Pearls in Ophthalmology

Volume 3, Issue 2 - July 2008

noreply@blogger.com (MedRounds Publications) — Mon, 28 Jul 2008 05:33:00 +0000

Editorial Board

Pearls in Ophthalmology welcomes our new Editorial Board.

Residency and Fellowship Pearls

Pearls for Starting Ophthalmology Residency By Don Sauberan, MD

Pearls for Starting a Fellowship in Corneal Refractive Surgery By George O. Waring IV, MD

OKAP Scores…What do I do with this information? By Chris Ketcherside, MD

Practice, Clinical and Surgical Pearls

EyePodVideo Channel on YouTube

Surgical Pearls for Strabismus Surgery By Aaron Miller, MD, MBA

Pearls for Professionalism: When in Rome, Do as the Romans Do By Craig Wilkerson, MD

Icing on the Cake: Pearls for Dress Attire By Rob Melendez, MD and Kris Gillian, MD

Pearls for Starting Private Practice By Michael G. Haas, MD

Opening a Private Ophthalmology Practice: Part I: Seven Pearls By Kathy A. Mayo, DO and George L. Mayo, MD

Health and Well-Being for the Ophthalmologist By M. Kelly Green, MD

Pearls for your Transition from Residency to the First Year of Practice
By Molly Ritsema, MD

Looking for a Job: Guide to Contract Negotiation for Ophthalmologists By Albert P. Lin, MD

Career Decision Making, Made A Little Easier By Jim Rienzo

What is a COA? COT? COMT?: Encourage your staff to become certified
By Anne Dwyer, COMT

Staffing Your Ophthalmology Clinic and Practice By Jane T. Shuman, COT, COE

Utilizing the Internet to Market Your Practice By Andrew Doan, MD, PhD

Question from a reader: Is Southern California Over Saturated with Ophthalmologists? By Andrew Doan, MD, PhD

Question from a reader: how to use the Akahoshi prechopper? By Rob Melendez, MD

PIO Grand Rounds

Neuroretinitis ? ? ? By Rob Melendez, MD

Announcements

Craig Wilkerson, MD (one of our PIO editorial board members) will be speaking at the AAO meeting: Reality 101: Real World of Ophthalmology.

Rob Melendez, MD Receives AMA Award (Submitted by Andrew Doan, MD, PhD)

Do you have an announcement to share with our community? Please send it to: editor@eyepearls.com

Photo Quiz

Can you name structures in the eye that have this hexagonal pattern?

Answer

Do you have a story, interesting article, or eye case? Submit your article to the editor.

Pearls in Ophthalmology is published quarterly and is read by hundreds of ophthalmology residents and ophthalmologists starting their practice.

Photo Quiz: Can you name structures in the eye that have this hexagonal pattern?

noreply@blogger.com (MedRounds Publications) — Mon, 28 Jul 2008 05:27:00 +0000

By Rob Melendez, MD

Photo taken with my cell phone (iPhone).

Answer:

The hexagon (mosaic, honeycomb) pattern is common to many epithelial
structures.

1. Corneal Epithelium
2. Corneal Endothelium
3. Lens Epithelial Cells
4. Retinal Pigment Epithelial Cells
_____________________________
Acknowledgement: Thanks to Bill Lloyd, MD (U.C. Davis, CA)

If you have interesting photos that resemble the eye, please send them to the Editor, and we will credit you for your creativity. editor@eyepearls.com

Craig Wilkerson, MD

noreply@blogger.com (MedRounds Publications) — Mon, 28 Jul 2008 05:19:00 +0000

Dr. Wilkerson attended medical school at the University of Wisconsin School of Medicine in Madison, Wisconsin. He completed a Postgraduate Research Fellowship in Ocular Pathology at the University of Wisconsin. Dr. Wilkerson completed his internship at Deaconess Hospital in Spokane, WA. He completed his residency in Ophthalmology at the University of Wisconsin, Department of Ophthalmology and Visual Sciences. Most recently, Dr. Wilkerson was in private practice in Spokane, Washington. He is married to Michelle Wilkerson and has five children.

Grand Rounds - Neuroretinitis

noreply@blogger.com (MedRounds Publications) — Mon, 28 Jul 2008 05:14:00 +0000

By Rob Melendez, MD

Download the high resolution slides and follow along with the presentation.

Question from a reader: how to use the Akahoshi prechopper?

noreply@blogger.com (MedRounds Publications) — Mon, 28 Jul 2008 05:09:00 +0000

By Rob Melendez, MD

This was a question from one of our readers:

Recently I saw your video on-line regarding the Akahoshi prechopper. I had a few questions regarding the procedure. How deep are you going on the prechopper? If a surgeon uses this on a borderline 1+ to 2+ lens, what would they generally see if it’s a bit gummy? Finally, are you completely eliminating the sculpt and going straight to quadrant removal? Would you ever recommend a bit of sculpt and then prechopping (e.g. 3++ NS). Thank you for your time and consideration. I appreciate the shared knowledge and any further expertise you may share.

Thanks for your email. The Akahoshi prechopper is best used for 2-3+ NS. The 1+ NS is too soft for this instrument. The depth is about 60%. I am eliminating the sculpt mode. This technique cuts down on the phaco time. Once the 4 quadrants are generated, they are easily removed. I also perform a hydrodelineation in addition to the hydrodissection. The hydrodelineation provides additonal protection.

Thanks,
Rob Melendez, MD

Question from a reader: Is Southern California Over Saturated with Ophthalmologists?

noreply@blogger.com (MedRounds Publications) — Mon, 28 Jul 2008 04:57:00 +0000

By Andrew Doan, MD, PhD

This was a question from one of our readers:

I am interested in working as an ophthalmologist in Southern California. Is Southern California over saturated with eye surgeons?

People want to live near large cities. Great restaurants, professional athletics, and culture are some benefits of living near a big city. However, young physicians will pay a price when seeking practice opportunities near large cities where there are established ophthalmology practices. In the San Diego area, for instance, ophthalmologists may perform 4 to 6 cataract surgeries a week. However, moving one hour away from San Diego in a growing city will allow you to perform 8 to 12 cataract surgeries a week. Although living in a growing city may not be ideal as you'll be farther away from city amenities, you'll make more money and the cost of living will also be significantly lower.

I've always encouraged residents to seek job opportunities in areas where other physicians do not want to live. The fastest growing and busiest practices are located in towns where there is a population of 100,000 people living in an area away from major cities. If you want to live in Southern California, then look for growing areas where people are forced to move because of rising housing costs.

