Pediatrics + Comprehensive Ophthalmology

[Titus345]

Hey everyone! I'm an second year medical student and ophthalmology is definitely my #1 choice as of now (although I realize I have a lot of time ahead of me). I'm from a rural town in my state and I'd like to return there to practice (town ~18,000 people). The only thing that's keeping me from jumping head first into ophtho is that I think I'd maybe like to work with kids as well. I'm not sure how important working with kids will be (still trying to figure that out), but I'm pretty sure I'd like procedures/surgery in my chosen field. I've also considered ENT because it seems like they have more inherent peds patients, but I definitely like the eyes more than ears, noses, and throats so far lol.

There is an ophtho private practice in my town and I've shadowed him a lot and worked with him between my first and second years of med school, and he seemed to be grooming me to buy his practice if I did indeed go into ophtho (I know, that's a long way into the future, but the timeline would work out for him retiring, hence why he brought it up). My question is, in a town that small, if I did ophtho and then did a peds fellowship, how likely would I be able to see kids/do strabismus surgeries + still practice comprehensive ophtho? Do peds ophthalmologists ever practice both peds and comprehensive? How feasible is this to do and still be profitable as a private practice owner (as I understand it, peds reimburses at a lower rate than other specialties within ophtho)? There's definitely not a peds ophthalmologist in at least a 50-100 mile radius as my rural town is surrounded by many smaller towns. Let me know if you need any additional info, obviously I know that you may not be able to provide definitive, 100% yes or no "you'll be able to do this," answers, but I'm really pretty ignorant on the actual practice of medicine (ask me the chromosome that neurofibromatosis type I is on though 😉) and I'd like to know if I could logistically treat kids in a small town.

TL;DR - I love ophtho, want to treat kids, want to live in a small town by family, don't know how feasible it would be/what it would look like.

Thanks everyone!

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[Slide]

Hey everyone! I'm an second year medical student and ophthalmology is definitely my #1 choice as of now (although I realize I have a lot of time ahead of me). I'm from a rural town in my state and I'd like to return there to practice (town ~18,000 people). The only thing that's keeping me from jumping head first into ophtho is that I think I'd maybe like to work with kids as well. I'm not sure how important working with kids will be (still trying to figure that out), but I'm pretty sure I'd like procedures/surgery in my chosen field. I've also considered ENT because it seems like they have more inherent peds patients, but I definitely like the eyes more than ears, noses, and throats so far lol.

There is an ophtho private practice in my town and I've shadowed him a lot and worked with him between my first and second years of med school, and he seemed to be grooming me to buy his practice if I did indeed go into ophtho (I know, that's a long way into the future, but the timeline would work out for him retiring, hence why he brought it up). My question is, in a town that small, if I did ophtho and then did a peds fellowship, how likely would I be able to see kids/do strabismus surgeries + still practice comprehensive ophtho? Do peds ophthalmologists ever practice both peds and comprehensive? How feasible is this to do and still be profitable as a private practice owner (as I understand it, peds reimburses at a lower rate than other specialties within ophtho)? There's definitely not a peds ophthalmologist in at least a 50-100 mile radius as my rural town is surrounded by many smaller towns. Let me know if you need any additional info, obviously I know that you may not be able to provide definitive, 100% yes or no "you'll be able to do this," answers, but I'm really pretty ignorant on the actual practice of medicine (ask me the chromosome that neurofibromatosis type I is on though 😉) and I'd like to know if I could logistically treat kids in a small town.

TL;DR - I love ophtho, want to treat kids, want to live in a small town by family, don't know how feasible it would be/what it would look like.

Thanks everyone!

If you truly want to work in a small town/rural area, this is very much possible. In general there is a high need for pediatric ophthalmologists. The main reason why reimbursement is low is because there's a good possibility the majority of your pediatric patients will be on Medicaid. If your pediatric volume has a large portion of insured patients, you may not necessarily be as poorly compensated as you think. With the cuts in cataract surgery taking effect, there is literally less value in cataract surgery and diversifying your skill set would be useful.

The caveat is that if you do a pediatric ophthalmology fellowship, you may lose some of the comprehensive surgical skills you have honed during residency. However, it can work out that you feed your partner cataract surgery while you take on the pediatric cases.

