Ophtho Call in Private Practice

[rocketbooster]

---

Members don't see this ad.

What's the call schedule like?

Everyone always says ophthalmologists work 8-5 M-F, but now that I have been doing an ophtho rotation I realize someone has to do the call.

What do you for your pts on weekends?

Do you refer them to the ED and just have the eye doc covering the ED see them?
Do you cover the ED yourself?
Do you just refer them to the academic center for the residents to manage if you have that available to you in your area?

Everyone says only the retina specialists have a bad lifestyle because most true emergencies affect the retina. But what about all the mindless calls you get from the ER docs? I've seen the on call residents have to deal with all kinds of BS from the ER. Most of their calls from the ER are things that are not true emergencies. If you have no residents to cover those for you, who does it? I feel all ophthos, not only retina docs, would have to manage those mindless calls from the ER. Is it that there are always some ophthalmologists or optometrists out there willing to cover the ER? If you don't want to take ER call, wouldn't you be worried about losing your patients to those other docs/optoms on call in the ER, or do they generally still have the pts follow up with you in clinic?

 

[LightBox]

What's the call schedule like?

Everyone always says ophthalmologists work 8-5 M-F, but now that I have been doing an ophtho rotation I realize someone has to do the call.

What do you for your pts on weekends?

Do you refer them to the ED and just have the eye doc covering the ED see them?
Do you cover the ED yourself?
Do you just refer them to the academic center for the residents to manage if you have that available to you in your area?

Everyone says only the retina specialists have a bad lifestyle because most true emergencies affect the retina. But what about all the mindless calls you get from the ER docs? I've seen the on call residents have to deal with all kinds of BS from the ER. Most of their calls from the ER are things that are not true emergencies. If you have no residents to cover those for you, who does it? I feel all ophthos, not only retina docs, would have to manage those mindless calls from the ER. Is it that there are always some ophthalmologists or optometrists out there willing to cover the ER? If you don't want to take ER call, wouldn't you be worried about losing your patients to those other docs/optoms on call in the ER, or do they generally still have the pts follow up with you in clinic?

Our practice has a few optometrists that take all of the after-office-hours call. The ophthalmologists in our practice do not take ANY office call. Of course, the optometrist-on-call is free to call us anytime if he or she is worried about a patient (especially post-op patient).

Only one of our ophthalmologists takes hospital call -- one week out of 2 months. This is mainly for political reasons and to maintain hospital OR privileges because some of our patients cannot be operated on at our ASC (i.e. since our ASC will not take their insurance).

The ER will occasionally call us during office hours to refer an urgent patient to us. Our patients know to seek our optometrist's care first for any emergencies outside of office hours. Private practice is a very different world from the tertiary care center. We (thankfully) don't deal with as many train wrecks and emergencies compared to an academic center.

Yes, I love it! 😍

 

[RestoreSight]

What's the call schedule like?

Everyone always says ophthalmologists work 8-5 M-F, but now that I have been doing an ophtho rotation I realize someone has to do the call.

What do you for your pts on weekends?

Do you refer them to the ED and just have the eye doc covering the ED see them?
Do you cover the ED yourself?
Do you just refer them to the academic center for the residents to manage if you have that available to you in your area?

Everyone says only the retina specialists have a bad lifestyle because most true emergencies affect the retina. But what about all the mindless calls you get from the ER docs? I've seen the on call residents have to deal with all kinds of BS from the ER. Most of their calls from the ER are things that are not true emergencies. If you have no residents to cover those for you, who does it? I feel all ophthos, not only retina docs, would have to manage those mindless calls from the ER. Is it that there are always some ophthalmologists or optometrists out there willing to cover the ER? If you don't want to take ER call, wouldn't you be worried about losing your patients to those other docs/optoms on call in the ER, or do they generally still have the pts follow up with you in clinic?

There's a big difference between true emergency consults and general ophtho consults that come from the ED. Most ophtho consults can be put off until the next business day. Depending on the experience of the ED doc, sometimes you are called for simple conjunctivitis. True emergencies (chemical burn, open globes, retrobulbar hemorrhage, CRAO) need to be staffed quickly, but depending on the hospital these are few and far between. My hospital is an ophtho trauma referral center for a large metropolitan area staffed by the residents and we see a ton of these, but a private practice doc may see very few if any serious emergencies if they are not covering a trauma ER.