However, you’ll have to determine if you’re willing to give up the conveniences of living near the city for increased practice volume. This is a personal question that only you can answer. Keep in mind that being financially strapped to live in a major city can be quite stressful and lower your quality of life. On the other hand, living further away from the city may result in a lower quality of life that money cannot compensate for.

Some job hunting and building a practice pearls:

1) Ask yourself if you want to work for a paycheck or be an entrepreneur in private practice. If the appeal of a stable paycheck is irresistible, then settle for lower income and work for a hospital, Kaiser, the military, or university hospital. However, if you want to maximize your income, then look for a private practice position where your income is dependent on how many patients you see and how many surgeries you do. Successful private practice ophthalmologists have entrepreneurial drive.

2) If your entrepreneurial drive is strong, then consider taking out a business loan and starting your private practice. Call existing practices and ask how long will your mother wait before she can have cataract surgery? If the doctor can see her in a few days, then don't consider practicing in the area. If there is a month wait, then open your practice across the street.

3) Research the demographics of the areas you're considering working as an ophthalmologist. Find out the number of patients over 65 years of age, the prevalence of specific diseases, such as diabetes, and the number of ophthalmologists serving these patients. Pick the areas with the highest patient to ophthalmologist ratio.

4) Get to know and contact the local pharmaceutical sales team, particularly the surgical representatives. They will have numbers on the volume of supplies used for different areas. They may have good advice on how to setup your practice as they have incentive to see you busy.

5) Build relationships with physicians and optometrists in the area. Assure optometrists that you'll return patients to them after surgery and let the optometrist prescribe the post-cataract surgery glasses. In medicine, remember to treat others the way you want to be treated.

6) Give local internal medicine and family practice doctors business cards to give to their diabetic patients for diabetic examinations.

7) Offer to take call for local hospitals.

8) Learn the billing requirements for insurance companies and setup accounts with the companies.

9) Learn coding, billing, and accounting. This will assure that you're paid for your services and keep you out of federal prison for fraud.

10) Ethics will keep you happy and your patients healthy and content. Do no harm, be honest, and practice impeccable ethics.

In summary, while there are many ophthalmologists working in Southern California, consider working outside of the major cities. There are rapidly growing areas with increased demand for ophthalmologists. These growing areas provide the best practice opportunities and income potential for young ophthalmologists in private practice. If city living is important to you, then be prepared to accept lower income to live in or near a city.

Utilizing the Internet to Market Your Practice

noreply@blogger.com (MedRounds Publications) — Mon, 28 Jul 2008 04:46:00 +0000

By Andrew Doan, MD, PhD

The Internet is a powerful tool to reach out to your patients. Utilize the Internet to market your expertise and services. When used effectively, Internet marketing increases your patient referrals, maximizes your return on investment (ROI), and is cost effective.

This article discusses pearls to help you get started in marketing your medical practice on the Internet.

Pearl #1: have a professionally designed website for your practice. Your website is your electronic business card. A professionally designed and graphically pleasing website conveys professionalism, expertise, and value.

Pearl #2: organize your website into basic pages, such as a homepage, frequently asked questions, contact, practice information, and landing pages for specific services. There should be a universal navigation bar to allow access to any web page from every page.

Pearl #3: use Google Adwords to have common search terms lead potential patients to your landing page. Google allows your practice to place your ad in the "sponsored links" areas on news websites, blogs, and on Google search results. You only pay for clicks that bring patients to your landing page. You also set your monthly budget so that you can invest as little as you want or as much as you want for online advertising. If this form of marketing works for you, then increase your monthly budget. The cost-per-click (CPC) depends on the search term and how much your competitors are bidding for the same search term. For instance, the term "LASIK" may cost on average $5.00 per click. If you budget $1000 per month, then you may receive 200 patients to your site. Once you get the patient to your landing page, the page should captivate and encourage patients to request more information. If you recruit one percent of the visitors to your site as new patients, or two patients, then you will more than pay for your $1000 per month investment in Google advertising. With GeoTargeting (a service included in Google Adwords), only internet users in your area will see your ads; thus, this increases your number of potential patients.

Pearl #4: the landing page should be divided into two main columns with a professional and graphically pleasing layout. In the left column, consider streaming a professionally produced 30 second video about you, your practice, and your medical service. People prefer watching and listening to a video than reading a sales pitch. In the right column of the landing page, place a form for patients to contact your practice for more information.

Pearl #5: follow-up with all leads. Call the patient and send them a personalized letter. Enclose a brochure and information booklet for reference. The key is to follow-up all leads on the internet with a phone call and personalized letter.

The internet is one of the most cost-effective ways to market your practice. Use it to your advantage.

Looking for a Job: Guide to Contract Negotiation for Ophthalmologists

noreply@blogger.com (MedRounds Publications) — Mon, 28 Jul 2008 04:44:00 +0000

By Albert P. Lin, MD

Looking for the first job as an ophthalmologist can be a daunting experience. While we have had guidance on how to perform surgery and take care of patients, most of us have not had a lecture on how to get a job. This article will focus on the later portion of this process and provide you with the basic framework of an ophthalmology contract to join an existing private practice.

Salary and contract are rarely mentioned during the initial interview, whether over the phone or in person. These topics should be broached by the practice, not the perspective employee. Once the practice is sufficiently interested in you as a candidate, they will likely ask you how much salary you are expecting and whether you are interested in becoming an associate or if you will eventually want to become a partner in the practice. Once an oral agreement is reached here, a formal detailed written contract will be sent to you for your review. You and your lawyer can negotiate the terms of the contract until an agreement is reached between you and your future employer. Once you sign your contract, you will be on your way to becoming a practicing ophthalmologist!

A list of some of the more important aspects of the contract is as follows:

1. Salary: the annual salary can vary widely based on geographic location. Generally, large cities and desirable living areas will command a lower salary. For example, in Los Angeles, starting salary can vary from $90,000 to $200,000. A good starting salary in a large city such as Los Angeles will be $120,000 to $150,000 for a comprehensive ophthalmologist or an anterior segment specialist. Retina specialists will command a higher starting salary. In rural areas, salaries can start as high as $250,000.

