Why ophthalmology?

[sunflower79]

What's the attraction? (and please don't mention money)

I'm not nuts about general surgery, but I do have patience and skill with manual dexterity, and eye surgery seems neat and clean. At the same time, I find no compelling reasons to enter the specialty besides the nice work hours.

cheers,
sunflower79

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[prominence]

Originally posted by sunflower79
I find no compelling reasons to enter the specialty besides the nice work hours.

heres an idea: dont enter the specialty.

 

[Andrew_Doan]

Originally posted by sunflower79
What's the attraction? (and please don't mention money)

I'm not nuts about general surgery, but I do have patience and skill with manual dexterity, and eye surgery seems neat and clean. At the same time, I find no compelling reasons to enter the specialty besides the nice work hours.

cheers,
sunflower79

Sunflower79,

This is a good question, and I'm glad you asked. I need a break from mowing the lawn anyhow. In addition, I think few people and physicians know what ophthalmologists do.

The number one aspect that drew me to ophthalmology was the ability to make a huge difference in someone's life. Ocular health is so important and most people don't even think twice about the health of their eyes until something goes wrong. When something does go wrong, people are extremely grateful for the services received. As an ophthalmologist, there are so many therapeutic modalities available to you when managing diseases. It's also a nice amalgamation of surgery and general medicine applied to the complete spectrum of ages. For instance, in premature babies, there is an increased chance of developing retinopathy of prematurity (ROP). If ROP is missed, the child can progress to complete retinal detachments within 6 months of age and complete loss of vision. If diagnosed and treated by cryotherapy or lasers, the child can growup with normal vision. There are also dozens of disorders that cause premature cataracts. If treated early, then vision is preserved. In children, we also see strabismus (crossed eyes) and amblyopia (lazy eye with vision loss); and if diagnosed and treated early, then vision is saved. There are hundreds of challenging diseases that affect the young, middle-aged, and elderly.

Many diseases also manifest first in the eye. For example, one of my colleagues diagnosed Whipple's disease based on the eye exam and a complete review of systems. The GI doctors didn't believe this was Whipple's disease and was hesitant to do colonscopy. They finally agreed, and a biopsy confirmed the diagnosis of Whipple's disease. The patient was treated with antibiotics and his condition improved. If he had gone untreated, the organism could have caused severe damage to the eyes and possibly spread to the brain.

Other diseases that we deal with that can cause inflammation in the eyes include: lymphoma, malignancies, TB, sarcoid, sphyillis, lyme's disease, bartonella, toxoplasmosis, auto-immune diseases, and numerous infectious organisms. If you like infectious diseases, then ophthalmology will be stimulating. Many corneal diseases consist of exotic and difficult infectious diseases, such as acanthamoeba keratitis.

Another reason that draws me is the variety within the field. If you enjoy neurology then there is neuro-ophthalmology. Glaucoma is interesting because there are numerous entities that can cause increased intraocular pressures resulting in severe damage to the visual system. If you enjoy microsurgery and working with a delicate system, then retina is an extremely fulfilling field. For those who enjoy pathology, then they can pursue training as an ocular pathologist. There's the pediatric fellowship for those who enjoy working with kids and adults with visual disorders. The corneal specialists save vision with transplanting corneas and managing difficult corneal diseases. Cataract surgery is rewarding, and patients walk away loving you. In every aspect of ophthalmology, the patient will be very grateful and appreciative. I even find helping patients see better with a pair of glasses gratifying; they're happy, and I'm happy. 🙂

If you want "action", then you'll have to be an oculoplastics or retina specialist. They see traumas, gun shot wounds to the face, metallic foreign bodies in the eye, ruptured eyes, and numerous other injuries people don't even think about. I saw a kid playing with a potato gun which blew up and sprayed hot glue onto his eyes. We also see a lot of chemical and radiant burns to the face and eyes. Burn patients are extremely challenging to manage.

For those interested in oncology, then ophthalmology is a great field to be in. We see the whole spectrum of malignancies and benign tumors of the skin, lids, lacrimal gland, conjunctivae, ciliary body, iris, retina, and bone. These patients are very challenging. Early diagnosis and treatment (either medically or surgically) is often life saving.

