Practice model may evolve with upcoming ophthalmologist shortage
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Every year at the OSN New York and Retina meeting, in a superb educational forum, Eric Donnenfeld, MD, presents a series of cornea and external disease medical management cases for discussion by a panel of experts.
But rather than discussing the diagnosis and management of the cases in this issue’s cover story, I thought I would use this space to focus on workforce issues in eye care.
In 1996, the American Academy of Ophthalmology commissioned a study by the RAND Corporation on workforce issues in our field. In that study, RAND reported that the five most common diagnostic and management categories seen by an eye care professional were cataract, refractive error, retinal pathology, glaucoma and ocular surface disease. In 1996, there were approximately 18,000 ophthalmologists and 36,000 optometrists in the U.S. With a 1996 U.S. population of 270 million people, that was one ophthalmologist for every 15,000 Americans and one optometrist for every 7,500. RAND hypothesized that both ophthalmologists and optometrists were potential providers for most nonprocedural office care, and their combined workforce of 54,000 eye care professionals was at least 35% more than required for the eye care demand at the time. The bottom line: RAND concluded that there were too many ophthalmologists in 1996, and it did not project the need would increase significantly over time.
Now, fast forward 3 decades. Things have changed dramatically since 1996. First, the U.S. population has grown significantly from 270 million in 1996 to 340 million in 2023. Second, the number of patients older than age 65 years has grown even more dramatically, nearly five times faster than the population in general. This is relevant as patients older than age 65 in the U.S. consume 10 times more eye care than patients younger than age 65. Third, we have fewer uninsured patients, and access to care has increased. Finally, we have an amazing array of new treatments that have increased the demand for an ophthalmologist’s services significantly.
Let’s look at where we stand today. The number of ophthalmologists has remained stable, with 18,500 ophthalmologists to care for a U.S. population of 340 million, or one per 18,400 Americans. As I look ahead, we graduate approximately 480 ophthalmologists in the U.S. each year and about 20 enter from outside the U.S., generating 500 new practitioners each year. With 18,500 ophthalmologists, if we work for 35 to 40 years, retiring at age 65 to 70 years, we will lose 462 to 555 of us each year.
Looking ahead, I project by 2030 we will be back to the same number of ophthalmologists available in 1996 with a slow, continuing decline of about 500 per decade. This will not be noticeable year to year, but the ophthalmologist starting practice today with 18,500 colleagues will retire in 40 years with only 16,500, while the U.S. population grows toward 425 million. That will represent one ophthalmologist for every 25,000 Americans, with an even higher percentage of patients being older than age 65. Rather than 5,000 to 6,000 too many ophthalmologists as calculated by RAND in 1996, an analysis by the Health Resources and Services Administration and the Association of American Medical Colleges projects that we will have 4,000 too few ophthalmologists by 2032, along with a general shortage of MDs approaching 122,000. The ophthalmologist of the future will be in high demand, be very busy and, in my opinion, be very valuable.
What about our optometric colleagues? While the number of ophthalmologists has remained flat, which will continue, optometry training programs have continued to expand the number of graduates from 36,000 in 1996 to about 43,000 today, with projections for 51,000 in 2030. The National Center for Health Workforce suggests there will be 4,050 too many optometrists in 2030.
I have long been an advocate of the ophthalmologist-led integrated eye care delivery (OLIED) model, which is the model we employ at Minnesota Eye Consultants with 15 ophthalmologists working collegially side by side with 12 optometrists and three physician assistants. Some practices, including Vance Thompson Vision, which also employs the OLIED model of practice, have found the ideal ratio for a busy surgeon is two optometrists per ophthalmologist.
In conclusion, we are facing a shortage of ophthalmologists, and there is no evidence that any significant increase in ophthalmology residency training will materialize. Optometry appears to have an adequate number of new graduates to meet the demand and may be facing an excess by 2030. In the future, I expect more ophthalmology practices to evolve toward the OLIED model. Ophthalmologists, optometrists, ophthalmic technicians/technologists/assistants, opticians and even physician assistants/nurse practitioners will be working side by side to meet the ever-increasing eye care needs of our growing and aging population.
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