2. Status: associate vs. partnership option. Some practice may seek permanent employees called associates. As an employee, you do not need to worry about running the practice or collecting the bills. You receive a salary along with a production bonus. Most of us eventually want to become a partner in a practice to share in the income of the entire practice. Most practices will want you to work as an associate for 1-3 years before allowing you to buy into the practice. Buy-in option can be included but the specific buy-in terms are not specified in the initial contract. After you have worked well with the existing partners for a few years, you will then be expected to buy into a fair share of the practice to become a partner. For example, as the 4th partner to join a practice, you are expected to pay ¼ of the value of the practice. If the practice is valued at $2 million, you pay $500,000 to the first three partners (usually divided over a number of years taken out of your salary). The practice can be valued from 1-2.5x the annual practice income. The buy-in can also vary depending on whether the practice owns the office, land, or the ASC. It is not customary to examine the books until just before the buy-in. The best way to determine if the buy-in will be fair will be to speak to the last 2 people who joined the practice and to find out whether people have left after working 1-2 years on the partnership track. Partners also divide the income in different ways- production bonus vs. profit sharing. A practice that has the profit sharing model (less common) will likely have a fair buy-in. Lastly, it maybe more difficult to negotiate a fair buy-in with a solo-practitioner who has built up the practice over many years.

3. Production bonus: a fair production bonus will be 30-35% starting at 2-3x base salary. If your starting salary is $150,000 and your production bonus is 30% at 2x base and you bill $450,000 the first year, you will get a bonus of $150,000 x 30% = $45,000. When looking at production bonus, you need to be realistic about whether you can achieve the bonus. A practice where an older partner has left and needs you to take over his or her patients right away will likely allow you to bonus. A practice that is only booked out 1-2 weeks ahead will not likely allow you to bonus.

4. Vacation: two week vacation is standard in most contracts. You may also get 1 week for CME and national meetings. Vacation time will gradually increase in most practices. Some practices allow some flexibility, such as allowing you to work and take less vacation for more income or vice versa.

5. Call: this is something many people overlook when considering a practice. While most of us have no problem covering our own patients, the potential pitfall here is covering ER, trauma center, and hospital consults. The ideal situation would be for you to operate at an ASC and be privileged at only one hospital (for your sicker patients). However, some practices may have privileges at 3 hospitals and one of them may have an ER and the other maybe a trauma center. This means that in addition to taking call to cover patients in your practice, you will also be asked to cover ER and trauma (open globes) and see hospital consults. Make sure you understand the call structure before you commit yourself.

6. Malpractice insurance: as a starting ophthalmologist, your premium will be graduated. This is important because you want your practice to provide tail coverage in case you decide to leave the practice. For example, as a starting ophthalmologist, your first year premium is $3,000 and it increases by $1,000 per year to $8,000 after 5 years. If you decide to leave the practice after 1 year and your employer does not provide tail coverage for you, you will have to start at $8,000 at the next practice, making you a much less attractive employee. If you have tail coverage, you can start at $3,000 again. If you stay with the same insurance company, this does not apply and you will graduate to $4,000. However, it is difficult to guess whether the next practice will be using the same insurance company.

7. Disability and health insurance: I encourage physicians to buy personal disability insurance as most practices purchase policies that cost less and cover less as well. Practices generally allow physicians to choose the best health insurance policies available to the practice (may not be the same for other non-physician members of the practice). Examine the types of coverage you will be able to obtain and whether you will be able to cover your family if necessary.

8. Restrictive covenant: if you decide to leave a practice, your contract can specify a certain range (i.e. 5 miles from the practice) within which you cannot practice ophthalmology. Be sure to work with your lawyer to determine what the appropriate range is. For example, in Manhattan, the range maybe 2 city blocks. On the West Coast where cities are more spread out, it is usually indicated in miles. Make sure the clause also specifies distance measured from which office(s). If a practice has 1 main and 2 satellite offices, a 5-10 mile radius from each office can cover the whole city!

There are many other finer points to negotiating a contract. Hopefully, this article has provided you with some basic guidelines to help you ask the right questions as you start interviewing for your first job. Perhaps the most important aspect to contract negotiation is to get yourself a good lawyer- ideally this person looks out for your best interest and is experienced in working with ophthalmologists.

Staffing Your Ophthalmology Clinic and Practice

noreply@blogger.com (MedRounds Publications) — Mon, 28 Jul 2008 04:40:00 +0000

By Jane T. Shuman, COT, COE

Congratulations! You have just completed your residency in ophthalmology and perhaps even a subspecialty fellowship. You have joined an existing practice, agreed to succeed a retiring ophthalmologist, or are about to hang out your own shingle. You have been busy credentialing with the various health insurance plans, buying office equipment and other bare bones necessities. Now it’s time to turn your focus to staffing your clinic.

As you know, ophthalmology is different in many ways from much of medicine. The responsibilities given to ophthalmic assistants are one such variation. Not only do technicians take vital signs (vision and pressure), but a detailed history and accurate ancillary tests will help the ophthalmologist diagnose or monitor progression of eye disease. In many practices, the eye care provider also reviews and issues the manifest refraction performed by allied health personnel. Over time, the ophthalmologist learns to trust the data in the record and finds himself repeating tests less frequently.

According to the Census Bureau, the population is aging as the Baby Boom generation reaches maturity. It is predicted that there will be over 46,000,000 seniors (age 65 and older) by 2015 and over 54,000,000 in the year 2020. Not only do we need additional ophthalmologists and other doctors to address the increase in health problems, but those eye doctors will need additional staff to work up this volume of patients in an efficient manner.

To date, there are approximately 30,000 ophthalmic specific allied health personnel in the United States, half of whom hold certification as an assistant, technician or medical technologist. There are a limited number of accredited programs in Ophthalmic Assisting. Currently, there are no mandates regarding certification or licensure as clinical staff works under the license of the ophthalmologist. Your signature validates the findings documented by your staff.

Because of the increasing shortfall of experienced personnel, more and more practitioners are training staff personally. This is the time to do so since it is unlikely you will have a full patient load from the get-go. Although this will require a great deal of effort and planning, the rewards are numerous: loyalty and appreciation cannot be measured. The new hire is taught “your way”; there is no need to unlearn or relearn bad habits. If you hire someone with the interpersonal skills and other attributes for which you are looking, he or she should be able to learn the skills necessary to perform.

