Economics of optometry and lasers/procedures

[orbitsurgMD]

Wow.

This thread has really gone off the rails here.

Why are people so obsessed with this Ben Gaddie guy?

He is the president-elect of the Kentucky Optometric Association and is spearheading his state's professional organization's practice expansion efforts. His methods are suspect: he misrepresents his and his membership's skills with wildly incredulous claims of "250,000 procedures" and "no complications." That is what makes him a scam artist and really, a liar. Deliberate misrepresentation by making those kinds of claims in public forums is unethical, period. If he were an obscure outlier, he would be unimportant. But in Kentucky, he and his association successfully bought from the Kentucky legislature the right to practice medicine and surgery subject only to whatever the state board of optometry says they can't do. Everything else is fair game, and that means everything, not just laser procedures or "lumps and bumps" but really any kind of surgery on any organ. The state board of medicine no longer has any authority over what optometrists do in Kentucky. Optometrists can get hospital privileges with their new board certifications (a new certifying board was just established--no residency training needed to be board-certified by them) and then open a surgery center which they can staff and pretty much do as they please, meaning any kind of surgery that the Kentucky Board of Optometry does not expressly forbid.

Ben Gaddie, O.D., whatever his ethics, is very successful, and he has proven that the Kentucky legislature will sell the right to practice medicine in that state for the right price. Right now, that price is $400,000. It is a terrible precedent and it speaks volumes as to how debased the legislatures of many states are.

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[SurgbySurgeons]

Wow.

Why are people so obsessed with this Ben Gaddie guy? Someone should send him an email and ask him to join this forum. I doubt he knows he has such a "fan" club. He's getting more attention than Charlie Sheen.

That's a great analogy, Ben Gaddie and Charlie Sheen, they are both "Winning"

All these silly anecdotes about this patient going blind or that patient going blind mean little.

Going blind means little, uh, OK

I can tell all kinds of stories of patients coming to me for second opinions on cataract surgery and all they had was -1.25 oblique cylinder that was uncorrected.

Again, good analogy, somebody going blind in the hands of an OD and a buck n' quarter cylinder goes undiagnosed by an MD

But this little tit for tat game is useless. Some OD misdiagnosed a skin lesion. Big frickin deal.

Big frickin deal, uh, OK if you say so

It's about who will ultimately control the profession of optometry. Optometry, or "someone else?"

In my opinion "someone else," and in the opinion of any medical society. If you poll the general public the overwhelming majority do as well. The only people who agree with this are optometrists

Optometry has grown tired and weary of having to grovel before the medical board or having some sort of bull**** hassle every time some new beta blocker comes out. Or Latisse. Or the issue of foreign bodies in New York. Or the issue of medicated contact lenses. Or epilation for Christ's sake.

Oh, I'm sooo sorry a medical board is keeping you from pushing your agenda at a faster pace. I wish they weren't bothering me as well. All of their silly rules and regulations

Virtually no optometrists really care about YAGs and PIs. (yea, yea, I know....Ben Gaddie. Ben Gaddie.)

You're right, Ben Gaddie

 

[KHE]

The state board of medicine no longer has any authority over what optometrists do in Kentucky.

I think that THAT is a good thing.

 

[KHE]

All these silly anecdotes about this patient going blind or that patient going blind mean little.

Going blind means little, uh, OK


But this little tit for tat game is useless. Some OD misdiagnosed a skin lesion. Big frickin deal.

Big frickin deal, uh, OK if you say so

Obviously going blind and misdiagnosed skin cancer ARE big deals. The point I'm making is that you guys all come across like an ophthalmologist has never misdiagnosed skin cancer or mismanaged a glaucoma case.

 

[KHE]

As far as numbers, I only have my practice as a reference. We have five docs who regularly do YAG caps. As a practice, we do about 45 per month or average 9 per doc. Don't know about PIs. Those are much less common. Another procedure to consider is SLT. We have 2 docs doing those for about 15 total per month. We lease the SLT, so it's likely underutilized. As a repeatable glaucoma laser, SLT would be a good revenue potential for someone with a glaucoma focus. There are multi-mode lasers available now for around $60k that will do YAG cap, PI, and SLT. ROI wouldn't be bad.

But again, that's in a large, surgical based practice. These patients simply don't exist in an optometric practice in anywhere CLOSE to the numbers needed to make a laser worthwhile.

15 SLTs per month. That's 7 per doc. In what sounds like a busy ophthalmological practice. I can count on one hand the number of patients I've referred out for SLT on ONE HAND in the last year, and again.....my practice is more "medical" than the average optometric practice. That's including the nursing home patients I see.

I'm going to say it for the last time....this is NOT about surgery.

 

[Visionary]

I'm going to say it for the last time....this is NOT about surgery.

Aw, can you say it one more time, please? 😀

Seriously, I'm not interested in chasing my tail either. Let's just agree to disagree. I understand that most optometrists, like you, are not interested in surgery. Some, even if a minority, obviously are or there wouldn't be surgical privileges prominently displayed in these scope expansion bills.

