No longer doing glaucoma surgery

[mjohnsonets]

Over the last few years, I've encountered a growing number of glaucoma fellowship-trained ophthalmologists wanting to stop doing glaucoma surgeries. As a non-surgeon, I will never fully understand this feeling but I get those patients are challenging in that nothing really ever gets better and they will always be with you. It seems ripe for burnout which is typically reported to me as to why these surgeons want to stop.

For the glaucoma surgeons on her, what do you do to help stave off burnout from these patients/cases? What do you do to keep yourself intrigued? It seems burnout is more common with glaucoma surgeons than in other sub-specialties, does that seem true from your discussions with colleagues? I thought this would be good to have posted here since glaucoma fellowships are becoming more popular.

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[TheLesPaul]

I doubt a tube pays as much as refractive or premium lenses

 

[PLA2]

1. Low reimbursements from medicare and insurance for glaucoma surgeries
2. Comprehensive colleagues and optometrists mismanaging glaucoma patients so they come in at late stages, sometimes just salvaging islands of vision
3. Many glaucoma docs would rather just do premium lenses

 

[dantt]

This happens in all specialties. I'm a cornea surgeon and do not really want to do/manage full thickness transplants unless I have to. Just like glaucoma, complicated postops (people these days tend to have it for infections, auto immune conditions, etc so high risk for complications), life long risk for problems like infection and rejection, pays poorly, and hurts my back and neck doing it.

Plastics don't really want to do temporal artery biopsys. Retina doesn't really want to do retinal detachments nights or weekends. Ophthalmologists in general don't want to do call. The anesthesiologists don't want to do our cases.

That being said, minimally invasive glaucoma surgery is kind of fun. We'll all probably stop doing it when reimbursement goes to $34 (almost happened last year).

 

[immunology89]

Ways to prevent burnout as a glaucoma specialist:
1. Do a lot of phacos. Those happy POD 1's make you feel great and can offset the difficult post-op management of tubes/trabs. My current phaco:incisional surgery ratio is 20:1.
2. Have a colleuage(s) to discuss difficult cases with. I have lunch once a week with my glaucoma partner and talk on the phone regularly with other friends who do glaucoma. A lot of times in incisional surgery, patients can have bad outcomes and that can be hard to accept as a surgeon. Hearing similar stories from others is helpful.
3. Set very low expectations in patients when performing incisional surgery. Often times managing the patients frustration/disappointment with the difficult recovery is more challenging than managing the bleb. Most patients think eye surgery is quick and easy, and if its not then it's the surgeon's fault. Couldn't be further from the truth in glaucoma.

MIGS is great, but many patients absolutely need a tube or a trab to stop from going blind. Rarely, patients need a single digit pressure, which I find is really only possible with a trab. For me, performing the occasional tube and trab definitely breaks the monotony of the phaco assembly line. It also feels great to hit the occasional home run have have a patient off all meds after a beautiful trab.

 

[Iladelphia]

Welcome to performing surgery in the 2020's. This is a problem across the board, but has hit ophthalmology particularly hard.

Yes - surgery is interesting, challenging, and fun. But it is also risky, stressful, and litigious. Combine this with pathetic rates of reimbursement and you have a recipe for surgical burnout. Unless you are doing premium IOL's, cosmetics, or retina, it's just not financially rewarding. Example - I am a pediatric ophthalmologist and perform strabismus surgery. Our reimbursement for a 67311 horizontal eye muscle surgery was just slashed by over 20 percent in a single year. We are already the lowest paid field in ophthalmology. It almost doesn't pay to operate anymore - I can make more in the clinic hands down. But I do it because children need it, I believe in what I do, and it keeps things interesting.

Sorry, I didn't mean to hijack the glaucoma thread. I can only imagine what it must be like performing incisional glaucoma surgery, and I understand their reasoning completely for stopping.

