Like retina, but scared of the future?

[Cdnophthalresident]

Hi guys,

Sorry again - would love to ask some of the more senior residents, fellows, and attendings for their advice on this.

I started doing research in ophthalmology before med school, specifically in retina research (my PI was a retina doc). Afterwards, when I got in, I just wanted to continue to build my resume and publication list - I really enjoyed ophthalmology (mostly clinical, not a lot of surgical exposure yet). The publications and research work were tough but very rewarding. Now that I've matched and am a very junior ophthalmology resident, I'm just a bit lost in terms of advice for the future.

In Canada (where I'm from) retina seems to get a lot of flak from the other subspecialities. Everyone (to my face, some other subspecialists/comprehensive) keeps telling me that retina is going to be "dead" in 4-5 years as the number of injections and reimbursement goes down. There are very few surgical retina jobs far and few between in Canada unfortunately, and medical retina (as evidenced by another post here) has its advantages and disadvantages. Still hard to find work. The government is coming quite hard on ophthalmology in general.

For now I understand that I want to keep my "eyes" open as much as possible but not getting work or a job potentially scares me a bit, on top of how hard one has to work for advanced degrees and fellowships. I haven't had too much exposure yet to other specialties, but I would like to try to stand out as much as possible to be able to get a job.

Just wanted to ask maybe some advice around these matters:

1) what does the future of retina look like? I know it's a broad question and I have some ideas - for instance, very exciting that we were able to transplant some RPE cells in england, and the new anti-VEGF medications down the line.
2) what are some of the ways that you can build a more "niche" approach or practice for retina...for instance, ERGs? Uveitis? That you could build a more independent referral base from other ophthalmologists or optometrists.
3) Will there be niche or elective procedures in retina one day? for instance oculoplastics and cornea have things to fall back on if public funding for ophthalmology goes down the drain - for instance, could YAG vitreolysis be a thing that retina could do one day more exclusively?

Thanks so much!

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[paging_dr]

The practice of medical and surgical retina will only get busier in the future as the population ages, but in my opinion reimbursement will definitely go down, particularly for medical retina specialists.

Surgical specialists simply have a wider skillset (IOL dislocations, RD repairs, giant tear repairs, intraocular foreign bodies, vitrectomies, etc.) that will never be replaced, in addition to practicing the full scope of medical retina.

Medical retina has had a bit of a windfall in the last decade due to OCT and injections, but the downside is that a large part of their income is dependent literally on two fee codes, at least in Canada (OCT and injection). If the government cracks down on those two codes alone (like the OMA is currently proposing - another 25% cut, including for retinal lasers), medical retina specialists will lose a huge part of their income. You can only see so many more patients in a day to try to maintain it, and who wants to see 100 patients a day? The new drugs that are coming out won’t help you either - you’re still just billing the same single code. In fact things might be worse as some of the drugs have longer injection schedules.

Lastly, effective anti-VEGF eye drops are on the distant horizon coupled with CPPs (cell penetrating peptides) that may potentially impact the field... better for patients, not as good for medical retina specialists.

Retina is great, but IMO put in the time for surgical. It will give you more to do and enable you to have a more resilient income. It’s only a matter of time until the government realises that even paying $90 for putting a needle in an eye is rediculous. This may very well be $70 next year if we lose arbitration in Ontario (not sure which province you’re from). Hard to believe they used to pay $180 at one point... I’m sure the older generation of medical retina specialists made some bank but the future ones, not so much.

 

[speyeder]

The practice of medical and surgical retina will only get busier in the future as the population ages, but in my opinion reimbursement will definitely go down, particularly for medical retina specialists.

Surgical specialists simply have a wider skillset (IOL dislocations, RD repairs, giant tear repairs, intraocular foreign bodies, vitrectomies, etc.) that will never be replaced, in addition to practicing the full scope of medical retina.

Medical retina has had a bit of a windfall in the last decade due to OCT and injections, but the downside is that a large part of their income is dependent literally on two fee codes, at least in Canada (OCT and injection). If the government cracks down on those two codes alone (like the OMA is currently proposing - another 25% cut, including for retinal lasers), medical retina specialists will lose a huge part of their income. You can only see so many more patients in a day to try to maintain it, and who wants to see 100 patients a day? The new drugs that are coming out won’t help you either - you’re still just billing the same single code. In fact things might be worse as some of the drugs have longer injection schedules.

Lastly, effective anti-VEGF eye drops are on the distant horizon coupled with CPPs (cell penetrating peptides) that may potentially impact the field... better for patients, not as good for medical retina specialists.

Retina is great, but IMO put in the time for surgical. It will give you more to do and enable you to have a more resilient income. It’s only a matter of time until the government realises that even paying $90 for putting a needle in an eye is rediculous. This may very well be $70 next year if we lose arbitration in Ontario (not sure which province you’re from). Hard to believe they used to pay $180 at one point... I’m sure the older generation of medical retina specialists made some bank but the future ones, not so much.

