Uveitis fellowship prior to surgical retina fellowship?

[EyeLandLife]

Hey, guys.

This is my first ever post on SDN.
I am currently a PGY3 ophthalmology resident in the US. I am looking for help for my future career options.

I was originally going to apply for surgical retina directly next year. However, I am considering uveitis fellowship prior to doing surgical retina for few reasons.

1. I think it will help strengthen my CV for surgical retina, which can be competitive to match.
2. Make myself more marketable after fellowship when looking for jobs.
3. I actually find uveitis very interesting and intellectually stimulating.

Now I have thought of some reasons for not to do uveitis.
1. I am currently interested in joining a private practice eventually. Not sure how easy/relevant it will be to be uveitis trained in private retina clinics.
2. Few SDN threads in the past commented that your retina clinic will be gradually be filled with difficult uveitis patients referred from outside. Although I loved learning about the uveitis pathology and solving mystery cases, I did find it emotionally/mentally difficult when patients suffered from poor outcome from severe uveitis.
3. Not doing surgery for 1 year before surgical retina may not be ideal.
4. I may have to move twice as my home program does not have a uveitis fellowship.

At the end, I know that I will be happy with either choice for my career. But I do not have any recent graduates from our program who went into uveitis or retina. Therefore, I wanted to ask for some insight from those who considered uveitis fellowship with retina training in academic vs private practice setting.

Thank you for reading my long post. I would really appreciate your help.

I forgot to add this:
1. Could anyone recommend any uveitis fellowship that offers some surgical experience?
2. Is it possible to apply for both uveitis and surgical retina at the same time? I am not sure how ranking will work though in this case. For example, would I be able to rank some uveitis programs above a surgical retina program (that is less desired)?

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[linevasel]

This is a goodie. I haven't posted in years, but your post brought me out of my slumber....
There were about 105 surgical retina fellows in my class. I think 4-5 of us were already Uveitis trained. We all know each other. Most of us wanted to do Uveitis and Surgical Retina from med school (crazy I know). My personal opinion is that the only reason to do Uveitis is reason #3. Thats my personal opinion. But obviously I have my bias.

Will it strengthen your CV. Yes. How much it strengthens your CV really depends on who you are, what your program thinks off you already. If you weren't going to be a heed fellow before uveitis... you probably won't be a heed fellow after uveitis. Having said that, I personally know of at least 2 middling to above average residents, who ended up doing two years of uveitis before going into surgical retina. Both of them significantly upped their appeal. One did go on to become a heed fellow (go figure...). The other matched well above his expected trajectory. Most of this again has to do with where you trained, who supported you, what was the name of your bigwig, etc etc. Again, the best reason to do uveitis is #3.

Uveitis made me very very good at managing difficult blinding diseases. I thought that was worth something on the private practice side. I learned a few things from my Retina colleagues during surgical retina training. Firstly, every Retina surgeon and their momma thinks they can manage uveitis. Did I say everyone? Yes... And their momma. Most of it is steroid, steroid, ozrudex, intervene with cataract/tube shunt, steroid steroid steroid, refer to rheum.- repeat. That's the reality of private practice. Does this happen everywhere ? Of course not. Does it happen more than I would like to see. Definitely. That isn't necessarily the fault of my retina colleagues. Most people don't have the training or the knowledge or the comfort to safely prescribe immunosuppressive therapy so it just isn't a part of the management (certainly not the early management). Additionally, many uveitis patients end up being managed by optometry, particularly the ant segment variety.

If you are good surgically, a year off from surgery won't be a big deal at all. The program that accepts you knows you took a year off. You'll be fine.
What will you do with your uveitis training in private practice ? Whatever you dam- well please. Will your colleagues send you interesting Uveitis patients ? Maybe. Some of your colleagues like their uveitis patients. They will ozurdex their birdshot patients to death, by the time they get to you their ERG readings will be falling of the cliff, and their ICGs will look like a lunar map (look it up). I can guarantee you though, that you will get the hard uveitis patients. These are the ones that no one wants. You may have an academic interest in their uveitis subtype. You may not. But once you hang your shingle. They will come your way. Again. The best reason to do uveitis is because of reason #3.

