Visionary, what do you think about the practicality of the very academic approaches to medical retina that are taught at these top fellowships? At large ophthalmology institutions they have access to ICG, autofluorescence, PDT, great technicians and they'll use these tools often in their treatment algorithms and to differentiate themselves from the run-of-the-mill-retina-specialist down the street. But out in the real world (in a comprehensive practice) it seems like the overhead for these tools must be high and you'd be lucky if you get access to an FA, an HD-OCT and a technician who knows how to use them.
Disclaimer: I'm a paid speaker for QLT, the makers of Visudyne.
I could easily sit down and have an hour-long conversation with you about this, but I'll give you the Readers' Digest version. Not only do I think it's practical, I think it's essential, but that's my bias. For me, fellowship was incredibly enlightening. I thought I knew a lot about retina, as that had been my primary interest throughout residency (and before). It didn't take me long to realize that I actually knew very little. When you're doing retina day in and day out and following individual patients for long periods, you begin to understand more about the different pathologies, their time courses, and their responses to treatment.
I would never manage AMD without access to advanced imaging, and frankly, I would never recommend that someone who was not fellowship-trained do more than screen for retinal disease. Most comprehensive docs just don't know what they're looking at. It's not about competence, it's about experience. You simply don't get enough experience in residency rotations to appropriately understand and manage retinal disease. I know there are some who will argue with me, but that's my opinion.
Imaging technologies like SD-OCT and ICG angiography really opened my eyes to the complexity of wet AMD, in particular. I've picked up pathology missed by TD-OCT with SD-OCT. Likewise, I've identified sources of resistance in wet AMD with ICG. Now, probably only about 10% of retina docs use ICG, but I feel it's invaluable. Not every patient will respond to injections--no one would argue that fact. So, what do you do? Keep injecting? Give up?
I turn to combination therapy, usually with anti-VEGF, PDT, and dexamethasone. I target mature neovascular complexes, as identified by ICG, with the PDT. I'd say my success rate in those cases is ~70%, so it doesn't work for everyone. Sometimes, you just lose, no matter what you try. Do I get ICG on everyone? No. The majority of patients will still respond to injections. If they aren't having a significant response after 3 injections, however, I get an ICG. What I usually find is a mature complex, but sometimes it's something like polypoidal. Injections against those pathologies is pissing in the wind.
I have a 6-mode Heidelberg Spectralis, which runs about $150,000. It does everything I need (IR, autofluorescence, SD-OCT, red-free, FA, ICGA). Of course, as a function of my annual revenue, it's really not that expensive. It was paid off in my first year of practice (granted, that was before OCT reimbursement was cut).
My main photographer is a COT who has a particular interest in (and apparent talent for) photography. It took her a while to get the hang of it, but she does well. When she's out, I can tell a difference in quality, particularly with angiography. So, I would say having a good photographer is important, but not that difficult to find.
Is the added stuff you learned during your medical retina fellowship useful and practical in private practice, over the basic medical retina knowledge that you learned from residency and on your own?
See above.
Also, when you were looking for a comprehensive practice to pitch your services too, what were you looking for in order to know that you'd be successful there with a medical retina practice? Was it basically a group you got along with and a lot of doctors who could refer you patients internally? Was there anything else?
If you are going into a comprehensive practice as a specialist, you need to understand that most other comprehensive ophthalmologists will never refer to you. They're afraid of losing business to your colleagues, simply out of patient convenience. Thus, you must have a group that provides a large enough referral base for you to be successful. My group is 8 docs, including me. The others are comprehensive, though one has plastics training. There are also 2 cornea docs in my building, who send me patients. That has given me a good base, but my practice would have built more quickly with more. I'm happy with it, though.
Another option is a multispecialty group without comprehensive. That gives you a broader potential referral base. As has been stated before, joining a retina-only group is less of a possibility, as most such groups want the newer docs to take surgical call. It does happen, though.
