Is doing medical retina/uveitis and uveitic cataracts a viable career option?

[docdoc2012]

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Hey Guys,
so it seems like the forum is pretty divided on the utility of a med ret fellowship if one wants to do cataracts, and a big reason for that seems to be that you are suffocating your own referral base

what if I wanted a career doing mostly medical retina/uveitis with 10-15 complicated cataracts a month? I really enjoy cataract surgery and am fairly good at it but I really like medical retina as well... and I figure if I do medical retina mostly I won't really need to do cataractw from an income perspective, and many cataract surgeons would rather not deal with the more complicated case due to interference with surgical flow...and doing 10 - 15 cases a month would not significantly impact my personal med-ret/uveitis clinic flow

any thoughts?

 

[DrZeke]

There are several uveitis programs in the country that do complex cataracts and do other surgeries/ procedures. However if you do a medical retina fellowship only you will not likely do any cataracts. I recommend doing a uveitis fellowship instead of a medical retina fellowship or doing both... Though you probably don't need both. Some people do 2 year uveitis fellowships. Do your research - talk to people doing uveitis - and you will find those fellowships that operate.

 

[Slide]

If you want to go into private practice and do medical retina/uveitis, you can kiss doing cataract surgery goodbye. It's a good way to stop your referral sources from sending more cases if you do cataracts, even if they're so complex that no one else wants to touch them.

In the academic community or at the VA you could do this. The big thing with uveitis is that it's such a clinically dominant field that if you also do medical retina, it may be difficult to keep up your cataract skills and it may ultimately be not worth the effort. Most uveitis guys that do a good amount of surgery have obtained surgical subspecialty training as well. To me, if you want to do medical retina and uveitis, you might as well do a surgical retina fellowship so you can do more, but that's just my two cents and after dealing with a lot of uveitis patients during fellowship.

 

[DrZeke]

If you want to go into private practice and do medical retina/uveitis, you can kiss doing cataract surgery goodbye. It's a good way to stop your referral sources from sending more cases if you do cataracts, even if they're so complex that no one else wants to touch them.

In the academic community or at the VA you could do this. The big thing with uveitis is that it's such a clinically dominant field that if you also do medical retina, it may be difficult to keep up your cataract skills and it may ultimately be not worth the effort. Most uveitis guys that do a good amount of surgery have obtained surgical subspecialty training as well. To me, if you want to do medical retina and uveitis, you might as well do a surgical retina fellowship so you can do more, but that's just my two cents and after dealing with a lot of uveitis patients during fellowship.

There are definitely academic uveitis people doing complex cataracts as well. I heard it straight from their fellows and former fellows mouths several weeks ago. I know for certain that they do them at MERSI, Northwestern...

Are they doing 10-15 a week? No. Again I would not train medical retina if you want to do this. If anything I would do two years of uveitis with someone who does surgery or add on surgical retina.

 

[Dusn]

Most medical retina people end up joining a large comprehensive or multi-specialty group that wants to keep their med-retina in-house. So in that case all your referrals are in-house and your group will likely be OK with you doing cataracts on the patients you're regularly seeing or who happened to be scheduled with you as a new patient. Just keep in mind the other members of the group will likely be much more experienced with cataract surgery than you are -- you won't be the one getting referrals for cataracts.

The downside is that it's generally better to join a retina group if you have that option (the whole practice will much more efficient in dealing with retina issues, you won't be on your own running/managing the medical retina part of the practice, and you might have better resources/photography).... in that case you will not be doing cataracts.

 

[Eyefixer]

I never understood the purpose of doing medical retina fellowship. If you wanna do retina, do a full surgical fellowship and have more carrier opportunities. What's another year in a grand scheme of things?

 

[MstaKing10]

Most medical retina people end up joining a large comprehensive or multi-specialty group that wants to keep their med-retina in-house. So in that case all your referrals are in-house and your group will likely be OK with you doing cataracts on the patients you're regularly seeing or who happened to be scheduled with you as a new patient. Just keep in mind the other members of the group will likely be much more experienced with cataract surgery than you are -- you won't be the one getting referrals for cataracts.

The downside is that it's generally better to join a retina group if you have that option (the whole practice will much more efficient in dealing with retina issues, you won't be on your own running/managing the medical retina part of the practice, and you might have better resources/photography).... in that case you will not be doing cataracts.

This is spot on. If your in a multi specialty group then medical retina is fine and you can do cataracts. Keep in mind surgical issues will have to be dealt with somehow. Most groups want to keep that in house too so unless you have a surgical retina person in house you will end up having to refer these patients to your competition.

