should I do a medical retina fellowship?

[soonmd1]

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Hey Guys!
PGY3 here. So over the past couple of years, I have really become interested in retina as a field.However, I came to ophthalmology thinking I would do general ophthalmology and go on to do international work and private practice. These two ideas now obviously do not gel well at all. What I am most afraid of is losing my cataract skills if I go into retina. Also I realized that most of what I like about retina is the clinical aspect of it (shots, lasers, interpreting imaging). I guess I have a few questions that you very wise folks could maybe help me with
1) how is the medical retina job market?
2) is it possible to be a medium volume cataract surgeon with a 1-2 retina days mixed into the week?
3) I am in a retina heavy program. I keep hearing that a medical retina fellowship is only going to distance me further from cataract surgery if I still want to pursue it without adding much to my daily clinical repertoire. any opinions in this?

Thanks so much!

 

[esodeviation]

If you're really interested in general ophthalmology plus injections and lasers, assuming you come from a retina heavy residency program, you should have enough experience to do a good number of injections for RVO, DME, and AMD as well as lasers without a separate medical retina fellowship. I do comprehensive and do 15-20 cataracts a week, do some plastics and strab, and see a good mix of comprehensive (cataract, dry eye, etc) and medical retina (RVO, AMD, DME) patients doing 20-30 injections a week as well. Anything that I don't feel comfortable with or atypical, I can still refer to a retina specialist. So depending on the amount of experience you get during residency, if you truly want to do comprehensive plus some medical retina, not sure you necessarily need to do a medical retina fellowship. May also depend on where you want to end up and how saturated it is with retina specialists. Although in that case, not sure you would be able to manage doing comp and retina anyway.

 

[MstaKing10]

Eso: are you in an area where there is limited access to retina specialist? What is your practice set up (multispecialty, solo etc)? Where do most of your referrals come from (optoms, FP's etc)?

I think these are important questions when determining weather your set up applies to the OPs situation.

 

[soonmd1]

If you're really interested in general ophthalmology plus injections and lasers, assuming you come from a retina heavy residency program, you should have enough experience to do a good number of injections for RVO, DME, and AMD as well as lasers without a separate medical retina fellowship. I do comprehensive and do 15-20 cataracts a week, do some plastics and strab, and see a good mix of comprehensive (cataract, dry eye, etc) and medical retina (RVO, AMD, DME) patients doing 20-30 injections a week as well. Anything that I don't feel comfortable with or atypical, I can still refer to a retina specialist. So depending on the amount of experience you get during residency, if you truly want to do comprehensive plus some medical retina, not sure you necessarily need to do a medical retina fellowship. May also depend on where you want to end up and how saturated it is with retina specialists. Although in that case, not sure you would be able to manage doing comp and retina anyway.

Thanks so much for the reply eso and king. eso: how does your practice setup work on a day to day basis? if you are doing 20-30 injections a week..do you have dedicated days for retina clinic? are there lasers mixed into this? also, are your weekly cataract numbers a function of a truly comprehensive practice (many other procedures mixed in) or are you in the midst of building your practice?

 

[esodeviation]

Thanks so much for the reply eso and king. eso: how does your practice setup work on a day to day basis? if you are doing 20-30 injections a week..do you have dedicated days for retina clinic? are there lasers mixed into this? also, are your weekly cataract numbers a function of a truly comprehensive practice (many other procedures mixed in) or are you in the midst of building your practice?

Weekly schedule is as follows:
Monday is surgery day, typically do 15-20 phacos, plus an occasional bleph or strab case. I start at 7:30, done by 11 or 11:30 depending on the caseload for that day. Off in the afternoon.

Tuesday See postops and general patients (8-4 with break from 12-1), with a few injections mixed in, but less than on other days due to the number of postops

Wednesday and Thursday - See a mix of general patients (refractions, dry eye, cataracts, uveitis, trauma, etc.) and do 5-6 injections on each of these days. Schedule is similar 8-4 on Wednesday, 8-3 on Thursday. YAGs are mixed in throughout the day, PRP and minor procedures (lid lesions, chalazia) typically done at the end of the day.

Friday - Originally planned to do all injections this day, but some patients have other obligations (chemo, dialysis schedules etc. that prevent them from coming on Friday), so now this day also has a mix of general and retina/injection patients. Probably do about half of my injections this day, with some general patients mixed in. Schedule is similar 8-4, off from 12-1.

Weekly cataract numbers reflect a growing practice, I'm now a few months into my third year with the volume building, but still not where my senior partners are at (20-25 cataracts a week consistently).

When I came, the closest retina was an hour away, and that practice actually sent me some of their patients to either take over completely or see for some of their injections to save patients on travel. Now there is a retina guy in town, but my practice is the predominant comprehensive group in town, so I still get the majority of the medical retina stuff.

