Question for upper level resident

[bustbones26]

Hi all, just want to ask some advice of some of you upper level residents and perhaps any attendings cruising through on this board. I want to ask some advice from those experienced in actually doing opthalmic surgery so no offense to med students, but your advice is not welcome.

Right now, I am a neurology resident. As a neurology resident, I have become familiar with doing some detailed neuro-eye exams and have recently become fascinated by neuro-ophthalmology. I realize that since neuro-ophth is traditionally non-surgical in nature that I can easily do a fellowship in this area with a neurology background and have lately been kicking around the idea of considering this (for now at least, you know how it is, might change my mind later).

Now, the one thing I don't like about neuro-opth is that to do this, I'd probably be limited to working at an academic institution in a neuro or optho residency, or from what I understand, some private ophtho groups hire neuroophths and gladly hand over consults for optic neuritis, pseudotumor, etc to them. Unfortunately, they are pretty much limited to outpatient as they have no experience in general ophthalmology and can't take call with the group.

To be honest with you, the more I explore it, the more fascinated I am becoming with ophthalmology. This is very unfortunate as I never explored ophtho as a med student or even considered it (just thought it was competitive and didn't even think about it). But in addition to neuro-ophth, I am beggining to believe that general ophth and eye surgery might be fascinating to me too. As crazy as it sounds, I might consider a future goal as a neuro-ophth who can do general work. I.e. whole other residency in general opthalmology down the road.

Now, here is the question I have for all of you experienced people. I was born with a strabismus that was corrected surgically as a child. Cosmetically, I have great alignment of my eyes. However, I did develope an amblopya and now although I have vision that can be corrected to 20/20 in each eye, I do not have binocular vision or good depth perception. This being the case, should I even consider seeking a specialty peforming surgery on such a small organ system?

I have heard some argue, "oh who cares, you can do it". But I do have to ask, what would happen if any of my patients ever learned of my condition? Even if for some reason I developed a good reputation as an eye surgeon, for the one time I mess up, couldn't a patient really devastate my career if they took me to court claiming I am inadequate due to my condition?

Any advice would be appreciated. Thanks to all for listening

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[Olddog1]

I was wondering why you didn't have a CAS application in hand until I got down to the amblyopia part. As you said, stereopsis is important, ie cataract surgery, membrane peels, and even a good exam in the clinic requires some level of depth perception. I have seen some surgeons who I believe had amblyopia and had an inordinate amount of complications. I would say it really depends on how much you want to give it a shot. The fact you are straight in primary gaze would mean you could likely get through the interview unscathed (unless there was a peds ophthalmologist paying alot of attention). Some programs require an eye exam with the application, so that would likely exclude some programs. If programs knew you were amblyopic they would likely not look favorably on your application because with so many qualified applicants we are looking for reasons to knock people off the list. The biggest question you need to ask yourself is what happens after 2 years of residency if you have a 20% complication rate with cataract surgery. Would you quit? Would you practice and risk blinding patients and getting fired after your partners realize they don't like the rep of having a high complication rate? Alternatively, you may have developed strategies to help you use visual clues to let you deal with the loss of stereopsis and things would go fine (hence the reason you likely don't get T-boned everytime you get behing the wheel).

I can't really comment on Neuro-Op except I would think with the amount of time you need to spend with a patient your yearly salary would not be that great (if you were unsupported and did only neuro-op). Where I went to medical school we had 3 Neuro-ophthalmologist (fellowship trained) and all were primarily Neurologist. Medicolegally, if a lawyer found out of course they would use it against you. However, if your complication rate was the same as the national average, and you had an adverse event in line with standard practive, you should be fine. (Disclaimer - I in no way am offering legal advice). I hope I didn't kill the dream, just giving you things to think about.

 

[bustbones26]

You by no means killed my dream. Although I have lately kicked around the idea of eye surgery, I still like neurology and would gladly do it if a career as an eye surgeon was not feasible. I certainly appreciate your honesty, and that was exactlywhat I was looking for.

You are right, since I was born with eye problems, I have certainly compensated well over the years. I know a general surgeon who had a bout of optic neuritis in his 40's and he never recovered well. STill, even though I have had a lifetime to learn to adjust to my condition, this does not mean that I should go out and be a surgeon.

I am also still not out in the cold on neuro-op. I am in the military, so if I actually did neuro-op, its doesn't matter how many patients I see per day, I still get paid the same amount as every other neurologist in the army. Also, would still have to see a small volume of general neuro patients and likely be involved in both neuro and opth residencies as teaching staff.

 

[shredhog65]

I knew a resident who had stabismus and was amblyopic. He still did surgery, although I think it may have been more difficult for him and he had a higher complication rate (I hope he's not reading this!). He actually went into neuro, and is an outstanding neuro-ophthalmologist.