 

[Titus345]

If you truly want to work in a small town/rural area, this is very much possible. In general there is a high need for pediatric ophthalmologists. The main reason why reimbursement is low is because there's a good possibility the majority of your pediatric patients will be on Medicaid. If your pediatric volume has a large portion of insured patients, you may not necessarily be as poorly compensated as you think. With the cuts in cataract surgery taking effect, there is literally less value in cataract surgery and diversifying your skill set would be useful.

The caveat is that if you do a pediatric ophthalmology fellowship, you may lose some of the comprehensive surgical skills you have honed during residency. However, it can work out that you feed your partner cataract surgery while you take on the pediatric cases.

Thanks for your response! Do many comprehensive ophthalmologists do strabismus surgery? It seems like in more metropolitan areas, physicians subspecialize within their specialty and practice (mostly) only that specific subspecialty. Growing up in a rural area, we didn't have many fellowship-trained physicians at all, other than maybe some fellowships off IM. However, I'm not sure how comfortable you would feel as a comprehensive ophthalmologist coming out of residency and doing strabismus surgery or if that's something that a fellowship would be necessary to get your surgical numbers up to the point that you felt comfortable operating.

 

[percyeye]

I'm an Optometrist in a rural area in a similar sized town but no General Ophthalmologist here and the closest is ~45 minutes away, which means fellowship trained docs are ~1-2 hours away depending on the day. If you work that rural you'll be so busy with general work that the medicaid reimbursement for that strab surgery may not be worth your time. And out of all the fellowships needed in rural America Glaucoma, and Retina would be the most help. We are the main private practice in a county of ~30,000 people and we get people coming in from the surrounding counties making us extremely busy. We send out constantly for Glaucoma or Retina but only a handful of times do we refer for Peds consults a year I'd say. There was a General guy who did Strab surgery occasionally, but if I were sending my kid for Strab surgery I would probably send them 2 hours away to the one who did the fellowship.

 

[Slide]

Thanks for your response! Do many comprehensive ophthalmologists do strabismus surgery? It seems like in more metropolitan areas, physicians subspecialize within their specialty and practice (mostly) only that specific subspecialty. Growing up in a rural area, we didn't have many fellowship-trained physicians at all, other than maybe some fellowships off IM. However, I'm not sure how comfortable you would feel as a comprehensive ophthalmologist coming out of residency and doing strabismus surgery or if that's something that a fellowship would be necessary to get your surgical numbers up to the point that you felt comfortable operating.

I have heard of a few comprehensive ophthalmologists doing strabismus surgery (we have one in town that does that as well as PKPs), but you not only see that with the older generation, but it mainly depends on your residency training. Some programs have heavy peds training, so residents feel accustomed to doing them. I do want to point out that for strabismus surgery, the tough part is not the surgery, but the clinical management of these patients (determining true amount of PD XT/ET, managing over/under corrections, amblyopia, etc.) is the tough part.

As PercyEye stated, glaucoma and retina are typically the biggest needs in rural areas due to those populations trending older (us dang millennials love urban living too much). Strabismus surgery is really more of a service to the community rather than an actual financial or RVU boon. However, it may potentially help open up referral streams down the road.

 

[mjohnsonets]

Thanks for your response! Do many comprehensive ophthalmologists do strabismus surgery? It seems like in more metropolitan areas, physicians subspecialize within their specialty and practice (mostly) only that specific subspecialty. Growing up in a rural area, we didn't have many fellowship-trained physicians at all, other than maybe some fellowships off IM. However, I'm not sure how comfortable you would feel as a comprehensive ophthalmologist coming out of residency and doing strabismus surgery or if that's something that a fellowship would be necessary to get your surgical numbers up to the point that you felt comfortable operating.

It depends on what you want to do which will likely change once you start doing the actual cases. If you want to live in a more rural area without many peds docs around and want to do comp. Do your residency, try to get as many strab cases as possible(ask for more if possible) and go out into your community and do them if you've gotten comfortable enough. Many residents report to me they feel comfortable doing them but don't want to see kids. You will not be prepared for vertical muscle strab or intraocular peds cases though and will still need to refer those out. However, being in a more rural area, likely to find them fairly rare anyway.