 

[speyeder]

Optometrists are not interested in surgery. Period.

Here's a novel idea. Don't lobby for surgical rights if you're not interested in surgery. Most ophthalmologists don't have a problem with optometrists prescribing medications and performing epilations, for example. But we draw the line at surgery.

 

[KHE]

Here's a novel idea. Don't lobby for surgical rights if you're not interested in surgery. Most ophthalmologists don't have a problem with optometrists prescribing medications and performing epilations, for example. But we draw the line at surgery.

Really? Is that so?

Then why, has every single scope bill been strongly opposed by ophthalmology in all 50 states? And I'm not talking about surgery. I'm talking about Patanol and epilations?

If ophthalmolgoists truly "didn't have a problem with it" then why didn't they SUPPORT it by saying "you know what.....we don't want our offices over run with minor allergic conjunctivitis patients and it's better for the patients that they see an optometrist with a slit lamp rather than a PCP who's just going to "eyeball" them (har har) and dump sulfacetamide on everything so yea....go ahead and let them prescribe Patanol and Tobradex."

Didn't happen. Not even once.

Here in Connecticut we JUST HAD a bill go before the insurance commission.

In optomety, we have a problem in many parts of the country where vision plans have made alliances with some major health insurers and optometrists are required to sign up for poor paying "vision" plans like VSP and Eyemed and Spectera IF ODs want to be on the corresponding medical plan.

So if an optometrist wants to be an Aetna provider let's say, then they MUST also enroll in and see Eyemed patients.

This same requirement is not made of ophthalmolgoists.

So a bill was introduced making this type of discrimination illegal. This would allow optometrists to only have to sign on for the poor paying routine vision plan IF that optometrist actually WANTED to.

You would think ophthalmology would support that, right? Because if the insurers do this to optometry, rest assured it's only going to be a matter of time before they do it to ophthalmology as well. Now, right now most ophthalmologists don't have opticals so they don't sign up for these plans and it's really of no concern to them. But wait......

Because here's the dirty little secret.....

Hypothetically, let's say that Aetna reimburses $100 for a 92004. VSP pays $60 for the same 92004.

What happens is that VSP goes to the insurance companies and says "hey....let us administer your eye care benefits. We will only charge you $80 for every 92004 your doctors see!"

And then what happens is VSP collects $80 from the major medical, and then turns around and pays the provider $60.

So the major medical SAVES $20. VSP MAKES $20.

Sounds like a win/win situation right? Oh.....but wait.....again.....

THE PROVIDER JUST LOST $40. Not quite so win/win is it?

Think that won't be happening in ophthalmology soon enough? Just wait. Pretty soon all you guys will be required to sign up for these crappy "vision" plans too. Don't think that it can't or won't happen. So it would make sense that this type of non-discrimination bill would be SUPPORTED by ophthalmology....wouldn't it?

I guess not. Ophthalmology testified AGAINST the bill.

Well.....they'll be lobbying FOR it soon enough. Mark my words.

 

[speyeder]

Really? Is that so?

Then why, has every single scope bill been strongly opposed by ophthalmology in all 50 states? And I'm not talking about surgery. I'm talking about Patanol and epilations?

If ophthalmolgoists truly "didn't have a problem with it" then why didn't they SUPPORT it by saying "you know what.....we don't want our offices over run with minor allergic conjunctivitis patients and it's better for the patients that they see an optometrist with a slit lamp rather than a PCP who's just going to "eyeball" them (har har) and dump sulfacetamide on everything so yea....go ahead and let them prescribe Patanol and Tobradex."

Didn't happen. Not even once.

Here in Connecticut we JUST HAD a bill go before the insurance commission.

In optomety, we have a problem in many parts of the country where vision plans have made alliances with some major health insurers and optometrists are required to sign up for poor paying "vision" plans like VSP and Eyemed and Spectera IF ODs want to be on the corresponding medical plan.

So if an optometrist wants to be an Aetna provider let's say, then they MUST also enroll in and see Eyemed patients.

This same requirement is not made of ophthalmolgoists.

So a bill was introduced making this type of discrimination illegal. This would allow optometrists to only have to sign on for the poor paying routine vision plan IF that optometrist actually WANTED to.

You would think ophthalmology would support that, right? Because if the insurers do this to optometry, rest assured it's only going to be a matter of time before they do it to ophthalmology as well. Now, right now most ophthalmologists don't have opticals so they don't sign up for these plans and it's really of no concern to them. But wait......

Because here's the dirty little secret.....

Hypothetically, let's say that Aetna reimburses $100 for a 92004. VSP pays $60 for the same 92004.

What happens is that VSP goes to the insurance companies and says "hey....let us administer your eye care benefits. We will only charge you $80 for every 92004 your doctors see!"

And then what happens is VSP collects $80 from the major medical, and then turns around and pays the provider $60.