Any other questions, feel free to ask.

 

[TheLesPaul]

Do you mind sharing where you trained, or if not specifically, the region and setting (i.e., large academic university in the South) so we get an idea of how your training was?

 

[long]

How big is the city you practice in?

 

[esodeviation]

Trained at UTSW. Currently in a city of approx. 50,000 with large rural catchment area.

 

[ophthope]

Trained at UTSW. Currently in a city of approx. 50,000 with large rural catchment area.

How is call in that sort of setting? Do you take hospital call for a local hospital(s)? And if so how is the volume?

I can never get a good sense of how often Ophthalmologists in rural/suburban areas actually repair an open globe or a canalicular laceration. I get a vague sense that as a resident I'm seeing quite a few transfers because the local Ophthalmologist hasn't repaired an open globe in quite a while. As someone who will likely end up practicing in a smaller population setting I'm curious about this stuff.

 

[esodeviation]

How is call in that sort of setting? Do you take hospital call for a local hospital(s)? And if so how is the volume?

I can never get a good sense of how often Ophthalmologists in rural/suburban areas actually repair an open globe or a canalicular laceration. I get a vague sense that as a resident I'm seeing quite a few transfers because the local Ophthalmologist hasn't repaired an open globe in quite a while. As someone who will likely end up practicing in a smaller population setting I'm curious about this stuff.

I do take call for the local hospital, 1 week at a time every 5th week. Hospital is not a trauma center. Have had two open globes in 2.5 years, both small corneal lacs, neither actually came through ED (one sent from an optom, 1 sent from a family doc in a rural area an hour away). Three or four lid margin lacs, only 1 involving canaliculus in 2.5 years. Probably get called 3-4 times in a week, mostly just to arrange follow up. Go into the ED on average less than once per week on call. Have only had 1 inpatient consult in 2.5 years.

 

[OPPforlife]

I do take call for the local hospital, 1 week at a time every 5th week. Hospital is not a trauma center. Have had two open globes in 2.5 years, both small corneal lacs, neither actually came through ED (one sent from an optom, 1 sent from a family doc in a rural area an hour away). Three or four lid margin lacs, only 1 involving canaliculus in 2.5 years. Probably get called 3-4 times in a week, mostly just to arrange follow up. Go into the ED on average less than once per week on call. Have only had 1 inpatient consult in 2.5 years.

As a first year resident who had a rough night on call last night...that's music to my ears!


Sent from my iPhone using Tapatalk

 

[Dusn]

I'll offer a different perspective. If you really enjoy retina; I think you should do a fellowship. The additional knowledge you gain will help you treat your patients better and let you see different ways of doing thing. There is a lot of variation amongst retina specialist on how we do things. A year of a medical retina fellowship (or even 2 years for surgical) is not a long time.

If you join a surgical retina practice, you will have a hard time doing cataracts because you won't get referrals if you do. If you join a comprehensive practice you can do cataracts but you may have a hard time getting the very expensive equipment you need, if you're the only retina doc. If you're not a specialist you will have even less pull to get the equipment you need for medical retina (which is at the very minimum a good FA, SD-OCT, and laser). The injection meds can also be a big loss to the practice if they are not billing person does not bill properly and in a comprehensive practice all this can be more of an issue. You also will have to train your techs and the photographer.

Medical retina is not as interesting without the imaging and without anyone to discuss cases with, in my opinion. If you're not retina trained and you're going to inject every time you see fluid without any thought process, that will make for a boring career and do some of your patients a disservice. The more interesting stuff involves ICG, autofluorescence and wide field imaging, in my opinion. In time, with newer medications and imaging technology, medical retina will get even more interesting but it will be hard to keep up in the wrong type of practice.

You also have to be honest with yourself about how good your training is (I think UTSW, where Eso went, gets good training). But after doing a fellowship, I now disagree with how many of my residency attendings or fellows treated retinal diseases. That being said, I do think some of the residents I train could handle straightforward medical retina cases as long as they have the equipment and they have a retina specialist available for the more atypical cases.

I think you also have to practice in a rural area if you're doing retina and you're not retina trained. Unfortunately, if you have a bad outcome the plaintiff lawyer will ask you at trial what your training was and why you didn't initially refer the patient. They will also get "expert" testimony saying you should have referred the patient. I don't agree with it but that's just the way it is. I've even seen them bring up "Why wasn't wide field angiography performed?" in posterior uveitis cases (even most retina and uveitis docs don't have wide field angiography yet).

