retina lifestyle update? surgical vs medical?

[soonmd1]

Hey Guys,
its the end of PGY2, and I think retina (medical or surgical) is fascinating... however, I keep getting this sense from other residents and attendings that doing a surgical retina fellowship is akin to signing away my life and the 'ophthalmology lifestyle'.

1) For those of you who chose medical retina, what factors played into your decision? do you miss the surgical aspect? how different are your patient bases?

2) If you are working in private, how many patients are you seeing a day? how long are your days? are there are lot of 'surprise' add-on cases at the end of the day like there seems to be in academics?

3) have you given up your weekends like people seem to say retina specialists have to do? how much vacation are you taking

Thanks so much for the input!

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[MullerCell]

Surgical retina lifestyle in private practice is very reasonable. It is certainly practice dependent, but cases are typically never done in the evening and only rarely on weekends. There are more "emergent" add-ons during the normal clinic day, but these are really just another patient you see and not a big deal. If clinic is over, it generally waits until the next day. There are very rare instances of endophthalmitis that may be seen after hours, but I've had 1 in the past 2 years. We can add on mac-on RDs the following day at our ASC, and a pneumatic is an option in many cases. I would estimate I see patients on the weekend 1-2 x per month, usually post-op or post-injection patients or patients with a possible tear or RD. This is not really a big deal (you just have them come in when you have 30 min to go see them). I operate on the weekend ~1 x every 2-3 months. As far as clinic volume, everyone is different. Most medical retina people I know are doing mostly comp ophthalmology because it is hard to build a practice if you aren't surgical. For surgical retina, 40-60 patients/day is normal for a reasonably busy practice, but you can survive on less or see more depending on how you want to balance work/life. Vacation is just part of your contract. Most people start at 2 or 3 weeks/year. Once you are buying in as a partner you can take as much as you want, but it will just slow your practice down since you will miss new referrals and a week of vacation costs you thousands of dollars (much more than plane tickets, hotel, ect. for the actual vacation) since you are still paying fixed overhead costs and missing out on revenue.

 

[Slide]

The part about signing away your lifestyle in going into retina is probably a bit outdated nowadays. In terms of the surgical aspects, that was definitely true over a decade ago. The retina attending I've worked with said that those days, surgery took longer because of the instrumentation and technology. Now, his surgery days last from 630 to around 3-4pm twice a week, but before his surgery days were often from 7-8 in the morning until 1 am at night! Of course, his schedule is probably on the extreme of most surgical retina, but the point is that surgery is much faster. With 20 gauge instrumentation and prior vitrectomy technology, it would take a while just to get started with the surgery; you'd have to do conjunctival peritomies, scleral incisions, and you'd have to sew in the infusion line. With previous machines, more of the functions were manual, and you'd sometimes have to operate upside down to repair retinal detachments! Bad PDR cases took a while because you'd have to repeatedly change the infusion settings. Now, getting the ports and infusion line in with 23g and 25g instrumentation takes less than 2 minutes, and newer vitrectomy machines automate a lot of functions for you. Taking the ports out is also much easier; even if you have to put a stitch in your sclerotomy, it takes less time to do than with 20 gauge instrumentation to close up.

Add-on cases also depend on the surgeon. Some old-school guys will operate on mac-off and mac-on RDs quickly, but the trend I'm seeing more is that the surgery can often wait until the next day without any significant decrease in outcome. This is especially true if the OR staff you have during the evening/nights vs regular work days are different because since the instruments are so specialized, most OR staff aren't familiar with them and this can cause the surgery to start much later than you want it and much longer than you want to. On that note, "emergent" add-ons in clinic or surgery usually aren't as emergent as presented on the phone. At least on my retina rotations, most "urgent" add-ons that the referring provider thought required surgery usually either needed injection therapy, a laser retinopexy, or the diagnosis was off.