Only reason to do uveitis is if you like it. Surgical management of uveitis is rare and mostly involves vitreous biopsies. Understand that uveitis is a chronic disease and as your career progresses you will collect a lot of these patients and this will eventually overwhelm your schedule (if that's what you want). Sure you'll get the occasional cataract but not sure about absolute numbers

 

[long]

Here is what I don't get about the "you won't have a referral base if you do cataracts" argument with regard to medical retina: why doesn't the same argument apply to, say, glaucoma? No one ever tells someone going into glaucoma that they will have a hard time getting glaucoma referrals in private practice if they do cataracts. To the contrary; people often go into glaucoma so they can still do cataracts and have something else in their back pocket, and glaucoma docs do just fine doing that. So why is it so different with medical retina?

 

[DrZeke]

Here is what I don't get about the "you won't have a referral base if you do cataracts" argument with regard to medical retina: why doesn't the same argument apply to, say, glaucoma? No one ever tells someone going into glaucoma that they will have a hard time getting glaucoma referrals in private practice if they do cataracts. To the contrary; people often go into glaucoma so they can still do cataracts and have something else in their back pocket, and glaucoma docs do just fine doing that. So why is it so different with medical retina?

I think it's reasonable to do complex cataracts on your uveitis patients if you are uveitis trained/medical retina-uveitis trained. Nobody is gonna refer you non-uveitis, straight forward cataracts....obviously the focus isn't gonna be cataracts if you are medical retina trained. If you wanna do 10-15 cataracts a week, don't do medical retina.

 

[Dave89]

Here is what I don't get about the "you won't have a referral base if you do cataracts" argument with regard to medical retina: why doesn't the same argument apply to, say, glaucoma? No one ever tells someone going into glaucoma that they will have a hard time getting glaucoma referrals in private practice if they do cataracts. To the contrary; people often go into glaucoma so they can still do cataracts and have something else in their back pocket, and glaucoma docs do just fine doing that. So why is it so different with medical retina?

I guess it's hard to justify going into each eye twice when it could be done once as a CE/trabectome, for example.

People who have glaucoma frequently will require surgical management in both eyes, and I think they also have an elevated risk of cataract development. So I think it's basically understood that it's sensible for glaucoma specialists to take care of cataracts while they're already in the OR.

 

[long]

Yes, but I've seen plenty of glaucoma specialists knocking out 10-15 cataracts in a morning in patients that aren't having any glaucoma procedures, and no one tells them to worry about their referral base.

 

[Dave89]

Yes, but I've seen plenty of glaucoma specialists knocking out 10-15 cataracts in a morning in patients that aren't having any glaucoma procedures, and no one tells them to worry about their referral base.

Ah. The glaucoma guys I've seen were only doing the combined procedures as far as I know.

I think that the main difference is that, as you said, many people do a year of glaucoma purely as a marketing tool, while intending to essentially function as comprehensives. So, yeah... they don't really have to worry about referrals because they are their own referral bases. I'm not very familiar with medical retina (I've only worked with retina specialists who were surgically trained), but the sense I get is that they tend to not want to do comprehensive; they want to focus on injections, lasers, etc. But I don't see how doing a medical retina fellowship can do anything but help you if you want to practice comprehensive... So they really do need those referrals. With that said, as Visionary (I think) has pointed out, medical retina is of limited utility in a comprehensive office if one doesn't have all the bells and whistles necessary to make a medical retina practice efficient and particularly lucrative.

 

[docdoc2012]

I always thought that if I decided I really hate cataract surgery 3rd year, I would go ahead and try to find a retina practice wanting a med ret person.
However, as I do like cataract surgery, I thought doing med ret and marketing myself as a 'comprehensive plus' to a strong multispecialty practice would let me do everything I want
I've gotten the question a lot about why not put in an extra year of fellowship and do surgical - it's a matter of interest...as much as I love retina, the idea of giving up anterior segment forever never sat well with me...not to mention lifestyle issues and constant emergencies that I don't love the idea of dealing with

 

[Dusn]

I suspect with the advice you're getting you're running into the first issue with medical retina. Which is a bias against medical retina because surgical retina specialist often don't like medical retina specialists -- medical retina takes lucrative work away from surgical retina and often at the same time surgical retinologists don't want to hire medical retina because they want the younger docs they hire to help with their call burden. So if they can't hire you; you're just competition. Unfortunately with huge cuts in retina surgery reimbursement the older surgical retinologists will want to be in the OR even less.

