Is there anything you wished you knew ahead of time about ophtho?

[SandP]

Yes we all know it's great but were there any unanticipated downsides to the field you wish you had known ahead of time (regarding technical skill in microsurgery, job saturation, things you don't consider as a med student etc. etc).

EDIT: would appreciate input from senior residents, fellows, and attendings. Thanks!

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[Shufflin]

I wish someone had told me ophtho was all about the eyes. Or else I would have picked something else.

(after a long day we can all use a little humor)

 

[martianmonster]

For medical students considering the field: don't think that your need to learn is complete once you get your MD. Ophthalmology residency is like medical school all over again in the sense that you don't know anything July 1 of your PGY2 year. If you want to be competent, prepare to spend a lot of time studying after a long day of clinic. I'm sure this is true in many fields but especially so in ophthalmology which is not emphasized in medical school.
While I am still in my residency, it seems that due to relatively large and recent decreases in insurance reimbursements, a substantial part of your compensation as a practicing general ophthalmologist is related to your ability to upsell premium lenses, lasik, etc (ie anything not covered by insurance).

 

[hello lady!]

For medical students considering the field: don't think that your need to learn is complete once you get your MD. Ophthalmology residency is like medical school all over again in the sense that you don't know anything July 1 of your PGY2 year. If you want to be competent, prepare to spend a lot of time studying after a long day of clinic. I'm sure this is true in many fields but especially so in ophthalmology which is not emphasized in medical school.
While I am still in my residency, it seems that due to relatively large and recent decreases in insurance reimbursements, a substantial part of your compensation as a practicing general ophthalmologist is related to your ability to upsell premium lenses, lasik, etc (ie anything not covered by insurance).

I hate this mentality. I don't think it's true at all.

Sure, you can turn your practice into a cataract mill and tell everyone they should have phaco surgery with femto and charge $5,000 extra per patient and take home your 7 figure salary, but is that really what you went to medical school for? To up-sell your patients on technology that study after study shows no additional benefit to the patient?

 

[martianmonster]

I hate this mentality. I don't think it's true at all.

Sure, you can turn your practice into a cataract mill and tell everyone they should have phaco surgery with femto and charge $5,000 extra per patient and take home your 7 figure salary, but is that really what you went to medical school for? To up-sell your patients on technology that study after study shows no additional benefit to the patient?

Me too. But it seems that's how the field is practiced to a certain extent. Which is what SandP was looking for...

 

[LightBox]

I hate this perspective because it is very naive. I've been doing this for awhile, and patients want all of these upgrades to have better range of vision, etc. And for the vast majority, they are very happy to have chosen them.

Residents get biased (almost brain-washed) by their academic/conservative attendings to think that premium lenses or femto or Lasik are "evil" to offer. In fact, patients want a lot of this stuff.

Lastly, it is easy to pontificate when you dont have bills or a staff to pay. Many academic-types would not last a year running a private practice.

 

[hello lady!]

I'm in private practice with plenty of staff and bills to pay. Just because I don't drink all of the industry cool-aid doesn't mean I'm brainwashed.

How do you justify FLACS when study after study after study after study after study shows no real benefit to femto over manual cataract extraction? I have patients who come in asking about FLACS and I spend an extra 5 minutes reviewing the data with them and educating them. I tell them I won't do femto but others in town will. So far not a single patient has left my practice to get the femto. Even ORA's results are underwhelming.

I offer torics and multifocals to everyone who qualifies but I present them in a non-biased way including the cons of the fancy lenses vs the standard lenses. I've seen handouts from other practices "Standard vs Premium" or "Good vs Better vs Best." The sales tactics presented make the patients feel that they're cheapening out on their eyes if they don't splurge for the most expensive option. Some practices in town are so aggressive that they implant multifocals in AMD patients, glaucoma patients, and others who have no business getting these lenses. I'm sure they all take home more money than I do - but I think it's straight up unethical.

 

[LightBox]

Most people that lambast FLACS dont actually have the laser. It is a self-affirming prophecy. It is a personal choice to use FLACS and it definitely helps to make catatact surgery more uniform in my hands. I guess I'm not as good of a surgeon as you though

 

[hello lady!]

