Q&A: Richard L. Lindstrom, MD, reflects on a career in ophthalmology
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In his 50 years of ophthalmology, Richard L. Lindstrom, MD, has seen it all.
He holds 48 patents, has published more than 400 peer-reviewed articles and has been a mainstay on lecture stages throughout his career. This year also marks his 40th year of collaboration with Healio/Ocular Surgery News as a member of the editorial board.
Healio/OSN spoke with Lindstrom, now OSN Chief Medical Editor, about his career and how things have changed in the world of ophthalmology.
Healio/OSN: What has been the biggest change in ophthalmology since you started practicing?
Lindstrom: The biggest change from an external environmental standpoint has been the engagement of the payer in every decision that we physicians make for our patients. When I started practice in 1978, there was only two people in the exam room, the patient and the physician. Together they developed the best possible plan for each individual patient. Now, there is a third party in every treatment discussion: the payer. The doctor and the patient may decide what they think would be the best treatment plan, but in some cases, the payer will not reimburse it, or the preferred drug or procedure may not be on the insurer’s list for reimbursement approval, or some type of step therapy or preauthorization may be needed.
The other big change is also related to the payer. On the surgical side, there has been a continuous reduction in reimbursement per procedure for the surgeon. When I started in practice, I was paid $2,500 for a cataract operation with IOL implantation. Today, I am paid $500 for a better cataract/IOL operation. On the other hand, reimbursement per unit of care in the office has gone in the opposite direction. In 1978, I was paid $50 to do a complete eye examination. Now, I get paid $250 including fees for ancillary testing. While surgical reimbursement has gone down five times, office-based reimbursement has gone up five times, and many ophthalmologists do not appreciate this fact or understand how important their office-based practice is in today’s reimbursement climate. If an ophthalmologist sees six patients an hour in the office at $250 per patient, that is $1,500 for 1 hour’s work. If the same ophthalmologist does two cataract surgeries an hour in a hospital or third-party owned ASC, that is $1,000 for 1 hour’s work. Many doctors can make more money in the office than they can in the operating room. That has been a major change.
Healio/OSN: What has been the most important innovation in ophthalmology during your career?
Lindstrom: On the cataract side, the biggest developments have been phacoemulsification and IOL implants. Then, there are all of the adjuncts that go along with phacoemulsification and the specialized advances in the optics of IOLs.
On the cornea side of my practice, the biggest advancements have been the development of collagen cross-linking for keratoconus and ectasia and the transition to lamellar corneal surgery rather than full-thickness keratoplasty. Then, there is the whole new field of refractive corneal surgery. We did not have LASIK, PRK, PTK or SMILE when I entered practice. A whole new vertical that did not exist was created. We have seen the same thing happen in glaucoma surgery with the creation of a new vertical called MIGS — microinvasive or minimally invasive glaucoma surgery. MIGS procedures also did not exist when I first started practice, and MIGS has been a huge advance in glaucoma therapy.
Lastly, we have an amazing new array of pharmaceuticals, especially in the retina field where anti-VEGF biologics have revolutionized medical retina.
It is hard to pick just one advancement as the most important, but because most ophthalmologists’ bread and butter is cataract surgery, I would have to choose phacoemulsification and IOL implants, although anti-VEGF therapy is more important financially.
Healio/OSN: Looking to the future, what technology has the most potential for innovation or evolution?
Lindstrom: I have been spending more time on pharmaceutical innovation over the past several years. If you look at what is going on with our core business, which is cataract surgery, I think we are going to see eye drops to manage pain and inflammation go away. We are going to be using intraocular and extended-release options rather than eye drops. Cataract surgery will be the pioneering area for this, but alternatives to eye drops will affect other areas as well. We will be looking at extended-release drug therapy for everything that we do.
The big monster financially in our field today is anti-VEGF therapy in retina. Nobody wants to get an injection every month, so we need a therapeutic approach in which patients have to get an injection, or maybe some alternative to an injection, no more than every 6 months.
We have the same problem in glaucoma. Getting people to take drops every day is difficult. They need extended-release therapy. That might be a punctal plug, an insert or an intraocular implant. We are going to see all kinds of drug delivery innovation that makes the compliance and efficacy of our pharmaceutical regimens get stronger.
As far as the procedural side, innovation has been incremental of late, but I do see a few breakthroughs on the horizon, such as an accommodating IOL, endothelial cell transplantation, perhaps retinal cell transplantation, robotics, artificial intelligence and advances in gene therapy. I expect more incremental advance in devices and more disruptive advance in pharmaceuticals, with the transition away from eye drops and frequent injections of biologics to more toward extended-release approaches.
Healio/OSN: Do you have any advice for younger ophthalmologists looking to get the most out of their careers?
Lindstrom: I teach the same thing over and over to our fellows at Minnesota Eye Consultants. When a young ophthalmologist finishes their training, the first thing to do is to work hard at building a large and successful clinical and surgical practice. I see some young doctors look at the key opinion leaders in ophthalmology with envy and wonder, “How do I become someone who is on the podium or is the president of ASCRS?” The way to advance toward leadership in our field starts with first building a meaningful clinical practice.
The next step is deciding what part of ophthalmic practice you are passionate about. There is nothing wrong with being a great clinician for one’s whole career. It is a very rewarding pathway. However, if an individual decides later that they love corneal surgery, glaucoma surgery or ocular surface therapy with pharmaceuticals, then they can start to show interest in working with companies and teaching their colleagues. However, for the first decade, keep your nose down, see lots of patients, take good care of them and build a large clinical practice.
Healio/OSN: What is your proudest career highlight?
Lindstrom: I am most proud of the fellows, residents and colleagues I have played a role in training and mentoring. I started training fellows in 1978, and I have been doing that for almost 45 years. Right now, I am in the low 80s of fellows trained, and I am still close to them. That is what I am most proud of and has likely had the greatest impact.
As far as a product that I personally played a major role in developing, I am most proud of the corneal preservation solutions that we developed at the University of Minnesota that are still being used today. That was the first research and development project that got me started working collaboratively with industry. And here we are 45 years later, and Optisol-GS is still a market leader.
For more information:
Richard L. Lindstrom, MD, can be reached at Minnesota Eye Consultants, 9801 Dupont Ave. S., Suite 200, Bloomington, MN 55431-3200; email: rllindstrom@mneye.com.
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