Going to a rural area allows a comprehensive ophthalmologist a lot of autonomy in what they do and don't want to see.

 

[pianist]

Some programs have heavy peds training, so residents feel accustomed to doing them. I do want to point out that for strabismus surgery, the tough part is not the surgery, but the clinical management of these patients (determining true amount of PD XT/ET, managing over/under corrections, amblyopia, etc.) is the tough part.

Agree with above. Strabismus surgery is not technically difficult, it is developing the judgement surrounding the surgery. For that, you pretty much need to do pediatric fellowship. I saw and did quite a few during residency, there's no way I'd try strabismus surgery on a child after residency. There is also an art to examining kids that takes time to hone

It used to be difficult for pediatric trained person to do 100% pediatrics unless at an academic center. Perhaps things have changed. In the community and even in large cities, a pediatric person often has to do some general as well.

 

[Etorphine]

just my opinion, but I don't think you'd do either well if you combined peds and comp. that being said I know a few docs that do

 

[Fascia Lata]

So how about doing a pedi fellowship and still practicing comprehensive ophthalmology? I believe that’s a better alternative compared with not doing a fellowship and operating on peds/strab. I think I wouldn’t do pediatric surgery if I were not trained as a pediatric ophthalmologist, exactly the same way I would never do a primary PPV if I did not do a retina fellowship. Doing muscle surgery with attending guidance in residency is not the same as making the decision yourself and operating yourself. There is a widespread notion that muscle surgery is “easy”. I don’t know how this came about really. There are so many pertinent issues in the decision making process and so many intricacies in the surgical technique that certainly need fellowship training, even in cases that appear to be simple or straightforward.

 

[OphthoApplicant04]

Horizontal muscle surgery is technically easy... everything else about it (pre-op/postop) is not

 

[Titus345]

Thanks for everyone's replies! Sorry I haven't been able to reply to everyone (studying for class exams/step 1 has been brutal).

I'm doing research with a pretty well known glaucoma specialist now and that's definitely intriguing as well. I really like the innovation in the field so that could be a good fit too. But the one thing I keep coming back to is this feeling I could very possibly see myself at the point where I'm saying, "I really want pediatrics to a be a big part of my practice." But I'm just not even sure if my rural area/surrounding counties could support a peds ophtho with enough patients. Is there anywhere I could look to find some numbers on how many people it takes to support the specialties within ophtho? Not sure if that's a weird request but I feel like I've heard people throw out numbers on various specialties before.

 

[Hanky]

There are so many pertinent issues in the decision making process and so many intricacies in the surgical technique that certainly need fellowship training, even in cases that appear to be simple or straightforward.

Horizontal muscle surgery is technically easy... everything else about it (pre-op/postop) is not

Do you mind giving some concrete examples of apparently straightforward horizontal cases that are not straightforward? Assuming accurate tropia and phoria measurements.

With very rare exception the post-op complications for 1-2 muscle surgeries are basically the same as pterygia, don't you think? Plus prism fitting when needed.

 

[Hanky]

Is there anywhere I could look to find some numbers on how many people it takes to support the specialties within ophtho? Not sure if that's a weird request but I feel like I've heard people throw out numbers on various specialties before.

I was told anecdotally in residency that comp needs a catchment of ~30K people, and retina needs closer to 200K. I'd guess that peds needs more than retina, but that's purely a guess and of course depends on the community (eg, a retirement community will need more retina and less peds).

 

[mjohnsonets]

I was told anecdotally in residency that comp needs a catchment of ~30K people, and retina needs closer to 200K. I'd guess that peds needs more than retina, but that's purely a guess and of course depends on the community (eg, a retirement community will need more retina and less peds).

I can confirm these from my notes and experience. I have not seen it listed on the website but have heard from 2 different ASOPRS docs that an oculoplastic surgeon needs about 250,000.

 

[Fascia Lata]

Do you mind giving some concrete examples of apparently straightforward horizontal cases that are not straightforward? Assuming accurate tropia and phoria measurements.

With very rare exception the post-op complications for 1-2 muscle surgeries are basically the same as pterygia, don't you think? Plus prism fitting when needed.