Most people that lambast FLACS dont actually have the laser. It is a self-affirming prophecy. It is a personal choice to use FLACS and it definitely helps to make catatact surgery more uniform in my hands. I guess I'm not as good of a surgeon as you though

Ah, so ignore all scientific evidence and deliver a backhanded comment. So professional.

I genuinely wonder how widespread the adoption of FLACS would be if it ate from the surgeon's profit margin rather than padded it. If these intangible things like uniformity really matter and are worth profit to the surgeon when in the end the real-world outcomes are the same. But then again, I guess I'm just a naive, brainwashed naysayer who lives in a self-affirming prophecy to avoid new technology.

 

[airplanes]

It is a self-affirming prophecy.

But the same could be said about surgeons who insist FLACS for routine cases is safer or superior. Have one complication with manual surgery that could have or would have happened anyway with FLACS and it reaffirms your own opinion. The empirical data simply just doesn't support its superiority in any clinically significant outcome. I have experience with FLACS and we have one readily available. I cannot and do not offer it to my patients. Toric and MF/EDOF lenses in appropriate candidates get the pros/cons explained to them.

Regarding the original discussion point from the resident above, the vast majority of Ophthalmologists in both private and academic do not depend on upselling elective lasers, lenses or procedures. For most of us, it plays a small to modest role in our compensation. This may change in the future, as the healthcare environment changes in general, but to say the ability to sell cash services is going to be important is just simply not true.

 

[airplanes]

I genuinely wonder how widespread the adoption of FLACS would be if it ate from the surgeon's profit margin rather than padded it.

I don't have to wonder at all how widespread it would be..

 

[LightBox]

To each his or her own. Use FLACS/premium lenses or not. It's really not a big deal either way. I wouldnt pass judgement on those who use them though. I never criticize my competition even if they do crazy sh**. It just undermines our patients' trust in the healthcare of our community. It is also the reason why optometrists are beating us since there is so much division among our ranks.

 

[LightBox]

I disagree with cash options not being important. They are extremely important in providing a buffer to today's healthcare environment. If you havent noticed, reimbursements are only declining, and offering cash-based services (e.g. optical, LASIK) definitely help you stay in business. The government and insurance companies dont care about you staying financially solvent. Like I've said before: 80% of the surgery is being done by 20% of the practices. You can guess what the 20% are doing to maintain that volume.

 

[Equality]

As an ophthalmologist, you will forever have to explain that you're not an optometrist or an optician to family/other people who will immediately say that they have "stigmatism" and their glasses need to updated as soon as you tell them you're an ophthalmologist.

As an ophthalmologist, when an ARMD patients goes blind even after many antiVEGF injections, or a young person with globe rupture goes blind after failed repairs, or diabetic patient gets neovascular glauc and goes blind, or a patient gets cataract surgery with you and gets horrible complications and goes blind (or even if it's recoverable like a dropped lens), you feel like you lost a battle.

As an ophthalmologist, you will want to pretend you're deeply asleep when you're flying across the Atlantic and the flight attendant makes an overhead announcement for anyone with medical expertise to come help a poor old lady who lost consciousness.

As an ophthalmologist, you will be pushed to see 40, 60, 70, maybe even more patients a day (how much time can you spend with each patient??). Your patients will never really consider you their "doctor" in the same way they will name their primary care doctor as "my doctor." You're more like an eye dentist.

 

[ball123]

As an ophthalmologist, you will forever have to explain that you're not an optometrist or an optician to family/other people who will immediately say that they have "stigmatism" and their glasses need to updated as soon as you tell them you're an ophthalmologist.

As an ophthalmologist, when an ARMD patients goes blind even after many antiVEGF injections, or a young person with globe rupture goes blind after failed repairs, or diabetic patient gets neovascular glauc and goes blind, or a patient gets cataract surgery with you and gets horrible complications and goes blind (or even if it's recoverable like a dropped lens), you feel like you lost a battle.

As an ophthalmologist, you will want to pretend you're deeply asleep when you're flying across the Atlantic and the flight attendant makes an overhead announcement for anyone with medical expertise to come help a poor old lady who lost consciousness.

As an ophthalmologist, you will be pushed to see 40, 60, 70, maybe even more patients a day (how much time can you spend with each patient??). Your patients will never really consider you their "doctor" in the same way they will name their primary care doctor as "my doctor." You're more like an eye dentist.