Of course, I am being a bit tongue-in-cheek. To address your question very seriously. Your uveitis training will most likely give you access to a certain cadre of groups and make you appealing. Once a group has 5-7 retina surgeons, it usually makes sense for them to start sub-specializing ie taking guys who are dual trained (onc-retina, peds-retina, inherited retinal diseases, uveitis-retina). However in the private practice world, if you make your practice 40-50% uveitis, your reimbursement will likely differ from your partners who are gleefully injecting bread and butter retina, keeping the FA/ICG imaging to a minimum and definitely not spending 15-20 minutes discussing the minutae of cellcept vs methotrexate with their patients. Some of this of course depends on the reimbursement structure of the group. Is this pure eat what you kill ? Is there profit sharing in the group ? All that to say, uveitis/retina = better job prospects. But uveitis/retina ≠ more money.

Others can chime in here. I know of one uveitis fellowship where there is no or minimal surgical exposure. NIH. And based on their surgical retina/uveitis alumn, they do (or at least did) just fine. So I wouldn't let that dissuade me.

Do not apply to both surgical retina and uveitis. You should have a good idea of your standing from your home program. This isn't rocket science. No need to aggressively hedge by applying to both. By the time you apply for surgical retina, you should have a good sense if you are a first round draft pick or not... Let me help you. If you are wondering if you are a top ten pick. You are not a top ten pick. And that's okay.

Your patients will have bad outcomes in uveitis. Your patients will have bad outcomes in surgical retina. If you can deal with the poor outcomes in surgical retina, you can deal with the poor outcomes in uveitis. The ones losing the battle for sight because of their inflammation know that they are losing the battle. They know that your management made a difference, because you took the time to explain to them, you followed their imaging, you worked them up, you followed up on their daughter's "chronic" hematuria that their pcp told them was "basically normal" and then referred them to see nephrology for TINU. You did all this and more. If you can deal with the poor outcomes in retina, you can deal with the poor outcomes in uveitis.

In summary the best reason to do uveitis is reason #3 [I actually find uveitis very interesting and intellectually stimulating]. Also... "I want to put myself in the privileged position of taking care of this vulnerable population" would be nice sentiment as well.

Lastly. IF I could do this again. I'd probably give serious consideration to doing uveitis after my surgical retina training. A few of the younger uveitis/retina surgeons followed this route. They all came from super strong retina programs so they kind of had their pick with uveitis fellowship. But it is a route worth considering.

 

[itsneverlupus]

This is a goodie. I haven't posted in years, but your post brought me out of my slumber....
There were about 105 surgical retina fellows in my class. I think 4-5 of us were already Uveitis trained. We all know each other. Most of us wanted to do Uveitis and Surgical Retina from med school (crazy I know). My personal opinion is that the only reason to do Uveitis is reason #3. Thats my personal opinion. But obviously I have my bias.

Will it strengthen your CV. Yes. How much it strengthens your CV really depends on who you are, what your program thinks off you already. If you weren't going to be a heed fellow before uveitis... you probably won't be a heed fellow after uveitis. Having said that, I personally know of at least 2 middling to above average residents, who ended up doing two years of uveitis before going into surgical retina. Both of them significantly upped their appeal. One did go on to become a heed fellow (go figure...). The other matched well above his expected trajectory. Most of this again has to do with where you trained, who supported you, what was the name of your bigwig, etc etc. Again, the best reason to do uveitis is #3.

Uveitis made me very very good at managing difficult blinding diseases. I thought that was worth something on the private practice side. I learned a few things from my Retina colleagues during surgical retina training. Firstly, every Retina surgeon and their momma thinks they can manage uveitis. Did I say everyone? Yes... And their momma. Most of it is steroid, steroid, ozrudex, intervene with cataract/tube shunt, steroid steroid steroid, refer to rheum.- repeat. That's the reality of private practice. Does this happen everywhere ? Of course not. Does it happen more than I would like to see. Definitely. That isn't necessarily the fault of my retina colleagues. Most people don't have the training or the knowledge or the comfort to safely prescribe immunosuppressive therapy so it just isn't a part of the management (certainly not the early management). Additionally, many uveitis patients end up being managed by optometry, particularly the ant segment variety.

