Specialty advice - Ophtho vs IR

[padkeemao]

MS2 at a T20 school trying to lock down a specialty. Based on a number of factors including lifestyle during/after residency, strong interest in procedural work, and alignment with future personal and financial goals, I've narrowed my specialty choice down to ophtho and IR (ENT and ortho are a distant third/fourth). I've spent a significant time shadowing both and I've made a pros/cons list for both but I still can't decide which one to go all in on. Additionally, I have a decent number (10+) of publications in various specialties based on the way ERAS counts them as well as strong home programs and faculty support in both specialties that I can count on when I decide to pursue one or the other. Any advice would be appreciated!

IR:
Pros:
- Good lifestyle during residency during 4 years of DR
- Incredibly broad and varied scope of practice with options to focus on interventional oncology/neuro IR in the future (particular areas of interest for me)
- Growing field with potential for technological innovation and partnerships with industry + good future job outlook
- Challenging/intellectually stimulating cases that require planning and improvisation - big plus for me
- Mix of high-adrenaline and chill/routine days (and option to fall back on DR later)
- Excellent income potential

Cons:
- Long (6+ year) residency
- Call can be brutal during residency and as an attending - not entirely opposed to call but I would like to limit it in the future and prioritize my health
- Lots of turf wars and encroachment from other specialties for the interesting/well-paying cases
- Don't especially enjoy the conveyor-belt model of DR practice which I would try to minimize in my attending career
- Concerns about being relegated to "hospital trash collector" and being limited to lines/drains/biopsies if I end up in the wrong job

Ophtho:
Pros:
- Fun, quick, highly rewarding surgeries with grateful patients
- Solid job market and demand for services
- Great lifestyle during and after residency + shorter residency
- Limited/nonexistent call and overnight emergencies
- Strong income potential eventually (though lower than IR)

Cons:
- Felt repetitive (got bored while shadowing a surgeon and watching them do 20 of the same surgery over and over again in a day)
- Dislike the idea of hyper-specializing on only 1 part of the eye
- Private equity consolidation and concerns about future outlook
- Lower starting salary out of the door, takes some time to build up

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[i-doctor]

Both are great fields! As an ophthalmologist in private practice for a long time, I can address your ophtho cons:

—Doing cataract surgery is a blast, even after many years or even decades. Shadowing is definitely boring. Don’t base it on that.
—Ophthalmology is indeed a narrow field. No need to specialize to make it narrower, unless you love one particular aspect. I did not specialize— I do cataract surgery, some glaucoma surgeries, eyelid/minor plastics, many different laser procedures, and some cornea procedures. I didn’t want to limit myself and be too narrow.
—Private Equity is only temporary. The whole industry will be in flux or even phased out when interest rates go even higher. (Their leveraged buyout model only works when there is access to cheap capital). In fact, most of the ophthalmologists who got buyouts from PE are sitting pretty and will be retired by the time you finish, leaving a huge doctor shortage
—The lower starting salary is already correcting itself due to the doctor shortage. Ironically, PE has been bidding up the starting salaries overall due to their desperation in replacing retiring doctors and difficulty in attracting new ones.

Best thing to do is try to do an early elective rotation in these two fields when reasonably possible. After a month of each, you may be lucky and the answer will be obvious. Every field has a lot of daily grind stuff that you need to see. I myself considered anesthesia but ruled it out after only 2 days in an elective rotation. Hated it.

 

[padkeemao]

I appreciate the advice! It sounds like ophtho was a great fit for you and hopefully many of the issues in the field will resolve themselves soon. As a generalist, where do you draw the line between doing a surgery yourself and referring out to a sub-specialist?

 

[i-doctor]

Interesting question. No exact answer. I think early in my career I wanted to build a practice and impress those that hired me so I actually referred out less than I should have. More likely it was naive over-confidence. Opposite of what one should do. Now I’m so crazy busy that I don’t hesitate to refer anyone out to sub-specialists. I don’t need the grief. However, I never refer out complex cataract cases. In fact, my cataract surgery volume is higher than anyone at the nearby university Ophthalmology program, and I don’t feel anyone nearby is more qualified than I am in these cases. (In fact, my partners send me some or their challenging cataract cases).