So how and where do you find this person? Ideally, you want to hire someone with health care experience. It might be a medical assistant, LPN, or a receptionist with outstanding follow through and attention to detail. If you are in an area with a community college or other educational institution, speak with the Career Services Department. At some point in time you might even consider becoming an internship site for medical assisting students. Craiglist.org and other internet resources seem to draw a greater number of respondents than traditional want ads. They are usually more economical, as well. If computer expertise is an important factor (i.e., the integration of an electronic medical record), the online postings will likely satisfy that requirement.

Once you have hired the trainee, assume they know very little about eyes and begin with the foundation. It is helpful to provide him or her with a copy of “the Ophthalmic Assistant”, available through the American Academy of Ophthalmology. This is also the recommended text for the Home Study test, a precursor to certification. Use three-dimensional visuals to demonstrate physiology and pathology.

The new hire should be provided with a list of commonly used ophthalmic abbreviations, so you and he/she can speak the same language on paper. She needs to become familiar with the forms you use and ocular triage before she can begin helping you. Once you are ready to begin, assuming the patient load is still light, work together. Just as in medical school, you watched before you performed and later instructed, the processes in the office should be similar.

Once you are satisfied with her histories and vision, progress to ancillary testing. Provide the rationale for the various tests, such as confrontational fields, Amslers and pupils. Verify that she is performing them accurately before you allow her to “go solo.”

Your new clinical staff may need encouragement to ask questions. Don’t forget to close the loop and explain interesting cases, particularly those she participated in. Have her look in the slit lamp as you progress. After all, a picture is worth 1,000 words.

Together, you will grow your practice and she is likely to instruct future new hires.

###
Jane T. Shuman, COT, COE
Eyetechs
71 Commercial St
Box 277
Boston, MA 02109
p: 617-314-6400
f: 617-367-5964
http://www.eyetechs.com/

Jane T. Shuman, C.O.T., C.O.E., President of Eyetechs, Inc., is a nationally recognized authority on clinical flow, scheduling and technician education. She worked in a high volume ophthalmology practice for over fifteen years and founded Eyetechs Inc. in 1999.

During her work as an Ophthalmic Technician and Clinical Manager, Shuman has seen first hand the many important issues confronting today’s busy ophthalmology practices. Based on her past experiences, she has learned the importance the proper schedule and competent technicians have on efficient patient flow and practice revenue.

Jane has taught countless seminars on the integral aspects of today’s busy ophthalmic practice including at many annual conferences of both the American Academy of Ophthalmology and the American Society of Ophthalmic Administrators. Jane is the current Director of the Nursing and Allied Health Program of the Royal Hawaiian Eye Meeting and has served as the Director of the Massachusetts Society of Eye Physicians and Surgeons Technician Training Program, helping to earn the 2002 AAO Star Award for Programs for Ophthalmic Administrators and Technicians. She has served on the Board of Directors of the American Society of Ophthalmic Administrators.

She has published numerous articles can be found in many publications such as Review of Ophthalmology, Administrative Eyecare, Ophthalmology Management and Eyeworld. JCAHPO approved online courses can be found on the Allergan Access website at http://www.bsmconsulting.com/.

What is a COA? COT? COMT? Encourage your staff to become certified

noreply@blogger.com (MedRounds Publications) — Mon, 28 Jul 2008 04:38:00 +0000

By Anne Dwyer, COMT

Obtaining certification as an ophthalmic allied health professional is a significant achievement. In ophthalmology, we are fortunate enough to have the Joint Commission of Allied Health Personnel in Ophthalmology (JCAHPO) as the regulatory agency overseeing certification. This organization certifies individuals as certified ophthalmic assistant (COA), certified ophthalmic technician (COT), certified ophthalmic medical technologist (COMT), and corporate certified ophthalmic assistant (CCOA). The agency also certifies registered ophthalmic ultrasound biometrists (ROUB) and ophthalmic surgical assistants.

In order to achieve certification, ophthalmic medical personnel must either graduate from a formal ophthalmic assistant program or perform a specific number of hours of on the job training, under the direct supervision of an ophthalmologist. Once a candidate has satisfied these requirements, he or she may apply to take a written test. For COT and COMT certification, both a written test and a practical exam are necessary in order to achieve certification. In order to maintain certification, ophthalmic medical personnel must earn continuing education credits, which must be JCAHPO approved. More credits are required at the higher certification levels.

Certification as a registered ultrasound biometrist shows that an individual possesses extensive knowledge and skills in ophthalmic ultrasonography. Ultrasound biometrists perform both A-scans and B-scans. They are responsible for accurately measuring axial lengths prior to cataract surgery, as well as performing diagnostic A-scans. They also perform B-scans, allowing physicians to diagnose ocular tumors, retinal detachments, vitreous hemorrhages, and a variety of other ocular conditions. Ophthalmic surgical assistants must possess a comprehensive knowledge of ophthalmic surgical procedures, surgical instrumentation, and operating room sterile technique.

As a physician or practice manager, it is essential to encourage ophthalmic medical personnel to achieve certification. It takes many hours of study and a practical knowledge of ophthalmic testing in order to become certified. Technical staff who strive for this certification gain knowledge of optics, pharmacology, ocular anatomy and physiology, visual fields, and many other aspects of ophthalmology, and become invaluable to a practice. With this knowledge, they become more skilled in obtaining patient histories and performing appropriate testing in order to assist the physician in arriving at a diagnosis. The value of skilled ophthalmic technical personnel cannot be underestimated. They help assess best corrected visual acuity, pupillary function, color vision, peripheral vision, and perform a host of other essential ophthalmic tests.

In order to encourage technical staff to become certified, ophthalmic practices should offer attractive incentives. These can include monetary bonuses and pay rate increases, along with reimbursement for certification testing fees. Non-monetary incentives may include company recognition, such as displaying employee certifications on a “wall of fame” within the organization.

Certification gives ophthalmic technical staff pride in their jobs. It enables increased physician productivity and efficiency, and tells patients that the practice employs highly skilled workers who care about their profession. There are many resources available to help ophthalmic staff prepare for these exams. JCAHPO has many education tools, including an on-the-job training kit for ophthalmic medical personnel, certification study guides, flash cards, and continuing education quizzes. Slack books has an entire bookshelf of valuable books, including Optics, Retinoscopy, and Refinement, Ophthalmic Medications and Pharmacology, the Slit Lamp Primer, and A Systematic Approach to Strabismus, along with many other topics. Educational resources are also available through the Association of Ophthalmic Technical Personnel in Ophthalmology (ATPO).