So the major medical SAVES $20. VSP MAKES $20.

Sounds like a win/win situation right? Oh.....but wait.....again.....

THE PROVIDER JUST LOST $40. Not quite so win/win is it?

Think that won't be happening in ophthalmology soon enough? Just wait. Pretty soon all you guys will be required to sign up for these crappy "vision" plans too. Don't think that it can't or won't happen. So it would make sense that this type of non-discrimination bill would be SUPPORTED by ophthalmology....wouldn't it?

I guess not. Ophthalmology testified AGAINST the bill.

Well.....they'll be lobbying FOR it soon enough. Mark my words.

I don't agree with ophthalmology's opposition to epilations and prescribing rights either. But the fundamental question still hasn't been answered: Why lobby for surgical rights if the majority of optometrists have no interest in it?

 

[orbitsurgMD]

I think that THAT is a good thing.

So Kentucky optometry wants parity, but not if that means being held to the same level of accountability as ophthalmology. They would rather have a separate state optometry board providing "oversight" while getting privileges that theretofore had to be subject to a medical board. Interesting.

It isn't as if optometry has a unique domain, like dentistry, where one could reasonably argue the state board of medicine would not be the best agency to provide supervision. What optometrists in Kentucky want is complete freedom to describe the scope of their practice, even when that practice has and is already described by the state board of medicine. And it just so happens that the optometry board has a more relaxed understanding of how much of a residency one has to do in Kentucky to do surgery: none. So now, in Kentucky, if you are a professional and do surgery, you are accountable to the board of medicine, unless you are an optometrist. Then you are accountable to the optometry board. Under those terms, you should forget about lasers; you could have fellowships in dentistry.

I have to hand it to them, they have made an object lesson of the real nature of medical qualifications: they are nothing more than whatever you want them to be, with the help of the right legislators.

And if the issue isn't about surgery, then why was the legislation specifically about surgery?

 

[SurgbySurgeons]

I have been looking at the different states now pushing for "optometric surgery" and found this to be interesting. Click on the Course Schedule link

http://nebraska.aoa.org/x17676.xml

What do you guys think about this quote, coming from the Oklahoma OD

There is so much more to learning surgical techniques
than what is found in books or during a lecture.
Training as an optometric surgeon must include the
clinical experience of performing procedures. The
NSUOCO faculty do a great job with the didactic and
clinical training. When students and practitioners
complete this course, they not only know how to
manage peri-operative complications but they
experience what it feels like to give injections and
remove lesions with different surgical instruments.
They also have the confidence that we are the most
qualified practitioners to be providing this care for
patients across the state. This course is a critical
component of providing safe and effective surgical
treatments for our patient's eyelid and adnexa
abnormalities.
– Dr. Chris Wolfe, NSUOCO graduate & NOA member

 

[Visionary]

I have been looking at the different states now pushing for "optometric surgery" and found this to be interesting. Click on the Course Schedule link

http://nebraska.aoa.org/x17676.xml

What do you guys think about this quote, coming from the Oklahoma OD

There is so much more to learning surgical techniques
than what is found in books or during a lecture.
Training as an optometric surgeon must include the
clinical experience of performing procedures. The
NSUOCO faculty do a great job with the didactic and
clinical training. When students and practitioners
complete this course, they not only know how to
manage peri-operative complications but they
experience what it feels like to give injections and
remove lesions with different surgical instruments.
They also have the confidence that we are the most
qualified practitioners to be providing this care for
patients across the state. This course is a critical
component of providing safe and effective surgical
treatments for our patient's eyelid and adnexa
abnormalities.
– Dr. Chris Wolfe, NSUOCO graduate & NOA member

Yeah, a 16 hour course should suffice. It's just eye surgery.

 

[orbitsurgMD]

I have been looking at the different states now pushing for "optometric surgery" and found this to be interesting. Click on the Course Schedule link

http://nebraska.aoa.org/x17676.xml

What do you guys think about this quote, coming from the Oklahoma OD

There is so much more to learning surgical techniques
than what is found in books or during a lecture.
Training as an optometric surgeon must include the
clinical experience of performing procedures. The
NSUOCO faculty do a great job with the didactic and
clinical training. When students and practitioners
complete this course, they not only know how to
manage peri-operative complications but they
experience what it feels like to give injections and
remove lesions with different surgical instruments.
They also have the confidence that we are the most
qualified practitioners to be providing this care for
patients across the state. This course is a critical
component of providing safe and effective surgical
treatments for our patient's eyelid and adnexa
abnormalities.
– Dr. Chris Wolfe, NSUOCO graduate & NOA member

Pretty frightening, trying first to persuade that it might be of some value to actually do surgery as part of training (all those different instruments, so confusing) and in the same paragraph, the risible "we are the most qualified practitioners to be providing this care" rubbish. Quite the leap.

This kind of thing makes me lose respect for their profession, that is all. This is akin to thinking that learning to wave a white stick makes one a conductor.