Just off The top of my head, dissociated horizontal deviation, which although by no means very common, as a pediatric fellow I used to see this misdiagnosed all the time. A much more common condition, partially accommdative esotropia, for instance, can be very tricky to assess, operate on, and get a good result. Also, it is very, very common for horizontal deviations to be associated with latent DVD or IOOA, and although these can be referred out (when appropriately diagnosed), i would, as a non-strab specialist, rather refer all to avoid missing any of these. Thing is, a sensorimotor exam in a child can be extremely tricky. I don’t think residency training adequately prepares trainees in peds/strab.
Disclaimer: I did a pedi fellowship but I do not currently practice strabismus surgery. In children, I do only cataract, glaucoma, and anterior segment surgery.

 

[Etorphine]

Do you mind giving some concrete examples of apparently straightforward horizontal cases that are not straightforward? Assuming accurate tropia and phoria measurements.

With very rare exception the post-op complications for 1-2 muscle surgeries are basically the same as pterygia, don't you think? Plus prism fitting when needed.

just taking the tropia and phoria measurements in a squirrely child is hard to do accurately and is also nausea inducing. also guess what... you can't just take the phoria and tropia measurements need to do the whole ped exam as responsible for any other developmental finding. good luck w that

 

[Trefoil]

Sorry to jump in here, but I’ve recently been considering a pediatric fellowship. It seems that salaries for peds ophtho run about $300,000-400,000. Is this perception correct? Additionally, it seems that it’s easier to find jobs in desirable areas (cities etc). Anecdotally, I’ve heard that a pediatric ophthalmologist will generally have a full clinic and someone ready to take that appointment slot as soon as there is a cancellation. I just want to make sure I’m understanding the decrease in salary and increase in demand correctly. I like job security, so I want to make sure that the skill I would be acquiring would be in high demand. Thanks for any input you have!

 

[mjohnsonets]

Sorry to jump in here, but I’ve recently been considering a pediatric fellowship. It seems that salaries for peds ophtho run about $300,000-400,000. Is this perception correct? Additionally, it seems that it’s easier to find jobs in desirable areas (cities etc). Anecdotally, I’ve heard that a pediatric ophthalmologist will generally have a full clinic and someone ready to take that appointment slot as soon as there is a cancellation. I just want to make sure I’m understanding the decrease in salary and increase in demand correctly. I like job security, so I want to make sure that the skill I would be acquiring would be in high demand. Thanks for any input you have!

$300-400K in a hospital setting, private practice is in the $200-250K range with opportunity for bonus. In general peds ophthalmologist seem to be busy everywhere and demand is high for their services.

One of the tough decisions you'll face is whether to do see both adult comprehensive and peds or just peds. This will affect your opportunity to find jobs as you would likely have a harder time finding a hospital-based position for both. From my experience it seems to be about 50/50 of fellows open/wanting to do adult comprehensive with geographic limitations typically being the cause of their openness to either but not the sole cause. You could go private but then you lose the higher base salary you mentioned.

 

[Trefoil]

$300-400K in a hospital setting, private practice is in the $200-250K range with opportunity for bonus. In general peds ophthalmologist seem to be busy everywhere and demand is high for their services.

One of the tough decisions you'll face is whether to do see both adult comprehensive and peds or just peds. This will affect your opportunity to find jobs as you would likely have a harder time finding a hospital-based position for both. From my experience it seems to be about 50/50 of fellows open/wanting to do adult comprehensive with geographic limitations typically being the cause of their openness to either but not the sole cause. You could go private but then you lose the higher base salary you mentioned.

Thank you for the response. I think I would really enjoy working as a pediatric ophthalmologist, and I do enjoy comp as it is what I’m currently practicing. I like the idea of expanding my practice, and I would like to continue some degree of comp and refractive if possible. It’s a tough decision to pursue more training for less money. I’ll probably continue to weigh it over the next several months. I would have to make a decision by next summer, so hopefully I can figure it out relatively quickly. Thanks again!

 

[mjohnsonets]

Thank you for the response. I think I would really enjoy working as a pediatric ophthalmologist, and I do enjoy comp as it is what I’m currently practicing. I like the idea of expanding my practice, and I would like to continue some degree of comp and refractive if possible. It’s a tough decision to pursue more training for less money. I’ll probably continue to weigh it over the next several months. I would have to make a decision by next summer, so hopefully I can figure it out relatively quickly. Thanks again!