Career Decision Making, Made A Little Easier

noreply@blogger.com (MedRounds Publications) — Mon, 28 Jul 2008 04:34:00 +0000

By Jim Rienzo

“It was probably the hardest decision I’ve had to make in my life.”

I heard that comment from a friend and former ophthalmology resident when he was coming out of residency and deciding whether to take a “good” position at a private practice or follow his heart and accept the cornea fellowship he always wanted. I empathized with him, knowing he was saddled with significant loans and really felt he needed to begin seeing patients and start earning an income. It was, indeed, a very tough decision to make!

Such a decision is just one of many that young physicians have to make as they leave medical school: what specialty should I choose, which residency program is right for me, should I accept a fellowship, should I enter private practice?

To help with the decision-making process, I have compiled a number of “peer success tips” I think will help young physicians navigate the challenging career-path process.

Get to know yourself. Make the time necessary to really understand your wants and needs. Try to find out what will make you happy. If, for example, being happy at work is more important than maximizing income, move that up your list of critically important factors.

Use your resources. Remember the people you meet along the way. Keep a list of people you meet in the profession whom you think might be able to help you later on. You never know when you may need them … or they may need you. Keep in touch with people you meet in the profession.

Be flexible. Life throws a lot of curve balls. Be ready for whatever comes your way, both personally and professionally.

Explore all options. You never know what opportunity is going to present itself … or when. Only by exploring all options are you able to determine with any degree of certainty that you are making the right decision. Find out what’s being offered out there.

Don’t close any doors. One new physician said he honestly did not know he was going into academic medicine until mid-way through his fellowship, but he had not closed any doors. He pursued private practice opportunities, and the interview experiences proved extremely valuable. They helped shape his decision to go the academic route. If he hadn’t experienced the private practice job search – the interviews, the offers, the whole nine yards – he said he would not have been so sure that the academic route was the right route.

Create a five-year window. Clearly decide what you want to do and what you want your world to look like in five years. Try to get a broad sense of what you want. Set a life master plan.

Prioritize your work/career. Try to understand that your “medical career” is something that you do when you are not practicing life. What you want in life should dictate what you do with your profession, i.e., where you work, what you specialize in, where you live, etc.

Have a sense of self-awareness. Understand what the decision matrix is going to look like when you are not practicing medicine. Try to understand how everything fits – the life, the spouse, the family, the relatives, etc.

Use common sense. Understand what you want and what is important to you (and your family). Be honest with yourself and set realistic expectations. Then look closely at each situation. Is it a compatible situation? Will this opportunity meet your needs and desires? Look at the intangibles that are important to you. Do your due diligence.

Determine your limits. What are you willing to do or not do in order to be happy with your work situation? You only get one chance at life; you want to be happy.

Whatever your “next” choice is regarding your career, these tips will help you frame a better plan of action when it comes time to putting pen to paper. For more “peer success tips” log onto the Future Focus® website and click on Peer Experiences.

###

Jim Rienzo is a Senior Eye Care Business Advisor with Allergan, Inc. He lives in Smithtown, N.Y. Contact him at rienzo_james@allergan.com.

These are a small sample of just a few of the resources available through the Future Focus® website, which also offers extensive coverage of contracting norms and negotiation, considerations for fellowship opportunities, detailed instructions for determining the viability of a solo practice, and many more tools.Current members can sign in through the link below. If you’re not a member, you can use that same link to register, allowing you full access to this invaluable information at no cost.Good luck! And let Future Focus® help you make the decision that’s best for you!

Pearls for your Transition from Residency to the First Year of Practice

noreply@blogger.com (MedRounds Publications) — Mon, 28 Jul 2008 04:29:00 +0000

By Molly Ritsema, MD

So you’ve finished residency, ideally taken a long vacation, and now you are about to start your first year of practice. Here are a few tips to ensure a smooth transition:

1. Get oriented: It can be unsettling to find yourself in an unfamiliar environment when beginning your first job. Even if your practice doesn’t schedule an official orientation, try to spend some time in each of your colleagues’ clinics during your first few weeks of work. Not only will you be able to match faces to names, but you’ll observe clinic flow, basic charting and billing, and different personalities and management styles. Your colleagues and staff are a wonderful source of advice on everything from patient management to local housing – get to know them!

Orientation to the OR and ER is essential, and you’ll likely have an interview at the hospitals where you’ll have privileges. Take advantage of this time to find out the policy on case supervision, how to book a case for the OR after hours, how to use the computers, and where to park – don’t wait until you’re called into the hospital in the middle of the night.

2. Find a mentor: This is invaluable. It can single-handedly change your first year of practice from a harrowing to pleasant experience. Sit in on your colleague's cases initially – again, this eases you into your new surroundings – and then add a few of your own cases. Having an experienced surgeon at your side -- pointing out areas for possible improvement -- can make the transition from residency to private practice much less stressful and will certainly make you a better surgeon. It is also helpful to spend some time in your mentor's clinic, learning how he or she evaluates and counsels patients.

3. Build your practice: So now you’re oriented to your new practice and have found a mentor. Chances are, you’re not coming to work and encountering a waiting room full of patients. Make the most of your down time by volunteering for vision screenings or attending health fairs on behalf of your practice. This is a nice way to provide a service to those in need, while simultaneously getting your name (and your practice’s name) out into the community. Also, set aside time to introduce yourself (in person) to the physicians and optometrists in the area. Make sure they can get in touch with you easily by leaving your contact information.

Hopefully, these suggestions will ease your transition from resident to an attending physician…Best wishes!

Health and Well-Being for the Ophthalmologist

noreply@blogger.com (MedRounds Publications) — Mon, 28 Jul 2008 04:27:00 +0000

By M. Kelly Green, MD

As physicians, we routinely counsel patients on the benefits of exercise and healthy eating habits. For the most part, among physicians as a group, as eye surgeons we have the serendipity to have time and theoretically energy to devote to the promotion of our own physical and mental well-being. We have schedules which can allow us time to go to the gym, and eat on a regular schedule even when at work. This section of PIO will be devoted to topics concerning our ongoing battle to stay fit and healthy as ophthalmologists.

There is much discussion regarding the benefit of regular aerobic exercise. Generally, we accept that exercise helps you live longer by reducing your chance of death from causes other than just heart disease, such as colon cancer. We will explore this area of research here in PIO.