Given that 95% or more of retina nowadays is medical, both medical and surgical retina specialists would largely be equally affected by cuts to injections and imaging. Unless you're really busy surgically most retina specialists can bill more in a clinic day than in the O.R.

 

[paging_dr]

Fair point, although I wonder how much cuts there would need to be to OCT and injections until you can bill more in the OR. How are billings for OCT and injections in the US? In Canada it varies by province although just a few years ago it was $180 CDN per injection, then cut by 50% to $90, and the government now plans to cut another 25% on top of that. OCTs are currently $35 CDN but will likely be down another 25% as well. There are also clauses that you can't bill for OCTs within certain time intervals so you're not billing the OCT each time you do it within a short time... that's my understanding anyway.

Also doesn't matter what miracle drug you're injecting into the eye - they bill the same. Is this the same in the US?

 

[skarim]

There's only going to be more pathology for retina specialists, as the population ages and as diabetes becomes more prevalent (unfortunately).

I agree with the above poster. I think it's definitely worth the extra year to learn to do surgery if you like retina. Anybody can do injections, a graduating resident can have done hundreds of them. No one else can fix detachments, remove lens fragments, explant posterior IOLs, etc. You want to be in a position where no other specialty/subspecialty can do your job. General ophthalmologists will send more patients to you when you can help out on their patients with dropped lenses, endophthalmitis, dislocated IOLs, etc.

 

[paging_dr]

Exactly... nurses and technicians already do injections in the UK, and deep learning is becoming more of a reality to diagnose/monitor from those fundus photos and OCTs (that even optom offices have). Sure there will be plenty of patients, but how many patients can you really see when your two fee codes (OCT and inject gets cut to nil)? Medical retina is becoming more automated, and the "windfall" of anti-VEGF injections and OCTs fees will come to an end.

You're always better off being surgically trained. If I had another 35 years left in my career, I'd be worried if I was just doing medical retina.

 

[docdoc2012]

I find this post incredibly reductive when discussing medical retina. If there is a true interest in retina surgery, then definitely pursue a 2 year fellowship. But to reduce medical retina specialists to injection pushers seems quite ignorant
1. Medical retina volume decreasing will not see a magical increase in surgical retina volume. Decreasing reimbursements do not mean changes in treatment paradigms - most retina treatments are done out of the office at this point, and those practices with high surgical volume have painstakingly cultivated and honed their practices to be this way - a majority of retina practices are not. A surgical retina specialists is most definitely irreplaceable if we have large systemic changes. But most medical retina specialists I know have their own niches in addition to medical retina such as uveitis, ocular oncology and retinal dystrophies. All of my medical retina friends who are 2-3 years out of fellowship deal with trainwreck retina cases on regular basis

2. Many medical retina specialists are also performing anterior segment surgery, and while this is largely due to persistent interest in the anterior segment, it is also a smart financial move to be able to step into a more surgical comprehensive ophthalmology role if reimbursements indeed do get hit hard.

If retina reimbursements get cut, everyone will get hit hard. But then again that is not a reason not to pick a specialty, because likely if it's happening to us, its happening to all of medicine. Vitrectomy surgery got a 26% cut in 2015. But people are still surviving. pick what you want to do!

 

[paging_dr]

Sorry, didn't mean to come off as reductive... just wanted to play the devil's advocate as these are the practical realities that we will all face in the near future. Declining reimbursement to medical retina will surely hurt many comprehensive docs as well since many do injections or at the very least follow retinal disease using OCT.

I would love to hear what a typical medical practice is like in a small private group practice outside of an academic centre... where I am training I think we all become disillusioned surviving day after day of brutal 160+ patient retina clinics with same-day 60+ injections staffed by multiple retina fellows plus residents and spending literally 1 minute with patient, cutting them off and exiting quickly before they can ask any questions... in which case it is very easy to see things as OCT and inject. Perhaps life outside of academic medical retina is more sane, but in Canada I believe most medical retina specialists exist in academic centres with multiple fellows to run the mill.

 

[pianist]

If you like surgery, do surgical training. If you absolutely don’t like surgery, do medical retina. There will still be lots of work to do over time. Although in the private practice world I haven’t seen a lot of medical retina people doing a lot of cataract surgery. It is usually the other way around with generalists doing injections.

Yes there are niches in uveitis and oncology in medical retina. But again, you have more flexibility if you can do diagnostic vitrectomies, retisert surgeries, plaque placements, transvitreal FNAB tumor biopsies, etc.

Phil Rosenfeld at BPEI, one of the biggest medical retina names today, encourages all of his medical retina fellowship applicants to do surgical training. This article also talks about the future of medical and surgical collaboration

Retinal Physician - Preparing Retina Fellows for the Future