Millennial ophthalmologists face different challenges than their predecessors

Millennial ophthalmologists are being trained differently, are practicing differently, are completing surgeries differently and are entering the work force differently than the baby boomer generation that preceded them in the field.

Typically defined as being born in the early 1980s, the millennial generation often carries with it a negative connotation. While it is true that burgeoning millennial ophthalmologists tend to have different values and place more emphasis on other aspects of their lives, Healio.com/OSN Section Editor Uday Devgan, MD, said the young physicians face a much more competitive medical school and residency environment than their older counterparts.

Devgan, who trains residents at the Jules Stein Eye Institute at the UCLA School of Medicine, said that the field of ophthalmology is “tougher now than it has ever been.”

Image: Loh JM

“Ophthalmology is more competitive now than ever. Every year, without a doubt, residents have gotten smarter than the previous years ... for example, my residency was 3 years, same as it is now, and I learned everything I needed to learn. But now, the residents have to learn what I learned and things that did not exist back then. Toric lenses were not in use. There were no diffractive multifocal lenses. On the retina side, there were no anti-vascular endothelial growth factor injections. OCT machines didn’t even exist back then, and you can write entire books on OCT machines now,” Devgan said.

A competitive field

Millennials looking to begin their medical careers may find it more difficult than it was decades ago. Only 40% of applicants to medical school were accepted this year, Devgan noted, down from 70% when he applied.

According to the Association of American Medical Colleges, in 2015-2016, 52,550 applicants submitted just more than 781,600 applications to medical schools throughout the country, with each applicant submitting an average of 15 applications. Only 20,631 applicants were accepted into medical school, for a matriculation rate of about 39%.

“Residency is even more so competitive. The number of people who apply is stupendous compared to the number of people who are accepted. In the United States as a whole, I think there were only 450 ophthalmology residency spots, period. That is nationwide, coast to coast,” Devgan said.

In 2015, according to the SF Match program, there were 644 applicants looking to be matched for an ophthalmology residency position. There were only 464 ophthalmology residency positions available throughout the country, meaning 180 applicants were not matched with a residency in 2015.

Too much technology

However, there is a concern that these newly trained ophthalmologists may be relying too heavily on technology and tend to stray from traditional techniques. With so many technological advances in the field, Ehsan Rahimy, MD, of the Palo Alto Medical Foundation, California, said he has seen instances of younger ophthalmologists depending too much on the new era of imaging modalities instead of trusting their own eyes.

“Technological innovations in the field are responsible for many diagnostic and therapeutic advancements, but you have to take the good with the bad,” Rahimy said. “Younger ophthalmologists have become so dependent on widefield photography, OCT imaging and OCT angiography that the basic fundamental examination techniques taught in training are being de-emphasized.”

“One of my mentors in residency at the Jules Stein Eye Institute, Dr. Allan ‘Buzz’ Kreiger, frequently stressed the value of investing the time and effort into developing sound retinal examination skills, especially of the peripheral retina. It is something I value to this very day. Technology is amazing, there is no doubt of that. But nothing substitutes what we can see as clinicians with our very own eyes,” he said.

Entering the workforce

One of the biggest differences between millennial ophthalmologists and older-generation physicians is what happens after residency, according to OSN Technology Board Member Jennifer M. Loh, MD, who is a member of the millennial generation and practices at Loh Ophthalmology Associates in Miami.

More ophthalmologists are leaving their residencies and looking for work at already established ophthalmology practices or are interested in full-time employment with institutions such as Kaiser Permanente. In generations past, the traditional route for an ophthalmologist who completed residency would typically be to start a practice, Loh said.

“I think that a lot of the millennial ophthalmologists are finishing their residencies and looking for employment vs. the traditional route of leaving their residency and starting their own practice. A lot of my friends and colleagues have tended to either join academic centers, join group practices or even join a solo practicing ophthalmologist at their practice,” she said.

