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A question for residents: Comprehensive ophthalmology or subspecialty fellowship?

Phelan Piehota, DO, and Andrew T. Strand, DO, examine the pros and cons of going directly into practice or continuing in education.

Issue: April 25, 2015

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CEDARS Debates is a monthly feature in Ocular Surgery News. CEDARS — Cornea, External Disease, and Refractive Surgery Society — is a group of cornea, cataract and refractive surgery specialists, here to discuss some of the latest hot topics in ophthalmology.

One of our missions is to promote resident education, including introducing residents to the process of speaking from the podium and contributing as authors in medical journals. This month, Dr. Phelan Piehota and Dr. Andrew Strand, residents at the Ohio University Heritage College of Osteopathic Medicine Doctors Hospital in Columbus, discuss a dilemma that all residents may face: the choice of whether to go directly into practice as a comprehensive ophthalmologist or to complete a subspecialty fellowship. We hope you enjoy the discussion.

Kenneth A. Beckman, MD, FACS
OSN CEDARS Debates Editor

A case for comprehensive ophthalmology

As one nears the end of residency, he or she comes to a crossroads that all past, present and future residents must consider. Do I subspecialize with a fellowship or enter the workforce? During my residency specialty rotations, I would find myself wondering, “Could I see myself practicing this specialty for the rest of my career?” Inevitably, the answer would be yes. So, it was easy to conclude, if all the specialties in ophthalmology appealed to me, a career in comprehensive ophthalmology is without a doubt the best fit.

Phelan Piehota

The most appealing aspect of comprehensive ophthalmology is the variety of pathology that can be seen on a daily basis. I enjoy the excitement of not knowing what will walk through the door. Pathologies ranging from macular degeneration to ptosis, from strabismus to cataract, could all be seen in one morning in a comprehensive ophthalmology practice. I will have the opportunity to diagnose and treat the whole family unit, ranging from little Timmy’s strabismus to mom’s presbyopia to grandpa’s glaucoma and cataracts. I chose medicine for the variety and mystery surrounding every diagnosis. Comprehensive ophthalmology offers variety with each new patient.

Comprehensive ophthalmology is inherently flexible. You could choose to practice in either a rural or urban setting. Your referral base consists of both primary care professionals as well as optometrists in the community, as opposed to specialists who rely mainly on other ophthalmologists for their patient base, which usually necessitates a more urban practice. Due to the projected shortage of comprehensive ophthalmologists by 2020, we will be in high demand in towns and cities of all sizes across the country. As reported by the American Academy of Ophthalmology, the demand will only continue to grow with baby boomers entering their twilight years and the rates of age-related eye diseases increasing with every birthday candle blown out.

Another advantage to becoming a comprehensive ophthalmologist is financial. While some fellowships have the potential of a robust income, the extra 1 to 2 years of lost income during a fellowship does not always guarantee an immediate return on investment. In the shadow of the uncertain future medical landscape, it would be more financially sound to have greater diversity in your practice to offset the ebb and flow of declining reimbursement year to year. For example, in 2015, a coding report listed significant decreases in many glaucoma shunt procedures, with some decreasing by as much as 30%. In this example, specialists in glaucoma will be disproportionately affected compared with a comprehensivist who performs a variety of procedures as well as ancillary services (optical, refractive, premium IOLs, cosmetic plastic surgery, etc.), which can insulate the bottom line from declines in reimbursement of specific procedures.

In conclusion, every person should come to this decision with his or her own list of priorities. We work harder, incur more debt and dedicate more training time vs. other professions. We owe it to ourselves, our families and most of all our patients to be happy in our career choices.

Fellowship may fit your career path

If Hamlet had been a young ophthalmology resident, he would have pondered, “To fellow, or not to fellow — that is the question: Whether ‘tis nobler in the mind to suffer the slings and arrows of outrageous fellowship or to take arms against a sea of comprehensive ophthalmology troubles’ … .” The decision to fellow is a personal choice, and each individual comes to the table with his or her unique set of circumstances and goals. Every resident should ask himself a few simple questions: What are my interests in ophthalmology? Am I adequately prepared to enter the workforce? Will completing a fellowship enhance my career opportunities? This brief article cannot answer these questions for you, but it will serve as a conduit for some mental aerobics in your decision-making process.

Andrew T. Strand

According to the official 2014 Fellowship San Francisco Match statistics (excludes the American Society of Ophthalmic Plastic and Reconstructive Surgery): There were 277 official programs for 386 spots among subspecialties, with 82% filled. There were 372 submitted rank lists among the 466 that registered with the match. The majority of positions were filled by U.S. graduates, and 55 applicants did not match.

According to the Ophthalmic Plastic and Reconstructive Surgery Fellowship Match 2013: There were 24 programs registered for 24 spots, with 24 filled. There were 58 registered, 43 participated, 24 matched and 19 unmatched.

As you complete your subspecialty rotations, make note of your likes and dislikes and compare your preceptor’s daily routine among these different fields. The majority of the inclusion/exclusion process will be self-evident. If you find yourself thinking, “If I have to streak another kid, I’m gonna … ” or “If I eat all D-15 Farnsworth test objects, will it be less painful than a day in neuro clinic,” then pediatrics and neuro-ophthalmology may not be for you. Chances are you will like different aspects of various subspecialties. If you generally like aspects of all subspecialties, then comprehensive ophthalmology may be for you. Similarly, if the thought of further graduate medical education makes you nauseous and you want to start a “real life,” general practice is a great option. You can always pursue further training at a later time.

Alternatively, you may have known in utero that a glaucoma fellowship was your destiny. Go for it. But still keep an open mind; you may surprise yourself. The toughest situation may be choosing between two or three fields that you could see yourself doing. Find a mentor, and network with as many people as you can in these fields. Ask them the tough questions, ask them the taboo questions, and ask them to give you an honest opinion if you have the moxie to thrive in that particular field.

It is time to be honest with yourself. What are your strengths and weaknesses? No resident leaves his program at the pinnacle of his career. Your skills will improve, hopefully, until you retire or die, whichever comes first. If you have confidence in your acquired skill set and your residency training program has prepared you to handle the endeavor of comprehensive ophthalmology, you may be prepared. But if you have doubt in your skills, whether it be clinical management, business management or surgical, a fellowship may benefit you. Or, if you want to practice comprehensive ophthalmology plus a specific desired field, and it will make you a more desired asset to a practice, fellowship may be for you.

Do the ends justify the means? Only you can answer this question. Fellowship training may or may not make you a more desirable practice partner, and it may not enhance your potential income opportunity at the expense of lost time. Make sure that you are truly passionate about the field and not doing it for ulterior motives.

Are you dead set on a fellowship? What type: academic vs. private vs. a hybrid model? The pros and cons of such may be often overlooked. The academic environment may suit your desires to stay in education on the leading edge of research and provide job security. But this may come at the expense of lower income, less autonomy and the frustration of working in a political, bureaucratic environment. Perhaps you will use your academic training and networking to obtain a desirable private practice position at a later date.

On the other hand, a private practice fellowship may give you exposure to a higher volume of patients and procedures, while at the same time providing you with a model or insight on how to run an effective practice from a business standpoint. This may be at the expense of the benefits of an academic education. Or you may get used as “cheap labor” and not gain new skills you could have on your own without completing a fellowship. Finally, the hybrid model fellowship may buffer the pros and cons of the aforementioned. Caveat emptor.

There is no easy answer. My final recommendation would be to physically write out your short-, intermediate- and long-term goals. List your priorities: family, faith, employment, lifestyle, etc., and work with trusted mentors and peers to plan a course that works for you.