If you are good surgically, a year off from surgery won't be a big deal at all. The program that accepts you knows you took a year off. You'll be fine.
What will you do with your uveitis training in private practice ? Whatever you dam- well please. Will your colleagues send you interesting Uveitis patients ? Maybe. Some of your colleagues like their uveitis patients. They will ozurdex their birdshot patients to death, by the time they get to you their ERG readings will be falling of the cliff, and their ICGs will look like a lunar map (look it up). I can guarantee you though, that you will get the hard uveitis patients. These are the ones that no one wants. You may have an academic interest in their uveitis subtype. You may not. But once you hang your shingle. They will come your way. Again. The best reason to do uveitis is because of reason #3.

Of course, I am being a bit tongue-in-cheek. To address your question very seriously. Your uveitis training will most likely give you access to a certain cadre of groups and make you appealing. Once a group has 5-7 retina surgeons, it usually makes sense for them to start sub-specializing ie taking guys who are dual trained (onc-retina, peds-retina, inherited retinal diseases, uveitis-retina). However in the private practice world, if you make your practice 40-50% uveitis, your reimbursement will likely differ from your partners who are gleefully injecting bread and butter retina, keeping the FA/ICG imaging to a minimum and definitely not spending 15-20 minutes discussing the minutae of cellcept vs methotrexate with their patients. Some of this of course depends on the reimbursement structure of the group. Is this pure eat what you kill ? Is there profit sharing in the group ? All that to say, uveitis/retina = better job prospects. But uveitis/retina ≠ more money.

Others can chime in here. I know of one uveitis fellowship where there is no or minimal surgical exposure. NIH. And based on their surgical retina/uveitis alumn, they do (or at least did) just fine. So I wouldn't let that dissuade me.

Do not apply to both surgical retina and uveitis. You should have a good idea of your standing from your home program. This isn't rocket science. No need to aggressively hedge by applying to both. By the time you apply for surgical retina, you should have a good sense if you are a first round draft pick or not... Let me help you. If you are wondering if you are a top ten pick. You are not a top ten pick. And that's okay.

Your patients will have bad outcomes in uveitis. Your patients will have bad outcomes in surgical retina. If you can deal with the poor outcomes in surgical retina, you can deal with the poor outcomes in uveitis. The ones losing the battle for sight because of their inflammation know that they are losing the battle. They know that your management made a difference, because you took the time to explain to them, you followed their imaging, you worked them up, you followed up on their daughter's "chronic" hematuria that their pcp told them was "basically normal" and then referred them to see nephrology for TINU. You did all this and more. If you can deal with the poor outcomes in retina, you can deal with the poor outcomes in uveitis.

In summary the best reason to do uveitis is reason #3 [I actually find uveitis very interesting and intellectually stimulating]. Also... "I want to put myself in the privileged position of taking care of this vulnerable population" would be nice sentiment as well.

Lastly. IF I could do this again. I'd probably give serious consideration to doing uveitis after my surgical retina training. A few of the younger uveitis/retina surgeons followed this route. They all came from super strong retina programs so they kind of had their pick with uveitis fellowship. But it is a route worth considering.

This is an awesome, thoughtful response. Out of curiosity, why would you do uveitis after surgical retina? And are there are any surgical retina programs where you'd get particularly good uveitis exposure and might end up more comfortable managing uveitis?

 

[linevasel]

This is an awesome, thoughtful response. Out of curiosity, why would you do uveitis after surgical retina? And are there are any surgical retina programs where you'd get particularly good uveitis exposure and might end up more comfortable managing uveitis?

Person that I personally know:
Finishing top ten surg retinal fellowship. Had agreement in place to work for a very selective group in desirable location. They ended up asking the fellow to do another year in uveitis if he/she wanted to seal the deal and they would agree to fly him/her every other week to the city (where his/her partner resided) while he/she completed uveitis fellowship.

Others just realize at some point in their training that they would like more familiarity with a specific group of diseases (usually for academic reasons) and so follow-up their surgical training with uveitis. One advantage of doing surg retina first is you are better equipped to develop an expertise during your subsequent uveitis year. For example, you may realize you really like white dot syndromes, or ARN, and you can pick a fellowship where you see more of a certain kind of uveitis etc etc.

Its not the traditional route for sure, but it is workable depending on your ultimate goals.