It will be open war on dermal papillomas, or rather "lumps and bumps."

 

[speyeder]

I have been looking at the different states now pushing for "optometric surgery" and found this to be interesting. Click on the Course Schedule link

http://nebraska.aoa.org/x17676.xml

What do you guys think about this quote, coming from the Oklahoma OD

There is so much more to learning surgical techniques
than what is found in books or during a lecture.
Training as an optometric surgeon must include the
clinical experience of performing procedures. The
NSUOCO faculty do a great job with the didactic and
clinical training. When students and practitioners
complete this course, they not only know how to
manage peri-operative complications but they
experience what it feels like to give injections and
remove lesions with different surgical instruments.
They also have the confidence that we are the most
qualified practitioners to be providing this care for
patients across the state. This course is a critical
component of providing safe and effective surgical
treatments for our patient's eyelid and adnexa
abnormalities.
– Dr. Chris Wolfe, NSUOCO graduate & NOA member

If I was an optometrist I would be embarrassed by this.

 

[Mirror Form]

If I was an optometrist I would be embarrassed by this.

Don't worry, KHE has assured us that OD's dont' actually want to do surgery 🙄

KHE is actually correct that most OD's aren't going to want to bother with procedures. The time, overhead, and reimbursement isn't worth it. But the concern is that now ophthalmologists may have to compete with optometrists who set up referral based practices.

 

[Frumps]

http://nebraska.aoa.org/x17676.xml

There is so much more to learning surgical techniques
than what is found in books or during a lecture.
Training as an optometric surgeon must include the
clinical experience of performing procedures. The
NSUOCO faculty do a great job with the didactic and
clinical training. When students and practitioners
complete this course, they not only know how to
manage peri-operative complications but they
experience what it feels like to give injections and
remove lesions with different surgical instruments.
They also have the confidence that we are the most
qualified practitioners to be providing this care for
patients across the state. This course is a critical
component of providing safe and effective surgical
treatments for our patient's eyelid and adnexa
abnormalities.
– Dr. Chris Wolfe, NSUOCO graduate & NOA member

This is unreal. They start out by saying that there is more to surgery than just books and a lecture, but I guess the 4 hour hands-on lab covers everything. In fact, in that 4 hours you become the MOST qualified practitioners in the state. Intro to suturing...seriously. Just flat out embarrassing.

 

[KHE]

Don't worry, KHE has assured us that OD's dont' actually want to do surgery 🙄

KHE is actually correct that most OD's aren't going to want to bother with procedures. The time, overhead, and reimbursement isn't worth it. But the concern is that now ophthalmologists may have to compete with optometrists who set up referral based practices.

Who is going to refer to them? I've already addressed this. Optometrists don't refer to each other for treatment of minor medical conditions. You think we're going to refer to each other for surgery? LMAO.

 

[JMK2005]

You think we're going to refer to each other for surgery? LMAO.

Of course ODs would refer to each other. What is would stop them?

 

[KHE]

Of course ODs would refer to each other. What is would stop them?

Again....we don't refer to each other NOW. For ANYTHING. You think we're suddenly going to START doing it for SURGERY?


Not a chance.

 

[Visionary]

I have been looking at the different states now pushing for "optometric surgery" and found this to be interesting. Click on the Course Schedule link

http://nebraska.aoa.org/x17676.xml

What do you guys think about this quote, coming from the Oklahoma OD

There is so much more to learning surgical techniques
than what is found in books or during a lecture.
Training as an optometric surgeon must include the
clinical experience of performing procedures. The
NSUOCO faculty do a great job with the didactic and
clinical training. When students and practitioners
complete this course, they not only know how to
manage peri-operative complications but they
experience what it feels like to give injections and
remove lesions with different surgical instruments.
They also have the confidence that we are the most
qualified practitioners to be providing this care for
patients across the state. This course is a critical
component of providing safe and effective surgical
treatments for our patient's eyelid and adnexa
abnormalities.
– Dr. Chris Wolfe, NSUOCO graduate & NOA member

Just read the flier again in more detail. Truly jaw-dropping. They even mention fluorescein angiography. What's the point of that? Unless you plan on treating retinal pathology, there's no need to do an FA. Think the retina doc will appreciate that, when you send the referral? Not to mention that performing an FA and interpreting one are vastly different skills. I was still learning the finer points in fellowship. I agree with speyeder. I'd be embarrassed. Demonstrates that they don't even know what they don't know.