There is a lot more I didn't discuss here. If you're interested in medicine, surgery, and the visual system, then ophthalmology is a wonderful profession. There are great medical and surgical challenges. The way I look at it, ophthalmology is the total package: comfortable life-style, interesting research issues, and medically as well as surgically challenging. If you have any specific questions, then I'd be happy to contribute my two cents.

Good luck!

 

[chef]

dang, andrew, that reply is worthy of a publication!! 😱

 

[sunflower79]

Thanks for the reply Andrew! That was incredibly thorough.

I would reply to your description of the specialty, but then realized I would have no idea what I was talking about since I am still so young (I am about to start med school). Since having a lot of exposure to general IM I am inclined toward primary care, but I will probably try to get an elective in ophtho anyway just to see what it's about. The amount of variety in the field and intellectual challenge certainly are a draw.

I do have another question though, and perhaps the answer could apply to specialties in general: I am concerned about monotony in seeing the same sorts of cases and doing the same sorts of procedures in everyday practice. Is this true for all but academic settings?

cheers,
sunflower79

 

[Brewster]

Monotony is a risk in all areas of medicine, even in an academic setting (although to a lesser extent than in private practice). All specialties have their "routine" cases, which you will end up seeing a lot of the time (common things occur commonly).

A physician I worked with once said that if you look at the routine case that is seen by a particular specialty (for example, cholecystitis for surgery, ear infections for peds, etc) and feel that you can handle doing that over and over, then you can do that specialty.

 

[ny skindoc]

As far as monotony goes.. whats interesting in medicine is seeing the various ways common problems manifest.Each patient is different and will require a unique approach no matter how typical the problem seems.For myself I would never go to a physician who does not do the "same sorts of procedures" every day,and would suggest you dont either.You want to be treated by someone who does your surgery or procedure with great frequency!

 

[JasonDO]

Originally posted by sunflower79
What's the attraction? (and please don't mention money)

I'm not nuts about general surgery, but I do have patience and skill with manual dexterity, and eye surgery seems neat and clean. At the same time, I find no compelling reasons to enter the specialty besides the nice work hours.

cheers,
sunflower79

To be come part of the $10,000,000 club...just kidding😉...ocular surgery news ran a story on this exclusive group of opthos that belong to the $10-$15 million club...I wouldn't mind being part of this club

 

[chef]

Originally posted by JasonDO
To be come part of the $10,000,000 club...just kidding😉...ocular surgery news ran a story on this exclusive group of opthos that belong to the $10-$15 million club...I wouldn't mind being part of this club

i dont believe this.. $10-15 mil / yr? maybe it's $15 mil over lifetime or something. i just cannot comprehend how any doctor can make $15 million / yr unless he's selling white powder on the side.. plus optho is not like cosmetic surgery where stuff arent covered by insurance

 

[JasonDO]

Originally posted by chef
i dont believe this.. $10-15 mil / yr? maybe it's $15 mil over lifetime or something. i just cannot comprehend how any doctor can make $15 million / yr unless he's selling white powder on the side.. plus optho is not like cosmetic surgery where stuff arent covered by insurance

of course...I'm making it all up...you got me🙄 and yes it is per year...it's not your average ophtho...these are only a small handful around the world that make these numbers

 

[Andrew_Doan]

Wait... Read the article again. These are $10-$15 Million Dollar PRACTICES (gross per year in annual collections). Be aware that some practices involve multiple offices and numerous physicians and optometrists. I've seen practices with more than 30 ophthalmologists!

Here is the article:

OCULAR SURGERY NEWS 5/1/03
The $10 Million Club: Solving problems on the way to becoming a much larger practice

Large practices can take steps to maintain their competitive edge, and use their size and resources as a basis for continued growth.
John B. Pinto

Only a small percentage of ophthalmic practices in the nation ever reach $10 million or more in annual collections. But the lessons learned along the way by these market leaders are critical to pass on to practices still striving for this benchmark, and perhaps equally valuable for surgeons with less-vaunted business goals.

