retina job
Started by jiggabot
What do you think? It's worse.
I just assumed that being a subspecialist makes you more marketable and thus opens up more opportunities in terms of jobs, but it seems like you're saying the retina job market is saturated as well.
It did, until a lot more folks started going into retina (and other subspecialties, for that matter). Just like more medical students are pursuing specialties, instead of primary care, more specialty residents are seeking subspecialty training. In the program from which I graduated, only a few residents have not gone on to fellowship in the last five years.
I wouldn't really say it's more saturated, but it's certainly not any better. Subspecialists need a larger catchment area to establish a successful practice. That means they will tend to flock to larger cities to an even greater degree than comprehensive ophthalmologists. It's in the popular larger cities, particularly on the coasts, that you find the worst saturation (and highest cost of living, I might add). If you can settle for a somewhat smaller town (not the boonies!), the jobs are there and your dollar goes much farther. I have friends on the east/west coast who started out making more than I and can't afford to buy a house. I bought a 3600 sq. ft. house on a golf course right out of fellowship.
Retina typically collects nearly twice per patient compared to comprehensive, but a comprehensive ophthalmologist can see more volume, as a general rule. There are some retina docs who make twice (or more) what the average comprehensive doc does, but they have to work incredibly hard to do so. For instance, in the same period of time I can comfortably see about 2/3 the number of patients that my comprehensive partners can. The imaging and procedures definitely bring in revenue, but they also slow you down.
Thanks for the great responses. If retina brings in so much more, why do people bother specializing in the other fellowships (eg. glaucoma), aka, why isn't competition for retina insanely difficult?
What I've heard so far (and please correct me if I'm wrong) is that as long as you go to a top 20 residency in ophtho, you can pretty much pick and choose which fellowship you want. Any truth in that?
Not sure where you are getting your information, but retina is the most competitive fellowship in ophthalmology (except maybe ASOPRS plastics), so it IS difficult. Moreover, there are really only about 20-25 "good" retina fellowships, despite how many are offered each year. Even if what you stated were true, it's exceedingly difficult to get into a "top 20" residency, and then you have to want to do retina, which not everyone does. It's not just about the money.
Having recently gone through the process of interviewing for Retina jobs, I think that there are plenty of good jobs out there. If you do well as a fellow and are coming out of a good fellowship, you should have options if you aren't completely geographically restricted. Starting salaries are mostly 200-300K, depending on location and academic vs. private. Some jobs are listed as higher, but I would be suspicious that they aren't being completely honest. Once you buy in to the practice the income potential increases significantly. Not sure that I agree that retina clinics see fewer pts/day than comprehensive. Many see 60-80/day and higher. You will likely have to travel to more satellite offices as a retina specialist. The loss of the consult codes and drop in OCT and injection reimbursements is certainly putting downward pressure on salaries, but many are still high. There reaches a point where you can't just keep seeing more patients in a day to maintain you collections.
I find this entire thread a little rediculous.
There are tremendous opportunities in ophthalmology now - this will only continue. Larger cities are tough for all subspecialties and comprehensive because there are too many doctors for the number of patients. Medium sized markets or even markets 45 minutes from a major city have great opportunity now and many are hurting for eye doctors.
For those of us who do not want to raise a family in Manhatan this is a great time to be in ophthalmology as half of graduates say "NYC, Chicago, LA or bust." They settle for starting salaries in the low $100s (Making $120 in downtown Chicago sounds fun -especially if you have a family). Like all fee-for-service models, you get paid on how much work you do. If you want to see 12 patients a day and do 6 cataract surgeries per month, stay in New York - but how do you expect to be paid $200,000 doing that much work.
For those who are willing to move 1 hour from these locations, we have higher starting salaries, see more patients, and much more opportunity for growth.
Finally, I realize money plays a role in carreer decisions, but jiggabot, there is more to choosing a specialty or subspecialty than just money. If one wants to make a lot of money per hour worked, go into radiology, anesthesiology, or emergency medicine - not ophthalmology. In other words, most retina doctors do not choose retina just because of money. Some actually do it because they enjoy it.