The topic of ergonomics in our workplace in particular has begun to be examined in the scientific literature. We will review current literature evaluations of causes for ergonomic error, and ways to avoid these career-shortening problems. Since we will have a longer life expectancy than any generation precedent to use, we will likely be working into our eighth decade of life; avoidance of repetitive-motion musculoskeletal injury will be critical.

We welcome contributions to this section, and we hope that you find it refreshing and enlightening.

If you have an interesting article to share about health and fitness, then please email: editor@eyepearls.com

Opening a Private Ophthalmology Practice - Part I: Seven Pearls

noreply@blogger.com (MedRounds Publications) — Mon, 28 Jul 2008 04:21:00 +0000

By Kathy A. Mayo, DO and George L. Mayo, MD

It is with great privilege for us to be engaged in the stimulating, challenging and intellectually rewarding field of Ophthalmology. Transitioning into a private practice can be an overwhelming experience. In an ongoing series we will be examining aspects of the process of opening a private ophthalmology practice. In this article we present seven pearls from our own experience in opening a private retina practice.

1. Join a club, join a second club, and then another club. This is important advice. We recommend joining a local social club, such as a Yacht Club or Country club. Although memberships can be pricey, the contacts will be invaluable, both is setting up your initial team of experts, outlined below, and ultimately in growing your practice. Also join your local medical and ophthalmology societies, as well as the Chamber of Commerce for your cities and adjacent cites.

2. Do not underestimate the amount of room you will need. It’s tempting to economize on space, but you have to be ready to spend 5 years in your initial location. During that time you will be adding staff as your practice grows. Extra rooms can become additional imaging or procedure suites that will optimize your efficiency. While purchasing or building office space is a good long-term goal, renting the first office makes more sense. Renting can minimize both risk and requisite capital. In today’s market and in most regions of the country, you can negotiate aggressively for office space rentals. We recommend allowing your attorney or real estate agent to handle the negotiations for you.

3. Don’t try to go it alone. Highly educated, intelligent people often feel that they don’t need to hire someone to do something that they can “figure out” on their own. While this is undoubtedly true and can often be the best course if you are trying to complete a particular task, it is a mistake to take this route when opening a practice. You will literally be following a hundred different paths simultaneously and need a team of experts, not to get you out of trouble but to keep you from getting into trouble in the first place. Each member will need to be vetted, but ultimately you will need an attorney, an accountant, a practice consultant, a banker, an insurance agent, and an information technology consultant.

4. Get an iPhone. Opening an ophthalmology practice is perhaps the ultimate exercise in multitasking. We believe that there is no better product available to help you do this than an iPhone. There won’t be any time to waste, and with email, the web, and your contacts in your hand you will get things done much faster. We estimate that the iPhone has quadrupled our efficiency during the startup period.

5. Order business cards. Once you have decided to open a practice, go ahead and start designing your cards. If you’re artistic, go ahead and draw out what you want. If graphic design is your thing, go for it. If you’re going to struggle for hours, hire a designer/graphic artist to do it for you. If you start early, then you’ll only have to have your address and phone number inserted once you get them. This way, you will have the cards ready when you need them.

6. Do not apply for Medicare. This sounds like the wrong advice, but the reality is that Medicare wants you to wait until you start seeing Medicare patients, and then apply. Once you are seeing patients, then you start the application process, which takes about four months to complete. You save all claims and submit them once you are approved. Medicare will accept claims for up to one year during your initial start up.

7. Do not underestimate the magnitude of the task. Opening a practice can sound easy. One of my professors told me, “Just open the door and patients will start showing up. I don’t know anyone that’s ever failed doing this.” Sounds great, and opening the door is the last step, but there are ten thousand steps that precede this. It will take six to eighteen months to complete all the necessary tasks to open your practice, depending on how much help you have and whether you are working full or part time. For us, it took the equivalent of 15 weeks, working 8 hours a day 5 days a week to approach being ready for opening day. If you have a spouse who can work part time or, as was our case, can quit her job to help with the start up, it will be time well spent to hurry the process along. As an excellent introduction, we recommend reading the medical economics article on the first steps of starting a practice.

Pearls for Starting Private Practice

noreply@blogger.com (MedRounds Publications) — Mon, 28 Jul 2008 04:18:00 +0000

By Michael G. Haas, MD

After four years of college, four years of medical school, a one-year internship and three years in residency (and possibly a fellowship), you have finally made it. Congratulations! Life just became easier and more enjoyable, but it became harder as well…

At some point during your PGY-4 you should have been in contact with potential employers. You may choose to start your own practice, join a solo practitioner or even join a large group. Either way, you will have some work to do. The first step, once you know where you will be working, is to start the process of obtaining a full license to practice medicine in your new state. Once you have obtained your license, you then need malpractice insurance and hospital credentialing (for hospitals your TB testing and CPR will likely need to be up to date). These are often required before the next phase of applying for and joining insurance panels (many insurers will require you to be credentialed with a hospital prior to getting on their panel). In addition to all this, you need to be credentialed with the ambulatory surgical center (ASC) where you’ll be performing surgery as well. The mountains of paperwork have begun, and if you are lucky someone in your new practice may help with this. This whole process can take anywhere from 4-6 months or more to complete. Full credentialing may take a few additional months as well. The best advice I can give is to start early, as soon as you have your job lined up.

Day 1. You are finally here. As the new associate, you should be respectful and courteous to your new staff. They can help to make or break you in your new position. Quickly learn the names of everyone in the office. Be friendly to your staff, and let them see you lead by example. Do not be late for work. Work hard, and always treat your patients with respect. Oftentimes, your reputation starts before you walk through the door, and word-of-mouth patient referrals will provide you with much of your long-term patient base. It will be very important to have formal (and informal) review sessions with your employer, especially in the beginning. It is important for you to know what is expected of you, and there should be no ambiguity as to whether you are achieving your benchmark goals. Monthly or quarterly meetings with your employer to review your production and bedside manner will help to assure that down the road, there are no surprises when it comes time to buy into the practice.

I would discourage everyone from having a narrow scope of practice, at least initially. You may or may not be fellowship trained, but now is the time to see as many patients and perform as many different types of procedures as you can. Over the years you will quickly learn what you enjoy and can adjust your patients accordingly.

Working in your new surgery center will also be an important time to be at your best. Again, you should know the names of the staff quickly, and do not hesitate to spend some extra time there initially to familiarize yourself with the equipment and/or personnel. You may or may not be familiar with the surgery center’s equipment and instruments. Halfway through your first surgical case is not the time to find out that you do not have something you need.

