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Fabulously wealthy ophthalmologists? What gives?
- Thread starter Toadkiller Dog
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I am compelled to weigh in. There are a lot of threads revolving around income in ophthalmology. General vs cornea vs retina, and citing compensation surveys. I will weigh in with my experience, the math, and maybe a broader perspective. I will be as honest as possible.
Me: general ophthalmologist (high volume cataract practice), 10 years in practice, hung out a shingle and started from scratch (didn't pay myself for 9 months). Two new associates now to help with work load, I work 4.5 days/week. Total pre-tax income was 1.1 million. 850K from practice, 150K from ASC ownership, 100K from emergency coverage at local hospital. Hopefully more next year as associates ramp up. I certainly would not call this fabulously wealthy, but it is certainly enough to have what I need and save a lot.
The thing to remember when trying to rationalize why one ophthalmologist makes more than another is volume. The bulk of your income, initially, will come from your practice. Generally speaking, I get paid the same amount to do a cataract as a guy in NYC or Fargo. Retina guys all get paid the same amount per injection or membrane peel. The guys who make more, do more. I know ophthalmologists who make 250K/year. They also see fewer patients and do 5 cases/week. That works for them. I know a cataract/lasik guy who makes >2 million every year. He is like a machine. Once again, volume. If you want to work hard, see a lot of patients, and do a lot of surgery, you will make a lot of money. This is just math. I do not mean to over-simplify this. The practice managers will factor in all of the other expenses that affect bottom line. However, they will also point out what a significant impact something as simple as doing 3 more cases/week, or seeing 3 more patients/day will have on your bottom line at the end of the year. This scales very nicely.
What about other stuff? Passive income is very important. This field offers a lot of ways to augment your practice income as your practice matures. They take time to implement but are very worth it. These things are what seems to make the difference between the guys to do "well", and the guys who kill it. Examples:
1) ASC ownership. You need to do this, period. The ROI on these, if well run, will beat almost anything else you can put your money in.
2) Clinical trials. Can be difficult to become an established center, but can be very lucrative and offers an alternative to just seeing patients.
3) Own your building/office. Takes time, but instead of paying a landlord every month, the practice pays you rent. Good for retirement
4) Associates. You pay your junior associate 250K/year. He collects 600k for the practice. Costs you 50K in overhead for him. You make 300K/year off his work. This also scales nicely.
5) ER coverage. Depending on the area, some hospitals pay specialists to cover their EDs.
6) Speaking/consulting. Not for everyone, and can time to establish yourself as an authority.
7) Non-reimbursed services. Lasik, premium lenses, botox. Self-explanatory.
8) Optical shop.
Not all of these apply to every location and practice arrangement, but can add a lot to your income. The people you think of as the most successful likely do many of these things.
Take home message: stop stressing. This is a great (the best?) field in medicine. If it is money you are after, it's there, but you will need to work for it. Do a fellowship if you want, but not because you see it as the road to riches. You do not need one to thrive. There are a hundred other factors to consider, but I will save those for another post. On a side note, I automatically like anyone who references Karate Kid. Strike first, strike hard, no mercy, sir!
Me: general ophthalmologist (high volume cataract practice), 10 years in practice, hung out a shingle and started from scratch (didn't pay myself for 9 months). Two new associates now to help with work load, I work 4.5 days/week. Total pre-tax income was 1.1 million. 850K from practice, 150K from ASC ownership, 100K from emergency coverage at local hospital. Hopefully more next year as associates ramp up. I certainly would not call this fabulously wealthy, but it is certainly enough to have what I need and save a lot.
The thing to remember when trying to rationalize why one ophthalmologist makes more than another is volume. The bulk of your income, initially, will come from your practice. Generally speaking, I get paid the same amount to do a cataract as a guy in NYC or Fargo. Retina guys all get paid the same amount per injection or membrane peel. The guys who make more, do more. I know ophthalmologists who make 250K/year. They also see fewer patients and do 5 cases/week. That works for them. I know a cataract/lasik guy who makes >2 million every year. He is like a machine. Once again, volume. If you want to work hard, see a lot of patients, and do a lot of surgery, you will make a lot of money. This is just math. I do not mean to over-simplify this. The practice managers will factor in all of the other expenses that affect bottom line. However, they will also point out what a significant impact something as simple as doing 3 more cases/week, or seeing 3 more patients/day will have on your bottom line at the end of the year. This scales very nicely.