There are tremendous opportunities in ophthalmology now - this will only continue. Larger cities are tough for all subspecialties and comprehensive because there are too many doctors for the number of patients. Medium sized markets or even markets 45 minutes from a major city have great opportunity now and many are hurting for eye doctors.
For those of us who do not want to raise a family in Manhatan this is a great time to be in ophthalmology as half of graduates say "NYC, Chicago, LA or bust." They settle for starting salaries in the low $100s (Making $120 in downtown Chicago sounds fun -especially if you have a family). Like all fee-for-service models, you get paid on how much work you do. If you want to see 12 patients a day and do 6 cataract surgeries per month, stay in New York - but how do you expect to be paid $200,000 doing that much work.
For those who are willing to move 1 hour from these locations, we have higher starting salaries, see more patients, and much more opportunity for growth.
Finally, I realize money plays a role in carreer decisions, but jiggabot, there is more to choosing a specialty or subspecialty than just money. If one wants to make a lot of money per hour worked, go into radiology, anesthesiology, or emergency medicine - not ophthalmology. In other words, most retina doctors do not choose retina just because of money. Some actually do it because they enjoy it.
It is interesting you say that because other people keep telling me ophtho is saturated all over. I'm sure you can find jobs, but at what price?
Also, I don't know if those other fields you mentioned pay more per hour. Rads makes 500k for some hard work, anesthesia is 400k, and EM is like 300k. I thought ophtho guys after partnership made around 400k average with retina guys pulling like 800k. Are these numbers way off I have? I was always interested in ophtho but with the whole optometry thing and the whole saturation thing, I got spooked. I don't need to be in LA proper, but suburbia LA or San Fran is what I'm aiming for.
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In Rads, anesthesia, and EM your work hours will be worse than ophtho. If you are aiming for LA or san fran, you are not going to come close to making that kind of money starting off in any of those fields, and most likely not even as a partner. Starting off at 400 in anesthesia means living in very rural mid america or alaska. Friend just signed a contract for 500k starting in anesthesia in the absolute middle of no where Arkansas with a very high work load. EM at 300 seems pretty high anywhere, but you could make that and more if you joined one of the 20-30% of practices that are private practice and not owned by a health management company. Although I know someone who just signed a contract for 325k per year for an ER job after med/peds residency (around 60 hrs a wk with 1-2 wks of nights per month). Your ophtho numbers are too high, although there are guys in every city making way more than that. Rads is about to get slaughtered for numerous reasons including this one:
http://www.nytimes.com/2011/06/18/health/18radiation.html?_r=1&ref=health
What you say is true but I'm not talking about starting incomes. I'm talking about a couple years out. My initial questions were why wasn't retina uber competitive and how the job market was in places like suburbia LA or San Fran.
It is uber competitive, and probably would be even more so if those who go into ophtho didn't care so much about their lifestyle. The job market in LA/san fran is terrible for any medical field. Simply finding a any job regardless of pay would be difficult. I am guessing that family or straight up internal medicine would be the easiest jobs to find. Derm would most likely be the easiest medical specialist job to find. If you have ties to the region, your search will be much easier.
" If you want to see 12 patients a day and do 6 cataract surgeries per month, stay in New York - but how do you expect to be paid $200,000 doing that much work."
@200UL - So True of a statement.
To Jiggabot, what everyone on here is saying is correct. I am a consultant specializing in search and placement of ophthalmologist nationwide and have done so for almost 15 years. While there might be opportunities in the Metro areas, don't expect to retire anytime soon.
It is common for a general oph looking in LA or NYC to be offered a base of around $100K. While this may seem low, if you don't take it, 20 others will. Regarding specialist in those areas, I see many who end up working for several practices, they piecemeal a full time practice together. Eventually one position builds up to a full time practice and the rest is history.
As was said before, there is a great demand for physicians just and hour or so outside of the metro areas. This is where the real physician shortage is going to occur in the future in my opinion. Besides, even if you were to live in the City, how often would you take advantage of the amenities? A typical day, you get up, got to the office, come home, go to bed to get up and do it again. You might enjoy the nightlife on Friday and Saturday night. So why not live just outside of the city, make enough money that you don't have to worry about the future and make enough to own a place in the city for the weekends?
