EyeWorld Dialogue
Young physicians and residents discuss the business of medicine

ABOUT THE PARTICIPANTS

Moderator


Elizabeth A. Davis, M.D., is adjunct clinical assistant professor, University of Minnesota, Minneapolis. Contact her at 952-888-5800 or eadavis@mneye.com.


Parag Parekh, M.D., M.P.A., is fellow, Minnesota Eye Consultants. Contact him at pdparekh@mneye.com.


J. Bradley Randleman, M.D., is assistant professor of ophthalmology, Emory University, Atlanta. Contact him at 404-778-2264 or jrandle@emory.edu.


Sherman Reeves, M.D., M.P.H., is in practice at Minnesota Eye Consultants. Contact him at swreeves@mneye.com.


Jason E. Stahl, M.D., is assistant clinical professor, Kansas University Medical Center, Kansas City. Contact him at 913-491-3330 or jstahl@durrievision.com

Business of medicine

Elizabeth Davis: Let’s now turn to the business of medicine. At least in my experience during residency, I had pretty minimal, if any, training in the business of medicine. Like it or not, medicine is a business, and I didn’t get any sort of training in this area until I started my fellowship, then that accelerated obviously once I got into practice. What I would like to know is did any of you experience anything different during your residencies? Where do you see the deficiencies in this area, and do you think it’s necessary to provide any training in the business of medicine in a residency programs?

Dr. Randleman: I am in an academic institution, so I probably have a little bit different perspective than the rest of you in private practice, and my answer may sound a bit contradictory. I absolutely do think that it would be valuable to provide business of medicine education to residents. However, there are a couple of the barriers that prevent doing that in a substantial way. One is limited training time, which we have already discussed, and the other is more practical—I think that the real business of medicine is difficult to learn and appreciate until you are actually out there in practice making those decisions. I am not sure that residencies are necessarily the places best prepared to teach people about this. I think, in fact, that organizations such as ASCRS are much better prepared to teach young physicians about the business aspects of starting a practice

Dr. Reeves: The time pressure is certainly there, but as it currently stands, if there is any learning about the business of medicine, it often comes only sporadically and usually from corporate sources, and you become increasingly more hungry for that information as your training goes on and the “real world” of medicine draws closer. The first years don’t certainly care as much better as the third years do. I always felt that in my program, there was a really large untapped potential for injecting some sort of medicine economics training into our curriculum. The medical faculty members don’t always have much of the day-to-day business sense of medicine. However, Duke has a first-rate business school which could easily be a source of fantastic information on the business of medicine for the residents. With just a little bit of cross-pollination effort involving the business school faculty, it seems that some sort of formal curriculum could easily be established. You can’t have everybody get an M.B.A. during residency, even though that would probably be helpful, but it’s certainly in the best interest of the profession to train doctors to not only be clinically confident, but economically competent as well.

Dr. Parekh: We should define specifically what we mean by ‘the business of medicine.’ Typically, I think of it as economic aspects that range from understanding health insurance plans to coding and billing. I would actually submit to you that today’s residents are far better prepared than the previous generation in these types of issues. Academic departments these days are under tremendous financial pressure, and the chairman tells that to the faculty, and the faculty tell that to the residents, and this transforms the environment such that people are thinking and talking about these financial issues regularly. As long as it doesn’t get excessive, I think this is a good thing. Residents today do learn a good amount about these issues in a very informal kind of way.
Furthermore, in our resident clinics, oftentimes we have uninsured or underinsured patients, and we learn very rapidly that we cannot prescribe them the most expensive glaucoma medication, for example, because we know that they will simply not be able to afford those medications. I think we have a lot of understanding and knowledge of the issue—far more than our predecessors did. A lot of this information is gained in an informal manner, however. I think it is rare for residents to have a lecture on any of these topics, for example.
In my mind, the problem is that the complexities of the system have grown incredibly fast, much faster than our ability to keep up. We know and understand these issues twice as well as our predecessors; the problem is that the amount of information has probably grown by a factor of 10. So, we are still deficient in that we need to learn a lot more about it, but I think we are doing much better than the previous generation.

Dr. Stahl: I had absolutely no training in residency related to the business of ophthalmology, and I think there needs to be a place for this as everyone has mentioned, but how to do it is the problem. I think that the majority of this is going to be learned once you are out in practice. The American Academy of Ophthalmology [San Francisco] has developed a publication called The Profession of Ophthalmology, and I think within it they do have some basics of practice management. Introducing the topics of how to deal with insurance, licensing, risk management, and personnel management are helpful for residents as they enter their professional career.

Dr. Randleman: I’d like to emphasize one of the things that Dr. Reeves said. I think it’s such a fantastic idea, especially at universities that have the ability to incorporate their business program and some of their business teachers into their lecture curriculum, to do so in a structured fashion. It could be a very easy match and a nice way to get some fundamental information about business aspects that you could take out into your practice. I think that would be a fantastic idea for residencies to try to do when the opportunity allows.

Ethics

Dr. Davis: Let’s now turn to the topic of ethics. There are a lot of changes in the medicolegal climate and a lot of pressures in that area, particularly in the area of refractive surgery. So for each of you, given the current environment, how do you maintain a personal sense of ethics and what sorts of changes, if any, do you see coming down the line for ophthalmologist in this area?