If a patient is seen on the weekend with an emergency that requires immediate follow up the next day you would tell the patient to return for follow up. An example, a recent pedi patient of mine with a traumatic hyphema and IOP of 30 we asked to return on Sunday for IOP check and to monitor for rebleed.

Retina sees more of these than other subspecialties, but the call as an attending is not so bad, especially if you have competent residents. Most ER consults can be handled with only a brief call to the attending. When they do come in its usually to staff an urgent OR case. In any respect call in ophtho is nothing like call in other specialties. My neurosurg buddies can attest to that

 

[rocketbooster]

Our practice has a few optometrists that take all of the after-office-hours call. The ophthalmologists in our practice do not take ANY office call. Of course, the optometrist-on-call is free to call us anytime if he or she is worried about a patient (especially post-op patient).

Only one of our ophthalmologists takes hospital call -- one week out of 2 months. This is mainly for political reasons and to maintain hospital OR privileges because some of our patients cannot be operated on at our ASC (i.e. since our ASC will not take their insurance).

The ER will occasionally call us during office hours to refer an urgent patient to us. Our patients know to seek our optometrist's care first for any emergencies outside of office hours. Private practice is a very different world from the tertiary care center. We (thankfully) don't deal with as many train wrecks and emergencies compared to an academic center.

Yes, I love it! 😍

Sounds like you have a sweet setup. I want lol 👍

As for the part in bold, why is that? How big of an area do you live in? Do pts really get flown in a few hours away to academic centers for retrobulbar hemorrhages and open globes? Seems like they would need to be emergently seen by the local ophthalmologist?

Who (ophtho/optom) covers the weekend ER calls during the other 7/8 weekend calls? Surely ppl come into the ER on the weekends...

There's a big difference between true emergency consults and general ophtho consults that come from the ED. Most ophtho consults can be put off until the next business day. Depending on the experience of the ED doc, sometimes you are called for simple conjunctivitis. True emergencies (chemical burn, open globes, retrobulbar hemorrhage, CRAO) need to be staffed quickly, but depending on the hospital these are few and far between. My hospital is an ophtho trauma referral center for a large metropolitan area staffed by the residents and we see a ton of these, but a private practice doc may see very few if any serious emergencies if they are not covering a trauma ER.

If a patient is seen on the weekend with an emergency that requires immediate follow up the next day you would tell the patient to return for follow up. An example, a recent pedi patient of mine with a traumatic hyphema and IOP of 30 we asked to return on Sunday for IOP check and to monitor for rebleed.

Retina sees more of these than other subspecialties, but the call as an attending is not so bad, especially if you have competent residents. Most ER consults can be handled with only a brief call to the attending. When they do come in its usually to staff an urgent OR case. In any respect call in ophtho is nothing like call in other specialties. My neurosurg buddies can attest to that

I see, I see. I was asking more about areas without a nearby residency program to cover all the random, non-emergent calls from the ER though. Residents go into the ER and do a good job screening those out for you so you don't have to come in unless it's a true emergency. What would you do about those calls (in which someone usually has to go to the ER to clear it up since ER docs don't know squat about the eye) if you didn't have ophtho residents in the area to cover them for you? Is there usually always some ophthalmologist or optometrist taking call at the ER for the extra $$ that covers all these annoying calls?

 

[RestoreSight]

I see, I see. I was asking more about areas without a nearby residency program to cover all the random, non-emergent calls from the ER though. Residents go into the ER and do a good job screening those out for you so you don't have to come in unless it's a true emergency. What would you do about those calls (in which someone usually has to go to the ER to clear it up since ER docs don't know squat about the eye) if you didn't have ophtho residents in the area to cover them for you? Is there usually always some ophthalmologist or optometrist taking call at the ER for the extra $$ that covers all these annoying calls?

I think most competent ER docs can handle a good amount of eye pathology so, again, most calls can be deferred to the next day. Since call is split up, everyone gets the same number of new patient encounters on average. Most ERs have slit lamps, tonopens, fluorescein strips, and of course CT, MRI, etc. Anything that is serious and beyond their training will be sent out, likely to a larger referral center. The pedi patient I mentioned earlier was sent from more than 100 miles away to receive care at our institution. I'm sure there were local ophthalmologists closer, but trauma and ER emergencies come down to experience and you want someone with the most up to date skills handling these cases, especially in kids.