In high demand

For the most part, many of these ophthalmologists looking to enter the workforce are finding they are in high demand. This is due to the growing number of aging patients, the growing number of cataract surgeries these aging patients require, and the growing number of baby boomer ophthalmologists who are nearing retirement. Presently, it is very much a “buyer’s market” for these young ophthalmologists, according to Elizabeth Yeu, MD, who is in private practice at Virginia Eye Consultants in Norfolk.

For the baby boomer generation, ophthalmologists coming out of their residencies had to begin their careers in less desirable professional locations, she said, or accept lower starting salaries to practice in popular locations throughout the country.

“There are more and more patients who need to be taken care of, as we know, because of the aging population. That has created a buyer’s market. As a result, and this will shift, but there are many coming out of training who are able to command the type of salary they want and the type of marketplace they want to practice, such as the primary market. Before, if you were looking for a private practice opportunity in Miami or Boston, you would have been willing to take a lower salary. Some people in larger cities were making even less than $100,000 when they started. That is no longer the case,” Yeu said.

Teamwork is commonplace

When these young ophthalmologists are brought into an established practice, it is evident that the “lone wolf” attitude that many older ophthalmologists had to employ to get ahead in their careers no longer exists, Yeu said.

Millennial ophthalmologists have been trained to work as a team, and most residencies foster an environment of teamwork, she said.

“The positive of that is when you hire a younger associate, younger associates are oftentimes going to be naturally open-minded and respectful of all health care professionals. At the same time, they also want to be treated somewhat of an equal to the older associates. They want to make sure their voices are heard. There is a component of wanting to know that they are getting the feedback, good or bad — they want that feedback. That is something much more common now because so much of the training has focused around that in the recent decades,” she said.

Balance between work, life

The way each generation approaches work and personal life is different, Marjan Farid, MD, director of Cornea, Cataract and Refractive Surgery at the Gavin Herbert Eye Institute, University of California, Irvine, said.

Millennial ophthalmologists have a much more well-rounded work and personal life balance than their older counterparts, Farid said.

“The millennial ophthalmologists have a broader and more global view of life and practice that is different from previous generations. To this group, work life is a part of life — not all of life. The balancing of family/social life with work life takes an important role in this newer generation. How this will shape the future of ophthalmic societies and leadership roles remains to be seen. For better or worse, the ambition and drive for leadership positions and financial power take a backseat to a balanced life that includes travel, family precedence and social living,” she said.

Younger ophthalmologists are more interested in employment opportunities that offer “ample vacation and family leave time” when compared with their older counterparts. Job sharing, in which two ophthalmologists fill the role of one in a practice, is also becoming more prevalent, she said.

Additionally, a higher percentage of female ophthalmologists who double up in their roles as mothers and physicians is now commonplace, according to Farid.

“Older generations, mostly male dominated, who would spend the majority of their time in the office are no longer of interest to this generation of ophthalmologists entering the workforce. Additionally, reimbursement cuts and changing fee schedules drive these doctors into large group organized health care practices, such as Kaiser, where the daily headaches of running a business or practice can be avoided. The pride, passion and time that older ophthalmologists put in to build an empire practice is not readily seen in the millennial group,” she said.

Balance is important

But just because the younger generation does not dedicate all of its time to career and ophthalmology, Loh said that does not mean millennial physicians are not as hardworking as earlier generations of ophthalmologists.

A good overall life balance is important to the millennial ophthalmologist, she said.

“It does seem the younger ophthalmologists are trying to find more of a balance, to not dedicate 100% of their waking hours to ophthalmology. They are as passionate about ophthalmology as the older generation, but there is a realization that they should also focus some of their time on their own personal interests, pursuits and families. They want to be well-rounded individuals,” Loh said.

Ownership may not be offered

However, in Loh’s experience she said many practices may not even offer a partnership or ownership opportunity when looking to hire a new associate.

Many practices will say there is an opportunity for ownership or a partnership “with time,” but Loh said she and colleagues have found this is not always the case when looking for employment in a private practice.