There are some surgical retina programs with strong exposure to uveitis. I hesitate to name the programs because I am absolutely positive I will leave out really good programs. I would look for programs with faculty members who are part of AUS. To be a member, you need to have completed a uveitis fellowship, or have two first author publications in uveitis. The bar isn't extremely high, but high enough that membership self-selects. Few programs that come to mind:
Vandy, Beaumont, Bascom, CCF, Emory, Duke, Wills, UofUtah, CPMC Namely the usual suspects....
Also, how much uveitis you learn or don't learn at any of these above programs is still dependent on you. If you don't wan't to learn inherited retinal diseases, or you aren't that interested in onc/uveitis, it doesn't matter if the World's authority/Guru on Uveitis is on faculty or not.... But starting with AUS and then looking at places that also offer a Uveitis fellowship will help you round out the list.

 

[DrZeke]

I agree with most of what linevasel said. If you do uveitis make sure you enjoy it. People will send you patients. Some people do uveitis and then don't practice. That tends to be more feasible in a private practice setting... The other thing to be careful of is some smaller private practices get excited to see you have uveitis training under your belt, but can't necessarily support you or your needs. You have to be careful about what people promise you vs. what they can actually offer you.

I do not think that uveitis gives you a big leg up on retina application unless you went to a residency program with retina faculty that have no connections. But I would not do uveitis for this reason. If you think you need more exposure to academic retina prior to starting a surgical retina fellowship or you want to do something more academic a medical retina fellowship is not a bad idea to help with that.

 

[linevasel]

I agree with Dr Zeke, attest that he/she is a real life uveitis provider, and would also advise modest expectations for an integrated uveitis/retina practice if courting a smaller private practice group.

 

[EyeLandLife]

This is a goodie. I haven't posted in years, but your post brought me out of my slumber....
There were about 105 surgical retina fellows in my class. I think 4-5 of us were already Uveitis trained. We all know each other. Most of us wanted to do Uveitis and Surgical Retina from med school (crazy I know). My personal opinion is that the only reason to do Uveitis is reason #3. Thats my personal opinion. But obviously I have my bias.

Will it strengthen your CV. Yes. How much it strengthens your CV really depends on who you are, what your program thinks off you already. If you weren't going to be a heed fellow before uveitis... you probably won't be a heed fellow after uveitis. Having said that, I personally know of at least 2 middling to above average residents, who ended up doing two years of uveitis before going into surgical retina. Both of them significantly upped their appeal. One did go on to become a heed fellow (go figure...). The other matched well above his expected trajectory. Most of this again has to do with where you trained, who supported you, what was the name of your bigwig, etc etc. Again, the best reason to do uveitis is #3.

Uveitis made me very very good at managing difficult blinding diseases. I thought that was worth something on the private practice side. I learned a few things from my Retina colleagues during surgical retina training. Firstly, every Retina surgeon and their momma thinks they can manage uveitis. Did I say everyone? Yes... And their momma. Most of it is steroid, steroid, ozrudex, intervene with cataract/tube shunt, steroid steroid steroid, refer to rheum.- repeat. That's the reality of private practice. Does this happen everywhere ? Of course not. Does it happen more than I would like to see. Definitely. That isn't necessarily the fault of my retina colleagues. Most people don't have the training or the knowledge or the comfort to safely prescribe immunosuppressive therapy so it just isn't a part of the management (certainly not the early management). Additionally, many uveitis patients end up being managed by optometry, particularly the ant segment variety.

If you are good surgically, a year off from surgery won't be a big deal at all. The program that accepts you knows you took a year off. You'll be fine.
What will you do with your uveitis training in private practice ? Whatever you dam- well please. Will your colleagues send you interesting Uveitis patients ? Maybe. Some of your colleagues like their uveitis patients. They will ozurdex their birdshot patients to death, by the time they get to you their ERG readings will be falling of the cliff, and their ICGs will look like a lunar map (look it up). I can guarantee you though, that you will get the hard uveitis patients. These are the ones that no one wants. You may have an academic interest in their uveitis subtype. You may not. But once you hang your shingle. They will come your way. Again. The best reason to do uveitis is because of reason #3.

