Optometry

[M-Hung]

Besides with the public not really knowing the difference between optometry and ophthalmology, what are your thoughts on putting more time into your training and studies for ophthalmology ?

In my point of view, optometrists are still fairly respected in a way of being able to prescribe glasses and contacts to their patient.

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[i-doctor]

Optometrists are respected, but the field is fairly saturated in many areas. And “Warby Parker”, “1-800-Contacts” and similar are chipping away at their bread and butter business of dispensing glasses and contact lenses. It will be challenging for sure in the future.
Ophthalmologists will have less challenges—surgery will always be needed.

 

[deleted941485]

Optometrists are respected, but the field is fairly saturated in many areas. And “Warby Parker”, “1-800-Contacts” and similar are chipping away at their bread and butter business of dispensing glasses and contact lenses. It will be challenging for sure in the future.
Ophthalmologists will have less challenges—surgery will always be needed.

Now that their bread and butter is gone plenty of time to go to various state capitals and lobby for cataract surgery.

 

[90sportsfan]

I considered Optometry as a career for a long time before ultimately choosing Medicine. One of the major drawbacks of Optometry (superficial) was the thought of going to the mall, a shopping center, or a corner store for work as a medical professional. I remember seeing optometrists going to work in a VisionWorks right next to a loud and crowded, smelly food court at my local mall with kids running around and yelling. It was so depressing that it partially drew me away from optometry.

But I digress…surprisingly, more lay people than I initially thought, knew the difference between an Optometrist and an Ophthalmologist. And many people I know (non-medical) specifically choose to go to Ophthalmologists if they have eye issues.

I think the biggest issue for Optometrists in our increasingly “Amazon/app” world, is that many younger people who are relatively healthy (no major eye issues), skip eye visits all together and go to 1800 Contacts, and even online sites where you just need a previous prescription and they will provide glasses without even seeing an Ophtho/Optometrists. Older people with real eye disease are seeing Ophthalmologists. Optometrists have a limited skill set as Ophtho can do everything they can plus more.

Also, someone mentioned encroachment. I think the real issue is how many Optometrists will want to do surgery when they will be held to the same standard of care that Ophthalmologists with years of medical training, along with medical residency/fellowship where they have done hundreds of surgical procedures and follow-up care when complications arose. My guess is that not many Optometrists will want that level of responsibility and liability.

 

[deleted941485]

I considered Optometry as a career for a long time before ultimately choosing Medicine. One of the major drawbacks of Optometry (superficial) was the thought of going to the mall, a shopping center, or a corner store for work as a medical professional. I remember seeing optometrists going to work in a VisionWorks right next to a loud and crowded, smelly food court at my local mall with kids running around and yelling. It was so depressing that it partially drew me away from optometry.

But I digress…surprisingly, more lay people than I initially thought, knew the difference between an Optometrist and an Ophthalmologist. And many people I know (non-medical) specifically choose to go to Ophthalmologists if they have eye issues.

I think the biggest issue for Optometrists in our increasingly “Amazon/app” world, is that many younger people who are relatively healthy (no major eye issues), skip eye visits all together and go to 1800 Contacts, and even online sites where you just need a previous prescription and they will provide glasses without even seeing an Ophtho/Optometrists. Older people with real eye disease are seeing Ophthalmologists. Optometrists have a limited skill set as Ophtho can do everything they can plus more.

Also, someone mentioned encroachment. I think the real issue is how many Optometrists will want to do surgery when they will be held to the same standard of care that Ophthalmologists with years of medical training, along with medical residency/fellowship where they have done hundreds of surgical procedures and follow-up care when complications arose. My guess is that not many Optometrists will want that level of responsibility and liability.

That hasn’t stopped anybody who isn’t a physician from fighting for the right to operate on patients. In the US, any type of expertise is looked at with disdain and skepticism. In this country’s quest for the cheapest option, Everyone is equal.

 

[KHE]

Optometrists are respected, but the field is fairly saturated in many areas. And “Warby Parker”, “1-800-Contacts” and similar are chipping away at their bread and butter business of dispensing glasses and contact lenses. It will be challenging for sure in the future.
Ophthalmologists will have less challenges—surgery will always be needed.

Warby Parker and 1800 contacts and similar ventures like them have chipped away slightly at private practice market share percentage but they have increased the overall market so much, I'm making way more money now than I did before they were around. I really should be sending them an edible arrangement.

 

[i-doctor]

Warby Parker and 1800 contacts and similar ventures like them have chipped away slightly at private practice market share percentage but they have increased the overall market so much, I'm making way more money now than I did before they were around. I really should be sending them an edible arrangement.

Sure there is plenty of business to go around in both optometry and ophthalmology. It’s just hard to know what the future will look like in either field, say, 10-20 years from now!