In a nutshell, there are 2 types of neuro-ophthalmologists. 1-The type that basically does not operate and sees only a few very complicated patients in a day. 2- The type that are more neuro-orbit, who operate alot (nerve sheth decompressions, strabismus, etc). This type is more likely to require good stereo. Both are very highly sought after (only like 3 or 4 people a year go into neuro). Also, neuro guys will sometimes supplement their income by also practicing general.

Good luck with whatever it is you choose. I have the feeling that if you apply for ophtho and tell them you want to go into neuro, you'll be much more competitive (especially if you've already done a neuro residency).

 

[Olddog1]

I knew a resident who had stabismus and was amblyopic. He still did surgery, although I think it may have been more difficult for him and he had a higher complication rate (I hope he's not reading this!). He actually went into neuro, and is an outstanding neuro-ophthalmologist.

In a nutshell, there are 2 types of neuro-ophthalmologists. 1-The type that basically does not operate and sees only a few very complicated patients in a day. 2- The type that are more neuro-orbit, who operate alot (nerve sheth decompressions, strabismus, etc). This type is more likely to require good stereo. Both are very highly sought after (only like 3 or 4 people a year go into neuro). Also, neuro guys will sometimes supplement their income by also practicing general.

Good luck with whatever it is you choose. I have the feeling that if you apply for ophtho and tell them you want to go into neuro, you'll be much more competitive (especially if you've already done a neuro residency).

I on the other hand wouldn't tell them. You have already shown a genuine interest. Every resident needs to fulfill general competencies to graduate and it would be worrisome if there was some doubt in your mind of being able to fulfill those. Also, the question would be why do an Ophthalmology residency if you didn't want to do surgery, general, etc... As you could already go into on of the million unfilled neuro-op spots.

 

[KC girl]

I apologize for changing the subject, but I can't figure out how to start a new thread...I'm a long time reader of posts, but it's my first "reply".
Is anyone going to be at the Retina society meeting in Nantucket next week? Students, residents, fellows, anyone?
Thanks!

 

[bustbones26]

Also, the question would be why do an Ophthalmology residency if you didn't want to do surgery, general, etc... As you could already go into on of the million unfilled neuro-op spots.

Okay, let me try to clarify this. I am a neurology resident. I might consider extra training in neuro-op which a neurologist can do. Unfortunately, I never took an interest in general ophth and eye surgery until recently. As a future goal, I really would not mind doing extra training in a general ophth residency in addition to neurology if it means that I can do general eye surgery in addition to neuro-op. Also, as somebody already pointed out, some neuro-op guys specialize in optic nerve and temporal artery surgery. Not something I could do with a neurology background.

Unfortunately, I do have a condition with my eyes that I fear would interfere with my abilities to be a good eye surgeon and was seeking advice from those that have actually done eye surgery. Since it appears as if a career as an eye surgeon might be a bad idea for me, I am pretty much forced to remain a neurologist who is able to obtain a neuro-op fellowship, and am happy with that, it this must be the case.

 

[NR117]

Slightly off topic but for your neuro-ophthalmology fellowship, I would recommend picking a supervisor with an ophthalmology background. Likewise, for ophthalmology trained candidates, it's best to do a fellowship with a neurology-trained neuro-ophthalmologist. That way people get exposed to cases they never had any experience with during their residency.

I'm sure you'll have your pick of fellowships, since neuro-opht unfortunately has developed a reputation as being difficult and not lucrative. It's great that the not lucrative part doesn't apply to you because of the military.

 

[bustbones26]

On a different note, I can tell how intense the specialty is. The chief of my neurology department is a neuro-opth. She is extremely detailed, sometimes painful, but I have learned more from her than any of my other attendings, even stuff that will be applicable to general neurology. And, she is intent on doing all types of neuro-ophth things when seeing patients, even though you really don't have to, but at the same time, she teaches it so well. This is probably one of the reasons why I started taking a liking to neuro-ophth. Although very detailed, they just do cool things on their exam.

I realize that as a career, its not lucrative, but I am very open to seeing general neuro patients too. But from what I understand, because neuro-ophth is mainly non-surgical, many general ophths at even private hospitals are more than happy to hand over diplopia, pseudotumor, optic neuritis, etc over to a neuro-opth if they are available.

As I understand, because the specialty is highly academic, mainly non-surgical, and not very lucrative, there is a shortage of neuro-opths. At my hospital currently, we do have a woman who did her neuro residency in the army and neuro-opth fellowship. When her army obligation was up, due to the shortage, she returned as a civilian contractor. Although neuro trained, she makes her home in the opthalmology clinic and preceptors both neuro and opth residents. Because she is a contractor, she does not take any call. Let's face it, she works 8-4 five days per week and gets the same flat rate pay as any other general neurologist in the army no matter how many patients per day she sees. Can't say that this sounds like a bad life.