What a pessimistic outlook. Perhaps true to a large extent, but I highly doubt patients view their ENT specialist who did one rhinoplasty, or an orthopedist who did one surgery, or their anesthesiologist/radiologist/plastic surgeon, etc as their doctor when asked. They will name their primary care physician - or the specialist they follow-up with regularly (generally not a surgeon).

I also think an orthopedic surgeon, ENT surgeon, IR, radiologist will also pretend to be asleep on the plane in those circumstances, although 98% of medical emergencies on the plane tend to be very trivial. The grass is always greener.

I understand the layperson getting an ophthalmologist confused with an optometrist but that can easily be mitigated by saying you’re an eye surgeon. Or if you’re sub-specialized, you can say retinal/corneal/glaucoma/oculoplastic surgeon. The emphasis being saying you’re a surgeon to displace any confusion.

No need to see that many patients in a day. You have the freedom to choose your working environment. Ho Sun sees 20 patients a day (with a low overhead) and still smashes the medscape averages.

 

[MstaKing10]

As an ophthalmologist, you will forever have to explain that you're not an optometrist or an optician to family/other people who will immediately say that they have "stigmatism" and their glasses need to updated as soon as you tell them you're an ophthalmologist.

As an ophthalmologist, when an ARMD patients goes blind even after many antiVEGF injections, or a young person with globe rupture goes blind after failed repairs, or diabetic patient gets neovascular glauc and goes blind, or a patient gets cataract surgery with you and gets horrible complications and goes blind (or even if it's recoverable like a dropped lens), you feel like you lost a battle.

As an ophthalmologist, you will want to pretend you're deeply asleep when you're flying across the Atlantic and the flight attendant makes an overhead announcement for anyone with medical expertise to come help a poor old lady who lost consciousness.

As an ophthalmologist, you will be pushed to see 40, 60, 70, maybe even more patients a day (how much time can you spend with each patient??). Your patients will never really consider you their "doctor" in the same way they will name their primary care doctor as "my doctor." You're more like an eye dentist.

These points are laughable. Eye dentist? Really? Just curious to know how long you have been in practice? You will find the relationship you establish with your patients, especially these AMD patients you speak of are far more intimate than you make it seem, maybe even more so than with their PCPs because we see them every 4 weeks! We don’t cause blindness, we prevent it!

Honestly who cares if the layperson confuses optom with ophtho? Explain it and move on. It’s not a big deal.

Pressure to see more patients is unanimous across the board in all medical specialties. Ultimately the decision is yours in terms of how to run your practice and how much you want to make.

It’s a highly gratifying field, been practicing for almost 10 years and can’t imagine doing anything else. I hope Equality is just a troll and not a practicing ophthalmologist.

 

[Shufflin]

I'm not an ophthalmologist. The issue of lay people confusing one kind of doctor for another professional happens across the board and should not make a difference for a physician. Psychiatrists are psychologists. Radiologists are rad techs. ObGyns just deliver babies. Dermatologists do cosmetics. Etc etc. Everyone has pressure to see more patients. Everyone. Doctors aren't alone in seeing their rates get cut.

Any medical field that allows you time and professional intimacy with your patients such as found in ophthalmology and, in my case, psychiatry, is very gratifying. Hold your field close to your heart. Most of medicine doesn't allow for that.

 

[hello lady!]

As an ophthalmologist, you will forever have to explain that you're not an optometrist or an optician to family/other people who will immediately say that they have "stigmatism" and their glasses need to updated as soon as you tell them you're an ophthalmologist.

Only if you're massively insecure.

Your patients will never really consider you their "doctor" in the same way they will name their primary care doctor as "my doctor." You're more like an eye dentist.

So, so wrong. Ever take on new patient who was transferred from a retiring doc? I usually hear a minute or two spiel about how wonderful the prior provider was. A lot of people get insanely close to their ophthalmologists - especially wet AMD and glaucoma patients.

 

[SandP]

Question- how often you ophthalmologists have complications during eye surgery? and if there is a complication, do you know right away or is this something the patient realizes down the road?

 

[MstaKing10]

To each his or her own. Use FLACS/premium lenses or not. It's really not a big deal either way. I wouldnt pass judgement on those who use them though. I never criticize my competition even if they do crazy sh**. It just undermines our patients' trust in the healthcare of our community. It is also the reason why optometrists are beating us since there is so much division among our ranks.