What about other stuff? Passive income is very important. This field offers a lot of ways to augment your practice income as your practice matures. They take time to implement but are very worth it. These things are what seems to make the difference between the guys to do "well", and the guys who kill it. Examples:
1) ASC ownership. You need to do this, period. The ROI on these, if well run, will beat almost anything else you can put your money in.
2) Clinical trials. Can be difficult to become an established center, but can be very lucrative and offers an alternative to just seeing patients.
3) Own your building/office. Takes time, but instead of paying a landlord every month, the practice pays you rent. Good for retirement
4) Associates. You pay your junior associate 250K/year. He collects 600k for the practice. Costs you 50K in overhead for him. You make 300K/year off his work. This also scales nicely.
5) ER coverage. Depending on the area, some hospitals pay specialists to cover their EDs.
6) Speaking/consulting. Not for everyone, and can time to establish yourself as an authority.
7) Non-reimbursed services. Lasik, premium lenses, botox. Self-explanatory.
8) Optical shop.
Not all of these apply to every location and practice arrangement, but can add a lot to your income. The people you think of as the most successful likely do many of these things.
Take home message: stop stressing. This is a great (the best?) field in medicine. If it is money you are after, it's there, but you will need to work for it. Do a fellowship if you want, but not because you see it as the road to riches. You do not need one to thrive. There are a hundred other factors to consider, but I will save those for another post. On a side note, I automatically like anyone who references Karate Kid. Strike first, strike hard, no mercy, sir!
Approximately how many surgeries are you doing in a week and how many patients are you seeing in a day? What percentage of cataract surgeries are you upcharching (premium lenses, laser, etc)? Do you do any lasik or other cash procedures?
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- ~25 cataracts a week
- See around 30-40 patients a day
- ~30-40% femto cataracts; ~30% premium lenses
- do lasik
- have 6 employee optometrists/medical ophthalmologists
- other cash based: lipiflow, dry eye products, optical, audiology
Definitely feasible in metro areas, but obviously a bit harder given competition. Like the previous poster stated, a cataract done in Orange County gets paid approximately the same as a cataract done in Fargo. There are only so many patients to go around.
On the flip side, patients in more affluent areas will likely pay more for elective and cash-based services. For example, I have a colleague who does 80-90% femto-cataracts since his patients are wealthy. So that extra elective income could offset some of the decrease in volume.
Lastly, there is a common saying in Ophthalmology that "80% of the surgery is done by 20% of Ophthalmologists." In other words, certain surgeons/mega-practices tend to dominate certain geographical areas. Thus the variance in surgical volumes is very wide. You just have to hope you are one of the 20%.
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Lightbox could you share your general income at that volume? I think you've shared it elsewhere, thanks for that.
And EyeDentist would you be willing to comment on your clinical and surgical volume?
I ask because we young Ophthalmologists and Residents often get half the picture from posts like this. Like EyeDentist works 4.5 days per week which is a good information, but I know of people working 3 days a week who likely take home more than SweepTheLegJohnny. They do 40-50 cataracts per week (a good amount of them multifocal/toric IOLs and/or femto) and a maybe handful of other surgeries/procedures in a week. They probably rarely see anything else but pre-ops or procedures in clinic.
Having the patient volume, surgical volume, and associated take-home information all together from people like you all can be useful to us when evaluating practices because you probably aren't going to just get told how much money the senior partner makes. But you can talk about volume and guess at some overhead/expenses.
In case it helps anyone starting out in my first year out I am salaried at $200,000/yr. Production bonus for year 2 is 15% of collections over 3x base. Pretty normal for private practice starting, maybe on the low end of bonus structure. I work like 45 hours per week, hospital call is infrequent and light (and unpaid), and my cataract volume bounces around 6 to 10 cases every week. Once I figure out what I can make with this volume I'll share it too.
As an aside to any residents looking at this - take all of this information with a grain of salt. Some people will tell you that everybody lies about their take home but I feel like an anonymous forum is pretty safe to share real information so hopefully all of the above is legitimate. Every practice is different, and there are tons of Ophthalmologists (maybe the majority?) doing <10 cases per week with few 'upgrade' IOLs, have a slower paced workday and see 20-something patients per day, and still take home $300,000+ and are happy.
And EyeDentist would you be willing to comment on your clinical and surgical volume?