 

[MstaKing10]

Warby Parker and 1800 contacts and similar ventures like them have chipped away slightly at private practice market share percentage but they have increased the overall market so much, I'm making way more money now than I did before they were around. I really should be sending them an edible arrangement.

curious, how did you think they increased the market? Did they somehow create a need for more contacts and glasses? How have you benefited in concrete terms? More visits? More referrals? More upcharge on nicer frames/lenses etc? Guess I don't understand and am interested. Thx

 

[Trefoil]

I think ultimately it depends on your motivation. You can make a good career of either profession. I think the exposure to general medicine etc. has been formative in my understanding of the world. My ability to be useful in medical situations means something to me. I might not be a primary care doctor, but I spent enough time on the wards to have an intuitive understanding of the system. Now, if your goal is to provide great eye care and have a relatively chill 9-5, then optometry is the better way to go. You can get there faster without the added stress of being exposed to a lot of death and dying (and hard hours) early in your career. You have to know what you want to get out of your experience. There is no right answer. Also there is no guarantee that you match to ophthalmology, so you have to remain open to medicine generally.

 

[KHE]

curious, how did you think they increased the market? Did they somehow create a need for more contacts and glasses? How have you benefited in concrete terms? More visits? More referrals? More upcharge on nicer frames/lenses etc? Guess I don't understand and am interested. Thx

Don't have the specific data in front of me but total amount consumers have spent on eyewear since these companies have come onto the scene has increased at a much higher rate than it had previously.

For contact lenses, it's simply been putting the idea that contact lenses exist out there and actually getting the product in front of people's faces. I mean....everyone knew that there was this thing called a "contact lens" before 1800 contacts but the commercials and advertisements showing people happily wearing contact lenses has increased demand. And most patients are happy to purchase their lenses from my office since for most lenses, we are actually LESS than 1800 contacts in terms of cost and we can ship them direct to their home as well. I flat out tell people that there are certainly some Chinese websites that I am NOT less costly than so if that's what they want....go ahead but our capture rate on contact lenses is quite high.

For eyeglasses, I have found that these companies like Zenni or WP have normalized the notion of having more than one pair of glasses. In the past, people would have ONE pair of glasses, forever, for everything. Maybe they would have a separate pair of sunglasses. Now, it's not uncommon for people to have multiple pairs and they are much more onboard with the notion of having a couple of pair of "cheap" glasses and a couple of pairs of "good" ones and they get the good ones from our office. There are obviously still those hardcore patients who have just one pair of Zenni glasses that they spent $40 on and they use them until they fall apart and then crazy glue them back together or hold them together with paper clips but those people were already not purchasing eyewear in my office anyways. They were already going to Walmart or Costco or wherever they could find a set for a nickel less than the last corporate optical they went to.

So yea....on behalf of my bank account, thanks 1800-Contacts and WP!

 

[Musty Goose]

Don't have the specific data in front of me but total amount consumers have spent on eyewear since these companies have come onto the scene has increased at a much higher rate than it had previously.

For contact lenses, it's simply been putting the idea that contact lenses exist out there and actually getting the product in front of people's faces. I mean....everyone knew that there was this thing called a "contact lens" before 1800 contacts but the commercials and advertisements showing people happily wearing contact lenses has increased demand. And most patients are happy to purchase their lenses from my office since for most lenses, we are actually LESS than 1800 contacts in terms of cost and we can ship them direct to their home as well. I flat out tell people that there are certainly some Chinese websites that I am NOT less costly than so if that's what they want....go ahead but our capture rate on contact lenses is quite high.

For eyeglasses, I have found that these companies like Zenni or WP have normalized the notion of having more than one pair of glasses. In the past, people would have ONE pair of glasses, forever, for everything. Maybe they would have a separate pair of sunglasses. Now, it's not uncommon for people to have multiple pairs and they are much more onboard with the notion of having a couple of pair of "cheap" glasses and a couple of pairs of "good" ones and they get the good ones from our office. There are obviously still those hardcore patients who have just one pair of Zenni glasses that they spent $40 on and they use them until they fall apart and then crazy glue them back together or hold them together with paper clips but those people were already not purchasing eyewear in my office anyways. They were already going to Walmart or Costco or wherever they could find a set for a nickel less than the last corporate optical they went to.

So yea....on behalf of my bank account, thanks 1800-Contacts and WP!

Wow would've never thought this would have been the case with online retailers. My initial assumptions were the online retailers would undercut local shops and therefore capture larger percentage of the market but glad its only increasing demand overall. Hopefully it continues like that!