We all need to live where we feel comfortable, but the expectations need to be tempered with what is reality.
@200UL - So True of a statement.
To Jiggabot, what everyone on here is saying is correct. I am a consultant specializing in search and placement of ophthalmologist nationwide and have done so for almost 15 years. While there might be opportunities in the Metro areas, don't expect to retire anytime soon.
It is common for a general oph looking in LA or NYC to be offered a base of around $100K. While this may seem low, if you don't take it, 20 others will. Regarding specialist in those areas, I see many who end up working for several practices, they piecemeal a full time practice together. Eventually one position builds up to a full time practice and the rest is history.
As was said before, there is a great demand for physicians just and hour or so outside of the metro areas. This is where the real physician shortage is going to occur in the future in my opinion. Besides, even if you were to live in the City, how often would you take advantage of the amenities? A typical day, you get up, got to the office, come home, go to bed to get up and do it again. You might enjoy the nightlife on Friday and Saturday night. So why not live just outside of the city, make enough money that you don't have to worry about the future and make enough to own a place in the city for the weekends?
We all need to live where we feel comfortable, but the expectations need to be tempered with what is reality.
This is true, but I guarantee that if you are seeing 60-80 patients/day in a retina clinic, one or more of the following is occurring:
1. You're working long hours. Perhaps 7-7 or worse, five days/week.
2. You're going to burn out quickly. It's just tough to keep up that sort of pace long-term.
3. You're not spending much time talking to your patients. The Q & A about their disease process is either non-existent or falls to ancillary staff. This can be a major turn-off for some patients. I can't tell you how many have come to my practice after leaving another and said they were never really told what was wrong with them or why they needed such and such procedure.
4. You're missing things. Again, I've seen a number of patients from other practices that were simply misdiagnosed. When you go really fast, it's hard to be thorough.
5. You're delegating a huge amount to fellows. In fellowship, we had a satellite office where it was routine for the attending to see 60-80/day. The (two) fellows did the overwhelming majority of injections and all of the lasers. They also did a lot of the initial legwork on patients, with the attending flying in for a cursory exam to okay the plan.
On the bright side, you will make a lot of money, if you see that many patients. I decided in fellowship that I didn't want to ever see more than about 40 patients/day, because I don't want #1 or 2, I don't think #3 & 4 are good patient care, and I don't have regular access to #5. But, that's my choice.
I completely agree with all 5 points.
On a somewhat related note, how hard is it to get a job in academia as a retina attending? A lot of me think it's tougher than as a comp. ophthalmologist, but then again I wonder if the higher pay steers retina surgeons away from the academia track.
Actually, subspecialists, such as retina docs, generally have an easier time landing academic jobs than comprehensive docs. Usually, cataracts and the like are performed by the glaucoma and cornea docs in an academic practice. That is not to say that there are no comprehensive docs in academics, but most are subspecialists.
As to the pay, there are other incentives than pay that make academics attractive to some. Call coverage by residents/fellows, access to state of the art equipment and research facilities, freedom to attend multiple meetings in sometimes exotic locales, prestige, etc.
If you want the latest survey of different salaries for all specialties, starting, mid and end career all together see below link. You can see Ophtho is in the middle. Don't go into ophtho for the money. The above response was correct. If you are after money go into Rad, Anesth, Ortho. ED makes a lot too and other surveys show they work the fewest hours and they are shift workers which is relatively unique.
http://www.medscape.com/features/slideshow/compensation/2011/
So far, during my short stint in private practice, these are my observations of how people make lots of money in Ophthalmology:
1) RETINA - order a OCT/FA on every other patient even if there is questionable indication to do so, but make sure to document some type of indication; put a few shots of laser in even if the patient already has had full PRP or grid already done by someone else; repeat for the 80 daily patients in your retina clinic mill; always put a few shots of endolaser in during your vitrectomies even if it's for a membrane peel.
2) GENERAL/CORNEA/GLAUCOMA - order a OCT/VF/pachy/gonio on every patient; perform 20/20- or 20/25 "cataracts"; perform clear-lens extractions or ICLs; perform 91-day post-op YAGs; perform "prophylatic LPIs" on everyone including your grandmother; talk up Crystalens and charge $3500 even if it doesn't give the patient good reading vision ("don't worry your brain will adapt"); get into LASIK and advertise like crazy; do cosmetic blephs and BoTox and Latisse.