 

[coppertopdoc]

I have been looking at the different states now pushing for "optometric surgery" and found this to be interesting. Click on the Course Schedule link

http://nebraska.aoa.org/x17676.xml

What do you guys think about this quote, coming from the Oklahoma OD

There is so much more to learning surgical techniques
than what is found in books or during a lecture.
Training as an optometric surgeon must include the
clinical experience of performing procedures. The
NSUOCO faculty do a great job with the didactic and
clinical training. When students and practitioners
complete this course, they not only know how to
manage peri-operative complications but they
experience what it feels like to give injections and
remove lesions with different surgical instruments.
They also have the confidence that we are the most
qualified practitioners to be providing this care for
patients across the state. This course is a critical
component of providing safe and effective surgical
treatments for our patient's eyelid and adnexa
abnormalities.
– Dr. Chris Wolfe, NSUOCO graduate & NOA member

Holy Crap! NSUOCO does have an ophthalmologist on staff that does train those procedures, but I cannot believe they are touting that "we" are "the most qualified". Really?

I am growing more and more weary of the turf battles and the lines "they" are crossing! I have long thought it was irresponsible to wrtie legislation open ended enough that it will allow for expension into areas in which we have no training, i.e. cataract surgery.

Can't say I'm proud to be an O.D. any longer.

 

[Shnurek]

Yea I can't say I agree with: "They also have the confidence that we are the most qualified practitioners to be providing this care for
patients across the state."

The only exception would be Dr. Richard Castillo, D.O., O.D. that shows off here: http://www.theoptometricproceduresinstitute.com/[OD]On-Demand/FREE_ODTV.html

 

[eyesupply]

I cannot say what Kentucky optometrists will do with laser.

Will they branch out to hair transplantation? 😱

I can say that I have seen another profession that calls themselves "doctor" and are not MDs (or DO) and also not dentists. With that profession, they have no shame in asking patients to come back 30 times and do what seems to be unnecessary work.

With ophthalmologists, most practice about the same. Florida seems like a wild place with some wacky plastic surgery done (not by ophthalmologists) but a few (very few) are rumored to do screening hearing tests. 😱 With that other profession that I mentioned about in paragraph 3, there are wild swings.

For the public interest, it would be better if Kentucky optometrists behave themselves.

 

[Visionary]

Yea I can't say I agree with: "They also have the confidence that we are the most qualified practitioners to be providing this care for
patients across the state."

The only exception would be Dr. Richard Castillo, D.O., O.D. that shows off here: http://www.theoptometricproceduresinstitute.com/[OD]On-Demand/FREE_ODTV.html

Yeah, that's because he's an ophthalmologist. He, appropriately, went to med school and ophthalmology residency after optometry school, upon deciding he wanted to do surgery. Of course, training "optometric surgeons" must be a great revenue stream for him. I saw that these mini-courses run from $800-1000 a head. Maybe I should offer to do some FA/ICGA, retina laser, and intravitreal injection courses there. Heck, I could retire early! Who cares if I'm selling out my profession? 😉

 

[Shnurek]

That's the problem with many Americans. Arrogance. My parents both had Masters degrees from Eastern Europe but when they came here, suddenly they were irrelevant. If the MD's didn't have their noses up in the air for many decades now, we wouldn't have all this confusion and unnecessary complication of the healthcare system. Instead of creating more MD slots and vertically integrating, DO's instead conformed to the MD model and now there is a confusing disparity (to the layman) between Medical Doctors and Doctors of Osteopathy.

Look at Anesthesiologists and the new legislation of Anesthesiology Assistants (AA's) and Certified Registered Nurse Anesthetists (CRNAs).
CRNA's now make more than General Practitioners and Family Medicine MD's/DO's! Look at Audiologists gaining ground on Otolaryngologists.

Wake up and smell the coffee people. If you (or the AMA) artificially keep the slots down while the demand grows. People find other ways of satisfying that demand and your profession suffers.

 

[Visionary]

That's the problem with many Americans. Arrogance. My parents both had Masters degrees from Eastern Europe but when they came here, suddenly they were irrelevant.

I'm missing your point here. What did they have degrees in? Why were they considered irrelevant? What does that have to do with this thread?

If the MD's didn't have their noses up in the air for many decades now, we wouldn't have all this confusion and unnecessary complication of the healthcare system. Instead of creating more MD slots and vertically integrating, DO's instead conformed to the MD model and now there is a confusing disparity (to the layman) between Medical Doctors and Doctors of Osteopathy.

MDs and DOs are both medical doctors. Allopathic and osteopathic programs do differ in many respects, but the core of both is broad-based medical training.

Look at Anesthesiologists and the new legislation of Anesthesiology Assistants (AA's) and Certified Registered Nurse Anesthetists (CRNAs). CRNA's now make more than General Practitioners and Family Medicine MD's/DO's! Look at Audiologists gaining ground on Otolaryngologists.

Yeah, and anesthesiologists make much more than CRNAs. You're comparing a specialty to general medicine. It's well known that primary care docs have been getting the shaft for some time.

As for need, there is no "real" access to care issue for ophthalmic surgical services, as the optometry lobby would have the public believe. The fact is that people who live in rural areas have access problems in regard to all sorts of services. That's because there is not enough customer volume density to justify the presence of those services. Why do you think that even the "optometric surgeons" in Oklahoma all practice in metropolitan areas? To have a thriving medical or surgical practice, you need an adequate patient volume and a decent payor mix. It may get marginally better, if rural physicians start being rewarded for staying put. Here's a good article that covers these issues: http://money.cnn.com/2010/03/26/news/economy/health_care_rural_care_country_doctors/index.htm

Wake up and smell the coffee people. If you (or the AMA) artificially keep the slots down while the demand grows. People find other ways of satisfying that demand and your profession suffers.