You can do cataracts and do medical retina you just need to join a large comprehensive practice or the VA or an HMO or academics, etc..
It's not simply the referrals that's an issue, however. The amount of demand for most medical retina right now is huge. When you first start, your practice may seem light and it may seem like you can easily do both. However, every new patient is a patient you may be seeing and injecting potentially every month for life. If you joined a large group, your practice will just continue to grow fast until you're almost overwhelmed. And pretty soon you and your group will have to decide whether you want to keep losing money by going to the OR or if you want to just hand those cataract patients over to the cataract surgeon in your group that has to go to the OR anyway. Your macular degeneration patients will not be able to get premium lenses and you will have fewer cases -- so you will really probably lose money by going to the OR as your retina practice builds. Your practice partners will like having you in the clinic to curbside you with retina questions.

You will also need to focus on building your retina practice to justify the expensive imaging equipment and staff you want to get to do medical retina well. This is the main reason you can't act like you're "comprehensive plus" if you want to do retina -- creating a retina practice that can treat retina patients well and properly takes a lot of upfront costs and effort.

You see a glaucoma specialist has to go the OR anyway; so adding on an extra cataract is no big deal. You, however, will be making your money in the clinic and have no other reason to go to the OR. If you operate at a hospital you may realize that giving up the OR means you can also drop hospital privileges and not deal with the hospital's annoying unpaid call.

Those are the reasons it's difficult to do cataracts with medical retina. But you can do it. Most medical retina specialists I know, including myself, do cataract surgery. I do it because I like it and I want to keep my surgical skills because who knows how things will change in the future. But dealing with going to the OR is becoming more of a pain in the butt every year.

 

[docdoc2012]

I suspect with the advice you're getting you're running into the first issue with medical retina. Which is a bias against medical retina because surgical retina specialist often don't like medical retina specialists -- medical retina takes lucrative work away from surgical retina and often at the same time surgical retinologists don't want to hire medical retina because they want the younger docs they hire to help with their call burden. So if they can't hire you; you're just competition. Unfortunately with huge cuts in retina surgery reimbursement the older surgical retinologists will want to be in the OR even less.

You can do cataracts and do medical retina you just need to join a large comprehensive practice or the VA or an HMO or academics, etc..
It's not simply the referrals that's an issue, however. The amount of demand for most medical retina right now is huge. When you first start, your practice may seem light and it may seem like you can easily do both. However, every new patient is a patient you may be seeing and injecting potentially every month for life. If you joined a large group, your practice will just continue to grow fast until you're almost overwhelmed. And pretty soon you and your group will have to decide whether you want to keep losing money by going to the OR or if you want to just hand those cataract patients over to the cataract surgeon in your group that has to go to the OR anyway. Your macular degeneration patients will not be able to get premium lenses and you will have fewer cases -- so you will really probably lose money by going to the OR as your retina practice builds. Your practice partners will like having you in the clinic to curbside you with retina questions.

You will also need to focus on building your retina practice to justify the expensive imaging equipment and staff you want to get to do medical retina well. This is the main reason you can't act like you're "comprehensive plus" if you want to do retina -- creating a retina practice that can treat retina patients well and properly takes a lot of upfront costs and effort.

You see a glaucoma specialist has to go the OR anyway; so adding on an extra cataract is no big deal. You, however, will be making your money in the clinic and have no other reason to go to the OR. If you operate at a hospital you may realize that giving up the OR means you can also drop hospital privileges and not deal with the hospital's annoying unpaid call.

Those are the reasons it's difficult to do cataracts with medical retina. But you can do it. Most medical retina specialists I know, including myself, do cataract surgery. I do it because I like it and I want to keep my surgical skills because who knows how things will change in the future. But dealing with going to the OR is becoming more of a pain in the butt every year.

Dusn thanks so much for your reply! Can you elaborate a little bit on your practice setting? What does your schedule look like for a typicalweek?

Do u think u can still have a lucrative practice if u have say...1 surgical half day a week?
I completely agree about keeping up your surgical skills...they're valuable and a lot of hard training went into calling ourselves eye surgeons...and who knows when u will need them

 

[Dusn]

Generally I do a half day of surgery every other week (and I take the other half of the day off) and the rest of the time I'm doing almost all medical retina in clinic in a multi-specialty practice. It's not a lot of surgery but I'm just keeping my feet wet. I don't do multifocals. But there is a huge variation amongst medical retina specialists. I haven't put a lot of effort (or any effort actually) into trying to get optoms to send me cataracts.