 

[MR1]

Retina is busier than general ophthalmology mainly because of the work ins and emergencies. It is not "bad" though. Typical week, I see 20-50 patients a day 4 days a week. The reason for 20 is because I am building a practice. Most retina it seems is in that 40-60 range as said above, a few I know only do 30ish, some push 80-100. I am in OR one day a week, only do ~3 cases usually scheduled but will probably double that when practice is built. 80% of my emergent add on cases, dropped lens and RD's I just do end of day or next day. I can often finish clinic at 4 so can do a RD and be out of here by 5-530 still. Often do RD's over lunch time. Probably only do handful of late cases every year, ie after 6-7pm. Just no reason to outside of endophthalmitis. Our OR is in the building so that makes running to do a case over lunch really easy. My contract gives me 3 years vacation and one CME week. I only come in one weekends if I am on call which is only every 8-10 weeks or occasionally come in Saturday morning just for a quick post op check for someone I did Friday. I work about 45-50 hours every week I guess.

Fellowship was different mind you. I worked 60-70 hours a week and was on call all the time it seemed. But that is just 2 years of my life.

In retina you have to except that you WILL get a call on Friday at 4pm with something, occasionally it might be a dump. You will have to do surgical cases outside your OR block, but they don't have to be at night or the weekend everytime. There will be emergencies. Sometimes those emergencies are nothing, as after you do a retina fellowship you realize how poor your BIO skills were during residency.

 

[Eye-eye]

Retina is busier than general ophthalmology mainly because of the work ins and emergencies. It is not "bad" though. Typical week, I see 20-50 patients a day 4 days a week. The reason for 20 is because I am building a practice. Most retina it seems is in that 40-60 range as said above, a few I know only do 30ish, some push 80-100. I am in OR one day a week, only do ~3 cases usually scheduled but will probably double that when practice is built. 80% of my emergent add on cases, dropped lens and RD's I just do end of day or next day. I can often finish clinic at 4 so can do a RD and be out of here by 5-530 still. Often do RD's over lunch time. Probably only do handful of late cases every year, ie after 6-7pm. Just no reason to outside of endophthalmitis. Our OR is in the building so that makes running to do a case over lunch really easy. My contract gives me 3 years vacation and one CME week. I only come in one weekends if I am on call which is only every 8-10 weeks or occasionally come in Saturday morning just for a quick post op check for someone I did Friday. I work about 45-50 hours every week I guess.

Fellowship was different mind you. I worked 60-70 hours a week and was on call all the time it seemed. But that is just 2 years of my life.

In retina you have to except that you WILL get a call on Friday at 4pm with something, occasionally it might be a dump. You will have to do surgical cases outside your OR block, but they don't have to be at night or the weekend everytime. There will be emergencies. Sometimes those emergencies are nothing, as after you do a retina fellowship you realize how poor your BIO skills were during residency.

How much of a hit does your salary take doing 40-60 a week versus 80-100? I've heard a crazy range of salaries quoted for retinal surgery, from like 200 starting to making 800k or more after a couple years; I'm not sure who to believe on this...

 

[MR1]

How much of a hit does your salary take doing 40-60 a week versus 80-100? I've heard a crazy range of salaries quoted for retinal surgery, from like 200 starting to making 800k or more after a couple years; I'm not sure who to believe on this...

Wow. Pulled up old one here. Starting salary is only a matter of what someone is willing to pay you. Most are probably 200 to 300k. Some less desirable places are more. Then there is your bonus depending on how busy you are.

Once you are partner and making what you are actually generating it depends on your overhead. Those can be 40 to 60 percent. My rule of thumb is figure 150 to 200 bucks per patient seen. So seeing patients 50 a day 4 days a week with one surgery day. That amounts to 1.5 to 2 million generated.

That is a lot of patients though and from what I have heard the folks seeing higher amounts don't see patients 4 days a week so it still averages out to about 800 patients a month. And yes there are folks seeing more and making more. Just as there are some only seeing 30 a day.

 

[Eye-eye]

Wow. Pulled up old one here. Starting salary is only a matter of what someone is willing to pay you. Most are probably 200 to 300k. Some less desirable places are more. Then there is your bonus depending on how busy you are.

