Dry eye care navigates growing physician shortage
Click Here to Manage Email Alerts
An impending physician shortage has been hanging over ophthalmology for years. The aging population needs more eye care, but as ophthalmologists are aging with that population, there are not enough incoming physicians to take their place.
According to an analysis of HHS data published in Ophthalmology earlier this year, the total ophthalmology supply is projected to decrease by 2,650 full-time equivalent ophthalmologists, or 12%, from 2020 to 2035. Meanwhile, the analysis projected that total demand would increase by 5,150 full-time equivalent ophthalmologists, or 24%.
Source: Laura M. Periman, MD
The overall supply and demand mismatch of 30% workforce inadequacy by 2035 is projected to be different depending on the area. The study found that metro areas would have 77% workforce adequacy compared with 29% in nonmetro areas. Out of 38 medical and surgical specialties, the study projected that ophthalmology would have the second worst rate of workforce adequacy by 2035, trailing only thoracic surgery.
According to Healio | OSN Board Member Laura M. Periman, MD, the physician shortage is already being felt in dry eye care, and this is reflected in patient chat groups.
“They’re frustrated,” she said. “They’re not making the gains that they need. There’s still very stormy water amongst the patient chat groups, and I do everything I can to help steer the ship, but we need more hands on deck.”
Healio | OSN Cornea/External Disease Section Editor Preeya K. Gupta, MD, said dry eye patients can be particularly difficult to care for.
“When we look at our ocular surface disease patients, not all of them but some of them can be more challenging. Maybe they require more time and more advanced technology to fully treat their disease process. There’s just not as many ophthalmologists who want to necessarily take care of this patient population,” she said.
Dry eye care can be time-consuming and complex, and it requires a different approach than other ophthalmic subspecialties, Periman said.
“I get asked a lot about what my algorithm is, and I cringe just a little,” she said. “It’s not algorithmizable. It’s much more of a Venn diagram and systems-based analysis. It’s just a different way of thinking. It’s more expansive and integrative and less linear in a lot of ways. I think that might be appealing to certain folks who enjoy thinking of the bigger picture and understanding cause and effect.”
Challenges
Dry eye disease comprises a massive part of eye care. However, many physicians feel like they do not have the time or resources to adequately address it.
“Ophthalmology as a field realizes that ocular surface disease is highly prevalent,” Gupta said. “It’s important to treat, but we’re often heavily focused on surgery and how things are impacting our surgeries.”
Gupta said more ophthalmologists might be interested in treating dry eye, but the investment and dedication required prevent some from integrating dry eye care into their practice. In-office procedures to treat conditions such as meibomian gland dysfunction require devices that can be expensive, and the entire practice must be prepared to handle all the administrative procedures that come along with dry eye care.
“A lot of times we’re prescribing medications that require prior authorization, and a practice needs to be able to handle that burden that insurance companies have placed on us,” she said. “Not every office is set up to do those countless prior authorizations, as well as things like appeal letters. We’re doing this every year for every dry eye patient we have. There is a significant burden, and [practices may] prefer to refer patients to someone who’s capable and willing to advocate for those patients and help them.”
For many ophthalmologists, working on patients with dry eye, particularly advanced dry eye, takes time away from surgery. It is hard to balance the time needed to see these patients, according to Healio | OSN Technology Board Member Kendall E. Donaldson, MD, MS.
“You could probably see three typical patients in the time you need to see a dry eye patient,” she said. “Unless you are doing a lot of procedural-type care items, then it’s hard to not have it drain from the rest of your clinical function. I see a lot of dry eye patients, but it definitely takes a lot of extra time. I’m fortunate to have a dry eye technician who helps me do a lot of the procedures, and I have a couple of optometrists who help me as well. However, making it efficient is very difficult.”
Donaldson said advanced dry eye care can also be difficult to administer in an academic setting because it requires a lot of self-pay procedures and products that are better suited for fee-for-service practices.
Drumming up interest in dry eye care would be beneficial in an ideal world. However, Healio | OSN Board Member Darrell E. White, MD, said the needs of the larger ophthalmic community might not allow for that.