The retina guys I know in private practice cover small ERs locally and outside of the area for extra cash and refer everything back to our center. They will handle what they can handle and refer out anything that is over their heads to us. There's no reason to tackle something that may blow up in your face if you don't have to. Not sure if that answers your question or not, but really call isn't that bad. It can be a pretty cool learning experience to see real emergencies.

 

[rocketbooster]

I think most competent ER docs can handle a good amount of eye pathology so, again, most calls can be deferred to the next day. Since call is split up, everyone gets the same number of new patient encounters on average. Most ERs have slit lamps, tonopens, fluorescein strips, and of course CT, MRI, etc. Anything that is serious and beyond their training will be sent out, likely to a larger referral center. The pedi patient I mentioned earlier was sent from more than 100 miles away to receive care at our institution. I'm sure there were local ophthalmologists closer, but trauma and ER emergencies come down to experience and you want someone with the most up to date skills handling these cases, especially in kids.

The retina guys I know in private practice cover small ERs locally and outside of the area for extra cash and refer everything back to our center. They will handle what they can handle and refer out anything that is over their heads to us. There's no reason to tackle something that may blow up in your face if you don't have to. Not sure if that answers your question or not, but really call isn't that bad. It can be a pretty cool learning experience to see real emergencies.

Do they just hang out at the ER until something happens, or do they take home call waiting for an ER doc to call them?

I'm still confused on how you don't get called much when you're on call as an ophthalmologist. I get that there aren't many true emergencies, but ER docs don't know that. The residents on call at my school get called in by the ER multiple times per night and they are almost never emergencies. The ER docs just don't know better. If you don't have a residency near you to cover those calls for you, I don't get how you are not the one who has to the answer the calls then. Someone has to answer them? So who does? The resident on call has to cover 3 different hospitals and are thus called in multiple times per night. I don't get why private practice ones don't have to do this also if there are no residents around?

 

[Dusn]

Do they just hang out at the ER until something happens, or do they take home call waiting for an ER doc to call them?

I'm still confused on how you don't get called much when you're on call as an ophthalmologist. I get that there aren't many true emergencies, but ER docs don't know that. The residents on call at my school get called in by the ER multiple times per night and they are almost never emergencies. The ER docs just don't know better. If you don't have a residency near you to cover those calls for you, I don't get how you are not the one who has to the answer the calls then. Someone has to answer them? So who does? The resident on call has to cover 3 different hospitals and are thus called in multiple times per night. I don't get why private practice ones don't have to do this also if there are no residents around?

You're not completely wrong. However, most community ERs don't have the capabilities to take care of an ophtho emergency. I disagree with RestoreSight when he or she said that "Most ERs have slit lamps, tonopens, fluorescein strips, etc;" most community ERs around where I live don't have ANYTHING. They definitely don't have the OR capabilities or an Eye team for eye cases. You'll go into the OR to repair a ruptured globe and they won't even have small enough suture. So most of these cases have to get transferred to a tertiary care hospital anyway and the resident you're shadowing is probably seeing them.

Ophtho is not necessarily an easy lifestyle by default (especially if you're comparing it to the lifestyle of non-physicians). In addition out-patient medicine, for example, has been finding ways to make their lifestyle easier through the use of hospitalists and avoiding hospital call (so ophtho is probably now less "easy" in comparison). If lifestyle is what you want you have to work at creating it in your practice and make the necessary sacrifices. Avoid hospital call and operate only in a surgical center (but you may end up with fewer patients being sent to you by an ER and it'll take more time to build your practice). Your ability to shape your career will be more difficult early in your career but traditionally is easier when you're more established (although now with hospitals buying out everyones practice, autonomy for all physicians may eventually change for the worse)

 

[RestoreSight]

You're not completely wrong. However, most community ERs don't have the capabilities to take care of an ophtho emergency. I disagree with RestoreSight when he or she said that "Most ERs have slit lamps, tonopens, fluorescein strips, etc;" most community ERs around where I live don't have ANYTHING. They definitely don't have the OR capabilities or an Eye team for eye cases. You'll go into the OR to repair a ruptured globe and they won't even have small enough suture. So most of these cases have to get transferred to a tertiary care hospital anyway and the resident you're shadowing is probably seeing them.