 

[percyeye]

People fear the online retailers for Optometry but all income surveys are up and there are unlimited jobs ads everywhere making it very difficult to hire any ODs right now. Even with adding more OD schools hiring is till very strong. The scariest thing right now imo is Private Equity. They are eating up all the large private practices and legacy practices. Which is also happening in Ophthalmology unfortunately.

 

[i-doctor]

The scariest thing right now imo is Private Equity. They are eating up all the large private practices and legacy practices. Which is also happening in Ophthalmology unfortunately.

It’s a two-way street. Private equity is only eating up practices because the boomers (and some younger) are willing to sell to them. And one of the main reasons for this is many young doctors don’t want to take risk and buy into partnership. So there is a void that private equity fills. They provide a (cash-up-front) retirement strategy for older docs, many of whom can’t find young partners willing to pay up and buy into their practices.

 

[MstaKing10]

It’s a two-way street. Private equity is only eating up practices because the boomers (and some younger) are willing to sell to them. And one of the main reasons for this is many young doctors don’t want to take risk and buy into partnership. So there is a void that private equity fills. They provide a (cash-up-front) retirement strategy for older docs, many of whom can’t find young partners willing to pay up and buy into their practices.

Some truth to that. It's more nuanced though. PE takes risk off the table for the entire practice in that they infuse funding for staffing, office maintenance, opening up new offices etc. That used to come out of a practices income and impacted the bottom line directly. They also provide and infrastructure to negotiate better contracts with payors (based on size/leverage), expand revenue streams, and grow a practices footprint in among other benefits. There's definitely some downsides to going the PE route of course, but there's a reason its gaining traction not only in eye care but in medicine as a whole.

 

[i-doctor]

Ok

Some truth to that. It's more nuanced though. PE takes risk off the table for the entire practice in that they infuse funding for staffing, office maintenance, opening up new offices etc. That used to come out of a practices income and impacted the bottom line directly. They also provide and infrastructure to negotiate better contracts with payors (based on size/leverage), expand revenue streams, and grow a practices footprint in among other benefits. There's definitely some downsides to going the PE route of course, but there's a reason its gaining traction not only in eye care but in medicine as a whole.

Sounds like you yourself sold your practice to PE, or you work in the industry!

 

[percyeye]

It’s a two-way street. Private equity is only eating up practices because the boomers (and some younger) are willing to sell to them. And one of the main reasons for this is many young doctors don’t want to take risk and buy into partnership. So there is a void that private equity fills. They provide a (cash-up-front) retirement strategy for older docs, many of whom can’t find young partners willing to pay up and buy into their practices.

It is a two way street and if I was in that situation and looking for a big pay day I would take a hard look at it as well. But we can be real about what PE is as well. They are just cash from some state Teachers pension fund looking for a 8-10% return. You go to medical school and extra training but in the end when you're in their portfolio of businesses and are no different than the garbage hauling businesses, restaurants etc they also own looking for those returns. And hopefully they can flip you one day for more profit. Other than a payday to retiring docs this absolutely is not a good thing for healthcare overall. It seems weird to go for all those years of training to end up working for a pension fund or Goldman Sachs.

 

[dantt]

It is a two way street and if I was in that situation and looking for a big pay day I would take a hard look at it as well. But we can be real about what PE is as well. They are just cash from some state Teachers pension fund looking for a 8-10% return. You go to medical school and extra training but in the end when you're in their portfolio of businesses and are no different than the garbage hauling businesses, restaurants etc they also own looking for those returns. And hopefully they can flip you one day for more profit. Other than a payday to retiring docs this absolutely is not a good thing for healthcare overall. It seems weird to go for all those years of training to end up working for a pension fund or Goldman Sachs.

20% return. Think long and hard about how one achieves that.

 

[Trefoil]

The trend is definitely problematic for the future of the profession. I have essentially vowed to never work for PE because I don’t think investment return should be a foundation for a practice. It obviously has to be a part of the picture, but it doesn’t feel right to me. I can see why it’s tempting to sell at the end of your career for a big profit, but it’s definitely a net negative for the future of medicine and anyone who wants to practice in the future. It’s kind of like over farming the land. Sure, you get a great yield, but the future generations aren’t going to be able to grow anything in dead soil.

 

[PLA2]

@RetinaDude Do you have any comments on PE in our field?

