Medical retina, uveitis, and cataract surgery: Fellowship choice

[prokofiev1996]

Hi there,
I'm a PGY-3 nearing fellowship application season. My ideal practice would involve a mix of medical retina, uveitis, and cataract surgery. Based on my current understanding, it would be difficult but possible to realistically practice all three given referral patterns, the tendency for MR and uveitis patients to accumulate, and the need to follow up labs and coordinate IMT, etc, for which support staff may or may not be available.

It seems that the two common job scenarios are MR/Uveitis in a Retina practice where one would not be able to operate but would have access to colleagues for discussion and adequate injection inventory/imaging/lasers, versus a split uveitis/comprehensive position where one can operate but may not have access to the Retina practice perks listed above.

That said:

1) Is my preferred practice split possible, and which practices types would accommodate this setup in a suburban/urban setting (eg, multispeciality vs academic vs Hospital/HMO)?
2) There are a few fellowships marketed as combined Medical Retina/Uveitis that I will be applying to (eg Wisconsin, UIC). Besides these, does it make more sense to apply to Medical Retina fellowships and ask for 1-2 days a week in Uveitis clinics, or to Uveitis fellowships with some MR time?
3) Are there specific fellowships you would recommend, particularly those where I can continue to operate?
4) I've read some other forums discussing how a medical retina/cataract practice is possible in the right multispeciality group, though there are several barriers. How feasible is practicing cataract surgery as a uveitis specialist in a private practice or Hospital/HMO setting?

If I have to sacrifice one of the three focuses, I would lean towards focusing on MR and cataracts while not being as heavily involved with uveitis. I imagine I could still see the typical uveitis cases being referred to Retina and offer injectables/local therapy as well as prednisone/antimetabolites but not manage biologics or be the one getting referred the very difficult cases.

Thanks!

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[Slide]

Ah yes, this isn't an uncommon scenario and have been asked this from my residents. My take from the retina community;
-your kind of setup ironically is best if you're going solo. The reality of medical business is that your practice revenue is largely supported by medical retina and doing phaco (esp premium lenses). Even with the increased reimbursement for level 4s + g2211 modifiers, uveitis patients are generally an opportunity cost compared to the straightforward stuff. In solo you make the rules about this but in a group practice, your practice will likely turn into a uveitis dumping ground (ask me how I know lol).
-doing cataract surgery as a uveitis specialist is fine in a hospital/academic setting - unsure about private setting and would be based on how fast you can operate and bring in premium revenue. Probably like above, your clinic will eventually turn into a medical retina/uveitis clinic because the profit leaders in the practice will offload more uveitis to you to both keep the revenue in house but at the same time keep their schedule going to crank out patients.

IMO if you really want to do uveitis, you would be doing a major disservice to yourself by not going to a uveitis-heavy medical retina fellowship or at least learning how to manage biologics. Most retina can do the local therapy and prednisone treatments, but few are willing to do antimetabolites, and rarely biologics - I'm happy doing antimetabolites but I don't have the training to handle biologics (which in retrospect I wish I had). The flip side is if you're doing more antimetabolite/biologic therapy, your PA burden is going to increase a lot more on top of your injectibles - insurances recently have been being major a-holes with PAs for biologics this year.

 

[docdoc2012]

You can have a successful practice like this in a smaller town without a lot of competition, or a multispecialty group with unopposed retina. You just have to be extremely careful about delineating your anterior and posterior days and sending pts back to other ophthos and not keeping retina referrals for cats and vice versa

 

[eyeeye_captain]

Academics, HMO, large multispecialty, and solo are all doable. Academics and something like a Kaiser make it easiest from a referral, care coordination, and productivity expectation perspective.

In the private world I’ve seen large single retina group, large multispecialty, and solo. You most likely won’t do any phacos with retina only, and you won’t be doing many premium lenses in the multispecialty since you’ll be drawing heavily from your MR and uveitis crowd unless they’re willing to give you a reasonable cut of regular cataract patients (hint: they may not since you’re probably more productive doing MR and that takes their bread and butter away).