Once you are partner and making what you are actually generating it depends on your overhead. Those can be 40 to 60 percent. My rule of thumb is figure 150 to 200 bucks per patient seen. So seeing patients 50 a day 4 days a week with one surgery day. That amounts to 1.5 to 2 million generated.

That is a lot of patients though and from what I have heard the folks seeing higher amounts don't see patients 4 days a week so it still averages out to about 800 patients a month. And yes there are folks seeing more and making more. Just as there are some only seeing 30 a day.

Thank you! Is there any good way to tell if a practice is sincere about bringing you on in a "partnership track" instead of just trying to use you for cheap labor for a couple years?

 

[DrZeke]

Thank you! Is there any good way to tell if a practice is sincere about bringing you on in a "partnership track" instead of just trying to use you for cheap labor for a couple years?

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[MstaKing10]

By the time you are in practice neuroguy91 all of these figures will likely change...perhaps a lot

 

[MR1]

By the time you are in practice neuroguy91 all of these figures will likely change...perhaps a lot

Yes. Unfortunately the new CMS reform is only the beginning. Who knows what reimbursement will be in 10 years

 

[Eye-eye]

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? I've heard of some people getting screwed over on this, so I didn't think it that outrageous to ask...

 

[Eye-eye]

By the time you are in practice neuroguy91 all of these figures will likely change...perhaps a lot

Yeah, I've wondered about that, too, with everyone saying that reimbursement is going down across the board...

 

[DrZeke]

? I've heard of some people getting screwed over on this, so I didn't think it that outrageous to ask...

I do actually find it insane to ask when you seem to be after MD/Phd implying you have at least 11 years between yourself and retina applications. Even if you aren't applying PhD that's 7 years. Rerax.

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[LightBox]

? I've heard of some people getting screwed over on this, so I didn't think it that outrageous to ask...

I always wonder why people feel like they are being "screwed" by not becoming a partner as a newbie associate. Partnership is a privilege, not an absolute right. Sure, it sucks if a practice "promises" you that partnership is going to happen after "x" number of years. Or keeps stringing you along. But if the practice owner(s) are upfront with you about not being particularly inclined toward giving up equity, then what's the big deal? All the financial risk is borne by the owners when hiring an associate. Most associates lose money for the first two years at least, unless they are just taking over for someone who is retiring from a mature practice. Most practice owners had to take huge financial risks and major personal sacrifice (e.g. time away from family) to establish and nurture the practice. So to expect an owner to give up equity easily to an associate who never had to risk bankruptcy or who has minimal entrepreneurial skills, is somewhat naive.

To those who feel that partnership buy-ins are too expensive (i.e. "being screwed again"), you can always take a bank loan and start your own practice. That's exactly what your employer likely had to do many years ago

 

[MstaKing10]

I always wonder why people feel like they are being "screwed" by not becoming a partner as a newbie associate. Partnership is a privilege, not an absolute right. Sure, it sucks if a practice "promises" you that partnership is going to happen after "x" number of years. Or keeps stringing you along. But if the practice owner(s) are upfront with you about not being particularly inclined toward giving up equity, then what's the big deal? All the financial risk is borne by the owners when hiring an associate. Most associates lose money for the first two years at least, unless they are just taking over for someone who is retiring from a mature practice. Most practice owners had to take huge financial risks and major personal sacrifice (e.g. time away from family) to establish and nurture the practice. So to expect an owner to give up equity easily to an associate who never had to risk bankruptcy or who has minimal entrepreneurial skills, is somewhat naive.

To those who feel that partnership buy-ins are too expensive (i.e. "being screwed again"), you can always take a bank loan and start your own practice. That's exactly what your employer likely had to do many years ago

Fair points. The problem is many predatory practices are not up front and the promises of partnership are not kept. If as owner you opt to hire an employee and are clear that there is no partnership offer and the employee agrees this is completely fair. I don't think the buy in is unfair at all, especially if the practice has been fairly valued. Most buy ins are pricey enough where they have to be financed so there is still a loan to be made and paid back.