“You will rarely find a private practice job that says you cannot be a partner. They are usually going to say ‘with X amount of time you can achieve partnership,’ but in my experience and speaking to other people, a lot of time that does not end up as a reality. There are so many of my peers that have moved from job to job, not being able to get to that next level. Knowing that there was a real intent on both sides to make this a partnership, that would have been really appealing for these ophthalmologists,” she said.

Skin in the game

Millennial ophthalmologists in a practice need more than just a paycheck to stay motivated. Giving younger ophthalmologists more “skin in the game” is an effective strategy to ensure more productivity and maximum effort, Devgan said.

If a younger ophthalmologist buys into a practice as a part owner or partner, the effort increases and they become “more invested” in the practice’s success, he said.

“If I am just collecting a paycheck, no matter what you do you still get the same paycheck each week, it is not as much of an incentive. If your paycheck does not change no matter how many patients you see, how many surgeries you do, how many hours you work, then you do not really care as much. But if I have skin in the game, if I am a part owner, then you really want to keep expenses down and productivity up. You are on board 100%,” he said.

However, Devgan warned millennial ophthalmologists to not jump into any practice if their employment is contingent on the signing of a non-compete clause.

Non-compete clauses, he said, will give the practice too much leverage over a young ophthalmologist’s career.

“Never sign the non-compete contract. Never. Because if you have a non-compete, they can let you out of your contract and you will have to practice 50 miles away. If you do not sign one, you can practice a block away and take a good chunk of their patients. You never sign the non-compete if you are a millennial,” he said.

Flexibility is needed on both sides

Practices looking to hire a young ophthalmologist may find the negotiation process different from dealing with an older-generation physician. A practice needs to realize how important family relations are to a potential new hire, Yeu said, and should be prepared to allow family members and significant others into the interview process.

The work and life balance is much more important now when it comes to choosing a potential job than it was when baby boomer ophthalmologists were looking to get into the business, she said.

“If a practice is interviewing new candidates for a position, you want to make the candidates have an open opportunity to bring family members and other important significant others into an interview. That is a huge consideration now,” Yeu said.

Consider the intangibles

Millennial ophthalmologists should also pay attention to certain intangibles in a practice they could potentially be joining.

“These young ophthalmologists should look to see if the practice has any potential mentor candidates who could help them transition into the workforce,” Rahimy said.

“Younger ophthalmologists should note if the doctors in the practice appear to be generally happy, regardless of salary, with their job and work well with each other,” he said. “Also, it is important to see if the physicians and ancillary staff have a cordial working relationship. If these are evident, it could be a positive practice to begin a career.”

Millennials have bright futures

Yeu said the term millennial often has a negative connotation when used by the older generation. Millennial ophthalmologists should not be viewed as being any less dedicated, intelligent or effective than their older counterparts.

“I hate even using the word ‘millennials’ because, at this point, that term has such a notorious connotation. Yes, every generation is slightly different, but they are doctors who want to do right by their patients. It can be very harmonious. Yes, we have to be sensitive to these differences, but at the end of the day the younger generation of ophthalmologists do recognize that there are things in life that are bigger than themselves,” she said.

Even with the many differences between the two generations of ophthalmologists, Devgan said he and other members of his generation will be in good hands when it is time for them to receive their own cataract surgery procedure in the next few decades.

“I have no worries that in the future, when it is time for my own cataract surgeries, one of these millennials will do an amazing job for me. They are among the smartest residents I have ever trained, they have a fabulous work ethic, and I like that they understand the work-life balance. I like that they are not working 100 or 80 hours a week. They are going home, spending time with their families, they are well rested, and they come in in the morning and do a beautiful surgery for me. I have no worries that two decades from now I will have a beautiful cataract surgery done by a millennial,” he said. – by Robert Linnehan

• References:
• U.S. medical school applications and matriculants by school, state of legal residence, and sex, 2015-2016. Association of American Medical Colleges. https://www.aamc.org/download/321442/data/factstablea1.pdf. Accessed July 21, 2016.
• Residency and fellowship matching program. Ophthalmology residency. SF Match. https://www.sfmatch.org/SpecialtyInsideAll.aspx?id=6&typ=2&name=Ophthalmology#. Accessed July 20, 2016.