Neither I nor the AMA nor any other physician organization artificially keeps the numbers down. The number of residency slots for various specialties are, in a sense, restricted by the government (Department of Health & Human Services, to be exact), which provides funding for the vast majority of programs. The number of funded residency slots has been capped by Medicare since 1997, despite a growing need for physicians. Attempts have been and are being made to create private funding, but Medicare continues to be the largest funding source. In turn, the medical schools can't just arbitrarily increase class sizes, or there would be too many graduates relative to residency slots.

Another problem is that increasing medical school class sizes really only leads to an increase in specialists, rather than primary care physicians, due to the terrible return on investment experienced by the latter (see above). Little wonder why so many primary care docs are seeking the shelter as employees. Trying to keep a private primary care practice afloat these days is very difficult.

 

[KHE]

Neither I nor the AMA nor any other physician organization artificially keeps the numbers down. The number of residency slots for various specialties are, in a sense, restricted by the government (Department of Health & Human Services, to be exact), which provides funding for the vast majority of programs. The number of funded residency slots has been capped by Medicare since 1997, despite a growing need for physicians. Attempts have been and are being made to create private funding, but Medicare continues to be the largest funding source. In turn, the medical schools can't just arbitrarily increase class sizes, or there would be too many graduates relative to residency slots.

Another problem is that increasing medical school class sizes really only leads to an increase in specialists, rather than primary care physicians, due to the terrible return on investment experienced by the latter (see above). Little wonder why so many primary care docs are seeking the shelter as employees. Trying to keep a private primary care practice afloat these days is very difficult.

Does anyone have any knowledge as to how much HHS provides in "funding" for a residency slot in ophthalmology?

I wonder about the possibility of charging tuition for residency training?

 

[eyesupply]

If the MD's didn't have their noses up in the air for many decades now, we wouldn't have all this confusion and unnecessary complication of the healthcare system. Instead of creating more MD slots and vertically integrating, DO's instead conformed to the MD model and now there is a confusing disparity (to the layman) between Medical Doctors and Doctors of Osteopathy.
.

DO schools are the problem. There were proposals to convert them to MD schools but the DO establishment refused. One major school did convert, the University of California College of Medicine in Irvine. Some schools are marginal and would have had problems meeting the standards but some could have done so without that much work.

As a result of wanting to be the leaders of a small field instead of being swallowed up by MD schools, DO schools remained separate. That hurts a lot of DO, some of whom feel like second class citizens (some don't).

In most countries, there are no DO's. In many countries, there are no optometrists, just MD's. The problem with that is that some may not like to do glasses.

I have seen a whole lot of variability in the quality of optometrists. Some are just quacks, some know very, very little, some seem sharp. In contrast, the quality of ophthalmologists are fairly even. I'm not sure why this is the case. Perhaps it is because of less stringent admission standards or that any school would find it hard to train 100 ophthalmology residents but optometry schools train that number, not just 3-4 per year. Another factor might be that only the better medical students can get into ophthalmology but that once you're in optometry school, you're set for life.

 

[orbitsurgMD]

Does anyone have any knowledge as to how much HHS provides in "funding" for a residency slot in ophthalmology?

I wonder about the possibility of charging tuition for residency training?

Funds are paid to the sponsoring institutions. The amounts vary, but rough figures might be at $100K per resident per year. The resident sees less than half that as a salary, the rest is kept by the institutions to support training activities. Benefits are minimal and there is no retirement plan for which housestaff are generally eligible. Most are employed on a renewable one year contract basis.

Remember, residents cannot do billable work and the work they do has to be under the supervision of a staff attending who is board-certified.

Many decades ago, ophthalmology was a post-doctorate master's degree course of study. I am not sure whether tuition was charged, but that was when few doctors did more than an internship and board-certification was rare.

A program that did so now would likely find itself among the least competitive for applicants as most residents expect a contract with salary, even if low-paying. Only those applicants with no better alternatives and enough private funds for self-support and tuition would likely be willing. And what kind of mission, except for a profit-making purpose, would a training program have to be graduating residents even more motivated to recover their investment?

 

[eyesupply]

Remember, residents cannot do billable work and the work they do has to be under the supervision of a staff attending who is board-certified.

Many decades ago, ophthalmology was a post-doctorate master's degree course of study. I am not sure whether tuition was charged, but that was when few doctors did more than an internship and board-certification was rare.