Ophtho is not necessarily an easy lifestyle by default (especially if you're comparing it to the "lifestyle" of non-physicians). In addition out-patient medicine, for example, has been finding ways to make their lifestyle easier through the use of hospitalists and avoiding hospital call (so ophtho is probably now less "easy" in comparison). If lifestyle is what you want you have to work at creating it in your practice and make the necessary sacrifices. Avoid hospital call and operate only in a surgical center (but you may end up with fewer patients being sent to you by an ER and it'll take more time to build your practice). Your ability to shape your career will be more difficult early in your career but traditionally is easier when you're more established (although now with hospitals buying out everyones practice, autonomy for all physicians may eventually change for the worse)

The capabilities of various ERs vary depending on their size, but I've never seen an ER without basic eye equipment. Eye complaints are a common reason for ER visits and I think they become competent at working up corneal abrasions and conjunctivitis, but I could be wrong. No one expects ER docs to be ophthalmologists.

I agree with the above that if you want to avoid call altogether private practice and ASCs are the way to go. Being connected to a hospital gives you access to more resources and more patients.

The best advice a lowly resident can give you is the following though: I would try and enjoy call for the learning experience as a resident and for the ability for it to benefit your practice and build your patient base as an attending. Ophthalmology can become routine like anything else. Having to close a globe at 2 am then perform a PPV +scleral buckle the next day will keep you sharp and ready for anything.

 

[90 diopter]

What's the call schedule like?

Everyone always says ophthalmologists work 8-5 M-F, but now that I have been doing an ophtho rotation I realize someone has to do the call.

What do you for your pts on weekends?

Do you refer them to the ED and just have the eye doc covering the ED see them?
Do you cover the ED yourself?
Do you just refer them to the academic center for the residents to manage if you have that available to you in your area?

Everyone says only the retina specialists have a bad lifestyle because most true emergencies affect the retina. But what about all the mindless calls you get from the ER docs? I've seen the on call residents have to deal with all kinds of BS from the ER. Most of their calls from the ER are things that are not true emergencies. If you have no residents to cover those for you, who does it? I feel all ophthos, not only retina docs, would have to manage those mindless calls from the ER. Is it that there are always some ophthalmologists or optometrists out there willing to cover the ER? If you don't want to take ER call, wouldn't you be worried about losing your patients to those other docs/optoms on call in the ER, or do they generally still have the pts follow up with you in clinic?

Every practice is a little different. Our practice has an agreement with several others around the area to split weekend call, so each person takes weekend call for all the practices once every 8 weeks. We only cover established office patients. If a patient calls the office, an answering service picks up, gathers all the necessary information, and calls me. If it's urgent, I meet them at my office, usually in the late afternoon. Our particular answering service is awesome; if a patient calls at 3 AM for a medication refill, they will wait until the next morning to call me instead of waking me up for something bogus.

I used to take call for the local ER and hospital, but it became a big hassle so I stopped doing it. Some of the other ophthalmologists still take hospital call, but that's on their own time and not factored into the shared schedule described above.

 

[MullerCell]

Like others have said, if you want to avoid hospital/ER call, go into private practice and operate at an ASC. I don't think this will significantly impact your practice growth. Patients seen on call in an ER are not exactly practice builders. In my experience, very few have insurance and most will never follow-up. However, you may need to keep the option of operating at a hospital open if you want to treat sick patients that aren't able to be done at an ASC or if your ASC doesn't accept all insurance types.

Im in private practice retina and for our practice, we pretty much just cover our own patients. If anyone is busy or leaving town on the weekend, we just cover for each other. There is no real call schedule. We don't operate at night. We just add on RDs the following morning at the ASC if they are mac-on and not amenable to a pneumatic. I very rarely get called. Occasionally on weekends I'll have to see patients at the office.

I spent some time on staff at a university and now am in private practice and they are very different. Hospital call in my community is split amongst multiple private practice ophthalmologists. We cover 2 hospitals that I believe are level 2 trauma centers (There is no academic center within about 200 miles). Call is incredibly easy compared to residency and we are pretty well compensated by the hospitals in exchange for taking call. In 1 year (~30 call nights), I've done 1 open globe and done 2 lid lacs. When there are things that are outside my scope, I tell them to send it somewhere else after evaluating the patient (i.e. canalicular lac in a child). For the majority of patients, the ER just asks you to see the patient for follow-up the next day or asks for advice. There are the typical floor consults for fungemia, rule out shaken baby, ect, but these aren't very frequent. Overall, it is completely different than residency where the ER will consult you on everything eye related that walks in the door. People make an effort not to call you and to allow patients to be seen as an outpatient when indicated. Unlike in residency, every floor fracture doesn't need an emergent ophtho consult.