No problem, hope it helps in your decision.

If you want to do both, I typically see docs being more adult comprehensive and strabismus. Obviously they see peds patients when they come in but I can't really think of many I've come across who are doing both anterior segment peds surgeries as well as refractive cataract surgery.

Why do you think hospital setting offers more than private practice? Or is 200-250k the starting offers for private with room for 2x when a partner.

Hospitals simply have more capital to use toward physicians' compensation. Also being larger, the risks are lower per doc than in a private practice. $200-$250 is the starting salaries, there is more to be achieved through bonuses and partnership.

 

[Trefoil]

No problem, hope it helps in your decision.

If you want to do both, I typically see docs being more adult comprehensive and strabismus. Obviously they see peds patients when they come in but I can't really think of many I've come across who are doing both anterior segment peds surgeries as well as refractive cataract surgery.



Hospitals simply have more capital to use toward physicians' compensation. Also being larger, the risks are lower per doc than in a private practice. $200-$250 is the starting salaries, there is more to be achieved through bonuses and partnership.

I’ve actually decided to go ahead and apply, but as I said logistically, it will be a couple of years before that happens. Do you have any recommendations on selecting a fellowship?

 

[mjohnsonets]

I’ve actually decided to go ahead and apply, but as I said logistically, it will be a couple of years before that happens. Do you have any recommendations on selecting a fellowship?

Depends on what you want to do. Some fellowships offer great peds anterior segment exposure and some don't. If you're planning on doing adult comp too, I would think you would go to one where you would focus mostly on strabismus. I would also check that you can some adult cataracts/cases while you're in training so you don't come out and haven't done a cataract in over a year.

 

[Trefoil]

Depends on what you want to do. Some fellowships offer great peds anterior segment exposure and some don't. If you're planning on doing adult comp too, I would think you would go to one where you would focus mostly on strabismus. I would also check that you can some adult cataracts/cases while you're in training so you don't come out and haven't done a cataract in over a year.

Good tips. Thank you. I do enjoy cataract surgery, so I want to keep that as part of my practice if possible. I would think that doing a few adult cataracts a month also keeps your anterior segment skills fresh for pediatric cataracts.

 

[linevasel]

Titus345, while the small-town feel of going home has its appeal, you really don't get a true reimbursement range of your sub-specialty until you start interviewing. The numbers being quoted above I presume are without ROP contracts. Once you add that on board (if you are willing to take that responsibility), you can add another 200k on top. At that point the decision to (1) go home and buy a practice vs (2)settling with a nice private practice situation with a rural-ish setting and hospital system needing ROP coverage might become more complicated. You do seem to like children (which is different from liking peds ophtho....). I would strongly consider doing a fellowship. If you don't do Peds, you wasted a year. Nothing to sneeze at, but it's not the worst use of a year. On the other hand, that extra-year studying something you enjoy would blow by and... give you a level of expertise that might expand your job opportunities when you are through.

Having just gone through the job hunt process, I can say I interviewed at 3 multi-specialty groups. 2 out of those 3 had Peds Docs making over 650K. I got the sense that the peds guys/gals are as busy as they want to be. Not sure why that is. Maybe a supply/demand issue?

 

[Trefoil]

Depends on what you want to do. Some fellowships offer great peds anterior segment exposure and some don't. If you're planning on doing adult comp too, I would think you would go to one where you would focus mostly on strabismus. I would also check that you can some adult cataracts/cases while you're in training so you don't come out and haven't done a cataract in over a year.

Do you have any recommendation for what number of fellowships to apply to? I see the average number overall is 23 for ophthalmology generally. There are a lot of “big name” fellowships…how does one assess their competitiveness? Most of my mentors are pretty far removed from this process at this time, so any advice would be appreciated.

 

[mjohnsonets]

Do you have any recommendation for what number of fellowships to apply to? I see the average number overall is 23 for ophthalmology generally. There are a lot of “big name” fellowships…how does one assess their competitiveness? Most of my mentors are pretty far removed from this process at this time, so any advice would be appreciated.

Send me a direct message, I can't send you one.