For those of you who will be performing cataract surgery, it is a very exciting time right now. If you have not yet read Phacodynamics by Barry S. Seibel, M.D., now is the time to do so. It is important to know the fundamentals of phaco, and there is a very real chance you will work on a phaco machine you have never used before. The knowledge from this book will ease the transition for you. It should be in every cataract surgeon’s library. The equipment has never been better, and you now have the option of premium, presbyopia-correcting IOLs to choose from too. In today’s market, your patients will expect perfection. It is important for you to have impeccable skills before offering these services. There is an art to guiding your patients to appropriate expectations, and in determining what is best for the individual patient. Before venturing into the premium IOL market, consider adding Mastering Refractive IOLs: The Art & Science by David F. Chang, M.D. to your collection.

It will be more important than ever to stay current in your education. You are not simply finishing your training. Rather, you are just starting your chosen career. You will finally start to enjoy the fruits of your labor. Read your journals, attend the meetings, and do not forget your CME credits. You will soon be taking your written and oral boards. Make sure you plan for your studying time. Too much time, effort and money is involved to not take these seriously. Check http://www.abop.org/ for more information.

On a last note, consider purchasing the new Ophthalmic Coding Series from the AAO as well. If you are the typical resident or fellow, you have had little exposure to coding in the real world. You have worked hard for your career, and this series can help to assure you are paid for your work, and it will lessen your chance of committing accidental billing fraud.

Above all, simply be yourself. Treat your patients as you would want yourself or a family member to be treated. We are privileged to provide eye care to the public, and it is our duty to always strive for excellence. By putting your patients’ best interest first, you have already started down the right path. There truly is no better time than now to be starting a career in ophthalmology!

Icing on the Cake: Pearls for Dress Attire

noreply@blogger.com (MedRounds Publications) — Mon, 28 Jul 2008 04:16:00 +0000

By Rob Melendez, MD and Kris Gillian, MD

Does dressing better mean you are more professional? Wearing a tie or a dress is not synonymous with professionalism. The purpose of this article is to provide pearls in projecting a professional image to your patients and to the public. Dressing well is merely icing on the cake. Eating cake alone is good, but with your favorite icing on the cake, it tastes even better and eating icing alone is good for awhile, but then it leads to emesis. The cake is the substance of professionalism (competence, concern, and communication). A well-dressed physician is the icing on the cake. Pearls in Ophthalmology (PIO) is about the cake, that is, focusing on competence, our concern for people, and improving our communication. Therefore, the icing on the cake in this case is a well-dressed physician. In future PIO issues, I will introduce what I refer to as sprinkles (Cuff Links, Knot Tying, Unique Socks, etc.). We will offer pearls for female physicians too.

I spoke to a friend of mine who shared his experiences at his first job after residency and how his other associates dressed too casually (no ties) and how he thought it affected the perception of him and his practice. He said, “I was really surprised to see my former employer walking around in Sketchers, black jeans and plaid button-down shirts to see patients. Next to him was me, wearing a lab coat, tie, and dress pants. It looked uneven, to say the least, and I'm sure it didn't help us to grow the practice. Needless to say, I moved on to partner with another group. Everyone wears a lab coat with our practice logo and name on our lab coats. Tie, dress pants, (or dress), is the attire, and I truly believe it injects confidence in the patient population.”

You have one opportunity to make your first impression in your new job (and fellowship and residency). Do your best to project a professional image. This article is not meant to tell you what to do, but is meant to provide some pearls to help you identify your compatibility with the existing norm in your practice. Understand your community and what they expect from their physicians. There are different norms across the country for dress attire. For example, read the article: “When in Rome, Do as the Romans Do, Pearls for Dress Attire” by Craig Wilkerson, MD in this issue of PIO. For example, in Hawaii, one may get away with dressing more casually because that is the norm. If this is how you like to dress, then this would be a great fit for you.

Practical Pearl:
Dress to impress the patient.
Shoes are the single most important item of your dress attire. I can recall on many occasions how I received numerous compliments on a pair of shoes that were “in style” and different from my standard shoes. If you are scheduling surgery on a patient, this one minor area, can reinforce their trust in you as a professional. Additionally, this will send a strong signal to your patients that you pay attention to the small details especially if your shoes are well shined.

Pearls:
- Above all else, be yourself.
- Press your Lab coats (I prefer heavy starch with a strong crease on the sleeves)
- Shine your shoes regularly
- Shave daily or Trim your beard and mustache often
- Cologne and Perfume: Use sparingly
- Dress professionally if you are a professional.

Pearls for the Fellow:
Pride yourself in looking your best. You are a junior faculty member representing the department and your respective University.

If you have articles or comments on this topic, please send them to me: editor@eyepearls.com

When in Rome, Do as the Romans Do: Pearls for Dress Attire

noreply@blogger.com (MedRounds Publications) — Mon, 28 Jul 2008 04:14:00 +0000

By Craig Wilkerson, MD

This article has nothing to do with Rome, Italy or even traveling abroad. It has everything to do with adapting to the surrounding culture. When deciding how to dress for seeing patients it is important to “when in Rome, do as the Romans do.”

We are taught as residents and fellows how to diagnose and treat disease. We learn how best to care for our patients. Some of the factors that affect us most in practice are never formally included in our training. Among these are dress and appearance. We all know the essentials of maintaining a professional appearance. However, what is most comfortable and appropriate for our patients can vary from one practice to another.

Pediatric ophthalmologists have a relatively straightforward task: dress with exciting and friendly colors that are non-confrontational to a child while being conservative and professional enough to not frighten their parents. A “silly” tie and the absence of a white coat go a long way. For the rest of us, the Roman analogy comes into play.

One of the safest strategies is to follow the lead of the senior ophthalmologists in the practice. After all, they are the ones who hired you and remember you in the clothes you wore when you first met them. If they wear white lab coats, then you should as well. If they are more casual, then follow their lead. If there is a variation of styles, then choose a style within the established range that best fits your tastes. When I joined my first practice, I wore a lab coat because all of the other providers in the clinic did. When I wore a shirt and tie without the coat, patients commented on my dress. They used neutral language, but the point was clear – I dressed differently than what they were used to at that practice. Perhaps they thought I would care for them differently as well.

