Role of comprehensive ophthalmology

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.

dantt

Member
15+ Year Member
Joined
Jun 28, 2006
Messages
997
Reaction score
260
I wonder what people's thoughts are regarding the role of new young comprehensive ophthalmologists.

Is it more advantageous (or less disadvantageous) in more competitive or less competitive markets? Are they primarily seen as primary care eye doctors or as referrals for cataract surgery consultation as well as lasers, chalazions, etc in markets where optometrists are not allowed to do those procedures? Is there any reason to hire a comprehensive doc for a partnership track when there already seems to be an unlimited capacity for cataract surgery and there is already a subspecialist who is better able to handle everything else?

I practice in a large group and it seems almost unfair to me to hire a comprehensive (cataract surgeon) to do the most lucrative procedures while everybody else gets corneal ulcers, bad glaucoma, retinal detachments, neuro bombs, eye lid lacerations, amblyopia, etc.

Members don't see this ad.
 
The thing is that most subspecialty trained docs want to practice their subspecialty and have no interest in doing tons of cataract Sx... the glaucoma doc wants to do glaucoma Sx, the retina doc wants to do retina Sx, and the corneal doc wants to do corneal Sx... it isn't always about the money. Some of the subspecialists at my centre does not even accept referrals for straight cataracts. There is simply not enough TIME in their clinic and OR to fit in a bunch of cataracts. At the same time there is a huge need for cataract Sx, especially in the upcoming years (every single person on earth eventually gets them), and this has mainly fallen into the realm of comprehensives docs. And like any surgery, the most cataracts you do, the more slick you get at it. If you're only doing 5 phacos a week, you're just not going to be as slick or safe as the person doing 30 a week. Not to mention nowadays there are plenty of advances in IOLs... you got your torics, multifocal, multifocal toric, etc. that you would need to keep up with the changing nuances of such advances on top of your own subspecialty interest.

Comp docs, at least where I am, also perform the most anterior segment lasers such as YAG PCO (as they perform the most cataract Sx) and SLT (as most mild-moderate glaucoma is managed by comps).

Comprehensive docs also receive lots of referrals for undifferentiated patients from GPs and optoms, and depending on the pathology they can generate lots of referrals for the subspecialists in the practice. In fact around where I am (academic centre in medium sized city with large catchment) the subspecialty clinics (outside of peds) rely almost exclusively on referrals from comprehensive ophthalmologists.

Lastly, there are a lot of patients with multiple ocular pathologies that simply does not require subspecialist care. Does it really make sense for a patient to see a glaucoma specialist Monday for their moderate stable glaucoma, then a retina specialist Wednesday to monitor for plaquinil maculopathy, then a cornea specialist Friday to follow up for their cataract, all the while waiting to have a biopsy of a minor lid lesion with an oculoplastic surgeon, when all they need is one visit with a comprehensive doc? This is the case more often than not.

Such is the case in Canada, not sure about the USA.
 
Last edited:
I wonder what people's thoughts are regarding the role of new young comprehensive ophthalmologists.

Is it more advantageous (or less disadvantageous) in more competitive or less competitive markets? Are they primarily seen as primary care eye doctors or as referrals for cataract surgery consultation as well as lasers, chalazions, etc in markets where optometrists are not allowed to do those procedures? Is there any reason to hire a comprehensive doc for a partnership track when there already seems to be an unlimited capacity for cataract surgery and there is already a subspecialist who is better able to handle everything else?

I practice in a large group and it seems almost unfair to me to hire a comprehensive (cataract surgeon) to do the most lucrative procedures while everybody else gets corneal ulcers, bad glaucoma, retinal detachments, neuro bombs, eye lid lacerations, amblyopia, etc.

It depends on how big your practice is and how your compensation model is set up. If you have busy generalists they will generate plenty of work for your subspecialists. If you have so many docs (who are compensated primarily on their production) and not enough patients, then sure, I can see why your subspecialists would want to cover a wider variety of things.

In my practice everyone goes home with equal pay. We all work equally hard. If your comprehensive doc is selling multifocals like crazy the glaucoma guy benefits either way so there's no pressure for him to crank out premium lenses in his combined cases (and no hard feelings).
 
Members don't see this ad :)
The thing is that most subspecialty trained docs want to practice their subspecialty and have no interest in doing tons of cataract Sx... the glaucoma doc wants to do glaucoma Sx, the retina doc wants to do retina Sx, and the corneal doc wants to do corneal Sx... it isn't always about the money. Some of the subspecialists at my centre does not even accept referrals for straight cataracts. There is simply not enough TIME in their clinic and OR to fit in a bunch of cataracts. At the same time there is a huge need for cataract Sx, especially in the upcoming years (every single person on earth eventually gets them), and this has mainly fallen into the realm of comprehensives docs. And like any surgery, the most cataracts you do, the more slick you get at it. If you're only doing 5 phacos a week, you're just not going to be as slick or safe as the person doing 30 a week. Not to mention nowadays there are plenty of advances in IOLs... you got your torics, multifocal, multifocal toric, etc. that you would need to keep up with the changing nuances of such advances on top of your own subspecialty interest.

Comp docs, at least where I am, also perform the most anterior segment lasers such as YAG PCO (as they perform the most cataract Sx) and SLT (as most mild-moderate glaucoma is managed by comps).

