BLOG: ‘How do I get your job?’ in subspecialty medical, surgical eye care
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This edition of the blog is directed primarily to optometry students and residents, although some experienced practitioners may find the content interesting.
For over 30 years, our referral center has been part of training of hundreds of current optometrists though externships, residencies and fellowships. It’s one of the most rewarding parts of our work. Occasionally, a brave student or resident will ask, “What would I need to do to be a strong candidate for a position at a medical-surgical referral center like Pacific Cataract and Laser Institute?”
Our first impulse is usually excitement: Obviously we think this is a rewarding and meaningful career choice. And we’ve written elsewhere about the future increasing demand for eye disease care.
In the past, optometrists in ophthalmology-optometry practices have usually provided vision and primary care. But the demand for refractive care will likely stay flat, and ophthalmology alone will not have the manpower to be able to meet the future increased demand for eye disease care. More eye disease will need to be managed by primary care ODs, but there will be more opportunities for optometrists to become subspecialty experts to work collaboratively in the same referral practices with retina, cornea, glaucoma and pediatric subspecialists. We have added many optometrists to our group in the past decade and we are not alone.
So, what’s the path to that kind of career? There are two categories for which we’ll provide guidance: professional credentials/skills and personal attributes. One really isn’t more important than the other. We’ll discuss this toward the end, but there is some practical commitment that can make it challenging — but not impossible — to return to a vision care-based primary care practice, so knowing yourself and your ambitions are important. Remember, these are just opinions and suggestions. I’m sure there are some out there who work in a practice similar to ours who took a different path.
Professional credentials, skills
In 2021, the completion of a residency is nearly as important as a Doctor of Optometry degree. It should be either an ocular disease or a hospital-based primary care concentration. There’s one exception. Anyone wanting to practice in a pediatric and adult strabismus referral setting would have better credentials completing a pediatric concentration, particularly a residency that provides strong exposure to perioperative strabismus care.
What is so special about a residency and why is it critical? Far from being another year of student externship, a good residency takes a newly graduated student who has never taken ultimate responsibility for a patient to a doctor with the ability to independently manage many complex problems that have risk. Perhaps the greatest difference between optometry school and residency is this: By the end of a great residency, a doctor has learned different decision-making skills and habits of learning to manage uncertainty, a somewhat foreign skill in optometry school and its emphasis on precise quantitative measurements, but always present in referral practice. Doctors don’t refer the easy and straightforward problems, but rather the ones for which they need help, often with greater risk to vision and occasionally even life.
In addition, a good residency teaches the language of medicine, how to speak to and understand nonoptometric physicians and other providers. Perhaps as important, a residency teaches how to work as a team, to learn to trust delegation of important tests and measurements to nurses, technicians and assistants. It’s not unusual for us to see 25 patients in a half day, a mix of post-ops, emergencies, ongoing medical care and new patients. It is impossible to do that without rewiring your concept of the optometrist’s role to one of quickly assimilating information gathered by others, perform an exam that’s limited to the problem and making a committed and confident decision.
The bottom line? Do a residency.
Personal attributes
A former Chief Justice once said that the U.S. Supreme Court was not final because it was supreme, but supreme because it was final. I think his point was that he and the members of his court had no specific skills or knowledge that set them apart from anyone else but that they had been granted supreme authority by both law and the people’s trust. Working in a referral center can often feel the same and can occasionally be a heavy burden. Managing a complex problem that may be vision and occasionally life-threatening and has also stumped a very capable primary care colleague is demanding and stressful. The pace is typically fast, and delegation and cooperation with nurses and techs is absolutely critical. Some feel invigorated by work with these heightened risks, consequences and excitement, while others do not. Most go into optometry to improve people’s vision with glasses and contact lenses. Make sure that’s something you’d be willing to give up.
While we have some patients with chronic disease who we follow long term, more often our care is limited in time but intensive. Our goal is always to return patients to their primary care optometrist as soon as they are stable. If your preference is to follow patients from cradle to grave, primary care may be a better choice.
Optometry often attracts independent sorts who prefer to work with little supervision and oversight. Coordinating care with many referring providers and surgeons requires humility and flexibility, learning and accepting that there are often several right ways of treating a condition. To be consistent and predictable when multiple doctors are involved in treating a case, our practice has medical policies that are expected to be followed. Most of us are employees and are not owners with ultimate say in business decisions. Some referring doctors have strong opinions on how they want their patients managed. Many of us went to optometry school to oversee everything and are hesitant to cede any control. But juggling many expectations so that the group runs smoothly as a whole can be rewarding, too.
The term leadership is one so overused these days that it’s almost meaningless. In our kind of work, it means much less about telling people what to do than it is to support them in any way possible. In our referral center, as in others that are similar, there is both the said and the unsaid expectation that our work doesn’t end in the exam room, but that we teach, speak, write and advocate for the benefit of optometry. All of us have a love of teaching in one form or another. One doesn’t need to be an extreme extrovert to do well in this kind of work, but embracing the roles in continuing education, lecturing, writing and research and professional society participation and leadership are expected because they develop relationships of trust and reliability. Not everyone wants to commit the extra hours and time away from home to do these things. Make sure you do.
We all want to be compensated fairly for our work. As nonsurgeons in a medical care-only practice, our value is based solely on revenue we can generate from exam fees and procedures, prices that are determined by payors. We have no glasses or contact lenses to sell. For those who are entrepreneurial and primarily business-oriented and who will be unsatisfied with any limits on earning potential, this line of work may be a poor choice.
With that in mind, your skills and experience will be financially rewarded. But, should someday you change your mind, narrow and deep expertise does not easily transfer to other forms of optometry where vision care with glasses and contact lenses is the foundation of success. Years away from refractive care means your worth and experience mean little. It’s not that it can’t be done, but relearning primary care is far from easy. Our advice is to look at this kind of work as a lifetime career commitment, understanding there will be less flexibility for relocating and fewer opportunities compared with primary care optometry.
So that’s the path — first accepting a residency and accepting opportunities to speak, write and participate in our professional organizations and societies. Should this match your interests and abilities, then go for it. The opportunities will undoubtedly be there.
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