 

[eyestar]

Well said DUSN. I will put in my two cents here. There is a lot to medical retina than just injections. If you really like retina-one year is nothing. I highly doubt Eso who has not done fellowship in medical retina is doing 20 injections a week.
If that was really true-and the claim that he/she obtained excellent training in residency to do without fellowship..
Then Eso is just injecting everyone who has diagnosis of AMD or CME.
(I went to residency in a top 3 ophthalmology residency program and although I was pretty comfortable in doing injections-its the art of figuring out who needs treatment and when).
If you choose to really practice in a small town where access to even comprehensive ophthalmology is scarce, then you can get away with doing variety of cases and procedures-that means for example in Texas:
You would have to be really practicing south texas-close to the border, Not in Houston, Dallas, or other larger cities.
Of course, patient wouldn't know enough in these places and you can probably do it all.
But like DUSN said, most comprehensive docs in major cities wouldn't do medical retina due to legal reasons.
I know of two comprehensive guys who got sued by patients where the vision deteriorated (most likely due to the disease process). But the patients won because the docs were not fellowship trained in medical retina and did not have adequate imaging modalities to prove their case.

 

[soonmd1]

thanks so much for the thoughtful replies!

from what you guys know and have seen, is it difficult to build a medical retina practice? i guess i'm trying to figure out what a typical day would be like being the medical retina person in a comprehensive practice vs the medical retina person in a retina practice

also is compensation effected by the type of practice you join? Thanks!

 

[pianist]

If you're really interested in retina, the most flexible thing to do is do a surgical fellowship. You can always drop surgery later.

It will be easier to find a job afterwards as you can participate in retina call if you join an all retina group. It is not always that easy to get a medical retina position at an all retina group. The senior people at retina groups will frequently want to be doing the medical retina, leaving the Friday 5 PM RD/Endophthalmitis/IOFB to the junior surgical associate.

It is possible to join a comprehensive group, though you will be highly dependent on internal referrals so it has to be a busy group with many general ophthalmologists to refer to you. Outside generalists will not refer to you, they will send to somewhere else that is not a direct competitor.

Also, in a comprehensive group, the retina person is not always compensated in proportion to their collections, "helping out" the other parts of the practice.

 

[Visionary]

Don't frequent this forum much nowadays, but as a medical retina doc for over 5 years now, I thought I should give my 2 cents here.

I did a 1 year fellowship after residency, and I have to agree with much of what has been said above. There is a big difference in being in a retina-heavy residency program and doing a solid year of medical retina. Half of my residency program faculty were retina specialists, so I'd call it retina-heavy. Doing injections and lasers isn't technically that difficult, but knowing when to treat and with what is key. Being comfortable with the diagnostics is also very important. I learned more about imaging interpretation in my fellowship than I ever expected to. That extra training shows. I've seen a number of patients who were being injected unnecessarily or not aggressively enough or with a suboptimal drug. I've seen aggressive "focal/grid" laser that has destroyed vision. There are a lot of things that a comprehensive ophthalmologist may think they know and are comfortable with that they actually have no business managing. Too much of a delay in referral or inappropriate treatment can result in irreversible damage. Likewise, I don't bother managing anterior segment issues anymore. I would be doing my patients a disservice. Like it or not, we're in the era of superspecialists. Along those lines, even with fellowship training, I'm not a fan of trying to "do everything" yourself. There's just too much to keep up with across ophthalmology. If you do a fellowship, you should really just focus on that, in my opinion.

I can also speak as someone who was the sole retina specialist in a comprehensive group, before moving to an all-retina group. The differences are substantial. The business models are vastly different. The cash flow with high cost injectables can be a major burden. If the infrastructure isn't there, you can get into trouble very easily. There are referral issues. I was in a comprehensive group with an optical. It was a large group, but from a referral standpoint, I was effectively on an island. No optometrists or even other comprehensive ophthalmologists were going to refer to me, even if they knew and trusted me. I ended up having to do a fair share of comprehensive ophthalmology just to stay busy. Being in an all-retina group has opened up my referral base tremendously and has allowed me to focus entirely on retina and to concern myself with what I think the best treatment for the patient is, rather than what is easier for the practice from a month-to-month cash flow standpoint. Getting into a group with other retina docs as a medical retina doc can be difficult, which is precisely why many of us end up in comprehensive groups. It can work, but there has to be a good understanding. Being in a multispecialty group with at least one other retina doc is preferable. Being in an all-retina group is optimal.

 

[soonmd1]

Don't frequent this forum much nowadays, but as a medical retina doc for over 5 years now, I thought I should give my 2 cents here.