 

[RetinaDude]

We’ve done everything we can to avoid PE. Yes, it would greatly benefit the “older” docs close to retirement, but we feel like we would be putting handcuffs on the younger partners who lose control (and money) at present, and down the road. No matter what these PE purchased docs tell you about how good it is with their new PE overlords, don’t take it all as complete truth. PE is a business and they expect to make money….money they make off of you. Yes, they’ll give you a big chunk of money, in the beginning, but they expect you to cut your salary, drug money, surgery center earnings, etc…., all to make sure they get their profits (this is why it’s great for retiring doc because they’ve already made their money, through the years). It’s not like PE purchases a retina practice and then sells stocks of the practice. No, they purchase the practice, you make the money for them (the returns on investment), and then they hope to sell to a bigger entity to make an even bigger return. Also, with PE, it appears to be harder to recruit new docs. Over the past few years, we’ve hired a few new docs, and they have all said they immediately ruled out a practice if it was purchased by PE (or was going to be). This impressed me because you always read how “young” or “new” docs no longer have the entrepreneurial spirit and just wanna be employees now. I’ve found that to be very untrue, with the young docs I’m meeting very much wanting to work hard to build a practice (and make the money that goes along with that).

 

[MstaKing10]

All good points. But private practice (non PE) is not without its issues. There are plenty of predatory practices who churn out employees, turning them over before they can reach partnership, or practices where the buy in is absurd. Non PE private practices are also looking for profit, and not always to the benefit of the younger physicians.

 

[i-doctor]

Anyway, if you’re a med student now, don’t worry about P.E. The whole model will have imploded by the time you’re in practice, which is at least 8 years from now. The whole private equity/leveraged buyout model is based on cheap debt and access to cheap capital. (For example, a P.E. fund with $75M in capital can leverage that into, say, an additional $200M to spend from their lender at a low interest rate. They are looking for their monthly investment income stream from their purchases to be much higher than their monthly debt service payments. That’s the profit). If/when interest rates are 8% and higher, the model no longer works. They would then have to offer much lower “multiples” to buy out practices, and for most docs it won’t be worth it any more. (This bond bear market will likely last 1-2 decades, with interest rates in the double digits again at some point).
Additionally, state legislatures will likely eventually ban such PE sales in the future. There’s some talk of that already in some state legislatures. That’s how it starts.

 

[dantt]

Anyway, if you’re a med student now, don’t worry about P.E. The whole model will have imploded by the time you’re in practice, which is at least 8 years from now. The whole private equity/leveraged buyout model is based on cheap debt and access to cheap capital. (For example, a P.E. fund with $75M in capital can leverage that into, say, an additional $200M to spend from their lender at a low interest rate). If/when interest rates are 8% and higher, the model no longer works. They would then have to offer much lower “multiples” to buy out practices, and for most docs it won’t be worth it any more. (This bond bear market will likely last 1-2 decades, with interest rates in the double digits again at some point).
Additionally, state legislatures will likely eventually ban such PE sales in the future. There’s some talk of that already in some states. That’s how it starts.

One thing I've learned over the past few years is nobody can predict the future.

 

[i-doctor]

One thing I've learned over the past few years is nobody can predict the future.

Yep. That’s why med students should primarily choose the field they think they’ll enjoy the most. The economics of all fields is unknown in the future.

 

[Trefoil]

We’ve done everything we can to avoid PE. Yes, it would greatly benefit the “older” docs close to retirement, but we feel like we would be putting handcuffs on the younger partners who lose control (and money) at present, and down the road. No matter what these PE purchased docs tell you about how good it is with their new PE overlords, don’t take it all as complete truth. PE is a business and they expect to make money….money they make off of you. Yes, they’ll give you a big chunk of money, in the beginning, but they expect you to cut your salary, drug money, surgery center earnings, etc…., all to make sure they get their profits (this is why it’s great for retiring doc because they’ve already made their money, through the years). It’s not like PE purchases a retina practice and then sells stocks of the practice. No, they purchase the practice, you make the money for them (the returns on investment), and then they hope to sell to a bigger entity to make an even bigger return. Also, with PE, it appears to be harder to recruit new docs. Over the past few years, we’ve hired a few new docs, and they have all said they immediately ruled out a practice if it was purchased by PE (or was going to be). This impressed me because you always read how “young” or “new” docs no longer have the entrepreneurial spirit and just wanna be employees now. I’ve found that to be very untrue, with the young docs I’m meeting very much wanting to work hard to build a practice (and make the money that goes along with that).

It’s easy for older generations to think the stereotypes about millennials are true, but the reality is that we are all constantly preparing for the next financial disaster. Being an entrepreneur is risky, so we may be a bit slower to embrace the virtues; however, I think it’s become more and more obvious that investors and many large organizations generally do not have physicians or patients in mind when they make decisions.

 

[TheLesPaul]

Has anyone seen a practice that is truly better due to a PE buyout?

 

[dantt]

Has anyone seen a practice that is truly better due to a PE buyout?

Depends on how you define better. Makes more money for the owners?

 

[TheLesPaul]

better for the younger physicians...

 

[dantt]

better for the younger physicians...

Plenty of abusive, exploitative, revolving door private practices out there become a little less abusive after PE buys them.