 

[guttata]

Most community hospitals cannot properly handle emergency eye patients. These hospitals may not have ophthalmology coverage. If coverage is available, they may not have properly trained OR nurses and/or own OR equipment.

There are many reasons for poor ophthalmology coverage. Most hospitals do not compensate us for taking call (despite paying other specialties). Also, there is less equipment infrastructure/support because cataract surgeries do not generate much revenue for hospitals (opportunity cost). Many ophthalmologists partially own ASCs - so they do not have a need to operate (or maintain privileges - ie, call) at the hospital. And, let's face it, many ophthalmologists are lifestyle MDs who enjoy little call.

So, many patients are sent to academic centers because community hospitals have no ophthalmology coverage. Obviously, you have to take call for your private practice/group. If you are solo, you can usually find a colleague to cover for you (and you would return the favor). Some cities have group call. Some may have an affiliation with the local academic center. Some will tell the patient to go to the ER (poor form). Private practice call is very benign compared to residency call.

This is a topic for another discussion, but you want a busy residency call - you want (or should want) to see everything. You never know when that case of conjunctivitis will be acute closure glaucoma.

 

[Slide]

What's the call schedule like?

Everyone always says ophthalmologists work 8-5 M-F, but now that I have been doing an ophtho rotation I realize someone has to do the call.

What do you for your pts on weekends?

Do you refer them to the ED and just have the eye doc covering the ED see them?
Do you cover the ED yourself?
Do you just refer them to the academic center for the residents to manage if you have that available to you in your area?

Everyone says only the retina specialists have a bad lifestyle because most true emergencies affect the retina. But what about all the mindless calls you get from the ER docs? I've seen the on call residents have to deal with all kinds of BS from the ER. Most of their calls from the ER are things that are not true emergencies. If you have no residents to cover those for you, who does it? I feel all ophthos, not only retina docs, would have to manage those mindless calls from the ER. Is it that there are always some ophthalmologists or optometrists out there willing to cover the ER? If you don't want to take ER call, wouldn't you be worried about losing your patients to those other docs/optoms on call in the ER, or do they generally still have the pts follow up with you in clinic?

Results vary by location, but it depends on the attitude of the practice and affiliation of the practice with a hospital. Maybe I'm a bit jaded by my community's ophthalmologists, but anything requiring more than 5 seconds to figure out gets dumped at the academic medical center. In private practice you have the ability to refer a patient to the nearest tertiary care center if you think you cannot handle it or simply don't want to deal with it.

 

[MstaKing10]

Like others have said, if you want to avoid hospital/ER call, go into private practice and operate at an ASC. I don't think this will significantly impact your practice growth. Patients seen on call in an ER are not exactly practice builders. In my experience, very few have insurance and most will never follow-up. However, you may need to keep the option of operating at a hospital open if you want to treat sick patients that aren't able to be done at an ASC or if your ASC doesn't accept all insurance types.

Im in private practice retina and for our practice, we pretty much just cover our own patients. If anyone is busy or leaving town on the weekend, we just cover for each other. There is no real call schedule. We don't operate at night. We just add on RDs the following morning at the ASC if they are mac-on and not amenable to a pneumatic. I very rarely get called. Occasionally on weekends I'll have to see patients at the office.

I spent some time on staff at a university and now am in private practice and they are very different. Hospital call in my community is split amongst multiple private practice ophthalmologists. We cover 2 hospitals that I believe are level 2 trauma centers (There is no academic center within about 200 miles). Call is incredibly easy compared to residency and we are pretty well compensated by the hospitals in exchange for taking call. In 1 year (~30 call nights), I've done 1 open globe and done 2 lid lacs. When there are things that are outside my scope, I tell them to send it somewhere else after evaluating the patient (i.e. canalicular lac in a child). For the majority of patients, the ER just asks you to see the patient for follow-up the next day or asks for advice. There are the typical floor consults for fungemia, rule out shaken baby, ect, but these aren't very frequent. Overall, it is completely different than residency where the ER will consult you on everything eye related that walks in the door. People make an effort not to call you and to allow patients to be seen as an outpatient when indicated. Unlike in residency, every floor fracture doesn't need an emergent ophtho consult.