I did a 1 year fellowship after residency, and I have to agree with much of what has been said above. There is a big difference in being in a retina-heavy residency program and doing a solid year of medical retina. Half of my residency program faculty were retina specialists, so I'd call it retina-heavy. Doing injections and lasers isn't technically that difficult, but knowing when to treat and with what is key. Being comfortable with the diagnostics is also very important. I learned more about imaging interpretation in my fellowship than I ever expected to. That extra training shows. I've seen a number of patients who were being injected unnecessarily or not aggressively enough or with a suboptimal drug. I've seen aggressive "focal/grid" laser that has destroyed vision. There are a lot of things that a comprehensive ophthalmologist may think they know and are comfortable with that they actually have no business managing. Too much of a delay in referral or inappropriate treatment can result in irreversible damage. Likewise, I don't bother managing anterior segment issues anymore. I would be doing my patients a disservice. Like it or not, we're in the era of superspecialists. Along those lines, even with fellowship training, I'm not a fan of trying to "do everything" yourself. There's just too much to keep up with across ophthalmology. If you do a fellowship, you should really just focus on that, in my opinion.

I can also speak as someone who was the sole retina specialist in a comprehensive group, before moving to an all-retina group. The differences are substantial. The business models are vastly different. The cash flow with high cost injectables can be a major burden. If the infrastructure isn't there, you can get into trouble very easily. There are referral issues. I was in a comprehensive group with an optical. It was a large group, but from a referral standpoint, I was effectively on an island. No optometrists or even other comprehensive ophthalmologists were going to refer to me, even if they knew and trusted me. I ended up having to do a fair share of comprehensive ophthalmology just to stay busy. Being in an all-retina group has opened up my referral base tremendously and has allowed me to focus entirely on retina and to concern myself with what I think the best treatment for the patient is, rather than what is easier for the practice from a month-to-month cash flow standpoint. Getting into a group with other retina docs as a medical retina doc can be difficult, which is precisely why many of us end up in comprehensive groups. It can work, but there has to be a good understanding. Being in a multispecialty group with at least one other retina doc is preferable. Being in an all-retina group is optimal.

Hi visionary! I was waiting for your response 🙂

would you mind elaborating a bit on your experience of joining a retina practice? Do u think it helped that you established yourself in a comprehensive practice first? Some of the posters mentioned the difficulty of joining a retina practice as a medical retina person...did u experience any of these Issues? How did u overcome them?

Lastly, in your experience aND what you've seen, how does med ret compensation compare to starting salaries for surgical ret and general?

Thanks!

 

[Visionary]

It was an unusual change, actually. I was with the first practice for about 5.5 years. I knew docs from the new practice already. They had recently opened a satellite in my town. They had a doc recruited away and needed a replacement. Seemed like a great deal all around. I was able to buy out my old practice and take my patients with me. Still have a good relationship with them. Sort of unprecedented. I do think that having a patient base established made me more attractive, but they said they would have taken me regardless.

As far as salary, I can't give you great info. I will say a started my old practice on more of a comprehensive starting salary. Not unreasonable, given the rest of the docs were comprehensive, and I was starting the retina part from scratch. With the new practice, I'm starting at double that, but that's with over 5 years of experience.

 

[RestoreSight]

Its very unusual for an all retina practice to include medical retina docs. Visionary seems to have a good setup, but its not typical. The better option is completing a surgical retina fellowship.

Comprehensive docs are treating DR, AMD and RVO and I don't think that trend is going to stop anytime soon. I would guess 90% of the time outcomes are acceptable and many patients may not understand the difference between a subspecialty trained ophthalmologist and a general ophthalmologist, but if I personally had a potentially blinding eye condition I would want someone who specializes in that condition to treat me. Retina is the wild wild west of ophthalmology and it takes considerable effort to stay up to date.

 

[Visionary]

Agree. I don't want folks to think my situation is typical. It's definitely not. In all-retina groups, it's usually the older docs who are the medical retina docs. Previously surgical, but have given up operating.

 

[soonmd1]

Agree. I don't want folks to think my situation is typical. It's definitely not. In all-retina groups, it's usually the older docs who are the medical retina docs. Previously surgical, but have given up operating.

so the general sense I'm getting is that the job market isn't that good. It almost seems like doing a medical retina fellowship is a lose lose situation in today's climate because u won't get retina referrals in a general practice if u only want to do medical, won't really be able to be part of a retina practice and finally will end up distancing yourself from cataract surgery for another year and won't be as sought after for comprehensive jobs....
man...times are tough

 

[Visionary]

What everyone needs to understand is that referrals make your practice. If you're doing general, including cataracts, you're not going to get referrals from general docs. If you have an optical, your not getting referrals from optometrists. That's the way this business works. The only way you can get away with doing medical retina and general together is to have a big optometry referral base. It can work, but you have to set it up correctly. This is the business stuff no one tells you in residency and fellowship.