While there is financial risk when hiring an associate, there is also potentially huge financial upside if they ramp up quickly and their contract is structured appropriately. Also there is sharing of responsibilities such as call, clinic and OR that can be delegated to the employee that frees up the owners to help grow their business. In this way, hiring an employee can have many financial as well as lifestyle advantages.

Ultimately, if your practice is not busy enough yet to expand or you are in an over saturated area then hiring someone would not make any financial sense. However, if there is a market you can tap into or area to expand or open a new office or you are simply too busy and are losing business because of that then hiring someone makes sense.

Partnering with someone who has a similar work ethic and who is entrepreneurial and is willing to put in all the effort the owners did while helping to expand the practice seems to make sense to me. This is why the partnership track takes so long. It truly is a business marriage and some don't want that commitment.

I would also argue that an employee, especially early in their employment, also takes on huge risk in that they are trusting the partners to pay them fairly and have their best interest in mind when making decisions. In some cases the employee is hired to be used and abused then not offered partnership. All the while, the employee is working long hours away from their family etc. This type of sacrifice, while different than what the owners went through, is still significant

 

[LightBox]

I think the bottom line is that all new associates should take as the "null hypothesis" that partnership will not be offered. New associates should work as hard as they can to bring in revenue to justify "rejecting the null hypothesis" No employer is obligated to ever share equity and it would be foolish to do so unless the new associate clearly brings in some benefit to the owner(s). As you said, it truly is a "marriage" and owners do not want to be stuck with someone for the rest of their professional lives unless that new person is (1) bringing the revenue in; (2) taking care of patients well; and (3) is easy to work with. When new associates nit pick at every little thing at the onset, the owners start to wonder if criterion #3 will hold true.

 

[MstaKing10]

I think the bottom line is that all new associates should take as the "null hypothesis" that partnership will not be offered. New associates should work as hard as they can to bring in revenue to justify "rejecting the null hypothesis" No employer is obligated to ever share equity and it would be foolish to do so unless the new associate clearly brings in some benefit to the owner(s). As you said, it truly is a "marriage" and owners do not want to be stuck with someone for the rest of their professional lives unless that new person is (1) bringing the revenue in; (2) taking care of patients well; and (3) is easy to work with. When new associates nit pick at every little thing at the onset, the owners start to wonder if criterion #3 will hold true.

Well said!

 

[MR1]

All good points. What I would add is often you can figure out whom the predatory practices are from folks that have worked there previously. If the practice had a tendency to go through employees every 2 to 3 years that is a bad sign. Just remember you are looking for a good fit too just as the practice is. Partnership isn't a guarantee.

 

[Eye-eye]

I've also thought about if I might want to simply start my own practice some day (obviously I have no clue at this point if I'll end up wanting to or not, but I may). If so, would it behoove me to try to get an MBA during med school? I've also heard that some residencies might see that as being in medicine just for the money or seeing it only as a business, though, so I wasn't sure if that would help or hurt, at least at that stage...

 

[LightBox]

I've also thought about if I might want to simply start my own practice some day (obviously I have no clue at this point if I'll end up wanting to or not, but I may). If so, would it behoove me to try to get an MBA during med school? I've also heard that some residencies might see that as being in medicine just for the money or seeing it only as a business, though, so I wasn't sure if that would help or hurt, at least at that stage...

No, a MBA is not necessary at all to running a successful medical practice. I would say that 99.9% of eye doctors do not have a MBA and do just fine. Sure, get a MBA if you are interested in it. But definitely don't do it because you think a MBA will teach you something about running a practice (it won't). The thing that teaches you the most about running a medical practice is actually doing it or by having a good mentor who is willing to share his or her knowledge about it with you.

 

[Eye-eye]

No, a MBA is not necessary at all to running a successful medical practice. I would say that 99.9% of eye doctors do not have a MBA and do just fine. Sure, get a MBA if you are interested in it. But definitely don't do it because you think a MBA will teach you something about running a practice (it won't). The thing that teaches you the most about running a medical practice is actually doing it or by having a good mentor who is willing to share his or her knowledge about it with you.

Good to know. Thank you!