Of course, I am being a bit tongue-in-cheek. To address your question very seriously. Your uveitis training will most likely give you access to a certain cadre of groups and make you appealing. Once a group has 5-7 retina surgeons, it usually makes sense for them to start sub-specializing ie taking guys who are dual trained (onc-retina, peds-retina, inherited retinal diseases, uveitis-retina). However in the private practice world, if you make your practice 40-50% uveitis, your reimbursement will likely differ from your partners who are gleefully injecting bread and butter retina, keeping the FA/ICG imaging to a minimum and definitely not spending 15-20 minutes discussing the minutae of cellcept vs methotrexate with their patients. Some of this of course depends on the reimbursement structure of the group. Is this pure eat what you kill ? Is there profit sharing in the group ? All that to say, uveitis/retina = better job prospects. But uveitis/retina ≠ more money.

Others can chime in here. I know of one uveitis fellowship where there is no or minimal surgical exposure. NIH. And based on their surgical retina/uveitis alumn, they do (or at least did) just fine. So I wouldn't let that dissuade me.

Do not apply to both surgical retina and uveitis. You should have a good idea of your standing from your home program. This isn't rocket science. No need to aggressively hedge by applying to both. By the time you apply for surgical retina, you should have a good sense if you are a first round draft pick or not... Let me help you. If you are wondering if you are a top ten pick. You are not a top ten pick. And that's okay.

Your patients will have bad outcomes in uveitis. Your patients will have bad outcomes in surgical retina. If you can deal with the poor outcomes in surgical retina, you can deal with the poor outcomes in uveitis. The ones losing the battle for sight because of their inflammation know that they are losing the battle. They know that your management made a difference, because you took the time to explain to them, you followed their imaging, you worked them up, you followed up on their daughter's "chronic" hematuria that their pcp told them was "basically normal" and then referred them to see nephrology for TINU. You did all this and more. If you can deal with the poor outcomes in retina, you can deal with the poor outcomes in uveitis.

In summary the best reason to do uveitis is reason #3 [I actually find uveitis very interesting and intellectually stimulating]. Also... "I want to put myself in the privileged position of taking care of this vulnerable population" would be nice sentiment as well.

Lastly. IF I could do this again. I'd probably give serious consideration to doing uveitis after my surgical retina training. A few of the younger uveitis/retina surgeons followed this route. They all came from super strong retina programs so they kind of had their pick with uveitis fellowship. But it is a route worth considering.

Thank you for your input and practical advice (especially after a long slumber!). Your suggestion of doing uveitis after retina was helpful, as I never really thought about that. If I discover a particular interest within uveitis during retina fellowship, I can do it after my retina fellowship. I will also not apply for both surgical retina and uveitis at the same time as you mentioned. Even if I don't match into surgical retina, I can always apply for vacant positions in uveitis (or medical retina as Dr. Zeke mentioned). I won't mind spending 1 more year to learn about something that I will practice for many more years in my career.

 

[EyeLandLife]

I agree with most of what linevasel said. If you do uveitis make sure you enjoy it. People will send you patients. Some people do uveitis and then don't practice. That tends to be more feasible in a private practice setting... The other thing to be careful of is some smaller private practices get excited to see you have uveitis training under your belt, but can't necessarily support you or your needs. You have to be careful about what people promise you vs. what they can actually offer you.

I do not think that uveitis gives you a big leg up on retina application unless you went to a residency program with retina faculty that have no connections. But I would not do uveitis for this reason. If you think you need more exposure to academic retina prior to starting a surgical retina fellowship or you want to do something more academic a medical retina fellowship is not a bad idea to help with that.

Thanks for your suggestions. A medical retina fellowship is a great idea. However, if I could choose between medical retina versus uveitis, I would probably go with uveitis due to my interest in uveitis.

 

[DrZeke]

Thank you for your input and practical advice (especially after a long slumber!). Your suggestion of doing uveitis after retina was helpful, as I never really thought about that. If I discover a particular interest within uveitis during retina fellowship, I can do it after my retina fellowship. I will also not apply for both surgical retina and uveitis at the same time as you mentioned. Even if I don't match into surgical retina, I can always apply for vacant positions in uveitis (or medical retina as Dr. Zeke mentioned). I won't mind spending 1 more year to learn about something that I will practice for many more years in my career.

I would be selective about whichl uveitis fellowship after surgical retina. I didn't operate besides globe call during my uveitis fellowship. I couldn't imagine doing that after my busy surgical retina fellowship. So, see if you can go somewhere where you operate a lot.