Residents do see patients unsupervised. It may shock reporters but it happens. Actually, a good residency has a little bit of unsupervised work because it's good training. But too much is bad. In our program, we (all the senior residents) used to do one thing completely wrong until I learned the correct way from a new faculty member. Actually, I think ophthalmology could easily benefit from being a 1+4 or 5 year program. One year, you'd do at another institution (exposing residents to different faculty) and if there were a 2nd additional year, you could do 2 6 month mini-fellowships.

In the 1800's to early 1900's, you could do a year or two of medical training even after high school and be a MD. 😱

 

[Visionary]

Does anyone have any knowledge as to how much HHS provides in "funding" for a residency slot in ophthalmology?

I wonder about the possibility of charging tuition for residency training?

As orbitsurgMD stated, the figures vary, but I've also heard ~$100k/resident/year. It's not just for ophthalmology, but for all specialties, including primary care. Resident salaries vary from mid $30k to mid $50k, with modest annual increases.

Tuition for residency, eh? That would really cause a physician shortage across the board! Even in the case of the shorter residencies, that could effectively double your debt. Given the ever falling (in relative terms, of course) reimbursements, it could take a couple of decades in primary care just to pay it all down! No way that happens. I've heard of fellowships that are unsalaried, but they don't charge tuition. Do optometric residencies and fellowships charge tuition?

 

[orbitsurgMD]

Residents do see patients unsupervised.

Yeah, I seem to remember, it wasn't that long ago. But every encounter was under an attending, whether on call or in a resident clinic. They do not have to be present for every moment, but they have responsibility for things you do as a resident.

 

[Visionary]

Residents do see patients unsupervised. It may shock reporters but it happens. Actually, a good residency has a little bit of unsupervised work because it's good training. But too much is bad. In our program, we (all the senior residents) used to do one thing completely wrong until I learned the correct way from a new faculty member. Actually, I think ophthalmology could easily benefit from being a 1+4 or 5 year program. One year, you'd do at another institution (exposing residents to different faculty) and if there were a 2nd additional year, you could do 2 6 month mini-fellowships.

In the 1800's to early 1900's, you could do a year or two of medical training even after high school and be a MD. 😱

Actually, if an attending doesn't sign off on your work, and they bill for the services, that's insurance fraud. If the patient is uninsured and indigent, that's another thing. As orbitsurgMD pointed out, the attendings are ultimately responsible. They should be present in the clinic, whether or not they actually go behind you on every patient. Attending comfort level varies with resident experience. At my program, there was always some degree of oversight. Complete lack of oversight is a disservice to you as a resident, as well as to the patients.

 

[orbitsurgMD]

Agreed. Lots of activity within the last couple days. Have a new puppy at home, so have been out of the loop.

I understand your points about control and how only a minority will be seeking surgical privileges, and I'm glad you see why we continue to be irked by the surgery issue. The reason Gaddie keeps coming up is because he is the KOA president-elect and, presumably (I have no inside knowledge), one of the primary architects of KY SB 110. He did a fellowship in glaucoma lasers before returning to Louisville to join his father's practice, knowing full well that he would not be able to perform said lasers. Then, voila, he is elected KOA president and this bill goes through. Not likely a coincidence.

As far as numbers, I only have my practice as a reference. We have five docs who regularly do YAG caps. As a practice, we do about 45 per month or average 9 per doc. Don't know about PIs. Those are much less common. Another procedure to consider is SLT. We have 2 docs doing those for about 15 total per month. We lease the SLT, so it's likely underutilized. As a repeatable glaucoma laser, SLT would be a good revenue potential for someone with a glaucoma focus. There are multi-mode lasers available now for around $60k that will do YAG cap, PI, and SLT. ROI wouldn't be bad.

The monthly cost for an SLT is covered by less than the payment for 4 eyes (using the portable unit as the basis for calculations); 15 per month is more than enough to justify purchase or lease. The problem with the Lumenis laser is its cost, much more than KTP or a multipulse laser.

 

[Visionary]

The monthly cost for an SLT is covered by less than the payment for 4 eyes (using the portable unit as the basis for calculations); 15 per month is more than enough to justify purchase or lease. The problem with the Lumenis laser is its cost, much more than KTP or a multipulse laser.

Exactly. We contemplated a multi-mode, because our argon is on it's last leg. With EHR already in the works, we couldn't justify it. Perhaps in the next couple of years.

 

[Light9]

... Truly jaw-dropping. They even mention fluorescein angiography. What's the point of that? Unless you plan on treating retinal pathology, there's no need to do an FA. Think the retina doc will appreciate that, when you send the referral? Not to mention that performing an FA and interpreting one are vastly different skills. I was still learning the finer points in fellowship. I agree with speyeder. I'd be embarrassed. Demonstrates that they don't even know what they don't know.

Are you saying you need to be a retinal specialist to perform & properly interpret FA?
I'm surprised that throughout your 4 years of pap smear & hernia check practice followed by your 1 year supervised multi-specialty slave work (required internship) they didn't stress the importance of FA as a great diagnostic tool. I would think that the 3 year ophthalmology residency would have at least taught a little about that.