3) IN GENERAL: hire 10 to 20 optoms who feed you as many cataracts, LASIK, lasers, etc as possible. Turf off all of the dry eyes and red eyes to the optoms or medical ophthalmologists or to young associates that you pay 125K to. Own the building and of course the ASC. Offer none of these to your young associates.
Retire at age 45 or earlier.
Yes, a bit cynical...but a lot of this stuff really does happen outside the "ivory towers" of academia. Sick yet?
1) RETINA - order a OCT/FA on every other patient even if there is questionable indication to do so, but make sure to document some type of indication; put a few shots of laser in even if the patient already has had full PRP or grid already done by someone else; repeat for the 80 daily patients in your retina clinic mill; always put a few shots of endolaser in during your vitrectomies even if it's for a membrane peel.
2) GENERAL/CORNEA/GLAUCOMA - order a OCT/VF/pachy/gonio on every patient; perform 20/20- or 20/25 "cataracts"; perform clear-lens extractions or ICLs; perform 91-day post-op YAGs; perform "prophylatic LPIs" on everyone including your grandmother; talk up Crystalens and charge $3500 even if it doesn't give the patient good reading vision ("don't worry your brain will adapt"); get into LASIK and advertise like crazy; do cosmetic blephs and BoTox and Latisse.
3) IN GENERAL: hire 10 to 20 optoms who feed you as many cataracts, LASIK, lasers, etc as possible. Turf off all of the dry eyes and red eyes to the optoms or medical ophthalmologists or to young associates that you pay 125K to. Own the building and of course the ASC. Offer none of these to your young associates.
Retire at age 45 or earlier.
Yes, a bit cynical...but a lot of this stuff really does happen outside the "ivory towers" of academia. Sick yet?
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I don't know about the other subspecialties but with Retina you do not seem to know what you are talking about. Sometimes, most often, you need to repeat laser if the situation calls for it. I would worry about optoms or general guys over ordering octs to help pay for the machine. Most retina conditions need oct especially with the intravitreals. Besides octs and intravitreals will continue to go down in reimbursement.
Not to get into a skirmish online, but I know lots of retina guys who truly do overtest patients (e.g. get a FA/ICG on patients with 20/25 epiretinal membranes, etc) and perform unnecessary lasers (e.g. putting in 20 more shots of PRP in someone whose retina is already black from abundant laser scars).
Look, it's not confined to retina docs. Tons of general Ophthalmologists and subspecialists are doing the same thing.
The government is smart... if I were a government regulator, I would cut OCT/FA/retinal laser reimbursements to about 33% of their present value. Trust me, given my profession, I would not want that to happen. But eventually, the government is going to wisen up and stop paying $800-$1000 for a focal.
I think the best situation (in terms of money) is to be a high-volume LASIK guy who doesn't depend on insurances at all. But obviously, that isn't the easiest position to obtain.
Look, it's not confined to retina docs. Tons of general Ophthalmologists and subspecialists are doing the same thing.
The government is smart... if I were a government regulator, I would cut OCT/FA/retinal laser reimbursements to about 33% of their present value. Trust me, given my profession, I would not want that to happen. But eventually, the government is going to wisen up and stop paying $800-$1000 for a focal.
I think the best situation (in terms of money) is to be a high-volume LASIK guy who doesn't depend on insurances at all. But obviously, that isn't the easiest position to obtain.
Actually, I'm 4 months into my solo practice in the Bay Area, and 12 patients a day and 6 cataract surgeries per month, based on my overhead will give me $150K+ a year. My break even point is a about 5 or 6 patients a day, albeit my new patient percentage right now is about 50%. My guess is 8 patients a day with the typical new/established breakdown will yield even. Ophthalmology management says that each encounter should yield an average of $125 per after all's said and done (diagnostics, surgeries, etc.) At this point, I'm at about $150 per, but should go down eventually. And I've absolutely been resisting operating on 20/20 cataracts, doing OCT's on someone with one MA in the periphery, etc.
