medical group in ultra competitive area and I sit on physician compensation committee for all specialities. Ophthalmology reimbursement is miserable. MGMA wRVU values are on par with Peds. Even family medicine is higher. This will likely continue to get worse as they keep cutting reimbursement for surgical procedures. The only way you are going to be able to make any kind of real money in ophthalmology in the future is by being an entrepreneur- surgery center, optical revenue, premium lenses, employing other doctors, etc. If you are not that type, DO NOT go into ophthalmology. You will be paid peanuts for your work by insurances.


Sent from my iPhone using SDN mobile

Can anyone else confirm this? Are you referring to competitive markets or nationwide? I've heard that the glory days are in the past, but I didn't think it was that bad

 

[LightBox]

It isn't that bad. Another way of stating "Eyefixer"'s post is: "No one is going to just hand you 500k for graduating residency. You actually have to (gasp) work for it and be savvy just like in any other profession in the world."

That being said, what starting salaries and bonus structures are newbies being offered these days?

 

[Eyefixer]

"Lightbox" is one of the few on here who eventually made partner in a good RURAL practice ( do you have Denny's down there bud?). But RURAL environment is not for everyone . Here is his post from 2012:

"I make about 300K total, 2 years out of training, but am practicing in a rural environment doing basically everything. I'm an associate and my boss basically will be screwing me, so I'll be moving on eventually.

Though 300K might sound like "alot", trust me... if you are receiving a W-2, the taxes really eat up your take-home salary. Plus, I have no stake in the real-estate, an ASC, or other tax-advantaged entities. That is another reason why owning the business is very important. You can keep your money "hidden away" in the business/real estate and draw a lower salary so that you incur less income taxes. You can still invest in stocks, municipal bonds, etc via your business. How do you think the super-rich only pay a 8-9% realized tax rate? It is because they do not incur high income taxes and keep their money in their businesses. They also deduct everything via their business to lower their tax bill further.

Though my compensation is reasonable, I feel far from "rich" and definitely am not driving around a Benz or living the high-life. But then again, I'm trying to be as frugal as possible given I plan to move on. Hope that helps.

LightBox, Jul 21, 2012 Report"

 

[LightBox]

Haha, ahhh EyeFixer... I know you can't believe that someone could do well out in suburban America, but it is much more common than you think. I'm not sure why you felt the need to post an old post of mine from 2012 when I was a lowly associate somewhere far far away. Yes, 300k didn't feel like much but in retrospect, it was pretty good given that it was absolutely risk-free and didn't involve any administrative duties. Heck, even making 5x as much doesn't feel like "alot" I guess because one's priorities in life change. With more money comes more headache in terms of administrative tasks, dealing with staff, etc.

Anyways, my point is for some of you out there: stay positive. It really isn't as bad as some people make it out to be!

 

[Eyefixer]

The need was felt because you repeatedly posted in the past that you are not in rural America while "you can't really imagine only make $600k anymore". So just to give some perspective on your posts. That's all.


Sent from my iPhone using SDN mobile

 

[LightBox]

The need was felt because you repeatedly posted in the past that you are not in rural America while "you can't really imagine only make $600k anymore". So just to give some perspective on your posts. That's all.
Sent from my iPhone using SDN mobile

It's like any job out there -- once you make a certain amount of $$, it is hard to go backwards. Obviously, I could easily live on my compensation as an associate, but do I want to? Of course not! I live a relatively modest lifestyle (e.g. old car, <1M home, etc), but for me, if I am going to work, I might as well make as much money as possible and save for my family's security and future.

Anyways, my posts and perspective seem to bring out some sort of angst out of you. I'm just trying to give people the flip side perspective of things. You can do well in Ophthalmology.

 

[khajj]

I try to discourage my residents from going into cornea. I think you pretty much described the business situation accurately there. When I look at the typical retina, uveitis, or glaucoma clinic - most of the patients on the clinic schedule would go blind if they weren't seen and treated. When I look at the typical cornea clinic schedule (outside of some academics) I really wonder whether I could cancel the entire clinic and almost all of the patients would be completely fine. After seeing so many unhappy patients with multifocal IOLs I'm also not a fan of what they do there. It's an oversaturated sub speciality and they do little that comprehensive can't do.

Sorry to sound harsh to the cornea specialist out there but I wanted to be pretty straightforward to the residents here considering cornea.

I don't post often in forums such as this but as a cornea specialist this clearly represents a very poor understanding of the realities of cornea and external disease as a subspecialty. I think all sub specialties in ophthalmology do valuable work.

Saying that you could just cancel all the cornea clinic patients for the day and that the work that is being done is any less valuable than another subspecialty is degrading, unnecessary and wrong.

Would you say that corneal perforations, corneal ulcers, ocular surface neoplasias, herpetic eye disease, corneal scars or lacerations are not vision threatening problems?

Anterior basement membrane disease and graft versus host disease, Stevens Johnson, ocular cicatricial pemphigoid, PUK, and salzman nodular degeneration are all treatable conditions that cause severe vision loss just as much as diseases treated in other specialties.

The improvement in vision from treating dry eye and sjogrens can cause just as much improvement in vision as surgery for a macular hole or ERM and are critical for quality of life as well. A good cornea specialists treatment of dry eye is much more complex than 4x a day artificial tears versus 6x a day with ointment at night.

Trust me these problems are also not isolated to academic centers but are in fact extremely common in a private practice settings as well.

I am not sure of the reason for disparaging cornea specialists. I find my work in cornea very rewarding and refractive procedures are also an extremely satisfying experience that can dramatically improve patients' quality of life.

Cornea in large cities is probably not the most attractive job market but many other subspecialties like retina have a challenging job climate as well in these locations. Jobs are out there regardless, and I can't understand why someone would actively discourage residents from pursuing an entire subspecialty that many ophthalmologists love and find rewarding.

 

[FootballFoot]

Do ophthalmologists not make a lot of money anymore? Assuming general ophtho w/out fellowship, is 300k+ working 40 or less hours a week unreasonable in the field now if you are not an owner?

 

[DrZeke]

Who said it's 300+k working less than 40 hours a week if you are not an owner? Cuz that sounds inflated.


Sent from my iPhone using SDN mobile app