You?d think the owners of these larger practices had it made. But interestingly, practices in the ?$10 Million Club? have an even greater difficulty than smaller practices deciding where they should be heading next. Physicians in these practices often reach an elevated threshold, beyond which it?s difficult to conceive their next strategic destination.

Managing partner
This cohort of major practices typically has many characteristics in common. Starting at the top, they generally have one, highly driven, charismatic leader ? often the founder. But the physicians next in line below this lead physician rarely have the same talents; the pool is simply too small. Unlike a large manufacturing firm that can choose from thousands of potential CEOs, inside and outside of the company, large practices can only turn to a handful of ascendant partners or partners-to-be; or they must be ready to relinquish control to the skills of a superior lay manager.

Being the managing partner of a $10+ million practice is more than 10 times the challenge of leading a $1 million practice. And the two best solutions for this problem take years to unfold: grooming an existing partner for the job, or seeking out in the next partner-track associate a physician with proven leadership talent.

This means the leaders of larger practices can?t put off until the bitter end their selection of a successor. In small practices the partnership can draw straws to pick their next leader, and turn out just fine. In large practices, the wrong grooming and selection of a leader can cripple the institution, especially as management difficulties compound in the future.

Losing competitive zeal
Large practices commonly feel as though they have run out of things to do next. By the time a practice reaches $10 million or more in collections, virtually all possible ancillary services have been developed. There is generally already at least one ambulatory surgery center. Optical dispensing is old hat, and the special testing department can?t really add any more patient services. In already-large practices, all or nearly all appropriate subspecialty areas are covered, and any that haven?t been added yet are likely of no interest to the founders, either due to an incompatible patient base (pediatrics) or lackluster economics (neuro-ophthalmology).

As the largest (or near-largest) player in their market, practices in the $10 Million Club often run out of the competitive zeal they once had. It?s a little like becoming the best tennis player in your club; you no longer have a ?pacer? out ahead, driving you to improve. Also, with age and relative success, the founding physicians can often run out of financial needs; with no more homes, cars or dream vacations on the list, or simply a desire for more free time, the motivation to strive dims. Medical entrepreneurs are like any other kind, driven in part by financial reward and a striving for social rank.

If the next generation of physicians in the practice hold similar or greater dreams, the practice can readily undergo another doubling on their watch. But without this, the practice is like a kingdom with an ineffectual prince in line for the throne. And when a lead physician leaves, you lose not only his leadership, but his production. Everyone else?s overhead rises, and a negative profit spiral can ensue, reinforced in turn by the lack of leadership.

Diseconomy
I?ve found that at or near the $10 million threshold, practices can go through a period of ?diseconomy.? This is the opposite of the expected economies of scale, where sheer complexity and all the moving parts demand a stronger middle management team, upgraded information systems, new facilities and endless meetings to facilitate communications up and down the line.

It almost inevitably happens in these settings that the partners (particularly the cost-sensitive younger and older partners) develop a preference for optimizing near-term physician take-home pay rather than long-term success. This conservative bias halts the growth of large practices in its tracks, although the partners may feel for several quarters or even a few years that cost-containment is working. After that, parsimony in areas like marketing, development of the management team and ongoing facility maintenance catches up and claws every dollar back from the partners in successive years. With continued short-term focus, practice profits slide even lower than they were before someone got the bright idea to fire the gardener, let the techs go without a supervisor and allow a junior clerk to take over a half-million dollar marketing program.

Centralize or not?
By the time big practices get big, they?ve had a chance to experiment deeply with centralization vs. decentralization and with outsourcing vs. insourcing. They?ve already found out that it?s better to centralize billing but decentralize phone pickup in a practice with many office locations. They?ve rationalized down about as many costs as they dare, which is always a frustrating state to reach for the most cost-conscious partners. And even when they do find costs to shave, they?re often small in the context of a $10+ million budget. Long-gone are the heady days of being a loosely-run $5 million company, and finding a way to bring $50,000 to the bottom line with just one change in IOL vendors.