Dr. Reeves: Speaking as a person who is just six months into practice, it’s a very different world in the real world than it is in training because the new element of money has been injected into incentives structure, which during training was never really there before, and suddenly, the cataract you’re looking at is not just something impairing the patient’s vision, but is also 500 bucks extra towards your bonus or partnership goal. So, of course we all do the ethical thing and only do what is the right thing for the patient, but you begin to see that the world is suddenly much more complex than it was in training

Dr. Stahl: We all went into medicine because we wanted to be physicians; we wanted to be healers; and we wanted to help people. These are still our guiding principles. For instance, when I counsel a patient on a surgical procedure, I just tell them what I would tell a loved one if they were in the chair. That makes it really easy in counseling a patient. My role as a surgeon is to tell the patient when surgery would be a benefit to them, not that it’s needed, but when it would be a benefit to them and give the patient a proper and informed consent and then let the patient decide for themselves if it’s the right time. I think that we all want to do the right thing for our patients.

Dr. Randleman: I believe the majority of ophthalmologists are ethical individuals, and I agree with what Dr. Reeves and Dr. Stahl said that in general, I don’t think that ethics are a major concern for the majority of ophthalmologists. However, looking especially at our field as opposed to some other fields, I think the real ‘ethical dilemma’ that faces us as practitioners is getting the real and correct information on the latest technology, such as premium intraocular lenses, to our patients, and helping them fully understand the risks and benefits of these technologies and procedures completely free of commercial bias. It is our responsibility as practitioners to make sure that we get the appropriate information on this technology and that we understand the sources of our information, and we also need to make sure we are performing the appropriate clinical trials to determine the real efficacy of all new technology that we have to offer our patients. That is the primary challenge that we face in cataract and refractive surgery.

Dr. Parekh: I like what Dr. Stahl said about picturing the patient as a family member and the advice we would give in that situation. I try to do the exact same thing with every patient.
My concern going forward is, as the issue of ethics gains more press coverage, what pressures and requirements will be placed upon the residency training programs from various regulatory bodies. I can imagine that there will be more requirements about ethics-related teaching—didactic lectures, etc. While this is a good start, simply attending a lecture about ethics certainly does not make a resident ethical. So, the requirement is fulfilled, but that probably won’t change behavior. Thus, the challenge is how do we teach residents to be ethical without simply creating additional burdens for program directors. Between all the requirements from the different regulatory committees and accreditation bodies, there is already enough paperwork that they have to deal with. That’s the interesting challenge going forward for our professional societies and our training programs.

Professional aspirations

Dr. Davis: Looking forward as cataract and refractive surgeons, what do you see for the future five, 10, and 20 years from now for you and the field in general? What excites you about the field, what keeps you motivated, and how do you see yourself shaping your practice? Also, how do you maintain a work-life balance, and do you see that emphasis changing amongst younger ophthalmologists versus older ophthalmologists? I think that’s important to consider because there is going to be a merging of these two generations in practices. The older ophthalmologists who are retiring are going to bring on the younger ophthalmologists who have different motivations and aspirations of how they view their careers.

Dr. Stahl: I really believe the future of refractive surgery is currently and will continue to be advances in intraocular lenses technology. I think we are doing great with our current presbyopia lenses, but I am excited to think about what I am going to be implanting 10 years from now. What I see happening, and this is actually already taking place in my practice, is that I am becoming what I consider a presbyopic surgeon. Early presbyopia can be initially treated with corneal refractive surgery with monovision CK or LASIK. As the natural lens continues to age, resulting in early nuclear sclerosis, we can perform a refractive lens exchange with presbyopia IOLs to accomplish four things: improved distance vision, improved near vision, eliminate cataracts from the future, and stablize the lens systems which will no longer age. Once a truly accommodative lens is developed, I believe the age of when we perform refractive lens exchange surgery will continue to decline. I think one day we will primarily correct refractive error with refractive lens exchange, where we will permanently correct the patient’s vision for rest of their life, and they won’t ever develop presbyopia or cataracts. I hope I get to see that in my lifetime, but I can certainly see a progression toward doing refractive lens exchange with these presbyopia lenses happening at an earlier and earlier age. There will always be a need for corneal refractive procedures. We have done a great job with LASIK and PRK procedures, and we can continue to improve them too.

Dr. Reeves: Echoing Dr Stahl, I think that there are going to be some exciting advances during our careers in presbyopia correction options. The current generation of presbyopic IOLs are just the tip of the iceberg, and I think this is going to be a really great ride for patients and surgeons alike as we finally conquer the challenge of presbyopia.
Regarding the work-life balance question, I think that this is an important issue for the young generation of ophthalmologists. I think both men and women alike are looking for full professional lives as well as full family lives today. There is inherently a tension there between these two spheres, as both require time and effort to be done right, and the balance occasionally gets out of whack, but I think my generation may see the picture a bit more through the balance lens, in general, rather than pursuing work at the exclusion of family. That being said, I think that the older generations of ophthalmologists should know that we young bucks are ready and willing to work very hard in our careers and continue to develop and grow the practices and profession that others have trailblazed for us.

Editors’ note: None of the physicians who participated in this dialogue have financial interests related to their comments.

The initial part of this EW dialogue was published in the May issue of EyeWorld.