Spot on. Residency and real life/private practice outside of academia are totally different beasts. Ophthalmology, even retina, is predominantly an outpatient field and there is very little that needs to be managed after hours or as an inpatient.

I used to think that private practice docs dumped everything on academic centers as was mentioned above, but now in practice I can tell you that is very rare. I think there are a few docs that are guilty of this, repeat offenders, that gave me that impression. Don't think this is commonplace though, at least not in our practice.

 

[cyclopz]

Interesting thread. The privt practice I know rarely go in.

 

[rocketbooster]

Spot on. Residency and real life/private practice outside of academia are totally different beasts. Ophthalmology, even retina, is predominantly an outpatient field and there is very little that needs to be managed after hours or as an inpatient.

I used to think that private practice docs dumped everything on academic centers as was mentioned above, but now in practice I can tell you that is very rare. I think there are a few docs that are guilty of this, repeat offenders, that gave me that impression. Don't think this is commonplace though, at least not in our practice.

So the ER call is different because as a resident you cover all ophtho pts in the ER but even in private practice you only see your own pts?

If you are only on call for your own pts, how do you get new pts sent to you when you're first trying to build your practice? Does your group tend to send you the new pts?

 

[MstaKing10]

So the ER call is different because as a resident you cover all ophtho pts in the ER but even in private practice you only see your own pts?

If you are only on call for your own pts, how do you get new pts sent to you when you're first trying to build your practice? Does your group tend to send you the new pts?

You may end up taking some general ER call, not only covering your own patients but perhaps new patients as well. Very rarely do these require emergency room visits, usually tell ER doc to send it to office the next day. Alternatively, can have pt sent to your clinic and evaluate them there. Seeing patients in ER without slit lamp and other pertinent equipment is not ideal.

Practice building is a complex issue and depends on the practice set up (multispecialty, one specialty only etc). But building a practice vie ER alone call would not be a good situation because the calls are very infrequent and the patients are not ideal for growth of a sustainable practice.

 

[Slide]

Spot on. Residency and real life/private practice outside of academia are totally different beasts. Ophthalmology, even retina, is predominantly an outpatient field and there is very little that needs to be managed after hours or as an inpatient.

I used to think that private practice docs dumped everything on academic centers as was mentioned above, but now in practice I can tell you that is very rare. I think there are a few docs that are guilty of this, repeat offenders, that gave me that impression. Don't think this is commonplace though, at least not in our practice.

To think of it, that makes sense. It always seems to be the same attendings that do this over and over again, from what I hear from the upper ranks.

To the OP, as far as ER call goes in private practice, if the clinic is attached to the hospital or near the ER, often the ophthalmologist will tell the ER attending to send them to clinic instead. It's hard to do an exam in the ER, especially with no portable slit lamp or indirect; even if you have those, your exam won't be as good as one with a regular slit lamp. When you're on your own, you can see patients on your own terms a bit better.

 

[LightBox]

Results vary by location, but it depends on the attitude of the practice and affiliation of the practice with a hospital. Maybe I'm a bit jaded by my community's ophthalmologists, but anything requiring more than 5 seconds to figure out gets dumped at the academic medical center. In private practice you have the ability to refer a patient to the nearest tertiary care center if you think you cannot handle it or simply don't want to deal with it.

I DO think it's lame for community ophthos to dump on the academic center's residents. It also isn't the greatest for practice building if you get the reputation as the guy who only wants to do cataracts and lasik.

I can handle most anterior segment things via my training, but I think dealing with some patients is best left for academic centers that have fellows (aka slaves) taking care of the attendings' patients. Stuff with very high complication rates like K-pro's just aren't worth the sacrifice away from my family. And I would feel guilty being away from these patients if they had a problem with the procedure. But you won't see me shuffling emergency patients out the door at 4 pm on Friday afternoon... 🙂

Yes, pure economics affect behavior. If managing a certain type of patient is a monetary-losing endeavor, then it doesn't make sense to see a ton of those patients.