I found this comment interesting. I would argue trust is being undermined more by unscrupulous money hungry surgeons up charging premium services unnecessarily or even worse when it’s contraindicated. Or docs with shady billing practices. I too am in private practice and understand the issues related to overhead and so on but wouldn’t be too quick to dismiss those that have an opinion different from your own. I don’t think that has anything to do with optoms beating us (not sure what that even means really), rather, keeps the conversation balanced. No one is criticizing, simply offering a different opinion. To each their own for sure.

 

[LightBox]

I found this comment interesting. I would argue trust is being undermined more by unscrupulous money hungry surgeons up charging premium services unnecessarily or even worse when it’s contraindicated. Or docs with shady billing practices. I too am in private practice and understand the issues related to overhead and so on but wouldn’t be too quick to dismiss those that have an opinion different from your own. I don’t think that has anything to do with optoms beating us (not sure what that even means really), rather, keeps the conversation balanced. No one is criticizing, simply offering a different opinion. To each their own for sure.

The people that are preaching how they are "holier than thou" should not upcharge anything for toric or multifocal lenses then. Or charge a very nominal rate (e.g. $100) since they care only about the patients' financial well-being. We all know that inserting these IOLs does not require $1000 worth of work. They also should not charge out for epilation, bandage contact lens insertion, extended ophthalmoscopy, or removing a corneal foreign body. This line of thinking can keep going on.

 

[Hanky]

The people that are preaching how they are "holier than thou" should not upcharge anything for toric or multifocal lenses then. Or charge a very nominal rate (e.g. $100) since they care only about the patients' financial well-being. We all know that inserting these IOLs does not require $1000 worth of work. They also should not charge out for epilation, bandage contact lens insertion, extended ophthalmoscopy, or removing a corneal foreign body. This line of thinking can keep going on.

But that's not the point being discussed, right? Epilation reduces eye irritation; removing a corneal foreign body reduces pain and decreases infection risk; a scleral depressed exam may diagnose a small tear -- these all benefit patients. The studies above are showing that multifocal lenses are not superior and are in some ways inferior to monofocal lenses. So it's not a debate about charging for our services, it's a debate about offering an inferior product (toric lenses not included).

I always appreciate your posts on this forum, by the way. You're one of the few people who adds an honest private practice perspective.

 

[airplanes]

I found this comment interesting. I would argue trust is being undermined more by unscrupulous money hungry surgeons up charging premium services unnecessarily or even worse when it’s contraindicated. Or docs with shady billing practices. I too am in private practice and understand the issues related to overhead and so on but wouldn’t be too quick to dismiss those that have an opinion different from your own. I don’t think that has anything to do with optoms beating us (not sure what that even means really), rather, keeps the conversation balanced. No one is criticizing, simply offering a different opinion. To each their own for sure.

Very much this. Why should we hold our tongues if colleagues are doing “crazy ****”? Not doing so absolutely has the potential to undermine our credibility. Solidarity has no bearing if you don’t have standards. And to be clear, I am not saying I consider Femto or MD/EDOF lenses crazy or unethical.

 

[Dusn]

I would agree with the idea that the culture in ophthalmology in private practice (along with most other procedure oriented fields) is far more money oriented than medical fields (Such as your academic internal medicine mentors in medschool). Churning through 40+ patients (sometimes way more) is expected in private practice, to the point where people miss stuff (ie. the pt with blurred vision because she's having a stroke but has a "normal" eye exam, or doing cataract surgery on patients with undiagnosed wet AMD). The discussions in private practice are on improving YELP reviews, getting more optom referrals, and improving efficiency way more than on interesting cases.

I personally would never want a multifocal IOL in my eye, even the view to the retina in these patient's isn't as clear and the vision loss from any other eye pathology is much worse in patients with multifocal lenses.

(Disclaimer: You asked for the downsides. There are huge positives as well, of course. The biggest positive in my opinion is the ability to see the pathology on exam 95% of the time. When you can actually see what's wrong or easily get objective testing, you'll realize that patient histories can be very misleading and I feel sorry for all specialties that have to rely almost entirely on history to make their diagnosis).