To answer your question more directly, my line is drawn on what I refer out for surgery by what procedures I myself have chosen to do and try to perfect.. I have 2-3 basic plastics procedures that I do, 2 glaucoma surgical procedures, etc. That’s my comfort zone. If it’s the right procedure for the patient, I’ll do it. Anything requiring more complexity or higher level of care I will refer out. And obviously I will also refer patients out when I have diagnostic dilemmas. I do no pediatrics or retina (itself a massive field).

One great thing about general ophthalmology is that you can do a lot of do things—cataracts, glaucoma surgery, lasik, plastics, some cornea—the stuff you LIKE to do, but without getting the emergencies (and dumps on Friday afternoons) that go to the specialists—such as a acute glaucomas, pending corneal perforations, horrendous corneal ulcers, retinal detachments, blow-out orbital fractures, etc.

 

[eyeeye_captain]

A lot of really really good stuff above about ophtho. Slightly different perspective as a retina surgeon (extra 2 years).

Your pros are all true, although the lower money than IR thing isn’t necessarily true. I caught up with/passed many of them by the time I was ~3 years out while working 35 patient care hours a week, seeing a call patient maybe 4 weekends a year, and almost never coming in overnight. Lifestyle is untouchable unless you like derm, and their PE issues are worse than ours.

For cons, it sounds like breadth is your issue. Turfing will limit you in IR somewhat. In ophtho, a lot of it is training and market. When I say training and market, the training part relates to comfort doing whatever procedures you are allowed to. i-doctor already went into that beautifully. Market relates to who is referring you patients and who else is in your vicinity. It’s harder to do lid surgery in a big city where you have competition down the block as a comprehensive doc than if you’re in the suburbs or a semi-rural spot just from established referral patterns in the community. Minimally invasive glaucoma surgery (becoming front line) is certainly doable, same with some bread and butter cornea. I have some referring docs who do their own retina lasers with varying degrees of skill based on when I’ve seen their patients down the line. It’s really cool that i-doctor goes broader scope than I usually see, but not always the case. Markets may limit you a bit. I can’t even practice full scope retina as I lack adequate community rheumatology and radiation oncology assistance for severe inflammation and oncology cases - those I co-manage with a university.

Edit: con you didn’t mention, since we’re outpatient based, there is a reasonable chance of more commuting than in IR.

Biggest differences: outpatient vs hospital based, lifestyle, perceived breadth. Both are great fields, keep exploring and find that works for you.

 

[matchpalmedical]

Private equity is a concern for all of medicine. An extra year or two of training isnt ideal, but shouldnt discourage you from doing what you love. IR will forsure offer greater income potential as well as clinical breadth, so if those things are important to you, you should pursue them. The main question is, do you want to be a radiologist at the core or not? The way training and employment in IR is structured these days, it would be a challenging road to embark on if you do not at least somewhat enjoy DR.

Feel free to check out our site to speak with our IR or Optho mentors if you feel that would be helpful!

 

[padkeemao]

Thank you all for sharing your perspectives! I think the biggest thing scaring me away from ophtho is the the fear that the job will start to get repetitive and automatic after a while (similar reason I want to minimize DR practice - I like the material itself but the practice model of sitting down all day and plowing through a list wouldn't work for me). Are the day-to-day cases in ophtho practice intellectually stimulating?

 

[Kuratz]

Hard to predict the future of IR as it relates to practices setup, but at least for now if you don’t like being a radiologist first and foremost then maybe reconsider. Many IRs out in the community spend a large percentage of time crushing the list and doing biopsies, drainages etc in-between. The 100% IR jobs are becoming more common, for sure, and who knows if OBL practice will take off or not. The OBL model seems more sustainable given the relative lack of emergencies and 5pm add-ons that make hospital-IR so taxing.

And if you do hope to do 100% IR then conversely I’m not sure you should plan on being able to jump back into DR. Rads is very much “use it or lose it”. Sure some of the bread and butter ER stuff isn’t rocket science but hard to cover the outpatient body/chest/MSK list when you haven’t done it for a decade and never honed those skills post-residency (which is extremely important if you want to actually be decent at it).

I’m just speculating but it wouldn’t surprise me if IR goes completely separate from DR a la Rad Onc. That’s possibly best for the field since it’s trying to garner referral patterns, set up clinics, and get away from lines/draines etc as their primary practice. If this were to happen then my guess is you wouldn’t be credentialed to read DR, the same way Rad Onc can’t.