I ask because we young Ophthalmologists and Residents often get half the picture from posts like this. Like EyeDentist works 4.5 days per week which is a good information, but I know of people working 3 days a week who likely take home more than SweepTheLegJohnny. They do 40-50 cataracts per week (a good amount of them multifocal/toric IOLs and/or femto) and a maybe handful of other surgeries/procedures in a week. They probably rarely see anything else but pre-ops or procedures in clinic.
Having the patient volume, surgical volume, and associated take-home information all together from people like you all can be useful to us when evaluating practices because you probably aren't going to just get told how much money the senior partner makes. But you can talk about volume and guess at some overhead/expenses.
In case it helps anyone starting out in my first year out I am salaried at $200,000/yr. Production bonus for year 2 is 15% of collections over 3x base. Pretty normal for private practice starting, maybe on the low end of bonus structure. I work like 45 hours per week, hospital call is infrequent and light (and unpaid), and my cataract volume bounces around 6 to 10 cases every week. Once I figure out what I can make with this volume I'll share it too.
As an aside to any residents looking at this - take all of this information with a grain of salt. Some people will tell you that everybody lies about their take home but I feel like an anonymous forum is pretty safe to share real information so hopefully all of the above is legitimate. Every practice is different, and there are tons of Ophthalmologists (maybe the majority?) doing <10 cases per week with few 'upgrade' IOLs, have a slower paced workday and see 20-something patients per day, and still take home $300,000+ and are happy.
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I would be hesitant to focus on the salaries here and be more focused on figuring out what type of ophthalmology you want to practice. I can tell what surgeons in my area are 7 figure ophthalmologists. It's not because they're wonderful clinicians but because they give such an aggressive sales pitch to anyone who walks in the door. I didn't go into ophthalmology to upsell all of my cataract patients on FLACS for $1-2k per eye extra when research shows that the benefits aren't really there and the complication rates tend to be higher.
Patients don't really know what cataract surgery entails - of course they're going to want the "latest technology" if you present it like that. Instead of requiring every patient to watch a FLACS commercial before seeing me I spend time with each patient who asks to explain what FLACS actually is and the research showing no clear cut benefit and how I'd rather save them money.
Some would say that I'm throwing away a financial opportunity. Does that make me a bad business person? Probably. But I think it makes patients trust me more and I have great satisfaction with my average salary and my brand new not-so-fancy $25,000 car in the driveway.
Patients don't really know what cataract surgery entails - of course they're going to want the "latest technology" if you present it like that. Instead of requiring every patient to watch a FLACS commercial before seeing me I spend time with each patient who asks to explain what FLACS actually is and the research showing no clear cut benefit and how I'd rather save them money.
Some would say that I'm throwing away a financial opportunity. Does that make me a bad business person? Probably. But I think it makes patients trust me more and I have great satisfaction with my average salary and my brand new not-so-fancy $25,000 car in the driveway.
There is actually quite a lack of focus on real-world salaries on this message board, and in training programs. Hence the original poster's question. I'm not saying people should be talking about money all of the time, but training programs do their residents/fellows a disservice by not providing sound, grounded-in-the-real-world advice.
I find it interesting that you assume that all 7-figure ophthalmologists are used car salesman. That's pretty self-righteous. Sure, there are Ophthalmologists that take things to the extreme or are even fraudulent. But I don't think that one can conclude that people providing "premium" (whatever that means) services are unethical. Some patients <gasp> have some disposable income and don't mind spending some of it to be able to read without glasses again, or to use the latest technology to achieve those goals. I think it's ridiculous that some surgeons don't even offer their patients non-monovision IOLs, because these surgeons don't know how to handle being off-target (e.g. don't know how to perform LASIK). I can't tell you the # of times a patient has come to me saying "Doctor X didn't even give me the option of a multifocal lens" even when all of their ocular parameters (e.g. macula, cornea) were pristine.
I do a ton of both "regular" and femto-cataract procedures, and I can honestly say that femto makes the vast majority of cases a breeze. I think that most people that don't like femto are the ones who haven't done a good volume of them, since like any other procedure, there are nuances and a learning curve to optimizing your technique. The other % of people that don't like femto is because it takes a little longer to perform (if one hasn't figured out how to adjust their surgery flow). If I or one of my family members had pseudoexfoliation and a 4+NS, I would definitely go for femto in a heartbeat. Obviously, if the cost is going to significantly impact a patient's finances, I don't make them feel bad for choosing non-femto surgery.