“We live in a world where there is something like 300 or 400 neuro-ophthalmologists for the entire country. And every single one of those ophthalmologists has two or three times as much work as they’re capable of doing, even if we only look at the most severe stuff,” he said. “I certainly agree that we need more people in dry eye care, but I am aware that, even in the comprehensive ophthalmology world, there are other needs.”
White envisioned a world in which each city, depending on its size, would have one champion of dry eye who could build a care network and take on referrals for patients in need.
“You’d be able to work in cooperative fashion and dramatically leverage the expertise, knowledge and willingness to take on complex cases,” he said. “I just don’t see comprehensive ophthalmologists and corneal specialists who have the option of spending their time in the operating room choosing to spend more and more of their time in the clinic behind the slit lamp talking to an unhappy dry eye patient.”
Meeting demand
Experts agree that the future of dry eye care is likely to involve the help of the optometric community. White said some practices are already leaning into this, particularly in areas that are underserved by ophthalmologists.
“There are some people who’ve been way ahead of this curve — Vance Thompson, Minnesota Eye — in places where the ratio of optometrists to ophthalmologists is something like 3- or 4-to-1,” he said. “That combined organizational structure is now becoming a bigger deal.”
White said more groups are hiring optometrists to do some of the medical eye care traditionally performed by comprehensive ophthalmologists. This can help extend the reach of each individual ophthalmologist, particularly in rural areas or areas where access to eye care can be limited.
“In those settings, in order to be able to expand access, those practices are now also taking on a combined MD-OD strategy so that you can increase the reach of the ophthalmologist,” White said. “The ophthalmologist will see the patient first, put together a plan and designate the optometrists to follow through managing the plan. It frees the ophthalmologist to take on more of the complex stuff on the medical side, and when you’re doing less on the medical side, that’s more time that you can devote to the surgical side of the practice.”
Gupta said optometric care can be a great option for patients, particularly those who do not have advanced dry eye. Although there is a clear need for more ophthalmologists to help treat the overwhelming number of dry eye patients, she believes that the optometric community will be a help.
“I have noticed an increase in the number of optometrists who are creating dry eye centers or clinical centers of excellence as it relates to dry eye, which I think is great because that’s going to help more patients get the care they need,” she said. “It could be that ophthalmologists end up shifting toward more of the severe and later-stage disease, and the early-stage disease might be picked up and initially treated by optometry.”
Donaldson said that Bascom Palmer created a virtual dry eye clinic to help ease the medical burden on ophthalmologists and guide patients through the process.
“Patients will go through the dry eye clinic with our optometrist before they can even get to see an ophthalmologist, where we make sure they’ve already exhausted all standard treatments for dry eye,” she said. “They go through a standardized series of questions. The optometrist gets all the baseline information of the prior treatments, and they start a baseline program. Once the patient has either succeeded or failed on that baseline program, which is a little more standardized, then they are triaged by the virtual program to whichever ophthalmologist might be most appropriate.”
Patients with advanced ocular surface disease can require complex care, and Donaldson said the virtual triage has helped streamline the process.
“It can be very complex involving three or four different doctors if they have advanced to that level,” she said. “But we’ve introduced more screening and baseline triage levels compared to what we used to have, which was becoming too time-consuming.”
Passionate care
The dry eye world has experienced a lot of advances in medical treatment options, with the potential for more targeted, specific therapies in the future. Periman sees that as a way to cut through the confusion and complexity of dry eye care.
“One of the best examples of direct identification and treatment is Xdemvy (lotilaner ophthalmic solution 0.25%, Tarsus Pharmaceuticals) for Demodex blepharitis,” she said. “Having more tools like that will help our younger colleagues effectively address some of the basics of dry eye care.”
Periman said dry eye has been difficult to treat because some patients respond adequately to immunomodulators and some do not. Now with more tools and knowledge about where and when to use therapeutics, patient outcomes and satisfaction are rising. She also sees potential for AI to play a part in dye eye care.