Again all of those are just food for thought and who knows what the future holds. Overall I extremely pleased with my decision to do Radiology, I think it is awesome for the right personality. And fortunately my residency has trained us well enough to do plenty of non-vascular procedures to break up the day. (Heck wouldn’t mind doing non-tunneled CVCs once in a while). I chose against IR because while I love procedures, I found myself getting bored doing mostly biopsies/lines/tubes and wasn’t as jazzed about the occasional embo, stent or whatever to make the additional training and lifestyle sacrifices worth it. I missed being challenged by DR and felt like procedural opportunities are abundant if desired.

Overall I think IR is a really cool speciality but faces some major logistical challenges as it relates to referrals and getting dumped on. If you are business savvy and build an OBL then it’s arguably one of the best gigs in medicine, but more commonly practiced is a ton of lines/biopsies/drains at the hospital with not uncommon 5pm procedure dumps and middle of the night emergencies. Not saying you shouldn’t do it, but you should just consider these realities/challenges. No field is perfect.

Honestly most people would be happy doing multiple fields. Spend as much time as you can in multiple practice setups to get a feel for what to expect and just go full steam ahead.

 

[odyssey2]

Hard to predict the future of IR as it relates to practices setup, but at least for now if you don’t like being a radiologist first and foremost then maybe reconsider. Many IRs out in the community spend a large percentage of time crushing the list and doing biopsies, drainages etc in-between. The 100% IR jobs are becoming more common, for sure, and who knows if OBL practice will take off or not. The OBL model seems more sustainable given the relative lack of emergencies and 5pm add-ons that make hospital-IR so taxing.

And if you do hope to do 100% IR then conversely I’m not sure you should plan on being able to jump back into DR. Rads is very much “use it or lose it”. Sure some of the bread and butter ER stuff isn’t rocket science but hard to cover the outpatient body/chest/MSK list when you haven’t done it for a decade and never honed those skills post-residency (which is extremely important if you want to actually be decent at it).

I’m just speculating but it wouldn’t surprise me if IR goes completely separate from DR a la Rad Onc. That’s possibly best for the field since it’s trying to garner referral patterns, set up clinics, and get away from lines/draines etc as their primary practice. If this were to happen then my guess is you wouldn’t be credentialed to read DR, the same way Rad Onc can’t.

Again all of those are just food for thought and who knows what the future holds. Overall I extremely pleased with my decision to do Radiology, I think it is awesome for the right personality. And fortunately my residency has trained us well enough to do plenty of non-vascular procedures to break up the day. (Heck wouldn’t mind doing non-tunneled CVCs once in a while). I chose against IR because while I love procedures, I found myself getting bored doing mostly biopsies/lines/tubes and wasn’t as jazzed about the occasional embo, stent or whatever to make the additional training and lifestyle sacrifices worth it. I missed being challenged by DR and felt like procedural opportunities are abundant if desired.

Overall I think IR is a really cool speciality but faces some major logistical challenges as it relates to referrals and getting dumped on. If you are business savvy and build an OBL then it’s arguably one of the best gigs in medicine, but more commonly practiced is a ton of lines/biopsies/drains at the hospital with not uncommon 5pm procedure dumps and middle of the night emergencies. Not saying you shouldn’t do it, but you should just consider these realities/challenges. No field is perfect.

Honestly most people would be happy doing multiple fields. Spend as much time as you can in multiple practice setups to get a feel for what to expect and just go full steam ahead.

What’s the right personality for DR, would you say?

 

[eyeeye_captain]

Ophtho can be repetitive, it’s part of the ballgame. I don’t think any of us go a day without at least 1 or 2 funky cases though. If the rads opinion above is true and you’d have to do a decent bit of DR to do IR, you’ll get more variety from the wider range of clinical questions. We get variety from patients themselves - I’ll explain.

Radiology in general has separation from the patient, whether you’re reading a study or placing a line, you don’t tend to have long term follow up. I can’t do my job without being in arm’s reach. Some patients I see monthly. To me it’s great, you get to know your folks and can have a chat. There’s a pretty decent personality divide in terms of what you want on the job between the fields - do you want some patient interaction? That I can’t speak to for you. Most of my procedures and surgeries, I’m talking with my patient during them. It’s cool from my perspective.