As stated above there is a crunch on neuro and peds ophthalmologists and some of that likely has to do with low reimbursement/pay for those sub-specialties. There are just not that many doing those fellowships and retirements are far outpacing newly trained. In private practice, you can become a partner in a practice and that helps make up the difference in pay. The key when partnering here is finding a group that values this service outside of just your production. Some groups see the benefit of this as not having to see these patients themselves and providing a well-rounded, true multi-specialty practice for the community.
Thanks for the detailed response. Would you happen to know the population size that various specialities require to have a full practice? I hadn't considered that as a variable.
That is tough because it's dependent on the age/health of the population too. The south for instance needs more retina because there's more diabetes.
At our practice the main reason retina travels is because there are a lot of older and poor patients who simply cannot come in for monthly visits for shots, we go to them. This definitely does improve patient catchment but we would be fine even without satelliting
This is not right. That would mean San Francisco should have 7 retina, 7 glaucoma, 3 peds, 25 comprehensive. West Coast Retina has 9 retina specialists,
This is the estimated minimum population to support 1 of each type of sub-specialist not the actual numbers per type.
This is an interesting comment, as having numerous satellites and driving is standard for almost all medium to large retina practices. Does not having multiple offices provide for economies of scale, in terms of employing doctors and techs and nurses, supplies, and so forth? Otherwise, there would be more, but smaller practices scattered across a geographic area no?
It depends on where you are. Our practice has 3 retina and we service about a 2 hr radius, have a large office building with multiple lanes. We would all be happier not traveling. Clinics are smoother, facilities are better than at referring doctors' offices.
I always wondered this... What if neuro-ophthalmologists created a cash-only/fee for service private practice? The wait times to get an appointment with neuro-ops is many months and I do think that patients will be will to pay cash for a visit. It may not be that ethical, but it is also really unfair that insurance companies continuously give abysmal reimbursements to these small niche specialties when there is such a high demand! Neuro-ops are very intelligent and hard-working and I believe they deserve to get reimbursed better (I am not a neuro-oph)... It is similar situation to psychiatrists setting up their own cash practices because insurances reimburse them poorly as well.
Talking to my glaucoma friends it really does sound like it's the new cornea - get dumped on, do the low revenue + bad pathology cases.
Yes, it’s the ultimate irony that—except for retina—general ophthalmologists are compensated more now than most of our sub-specialists. It’s actually remarkable. One year of internship, then 3 years of ophtho residency—only 4 years total, and you’re sitting in a great position as a general ophthalmologist. Almost every other field requires a 5-6 year residency and now an expected additional fellowship. For example, most new ENT docs and even radiologists need to do fellowships to subspecialize.
I know a "neuro-optometrist" who takes cash only and is doing ok. How much do you think patients would be willing to pay?
Glaucoma specialist here. These points are valid, although I think the emergency Friday patient is a bit overstated. Happens every now and then but very rarely for me, not nearly as bad as my retina partners. Most things can wait until the next Monday or at least be medically managed until then.
What about cornea? Do you actually end up being the dumping ground for friday night ulcers and impending perfs? It would seem like a practice wouldn't want to bring on a cornea specialist if their DSAEK, PKP, etc patients take way longer and lower overall revenue.
Practices definitely desire corneal specialists for the procedures you mentioned, and to send difficult problems (ulcers, perforations), as opposed to sending out... And maybe some LASIK. And of course most corneal specialists do a lot of cataract surgery as well.
The referral base cares more about the practice you will be joining and your schmoozing skills. No matter where you train, you are unproven until you send happy premium IOL patients back to optometrists, no matter how great your training is.
Doubt it's going to affect retinal specialists all that much. At least in my area, the retinal specialists are much busier with AMD than DR.
I would tell you from my desk, we need more comprehensive ophthalmologists. For the last few years, it's been about 50% of residents go onto fellowship, over the last 2 years we've seen a marked acceleration. Is that due to disruptions in training from COVID or just following a specialization trend? I'm leaning more into it being the trend since we've seen cataract numbers in residency mostly recovered since the 2022 graduates; 2023 graduates seemed to have pre-pandemic or exceeded pre-pandemic numbers.
Make sure you want to take care of glaucoma patients. many people are going into a glaucoma fellowship only to realize they don't want to do glaucoma surgery. I perform tubes/trabs/xen/CPC, making me marketable in a busy metro area. But in my area, I have 3-5 glaucoma fellowship-trained docs who have all decided they would rather do comp. The problem with glaucoma surgery is that it is not as predictable as a standard cataract post-op. If you do end up going into glaucoma and want to practice it make sure the office you join either already has an on-staff glaucoma doc performing tubes/trabs/Xen because it will be a shock to the practice flow if you are the first to start doing in office needling or have patients showing up with IOPs of zero post op or IOPs of 60-70 pre-op.
Are these anterior segment fellowships or all fellowships in general? Anecdotally there appears to be fewer applicants for retina these past few years.
Maybe it’s perception from residents seeing busy, inefficient academic practices. Those are also more prone to getting disasters through referrals or ERs. I don’t think most community retina people get far beyond 40 hours of patient care a week unless they really want to knock out 100 patients a day. I don’t cover Level 1s anymore, so call is just an inconvenience. Go in at night maybe once a year, go in maybe every other weekend I’m on. Answer some patient concerns 4-5x a week.
I hear this from pretty much every retina partner, owner, and experienced attending I talk to. The perception of the lifestyle is way worse than the actual lifestyle. I think much of this has to do with how bad call can be during fellowship and thinking it only gets a little better in practice.
You tend to figure out in the first 3-6 mos if you want to practice incisional glaucoma. You are fresh out of fellowship; hopefully, that did not kill your enthusiasm to perform glaucoma surgery. Then you are dealing with the fluctuations of tubes and trabs and the many unpaid post-ops that you are diligently performing. You glance over at your post-op phacos and realize they are doing fine for the most part and have a routine on when they need to be seen.
I know there are quite a few lurkers to this forum in training. Is there anything that a resident could think about more or do before deciding to go into fellowship to get an idea of how it really is?