Comprehensive docs also receive lots of referrals for undifferentiated patients from GPs and optoms, and depending on the pathology they can generate lots of referrals for the subspecialists in the practice. In fact around where I am (academic centre in medium sized city with large catchment) the subspecialty clinics (outside of peds) rely almost exclusively on referrals from comprehensive ophthalmologists.

Lastly, there are a lot of patients with multiple ocular pathologies that simply does not require subspecialist care. Does it really make sense for a patient to see a glaucoma specialist Monday for their moderate stable glaucoma, then a retina specialist Wednesday to monitor for plaquinil maculopathy, then a cornea specialist Friday to follow up for their cataract, all the while waiting to have a biopsy of a minor lid lesion with an oculoplastic surgeon, when all they need is one visit with a comprehensive doc? This is the case more often than not.

Such is the case in Canada, not sure about the USA.

Very informative post, thanks. Un(fortunately), optometrists in many areas in the US do not refer patients to comprehensive ophthalmologists for undifferentiated patients. They are usually more than capable of handling many medical things and know where to send patients when things get out of hand. The only other thing I would say is unless you're in an academic center, everybody understands that cataracts pay the bills enabling you to do your subspecialty.
 
Last edited:
Very informative post, thanks. Un(fortunately), optometrists in many areas in the US do not refer patients to comprehensive ophthalmologists for undifferentiated patients. They are usually more than capable of handling many medical things and know where to send patients when things get out of hand. The only other thing I would say is unless you're in an academic center, everybody understands that cataracts pay the bills enabling you to do your subspecialty.

I will manage the occasional issue that most comprehensive ophthalmologists manage (early-moderate POAG, dry eyes, blepharitis, early cataracts w/ refraction), but otherwise I would rather manage retina because I enjoy it more. I need the help of my comprehensive colleagues to help quarterback all the eye issues and manage any anterior segment pathology/cataracts as necessary. Sometimes the comprehensive guys will pick up on things I didn't notice before or did not pay much heed to that becomes vital to my management.

Also payment differs on your practice and your model. More comprehensive guys seem to be more savvy with the business aspect than the subspecialists from what I've experienced, which may be why in many centers the comprehensive guys may be getting paid more. As retina, our services contribute heavily to the finances of our department because we have a well developed, streamlined volume of procedures and surgeries.
 
The thing is that most subspecialty trained docs want to practice their subspecialty and have no interest in doing tons of cataract Sx... the glaucoma doc wants to do glaucoma Sx, the retina doc wants to do retina Sx, and the corneal doc wants to do corneal Sx...

Outside of Retina and Oculoplastics, this is not the typical situation. Glaucoma and Cornea specialists most likely will practice a mix between general and subspeciality. Today, there is not enough cornea casework for a full-time cornea practice and glaucoma is so depressing htat most want to perform general to break it up.
 
It depends on how big your practice is and how your compensation model is set up. If you have busy generalists they will generate plenty of work for your subspecialists. If you have so many docs (who are compensated primarily on their production) and not enough patients, then sure, I can see why your subspecialists would want to cover a wider variety of things.

In my practice everyone goes home with equal pay. We all work equally hard. If your comprehensive doc is selling multifocals like crazy the glaucoma guy benefits either way so there's no pressure for him to crank out premium lenses in his combined cases (and no hard feelings).

This is a very interesting model. So you are in a multispecialty group where regardless of productivity all docs take home equal pay? Is overhead shared equally? Is there a productivity bonus structure?

I’ve mostly dealt with an eat what you kill model or a shared profit model like yours but single specialty. I get a sense that this gets more complicated with a multispecialty group.
 
This is a very interesting model. So you are in a multispecialty group where regardless of productivity all docs take home equal pay? Is overhead shared equally? Is there a productivity bonus structure?

I’ve mostly dealt with an eat what you kill model or a shared profit model like yours but single specialty. I get a sense that this gets more complicated with a multispecialty group.

Yeah, everyone works the same days per week, same clinic/OR ratio, same vacation time, and everyone shares cost of staff/equipment equally. Front desk distributes patients equally. At the end of the year everyone is usually within 10% of each other regarding collections, so we split profits equally. It fosters a non-competitive and collaborative environment. A patient of the retina guy wants him to manage their glaucoma or chalazia because they have a good connection? No big deal. You have a trainwreck that you want to get rid of? Also no big deal. Everyone comes in, works hard, and there's so much less stress worrying about turf battles and money.
 
Yeah, everyone works the same days per week, same clinic/OR ratio, same vacation time, and everyone shares cost of staff/equipment equally. Front desk distributes patients equally. At the end of the year everyone is usually within 10% of each other regarding collections, so we split profits equally. It fosters a non-competitive and collaborative environment. A patient of the retina guy wants him to manage their glaucoma or chalazia because they have a good connection? No big deal. You have a trainwreck that you want to get rid of? Also no big deal. Everyone comes in, works hard, and there's so much less stress worrying about turf battles and money.

Very interesting and compelling model in theory. How do you convince a retina specialist or oculoplastics to be paid the same as a comp person?
 
Very interesting and compelling model in theory. How do you convince a retina specialist or oculoplastics to be paid the same as a comp person?

Well the comp guys are pulling via premium IOLs so we definitely pull our weight. Our end-of-year collections are always pretty close, so it hasn't been a huge issue
 
Top