Agree that boundaries and referral patterns are big things to be mindful of. If you even hint that you want to be the uveitis person, you will become the uveitis person. Sort of like Slide, when I started I made the mistake of doing a second opinion for a retina doc a town over, and suddenly their entire uveitis panel was referred. I managed to cut it off after a couple, but jeez.

If you’re leaning more MR than uveitis, I guess you can check around and also ask at interviews what you can do schedule-wise to maximize your exposure. I don’t know the cataract volume at any, or if it’s even a thing. I think UCSF’s uveitis fellowship is relatively cataract friendly since it’s more anterior segment focused.

A smaller town won’t really work because you won’t get enough uveitis patients unless there’s something in the local gene pool. You can still crush it with comp/MR and the occasional uveitis-lite.

 

[mjohnsonets]

Everything said above are great responses.

If you have specific cities you're targeting, feel free to message me directly and I can likely tell you about the market there and if this is possible. I'm less tuned in with the northeast though.

 

[linevasel]

Short Answer :

1. It is doable
2. You will have to be very specific about the boundaries of your "tri-brid" practice. You are not in a position now to really know how to go about doing that, but as you can read from the above, the wrong practice model wil hurt your bottom line
3. If you aren't at a residency with a uveitis provider you need to go shadow one somewhere, preferable private practice.
3. Join Young Uveitis Specialists [YUS], if u intend on pursuing uveitis
4. You don't need a true uveitis fellowship.. it's true. There are members of AUS who aren't uveitis trained. But those are older members. Nowadays, it's rare to see anyone in this generation practicing serious uveitis beyond the level of your average retina surgeon without a fellowship
5. There are only 11 or 12 uveitis fellowships. I would do one that gives you good medical retina. Whether you need an extra medical retina year or not depends on how much and quality of medical retina exposure you get in residency.

When you get more serious about it, reach out to YUS, and see if you can connect with anyone who does what you want to do. It will help more than posting will. (Not an insult, just want to give you some direct advice)

6. Lastly. Uveitis has its own rewards. What it will do for you is make you imminently employable anywhere. It is interesting to those of us who do it. It will not make you more money as a hybrid. In fact you will likely lose money (people won't like me saying this...). Many of your peers won't see the value in what you bring to the group which may be tough to handle psychologically. Your patients however will be eternally grateful. If you are decent at surgery, I recommend maintaining your surgical skills. If money is all you want, just do medical retina and have a great life

I guess this was long answer 🤔

 

[Slide]

6. Lastly. Uveitis has its own rewards. What it will do for you is make you imminently employable anywhere. It is interesting to those of us who do it. It will not make you more money as a hybrid. In fact you will likely lose money (people won't like me saying this...). Many of your peers won't see the value in what you bring to the group which may be tough to handle psychologically. Your patients however will be eternally grateful. If you are decent at surgery, I recommend maintaining your surgical skills. If money is all you want, just do medical retina and have a great life

Last part is so true. It's the one part of ophthalmology I would argue is the most "medical" that uses what you learned in medical school and internship, and I find it the most intellectually stimulating subspecialty. It's the equivalent of being like Gregory House MD but for eyes. Perhaps the most grateful patients I have are well-controlled uveitis patients, especially since they often get bounced around. But unfortunately, it's like neuro-ophthalmology where the visits can be long and the pay is pretty poor (see 2-3 uveitis pts per hour vs knock out 8-10 injections in the same time). But OP, if stress and lifestyle are important, make sure you really consider how uveitis will affect that.

 

[docdoc2012]

We currently have a medret/uveitis doc who splits their time with anterior segment at our group. They've been here for 4 months and are busy on both ends.
We are an 8 doc multispecialty, 4 retina and 4 anterior and our practice head is retina. We split all drug and multifocal profits 40-60 (60% to partner pool). We are in the Midwest in a smaller city and are unopposed for retina for a surrounding 90 mile radius? Our ant docs are known for high volume and great outcomes.
In a place like this you can thrive. It is a unique setup but it's not a unicorn. You just have to look outside the bigger cities to find it