Residents & Fellows Corner | Jan/Feb '17

Is Subspecializing Necessary?

Over the past several decades, ophthalmology has gone from having few subspecialists to nearly 50% of graduates now heading for subspecialties. Many trainees take this route because their mentors in surgical training recommend such a course. After all, if the mentor did it this way, wouldn’t it make sense to advise his or her pupil to do the same?

Specializing in medicine carries many positives. It is imperative for us to have subspecialists in our field. However, it is a falsehood that an ophthalmologist will be unable to survive without credentials of a subspecialty. Every trainee should carefully weigh the pros and cons of each approach before deciding which path to pursue.

As a comprehensive ophthalmologist, I have listed below some of the perceived risks I saw in becoming a subspecialist and the benefits that can be afforded by remaining comprehensive. (This list is not exhaustive, and certainly there are valid counterpoints for each claim.)

RISKS TO SUBSPECIALIZATION

No. 1: Reimbursement. If you subspecialize, it takes one movement from the government to change reimbursement for a certain procedure, putting your subspecialty in financial trouble. Take retina, for example. What would happen if the government changed the reimbursement classifications, and injections became merely like vaccines for the pediatrician (re: essentially profitless)? You could quickly be put in a serious crunch.

Further, as a subspecialist in this setting, you may be left with just the skills you have practiced in the past 10 to 15 years. Can you imagine trying to restart learning cataract surgery today if you stopped performing the procedure in 1998? Femtosecond lasers, intraoperative aberrometry, topography, posterior corneal astigmatism, toric IOLs, multifocal IOLs, extended depth of focus IOLs, image guidance systems, drops versus dropless regimens—the list of changes you would have to adapt to is basically endless.

No. 2: Competition. If you subspecialize, you most likely have to live in a heavily populated area. Competition will be tough, sometimes devastating. Although it seems exciting to grow and flourish in a large city, recognize that it can be difficult to break into the already-crowded markets. Additionally, travel to and from work is time you could better spend elsewhere, like at home with your family.

No. 3: Scope. If you specialize, you run the risk of becoming solely focused on your subspecialty. Understandably, subspecialists often cannot keep up with all of the current literature in the field due to their sharp concentration on their area of focus. This can sometimes be difficult for patients, as many want to go to their eye care provider for information about their entire eye. Can you imagine being a patient and seeing a corneal specialist one day for your Fuchs, glaucoma the next for your primary open-angle glaucoma, retina the next for your age-related macular degeneration, plastics the following for your ectropion, and then your comprehensive for your glasses and contacts?

BENEFITS TO REMAINING COMPREHENSIVE

No. 1: Fewer constraints. As a general ophthalmologist, you have the ability to perform any procedure you desire within the field. When the newest injectable cosmetic comes out, you can use it. When the latest microinvasive glaucoma surgery arrives, go for it. Laser cataract surgery? Give it a try. You don’t have the constraints of being limited to one surgical area. If novel procedures arrive in 2030, your basic ophthalmic surgical skills will still be sharp, enabling you to take advantage of all new technologies introduced.

No. 2: Higher volume. In my practice, a typical week consists of eight to 10 cataracts, one to two dislocated IOL or aphakic patients, four to five ptosis/blepharoplasties, one entropion/ectropion, one pterygium, and sometimes small cancer removals. You truly become the eye care provider of choice to help patients with any problem that arises. With your ability to perform different types of surgery, you become more marketable and can reach more patients in your area. Many will tell you that you can’t possibly be good at all of that. That could be true for some, but I argue that it is a rule that is not constant for everyone. Plus, boredom never sets in when you have to constantly challenge yourself with new procedures.

No. 3: Greater security. As mentioned above, the government can quickly stop pay for a certain procedure. This has happened many times in the distant and not-so-distant past—cuts on vitrectomy, cuts on cataract surgery, cuts on glaucoma surgery, no blepharoplasty up-charges with ptosis, and so on. We almost always receive cuts rather than raises in reimbursement. One way to survive long term is to ensure that your practice is diversified. (Wait, isn’t that an Edward Jones motto?) By doing so, you will have to have the ability to weather any storm posed by the Centers for Medicare & Medicaid Services. Oh, and don’t think for a second a subspecialist is immune to such cuts. The greater your ability to keep a diversified portfolio of surgeries, skills, and procedures, the easier it will be to not lose all the eggs in your basket.

SUMMARY

Subspecialization is great for some, but it is certainly not a requirement to a successful career in ophthalmology. Trainees should feel empowered to make their own decisions rather than simply following someone else’s lead. And there are certainly benefits to just being a simpleton.

author
Michael Patterson, DO
author
Jessica Ciralsky, MD | Section Editor
  • Assistant Professor of Ophthalmology at Weill Cornell Medical College in New York, specializing in cornea, cataract, and external disease 
  • jbc9004@med.cornell.edu; (646) 962-2020

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