I find it interesting that you assume that all 7-figure ophthalmologists are used car salesman. That's pretty self-righteous. Sure, there are Ophthalmologists that take things to the extreme or are even fraudulent. But I don't think that one can conclude that people providing "premium" (whatever that means) services are unethical. Some patients <gasp> have some disposable income and don't mind spending some of it to be able to read without glasses again, or to use the latest technology to achieve those goals. I think it's ridiculous that some surgeons don't even offer their patients non-monovision IOLs, because these surgeons don't know how to handle being off-target (e.g. don't know how to perform LASIK). I can't tell you the # of times a patient has come to me saying "Doctor X didn't even give me the option of a multifocal lens" even when all of their ocular parameters (e.g. macula, cornea) were pristine.
I do a ton of both "regular" and femto-cataract procedures, and I can honestly say that femto makes the vast majority of cases a breeze. I think that most people that don't like femto are the ones who haven't done a good volume of them, since like any other procedure, there are nuances and a learning curve to optimizing your technique. The other % of people that don't like femto is because it takes a little longer to perform (if one hasn't figured out how to adjust their surgery flow). If I or one of my family members had pseudoexfoliation and a 4+NS, I would definitely go for femto in a heartbeat. Obviously, if the cost is going to significantly impact a patient's finances, I don't make them feel bad for choosing non-femto surgery.
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For those finishing training, you should see guarantees in the $200-250K range (depending upon location) and typically 30% of collections over 2.5-3 times base is the norm. This is assuming a practice runs a 60% overhead.
Most physicians earn between 300-400K per year. Those in 7 figures are not the norm so don't feel bad if you are not one of them.
And yes, the "telephone game" happens a lot when speaking of salaries and offers.
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That’s a good thing. No one discussed these issues with me during residency or fellowship. The business of medicine is a double edged sword, I have learned to embrace it in private practice but have plenty of close friends who prefer to minimize their involvement and go the academic or employee route. Not a wrong choice, just different.
Really glad lightbox has enlightened us on the way they run their practice and high income, congrats!
As a retina specialist I have less (almost no) elective or upcharge procedures, I chose retina specifically for this reason as I didn’t see myself as someone that would be good at that type of thing. There is nothing unethical however about offering premium services and upcharging the right patient, again, lightbox seems to be doing it the right way.
Great thread! Keep it up!
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I'm FM but was a tech/billing person for an ophthalmologist in college and his approach (high volume and ASC ownership), and income, was very similar to yours - though in 2004 the technology/procedures were a bit different.
~21 cataract extractions/week (upselling of lenses was maybe 10% of cases)
~20 various laser procedures (YAG capsulotomy being the most common by far)
3 days in clinic seeing ~70 patients/day
1 lasik half-day/month usually with 10-12 patients
Employed 1 full time OD who was seeing 30-40/day
Solo owner of his surgery center (his retirement package was selling that to the local hospital for, word is, just shy of 2 mil)
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Wow people reading this are going to get the wrong impression about the reality of ophthalmology. I've been in practice for about a year. Joined a solo practice in a desirable location, but it wasn't a very busy practice and it has been up to me to try and drum up business in a saturated market. It is very difficult and my practice has been slow to build, although it is steadily building. My starting salary is $175K (cornea specialist) and I won't reach a bonus, but I have no other options in town where our families are. Could move to somewhere more rural and get paid more, but location is important to us. People think they are going to graduate and make 400K working 4 days a week, and that may happen in some situation, but if you are headed into a saturated market getting that salary is going to take many years.
You gotta do what's right for you and your values in life. If being in a certain location is what will make you happy, then it's probably worth the sacrifice of working longer and harder. For others, the ability to retire a decade earlier is worth the sacrifice of not living on the beach. Obviously, there are some people who have the best of both worlds. It's funny that some people assume that all Ophthalmologists making 7 digits are practicing in the middle of nowhere. Shockingly, there are people in desirable areas who are also doing quite well for themselves.
All in all, it's best to keep expectations low, to live well below your means, and to save up as much as possible. Because who knows when this gravy train of Ophthalmology will end?
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People in desirable areas obviously can do well. But I agree it’s harder to start out from scratch and make a lot of money in a saturdated, desirable area than starting out in a rural underserved area.
Gill’s has long retired but he’s a legend. He use to have a cataract assembly line. He’d have PA’s from other countries doing the cataract surgeries and then Gills would come in and do one part of the surgery. He has one of the largest OD referral networks and he built one of the largest practices in the country.
