Retina concerns vs comp/anterior segment concerns

[Longhorn4]

Ophtho resident considering retina. Anterior segment and retina both have many positives but curious about what people think of future concerns in this post. A couple key concerns for me below:

Retina concerns: largely dependent on government insurance. If seemingly unavoidable socialism of healthcare occurs it will likely take a big hit with no out of pocket avenues to bolster pay/overhead.

Anterior segment/comprehensive concerns: seems most vulnerable to optom infringement, which is going to continue to be an issue as several states have already given them rights and YAG/slt seem like lowest hanging fruits.

Each of these have the opposite going for them in that ant segment/comp has major out of pocket revenue streams if/when insurance becomes a serious concern and retina seems furthest removed from possible optometry battleground procedures.

I realize this is a bit simplistic and that there are many more issues that could be discussed. Just curious to see the various opinions on these future outlooks from the folks on here. Appreciate any thoughts.

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[hurdlepup]

You should just do what you want to do. Either choice is good. If you do retina you should do it because you feel you want/have to do it. Otherwise you will hate it I think.

 

[MstaKing10]

You’re trying to predict the future, good luck. No way of knowing if some of these events you think are inevitable will ultimately come to fruition (ie socialized medicine, optom infringement etc). Who knows, maybe in 10 years some surgery or treatment is developed that may make one of these fields super lucrative. Maybe there’s some major shift in reimbursement and something that bills very little now may become more profitable. They are very different fields and my recommendation is to pursue the one you find more interesting. Both will have job security and you will do well financially either way

 

[Longhorn4]

Good thoughts from both of you. I appreciate it. It can be hard to not overthink this decision. I think focusing on what I enjoy most should be emphasized more vs all these secondary uncontrollable factors. Cheers.

 

[Dusn]

If I were a resident, I’d be way more worried about the “capitalization” of health care (ie private equity) than the socialization of it. Pharma and insurance companies are all powerful forces that will not let the govt stop them from draining the healthcare money pit. The only people getting reimbursement cuts will be doctors and that will happen either way because of our lack of political power. (An interesting aside: ophthalmologists in Canada make way more than Ophtho’s in the US).

Out of pocket procedures like lasik may seem like a refuge but private equity will find a way to take the money from you and are already buying out the optom referral practices and will have far better marketing than you.

As a young attending, Just continue to spend like a resident and invest your money. I’m 6 years out (as a retina specialist - but make less than most comprehensive docs) and I’m financially independent already. In fact I basically only need to work to pay for healthcare and if they switch to universal healthcare it would only help me. The cuts in healthcare will happen slowly. So relax. you’ll do fine either way if you don’t buy a mansion or a yacht.

 

[Slide]

Do whatever your heart wants, as cheesy as that sounds. I would not be as worried about the socialization standpoint because of the above points made, and retina specialists are still in very high demand in non high density urban areas. Retina is also a field where there is plenty of work that needs to be done that no others can really handle or want to touch. However, a two year surgical fellowship is nothing to scoff at and the lifestyle is not for everyone (though it's not as bad as it has been - I probably work 60 hours on my worst weeks and typically 40-50).

In anterior segment, as you noted there are many competing factors for a zero sum game - optometrists trying to get a slice of the pie, vs comprehensive ophthalmologists fighting for the same patients as glaucoma and cornea/refractive surgeons, at least in PP. There are cash only/OOP things like refractive surgery and "refractive packages" with cataract surgery that may help cushion you against reimbursement cutbacks, but the patient clientele can drive you up the wall to the point where you have CSCR, and private equity or a greedy partner may take some of that money as well.

I'm starting my third year as a retina attending, and while I'm not making as much as people in private practice, I'm making plenty enough where if I wanted to retire in 10 years, I'd do fine.

 

[LightBox]

I think a funny thing that a resident once told me was: "I only want to do either Retina or Oculoplastics". Because they are SOO similar fields. Basically, he was just pursuing whatever people think is/was the most competitive.

 

[Longhorn4]

Very interesting points. Thanks for your responses.