My department chief makes her home in neurology. She is still active duty and still is required to see some general neuro patients. Oddly enough, she sees her neuro-opth panel of patients in the opthalmology clinic and preceptors optho residents as well. But because her home is neurology, and she is still active duty, she is required to see a small panel of general neuro patients and take her turn taking neurology call and preceptoring neurology residents on the inpatient and consult service. She still gets paid the same flat rate as every other active duty army neurologist.

Neither of the above options sounds like a bad life to me. Even if I get out of the army, due to the shortage, it would be easy to get a civilian contract, especially since everywhere you find and optho residency in the army, you find a neuro residency too.

 

[Iseeu]

If you are sincerely interested in ophthalmology, do not hold back. One of my attendings does not have stereovision and still does well with surgeries. I have yet to see a major complication in her hands. If the program is going to "weed" you out because of your amblyopia, you would not have enjoyed being a part of their program.

 

[eyeCU]

hi, i'm a pgy-3 in ophtho.

i don't think the problem is that neuro-oph isn't lucrative. actually since there is a shortage (most people don't have the patience for or love of neuro to do it), they are few and far between. Many neuro-ops don't even accept regular insurance, and pts pay out of pocket!

anyway, are you sure you don't have any stereopsis at all? since there are degrees of stereopsis, you may still have some. if not, then ophthalmic surgery is not wise. but that doesnt preclude you from pursuing neuro-op. neuro-trained neuroophthalmologists (as opposed to ophtho trained) can still handle many of the necessary cases in neuro-op that don't require surgery. the neuroop at our program only does surgery twice a month anyway - mostly eye muscle surgery, and infreq optic nerve decompression/fenestration. also, neuroops (both neuro trained and ophtho trained) do botox injections for blepharospasm...and some will do the botox for cosmetic reasons as well. that can definitely help in the finance dept.

hope this helps.

Hi all, just want to ask some advice of some of you upper level residents and perhaps any attendings cruising through on this board. I want to ask some advice from those experienced in actually doing opthalmic surgery so no offense to med students, but your advice is not welcome.

Right now, I am a neurology resident. As a neurology resident, I have become familiar with doing some detailed neuro-eye exams and have recently become fascinated by neuro-ophthalmology. I realize that since neuro-ophth is traditionally non-surgical in nature that I can easily do a fellowship in this area with a neurology background and have lately been kicking around the idea of considering this (for now at least, you know how it is, might change my mind later).

Now, the one thing I don't like about neuro-opth is that to do this, I'd probably be limited to working at an academic institution in a neuro or optho residency, or from what I understand, some private ophtho groups hire neuroophths and gladly hand over consults for optic neuritis, pseudotumor, etc to them. Unfortunately, they are pretty much limited to outpatient as they have no experience in general ophthalmology and can't take call with the group.

To be honest with you, the more I explore it, the more fascinated I am becoming with ophthalmology. This is very unfortunate as I never explored ophtho as a med student or even considered it (just thought it was competitive and didn't even think about it). But in addition to neuro-ophth, I am beggining to believe that general ophth and eye surgery might be fascinating to me too. As crazy as it sounds, I might consider a future goal as a neuro-ophth who can do general work. I.e. whole other residency in general opthalmology down the road.

Now, here is the question I have for all of you experienced people. I was born with a strabismus that was corrected surgically as a child. Cosmetically, I have great alignment of my eyes. However, I did develope an amblopya and now although I have vision that can be corrected to 20/20 in each eye, I do not have binocular vision or good depth perception. This being the case, should I even consider seeking a specialty peforming surgery on such a small organ system?

I have heard some argue, "oh who cares, you can do it". But I do have to ask, what would happen if any of my patients ever learned of my condition? Even if for some reason I developed a good reputation as an eye surgeon, for the one time I mess up, couldn't a patient really devastate my career if they took me to court claiming I am inadequate due to my condition?

Any advice would be appreciated. Thanks to all for listening

 

[Free Radicle]

Have you check to see how much stereo vision you actually have. I have found often with early correction of amblyopia and good va OU that often children will achieve 5/9 circles on the stereo test. Medically/legally I do not know if there is even a requirement for surgery. I good indicator of how much stereo you have, might be from experience, i.e when doing histo did you see pretty good through the microscope, etc. Good luck

 

[schistosomiasis]

One idea, many neuro-ophs are also trained in peds or even oculoplastics. This means they do strabismus or oculoplastics surgery rather than cataract surgery (of course, everyone does cataract surgey during residency). There is much less demand for stereopsis for strab surgery than for cataract surgery, so decreased stereopsis wouldn't make as much as a difference.

But do you really want to do three or four more years of training?????