On the revenue side, large practices have the ?Proctor & Gamble? problem; you can?t drive a large company at high-percentile growth rates. Even a huge success is a relatively small addition to revenue. This takes some of the excitement out of the game for entrepreneurial physicians who remember the profit pop when they first added refractive surgery or an ASC. Entrepreneurial physicians who are forced into mere stewardship over what they?ve built often get lax about the details, and their inattention can send their practices back down from where they came.

Most practice owners in enterprises at this scale have to be comfortable with the transition to an era of fine-tuning and polishing, sanding with 500-grit paper and waxing, rather than changing wholesale the shape of the company.

Practice scale begets opportunity
These apparent constraints that come with scale are also accompanied by a few gratifying opportunities for big-practice builders who get their second wind. Once you?re in the $10 Million Club, it?s easier to take on projects that others lack the resources to execute.

Mergers and acquisitions with other practices in the region are much easier for a larger practice to drive; such practices have the management depth, capital base, prestige and ?fear factor? that smaller practices don?t possess, and that local targets can find compelling.

Similarly, developing de novo satellite offices is a much lower hurdle. A large $10 million practice may only have to put 3% of its annual cash flow at risk to develop a new office; a smaller practice might risk 20% or more of its annual cash flow for the same opportunity.

Branding improvements are much easier to accomplish if your practice is large, for three reasons. First, you already have the high ground, and existing name recognition. Second, you can likely tout that you are among the largest, the oldest, the most diversified or the most convenient practices in your community (or all these things.) Third, you have a lot more media budget to play with. Here?s how. It?s reasonable for a general practice to spend 3% or more of its annual collections on marketing. That?s $300,000+ in a larger practice, and perhaps a fifth of this or less in a small practice. Which practice would you bet on to win the promotional race?

Institutional and payer alliances are more readily crafted by large practices than smaller players. Joint ventures with hospitals and preferential treatment by third-party payers were the order of the day a decade ago in the last era of health care reform. Now as then, larger practices are better positioned to be deal-makers in their markets. A new era of alliances may be upon us.

Finally, even if all common sources of passive eye care income have been tapped, there is at least one last opportunity that can be best executed by larger practices. This concept of passive income is critical, given the tipping point that ophthalmology stands at today. Physicians in larger established practices are nearing the limits of their personal productivity, and nearing the limits of cost containment as a means to raise profits.

As we have discussed, it?s likely in your large practice that ancillary opportunities have all been executed, and fees are poised to decline in the years ahead. So the only way that physicians in fully mature practices can engineer a pay raise for themselves is through the passive income of other employee physicians.

-Article cut short due to length-

 

[JasonDO]

I did read the article Andrew. However, the statement is still accurate. Dr. Charles Kelman receives 15 million/yr alone just from his patent. Dr. Howard Fine is another that comes to mind...Dr. Lindstrom the editor-in-chief of OSN wrote a brief commentary in OSN awhile back about a surgeon who grossed nearly 200k/week on his surgery days...so believe it or not it's true...

 

[Andrew_Doan]

Originally posted by JasonDO
I did read the article Andrew. However, the statement is still accurate. Dr. Charles Kelman receives 15 million/yr alone just from his patent. Dr. Howard Fine is another that comes to mind...Dr. Lindstrom the editor-in-chief of OSN wrote a brief commentary in OSN awhile back about a surgeon who grossed nearly 200k/week on his surgery days...so believe it or not it's true...

JasonDO,

This article was not in reference to the few that make millions on patents or the few surgeons that can make millions on elective surgery, which is fewer now because the price of LASIK is going down the drain. Money made from patents and inventions is a different issue. This article makes no reference to these individuals.

This article was talking about the large practices with multiple offices that collect more than $10 million in patient billing. In addition, the physicians in these "large practices" are not pulling home $10 million a year each. This is what they collect from patient billing, not NET. As I stated earlier, many large practices consist of numerous physicians and numerous offices. Most of these practices may have 10, 20 or more physicians in the group.

If you read the article, these are the practices the article is referring to.

 

[JasonDO]

Oh, I see...I was referring to a different scenario altogether...my mistake..