Of course, if you're working for a practice empire with 20 employees, you'll need to see more patients to meet overhead. I have one employee, and I'm my own tech right now. Completely on my own, I think I should be able to manage 13-15 a day.
But I have to agree with WhatNEyetem. I interviewed all over the place for jobs, and I couldn't take any of them because they were doing things just because they could and because they got paid for it.
I'll have to say that I've seen the same things. Unfortunately, further cutting reimbursements, as you later mentioned, does not fix the problem. It only leads to more abuse, as physicians scramble to maintain a steady cash flow level. That's one of the main reasons these abuses occur in the first place. Every time CMS/private carriers cut reimbursements, something needs to be done to compensate. That compensation can come in many forms: cutting your own pay, laying off an employee, dropping a cheapskate carrier, abusing the system,.... We private practitioners are all essentially small business owners. In our case, though, the government controls both the in (CMS reimbursement) and the out (taxes). We're not in a free market system, like most small businesses. We're just along for the ride. Yee-haw.
what a depressing thread for an incoming resident...
It is a bit depressing but don't let it get you down. The job market isn't great amongst many fields in medicine right now. But I think you can get a job if you're willing to move to where you're needed.
I actually think the part about the overuse of tests and procedures amongst ophthalmologists is not generally true from what I've seen. In fact, I think we often under-treat.
Very few ophthalmologists use intravitreal anti-VEGF on a strict monthly basis, even though it is FDA approved to do so. In fact, most of us try to give as few injections as possible, sometimes to the point where our patients lose vision and we're doing them a disservice by undertreating (look at the Horizon trial, where retina docs only gave ~4 injections per year when they no longer had to follow a trial protocol... and patients ended up losing vision).
We've pushed the use of avastin, despite it being off-label, instead of the far more expensive on-label lucentis and eylea. This saves a lot of healthcare spending
FAs are used much less often (even though I think they still have an important role and are underutilized)
I rarely see glaucoma patients getting laser as first line treatment (or second or even third line) despite studies showing that it's effective as first line. Patients often have to be on 4 drops before I see many ophthalmologists offer them a laser treatment.
Many ophthalmologists probably do see too many patients per day and spend too little time actually talking to them... but that's what's happening to all fields of medicine in the name of "efficiency."
I actually think the part about the overuse of tests and procedures amongst ophthalmologists is not generally true from what I've seen. In fact, I think we often under-treat.
Very few ophthalmologists use intravitreal anti-VEGF on a strict monthly basis, even though it is FDA approved to do so. In fact, most of us try to give as few injections as possible, sometimes to the point where our patients lose vision and we're doing them a disservice by undertreating (look at the Horizon trial, where retina docs only gave ~4 injections per year when they no longer had to follow a trial protocol... and patients ended up losing vision).
We've pushed the use of avastin, despite it being off-label, instead of the far more expensive on-label lucentis and eylea. This saves a lot of healthcare spending
FAs are used much less often (even though I think they still have an important role and are underutilized)
I rarely see glaucoma patients getting laser as first line treatment (or second or even third line) despite studies showing that it's effective as first line. Patients often have to be on 4 drops before I see many ophthalmologists offer them a laser treatment.
Many ophthalmologists probably do see too many patients per day and spend too little time actually talking to them... but that's what's happening to all fields of medicine in the name of "efficiency."
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Hey, haven't seen this thread in a while.
Consider it more eye-opening than depressing. Very few are aware of the business aspect of medicine going in. We just wanted to be doctors, right? Knowing what you're getting into helps soften the blow. Too many docs nowadays are coming out of training and jumping directly into an employment situation, foregoing private practice altogether, because the business side scares the tar out of them. They soon realize that being an employee is not all it's cracked up to be, especially after having spent so much time in school (face it, doctors are some of the most educated people on the planet). Make sure and educate yourself on the business side of medical practice. As a physician, you'll be able to find a job and you'll make good money. You just may have to adjust your expectations somewhat and be more open to going where the jobs are.
Say you don't go to a top 20 residency...how do you land one of these "great" fellowship spots that can help set you up for what you wanna do whether that's academics or private practice?
Or is that just not possible?