“Machine learning can take that complex patient input, history, lifestyle, all these multiple factors that lead to dry eye and learn from these subtle variations in dry eye presentation and risk factors,” she said. “You’re not going to have to do all this thinking ‘manually,’ like I currently have to do with every patient. It can offload the complexity and decision fatigue involved in each patient.”
Periman hopes that she can be an example to other physicians who might consider dipping their toe into advanced dry eye care. She said she understands that most ophthalmologists want to spend their time doing surgery, but focusing on treating dry eye patients can be a good opportunity to grow a business.
“Some people really love to do surgery, and that’s fine,” she said. “But their cataract reimbursement is a fraction of their potential in dry eye care. I worry that the younger generation is just being brought up to be cogs in the wheel. They’re not trained to look for other ways of doing medicine. I think that can be detrimental to mental health and lead to burnout.”
Periman said the pathway to partnership in traditional practices is not what it used to be due to changing economic models. In addition, the pressure on physicians to see more patients in less time is a perfect storm for a lot of dry eye to go untreated. Creating a dry eye specialty practice offers physicians the opportunity to take more control over their careers.
“When I was an employed physician, my pain point was that patients just needed more time,” she said. “But you can’t give them more time. You’ve got to see more patients in order for the practice to survive. For us, we just flipped the whole thing on its head and centered everything around the needs of the dry eye patient.”
“When you extract yourself from the insurance company abuse model, you get to be the doctor again, actually solve patient problems and enhance your satisfaction as a doctor.”
Periman said she was inspired by colleagues in primary care, cosmetic dermatology and oculoplastics to set up a direct patient care business model, which has allowed the practice to grow as a viable business while paying staff well and acquiring new technology.
“Hiring optometrists can be great career development for them, for sure, but I think that’s also missing out on the joy of doing it yourself. It’s fun when you get to understand these things on a new level,” she said.
Gupta said what makes her passionate about dry eye care is the patient population. In her experience, they are some of the happiest and most grateful patients she has worked with.
“They’ll say, ‘I’ve seen three doctors, and no one’s been able to help me,’” she said. “The dry eye or ocular surface disease patient who’s in that more advanced stage, you really have the ability to change the trajectory of their life.”
Gupta has seen patients who feel like they have lost the ability to be functioning contributors to society, and she has been able to turn that around.
“They feel like there’s no hope and there’s nothing that they can do to improve their situation,” she said. “When people ask me why I’m passionate, it’s because I think it can have a really strong impact on patients’ quality of life.”
White said it can be frustrating to fight against the perception that dry eye care is a loss leader in ophthalmology. In practice, the opposite can be true, he said.
“If you’re young, new to a city or to a group, and you show willingness to take dry eye seriously and do it well, you can become very busy very quickly,” he said. “When you make people who are uncomfortable with dry eye feel normal, they become raving fans.”
When White started a new practice, he marketed exclusively to dry eye patients. It turned out to be a great way to build relationships so people would come back when they needed other eye care services.
“We went from zero to 5,000 active patients in a year,” he said. “It took a couple of years before my surgical volume caught up to where it had been, but it didn’t take me 10 years.”
When people experience profoundly negative effects from dry eye disease, White said helping them is a great way to catch attention.
“The payback is that you get people who say really nice things about you, and they tell everybody about you,” he said. “It’s a wonderful practice builder, and the notion that it’s an economic desert is just not true.”
Click here to read the At Issue, “What is the most rewarding part about treating dry eye disease?”
- Reference:
- Berkowitz ST, et al. Ophthalmology. 2024;doi:10.1016/j.ophtha.2023.09.018.
- For more information:
- Kendall E. Donaldson, MD, MS, of Bascom Palmer Eye Institute, can be reached at kdonaldson@med.miami.edu.
- Preeya K. Gupta, MD, of Triangle Eye Consultants in Raleigh, North Carolina, can be reached at preeyakgupta@gmail.com.
- Laura M. Periman, MD, of Periman Eye Institute in Seattle, can be reached at dryeyemaster@gmail.com.
- Darrell E. White, MD, of SkyVision Centers in Westlake, Ohio, can be reached at dwhite@healio.com.
Collapse
Read more about
Click Here to Manage Email Alerts