 

[Shnurek]

Are you saying you need to be a retinal specialist to perform & properly interpret FA?
I'm surprised that throughout your 4 years of pap smear & hernia check practice followed by your 1 year supervised multi-specialty slave work (required internship) they didn't stress the importance of FA as a great diagnostic tool. I would think that the 3 year ophthalmology residency would have at least taught a little about that.

Na, they just focus on how to do surgery and apparently I heard they HATE doing subjective refractions 🙂

But seriously lets not add oil to the fire. I've used those "extraneous education" arguments along with my neuroplasticity argument ad nauseum and really one side is never going to convince the other. We must "buy" our medical degree from legislators as they put it.

 

[Visionary]

Are you saying you need to be a retinal specialist to perform & properly interpret FA?
I'm surprised that throughout your 4 years of pap smear & hernia check practice followed by your 1 year supervised multi-specialty slave work (required internship) they didn't stress the importance of FA as a great diagnostic tool. I would think that the 3 year ophthalmology residency would have at least taught a little about that.

Your first foray into SDN, and this is your contribution? Pretty pathetic. Let me guess: pre-optometry?

 

[jsh1986]

Last week while seeing consults with my attending, we diagnosed lyme disease and hepatitis C in two of the patients on the inpatient neurology service. The CC of the pts? "Blurry vision."Knowing the pathophysiologic bases and basic science principles for gastroenterological, vascular, infectious, etc. diseases sure didn't seem extraneous then...

It is so disheartening to hear some of the ridiculous and at times hateful comments put on this forum. I'm sorry, but many of you do not know how little you know. And that is very frightening.

 

[Shnurek]

Do you realize that what optometry schools teach now is very different than what they did 20 years ago? They learn all ocular pharmacology and all ocular manifestations of systemic disease. So yes, they can refer that properly as well.

 

[jsh1986]

Yes, I'm quite sure you do 😀

Do you realize that what optometry schools teach now is very different than what they did 20 years ago? They learn all ocular pharmacology and all ocular manifestations of systemic disease. So yes, they can refer that properly as well.

 

[Shnurek]

Yes, the board exams were recently changed to become more clinically relevant. This year there was only a 72% national pass rate.

I agree that those older optometrists are just happy doing refractions everyday but as the profession is evolving, so is the education.

 

[bungo]

Do you realize that what optometry schools teach now is very different than what they did 20 years ago? They learn all ocular pharmacology and all ocular manifestations of systemic disease. So yes, they can refer that properly as well.

You are proving this point:

"I'm sorry, but many of you do not know how little you know. And that is very frightening."

 

[bungo]

Do you realize that what optometry schools teach now is very different than what they did 20 years ago? They learn all ocular pharmacology and all ocular manifestations of systemic disease. So yes, they can refer that properly as well.

You are proving this point:

"I'm sorry, but many of you do not know how little you know. And that is very frightening."

 

[speyeder]

Are you saying you need to be a retinal specialist to perform & properly interpret FA?
I'm surprised that throughout your 4 years of pap smear & hernia check practice followed by your 1 year supervised multi-specialty slave work (required internship) they didn't stress the importance of FA as a great diagnostic tool. I would think that the 3 year ophthalmology residency would have at least taught a little about that.

Troll

 

[Shnurek]

http://www.youtube.com/watch?v=T0xoKiH8JJM

Ultimate troll 😀

 

[Light9]

You are proving this point:

"I'm sorry, but many of you do not know how little you know. And that is very frightening."

Thanks. Hopefully with your superior knowledge you understand how years spent performing clinical procedures that you will never repeat in practice (ie: casting a leg, pap smear, turn & cough, rectal exams...) is MORE beneficial than learning and appreciating these procedures, recognizing their associated pathologies, relating them back to eye health, and practicing ocular health care instead.

 

[Light9]

http://www.youtube.com/watch?v=T0xoKiH8JJM

Ultimate troll 😀

haha, terrible ultimate troll.

 

[bungo]

Thanks. Hopefully with your superior knowledge you understand how years spent performing clinical procedures that you will never repeat in practice (ie: casting a leg, pap smear, turn & cough, rectal exams...) is MORE beneficial than learning and appreciating these procedures, recognizing their associated pathologies, relating them back to eye health, and practicing ocular health care instead.

Few people will give you the argument you want.

 

[Light9]

Last week while seeing consults with my attending, we diagnosed lyme disease and hepatitis C in two of the patients on the inpatient neurology service. The CC of the pts? "Blurry vision."Knowing the pathophysiologic bases and basic science principles for gastroenterological, vascular, infectious, etc. diseases sure didn't seem extraneous then...

It is so disheartening to hear some of the ridiculous and at times hateful comments put on this forum. I'm sorry, but many of you do not know how little you know. And that is very frightening.

Maybe that is because the diseases you listed are not extraneous. They are (and should be) relatively common knowledge to any 1st year optometry, dental, medical, podiatry... student these days.