I’m definitely on the same page with living below your means and saving early in your career because you never know what will happen. I’m also on the same page about refractive clientele and think dealing with them is probably not worth all that extra cash.

With regards to these two having nothing to do with each other, I don’t know that I see it that way (at least they seem far less different than retina and plastics). I love retina but also really enjoy cataracts. I have seen other people in here post about jobs where they do cats and a good bit of medical retina. Both fields are intraocular surgery and med retina is a common ground (yes, I know retina surgery is very complex and very different). Also, I don’t think general is considered “prestigious”, like that matters anyway. So not sure what to do with that comment.

Anyway, thanks to the more senior members of the forum for your thoughts. I welcome any others.

 

[Dusn]

I’ll add one more thing: Private equity is far better at predicting the future financial landscape than most of us and they seem to think ophthalmology, retina, and other medical specialty practices are great investments.

I would focus on the realities right now rather than trying to predict the future. When I was finishing training everyone was talking about how Obamacare was going to destroy us all — whatever, I’m doing fine. The realities right now are that private equity and the ridiculous non-compete most practices will ask you to sign are your biggest threats when starting out.

 

[ocularis]

Retina concerns: The insurance concern is valid. However it still remains insanely lucrative, more so than regular cataract surgery by far. The field of retina is changing, nobody can predict where it will be 10 years from now. We know injections will decrease in frequency due to longer acting anti-VEGF, we do not know how much these drugs will cost or how billing will be effected - either in the positive or negative sense for physician earn out. It's a grab bag and I think the field is far away from saying that retina physicians incomes will be declining anytime soon. If imaging reimbursement is cut, there will always be a new door that opens. Diabetes is on the rise, the aging population is on the rise, gene therapy is evolving, and all the indicators point to increased retina demand.

Anterior segment/comprehensive concerns: While optom infringement may not be far off, I think the field is far off from being truly threatened by optom infringement. They won't take cataract surgery from us. And when you are comp., you have unlimited opportunities of things you can pick up and how you can evolve your practice. New technology, treatment methods, and cataract surgery and pre and intra-op modalities are constantly evolving. Yes, some component to it is cash based, but that's only if you convert many of your patients into premium lenses.

There are many ways to make $$ in ophthalmology and those methods will be different 10 years from now, I don't know what they will be, but I do know they will be there.

Focus on picking what you like and after that, maximizing your skill set in that scope. Do you like vitrectomy surgery? Do you like refractive surgery and/or corneal transplants? Do you just want to do cataracts? Do you even want to operate? Each of these paths opens the door to many opportunities, pick what you like and what you think is the best skill set combination for your future, and after that iterate on it to maximize your scope of practice.

If you are torn on liking retina and wanting to do cataracts, then either do retina surgery and plan on practicing in a very rural area where you can also do cataracts, or do medical retina + cataracts. I think if you do retinal surgery, you will be busy enough and immersed enough in the OR that your life will be OK without cataracts. If you do medical retina, then cataracts will be your gateway to the OR. There will always be a challenge in balancing both, but it can be done in the right setting.

 

[Longhorn4]

Really appreciate your thoughtful responses. I think great points to be made about private equity, the shifting and unpredictable landscape of treatments and reimbursement, and how there always seems to be some doom’s day type scenario people obsess over as different generations of trainees progress and graduate. Most of us humans find something to fixate on and be fearful or anxious about by nature. Good to remember that medicine is worth practicing for the people you help and the intellectual stimulation inherent in the years of training and being an lifelong learner thereafter. Plus the financial situation though less lucrative is unlikely to become dire at any point.

Again I think “doing what you like” is a great mantra to return to. I will say it is somewhat hard to “know what you like” with some things, particularly retina. As a resident, you do a bunch of cataracts, but you’re lucky to do more than a dozen or so core vitrectomy and no cortical vitrectomy or surface work(which is reasonable but also where the majority of the art and decision-making come in with VR surgery). I know I like retina clinic but I think the surgery may have to be taken on faith if considering it for a fellowship. I am assuming you get used to it and improve dramatically as your case load increases, just like cataract surgery.

Anyway, thanks again folks. Good discussion.