 

[RetinaDude]

Glaucoma docs deal with a lot of the same type of pts we retina docs see……..pts who just do not understand why you can’t fix their problem and restore them to 20/20 vision again. Through the years, it becomes downright demoralizing dealing with these pts. Either they are going blind because of no fault of their own (ie, bad luck with a PVR afflicted RD) or because of non-compliance (ie, poor BS control, smoking, not using drops, etc….). When these pts go blind, they can blame you, or get mad at you. I tell pts all the time I wish I never had to operate on another RD for the rest of my career

 

[Iladelphia]

This is a very uplifting thread 🤣🤣😕

 

[TheLesPaul]

every field has its train wrecks. you have to decide which train wrecks you actually enjoy dealing with. or if you don't find any, work 3.5 days a week and go golfing

 

[dantt]

every field has its train wrecks. you have to decide which train wrecks you actually enjoy dealing with. or if you don't find any, work 3.5 days a week and go golfing

Note: dealing with training wrecks and working 3.5 days a week and being able to afford golfing are not mutually exclusive...in ophthalmology

 

[LightBox]

I deal with a fair amount of train wrecks as I do lots of real glaucoma surgery (not just MIGS). It can depressing at times, but then again I find great satisfaction since there are not many providers (in my area) that can save someone's eye from IOPs of 60. I would get very bored doing just easy stuff all day long.

 

[airplanes]

A select sampling of a few patients from the last few two days. Really fun conversations and very much satisfaction derived. (/s if unclear)

Patient 1: 85yo AAF. CF VA OD, exposed tube, IOP 10. Hx shunt revision with patch graft 3 months ago. 20/80 VA OS, 0.9 CDR, IOP 40. Sobbed uncontrollably when told she would need additional interventions OU.

Patient 2: 62yo WF, IOP 52/28. CDR 0.6 OU, Va 20/40. Acuity intact. Allergic to all drops except PGA. Hx SLT. Reports she is allergic to NSAIDs and steroids.

Patient 3: 92yo AAF, IOP 44, pain and discomfort. LP VA from CRVO. Lost to follow up for 4 months, IOP was 35 prior with plan for diode. Wants to pray about it before having anything done.

Patient 4: 60yo WM, Seeking second opinion after failed SLT and Xen OS. IOP 18/32. VA 20/50 OS, CDR 0.9. Allergic to all meds. Wants to avoid surgery.

(It's not all bad and we aren't the only field dealing with train wrecks and people actively going blind, but there is no cure and you're often pulling out all the stops to try and salvage vision, and sometimes the vision gets worse or the patients are dissatisfied that they aren't seeing better, which is frustrating when you feel fortunate to have saved their functional vision or central island)

Thankfully, my surgical volume is 80-90% phacos, I wouldn't survive otherwise.

 

[RetinaDude]

Airplanes, glaucoma and retina have a lot in common with regards to pts having terrible, non-curable disease and us having to fight the constant battles with them to prevent blindness (except we don’t get to do the phaco part)

 

[MstaKing10]

A select sampling of a few patients from the last few two days. Really fun conversations and very much satisfaction derived. (/s if unclear)

Patient 1: 85yo AAF. CF VA OD, exposed tube, IOP 10. Hx shunt revision with patch graft 3 months ago. 20/80 VA OS, 0.9 CDR, IOP 40. Sobbed uncontrollably when told she would need additional interventions OU.

Patient 2: 62yo WF, IOP 52/28. CDR 0.6 OU, Va 20/40. Acuity intact. Allergic to all drops except PGA. Hx SLT. Reports she is allergic to NSAIDs and steroids.

Patient 3: 92yo AAF, IOP 44, pain and discomfort. LP VA from CRVO. Lost to follow up for 4 months, IOP was 35 prior with plan for diode. Wants to pray about it before having anything done.

Patient 4: 60yo WM, Seeking second opinion after failed SLT and Xen OS. IOP 18/32. VA 20/50 OS, CDR 0.9. Allergic to all meds. Wants to avoid surgery.

(It's not all bad and we aren't the only field dealing with train wrecks and people actively going blind, but there is no cure and you're often pulling out all the stops to try and salvage vision, and sometimes the vision gets worse or the patients are dissatisfied that they aren't seeing better, which is frustrating when you feel fortunate to have saved their functional vision or central island)

Thankfully, my surgical volume is 80-90% phacos, I wouldn't survive otherwise.

Recall bias.

Throw in the bulk of patients who are happy and do well with our interventions to make a fair more realistic sample.

 

[airplanes]

Recall bias.

Throw in the bulk of patients who are happy and do well with our interventions to make a fair more realistic sample.

I mean.. I already prefaced by saying it was a select sample of tough cases within a 24 hour period so it has nothing to do with recall bias. Obviously not the majority.

I like my job, but I also recognize that it would be much easier to just be a cataract cowboy. I pretty much already am, I just throw a lot of bad glaucoma on top.