• For more information:
• Uday Devgan, MD, can be reached at Devgan Eye Surgery, 11600 Wilshire Boulevard, Suite 200, Los Angeles, CA 90025; email: devgan@gmail.com.
• Marjan Farid, MD, can be reached at Gavin Herbert Eye Institute at the University of California, Irvine, 850 Health Sciences Road, Irvine, CA 92697; email: mfarid@uci.edu.
• Jennifer M. Loh, MD, can be reached at Loh Ophthalmology Associates, 6705 Red Road, Miami, FL 33143; email: jenniferlohmd@gmail.com.
• Ehsan Rahimy, MD, can be reached at Vitreoretinal Disease and Surgery, Palo Alto Medical Foundation, 795 El Camino Real, Jamplis Building, Level 2, Palo Alto, CA 94301; email: erahimy@gmail.com.
• Elizabeth Yeu, MD, can be reached at Virginia Eye Consultants, 241 Corporate Blvd., Suite 210, Norfolk, VA 23502; email: eyeu@vec2020.com.

Disclosures: Devgan, Farid, Loh, Rahimy and Yeu report no relevant financial disclosures.

How would you bridge the gap between caring for more patients and having fewer ophthalmologists in the workforce?

No simple solution

Providing eye care during a time with a reduction in the number of ophthalmologists in the field and a growing demand for patient care does not have a simple solution. It is a crucial topic to discuss, and finding a solution for the growing number of Americans who need eye care for the upcoming decades is imperative. The baby boomers need cataract surgery! One solution is to increase our residency sizes and train more surgeons as well as medical ophthalmologists and optometrists. One idea would be to adapt a surgeon specific track, such as a “super surgeon” track, similar to that adapted in Germany, where certain specific MDs would undergo training to be pure surgeons. There would be very specific standards for these surgeons while optometrists and other medical ophthalmologists would provide routine eye and postoperative care. Optometrists would have to increase their medical eye diseases practices under the supervision of an MD. Just like raising a child, “it takes a village.” My feeling is that we will have to collaborate together to care for our growing number of patients.

Kathryn M. Hatch, MD, is an assistant professor of ophthalmology at Harvard Medical School, Waltham. Disclosure: Hatch reports no relevant financial disclosures.

Access to ophthalmologists is needed

There is no doubt with the aging and changing demographics of the population, and the aging of the current generation of ophthalmologists, that there will be a future need for patient access to ophthalmologists. What will have to happen as the next generation of ophthalmologists assumes this responsibility in their communities and for society?

Already we have evidence from American Academy of Ophthalmology surveys that younger ophthalmologists are subspecializing and practicing in larger groups that are more likely to employ allied health professionals, optometrists and full time administrators. These practice trends are paving the way for potentially more efficiency in caring for patient populations. Obvious efficiencies already available to young ophthalmologists include operating at ambulatory surgery centers rather than less efficient hospital outpatient departments, and partnering with employed optometrists to care for the estimated 25% of patients who are seen for routine exams and refractions in ophthalmology practices, allowing the more subspecialized ophthalmologist to concentrate on patients who need their expertise. Future efficiencies that we all desire are improvements in electronic health records to enhance and not hinder productivity, and reining in of government and payer requirements that take time away from actual patient care.

The likely reality is that care teams, practice workflow and patient communication/education tools will have to evolve to accommodate the influx of patients who need care for ophthalmic disease. Innovative technologies will become available that allow for better diagnosis, longer intervals between treatment, better compliance or interruption of the progression of disease. Although we are seeing poor attempts at using payment policy to change care delivery, in my opinion positive change will come from within our profession rather than external penalizing programs. The hope is for better and smarter care for our future patients.

Cynthia Mattox, MD, is the director of the Glaucoma and Cataract Service at the New England Eye Center, Boston. Disclosure: Mattox reports she is a consultant for Alcon, Allergan, Aerie and Ocular Therapeutix. She also receives research support from Transcend/Alcon and Allergan.