When I purchased my own practice from a retiring ophthalmologist, the choice of dress became more complex. Should I continue to dress in a lab coat as he did or establish my own more relaxed form of dress? In the end, the patients gave me the answer. In my comprehensive practice most of the patients are elderly. They often dress formally for their appointments. However, in Montana where I practice, few wore neckties or sport coats. As a result, I wear slacks and a dress shirt without a tie (or bolo).

How you dress in the office affects the perception that your patients have of you. It also sets the standard by which your partners and staff will view you. Are you overly formal and unapproachable or casual and unprofessional? So, when in Rome do as the Romans do. Just remember that the Romans include your patients, partners and staff.

Kelly Green, MD

noreply@blogger.com (MedRounds Publications) — Mon, 28 Jul 2008 04:12:00 +0000

The daughter of an ophthalmologist, Kelly Green was born in Arizona. From there her father’s military career took the family to several different Air Force bases. She studied chemistry at Trinity University in San Antonio, and then served two years in the Peace Corps in West Africa, where she taught physics and chemistry in French. Upon returning, she worked for two years as a teacher before making the move into medicine. She went to medical school at the University of Texas Health Science Center San Antonio, and did her transitional internship in Austin. She then returned to San Antonio for ophthalmology residency, where she is a senior resident, graduating in 2009.

Surgical Pearls for Strabismus Surgery

noreply@blogger.com (MedRounds Publications) — Mon, 28 Jul 2008 04:07:00 +0000

By Aaron Miller, MD, MBA

Strabismus surgery on children and adults can be a very rewarding experience for the general ophthalmologist. As a practicing pediatric ophthalmologist who completed fellowship training only a few years ago, I am fortunate enough to take part in this type of eye care on a daily basis. The volume of strabismus that you encounter is highly dependent on your practice area and personal interest in the topic. The following are some valuable surgical pearls when considering and performing strabismus surgery.

Pre-operative Assessment. When deciding to perform strabismus surgery, it is important to have consistent and reliable pre-operative orthoptic measurements. If possible, obtain measurements in the horizontal and vertical gaze positions for a horizontal strabismus. In individuals with a vertical component to their eye misalignment, measurements of all nine directions of gaze in addition to head-tilt positions should be obtained. Pay attention to A and V-Patterns and if they appear to correlate to oblique extra-ocular dysfunction.
Medical Consent. It is very important to properly discuss with the patient and document the risks, benefits, alternates, and complications to the surgical procedure that you will be performing. Strabismus surgery is somewhat unique in that the surgical results can be highly variable. Published reports on “surgical success” typically range from 60% to 80% on the first surgery. This means that from 20% to 40% of all patients will need another procedure at some point in their lifetime. I make it a point to stress this with all patients and parents to ensure that realistic expectations are set prior to proceeding with surgery. I also discuss the likely presence of diplopia in the early post-operative period for most adult strabismus surgery. In most circumstances, this resolves in the first one to two weeks after surgery but rarely can extend beyond this period.
Surgical Incision Type. The decision to perform a fornix or limbal incision in strabismus surgery is purely up to the surgeon and can be affected by many conditions. Fornix based strabismus surgery is highly dependent on the quality and experience of your assistant. Limbal based strabismus surgery provides better extraocular muscle visualization without a heavy reliance on the assistant. In my experience, individuals with fornix based surgery have less post-operative discomfort and less scarring. In the end, choose the technique that you are most comfortable with.
Surgical Dose Tables. There are dozens of published surgical dose tables to guide you on the amount of recession or resection to perform for a case. I have had surgeons who measure to the 0.1 millimeter during their surgery and others who have “small, medium, and large” surgical doses. There are so many factors that go into the pre-operative assessment and surgery that I typically only measure to the 0.5 millimeter. The published surgical dose tables should only be used as a guideline for your surgery since every surgeon has slight variations in surgical technique. Over time, you will become more familiar with your surgical results and adapt your surgical dose accordingly.
Post-operative Assessment. All individuals who have undergone strabismus surgery should have a post-operative clinic evaluation less than one week after surgery. The focus of this visit should be gross eye alignment, attention to possible wound infections or dehiscence, and dramatic changes in visual acuity. Another good thing to document is the presence of a normal red reflex on retinoscopy. The final strabismus outcome can be very difficult to predict based on this visit – I encourage patients and other surgeons to be patient at this stage. Long-term results can sometimes be predicted at the one month follow-up visit.
Adult Strabismus. It continues to amaze me on the frequency that I meet an adult with strabismus who has been told by an ophthalmologist that their problem is cosmetic or uncorrectable. Adult strabismus surgery in the great majority of cases is a medically covered procedure. Most insurance carriers easily approve this procedure when proper documentation is provided on the medical necessity for surgical correction. This includes resolution of diplopia, improvement in peripheral field, enhancement in depth perception, and addressing the psycho-social stress that the condition imparts on the patient. If medical necessity is in question, I would encourage you to visit the AAPOS Adult Strabismus Policy Statement on the condition.

Ophthalmology and Eye Surgery Channel on YouTube (Eyepodvideo)

noreply@blogger.com (MedRounds Publications) — Mon, 28 Jul 2008 03:56:00 +0000

Medrounds has launched a new eye surgery channel on YouTube: http://www.youtube.com/eyepodvideo

You will find a diverse collection of educational medical and surgical videos. New videos will be added regularly to create a freely available surgical and medical reference for your review and educational use. If you would like to publish your videos on Eyepodvideo, then please contact us at webmaster@medrounds.org

Here's one of the videos about Temporal Artery Biopsy for Giant Cell Arteritis

OKAP Scores…What do I do with this information?

noreply@blogger.com (MedRounds Publications) — Mon, 28 Jul 2008 03:49:00 +0000

By Chris Ketcherside, MD

Ah yes, the OKAPs. You’ve all probably gotten back your scores by now and are either jumping for joy or jumping off of some tall object. For those of you who did poorly (of course this is all relative as I know this guy who got mad about a 97%), let’s talk about what you can do to improve your knowledge base over the year. For those of you who did well (again, relative), remember to use your powers for good and not evil. Most of all don’t rub it in with your fellow residents if you know what’s good for you.

One of the most frustrating things that we all seem to deal with when thinking about this test, is that no one really seems to know what to study. We all go around asking the other residents in our program what they use, or maybe we just find that one person who happened to get a 99% and pepper them with questions. Anyway, I’ve now taken this test 3 times and won’t have to take it again, but I thought I’d try to at least put something together that could help those of you who are wondering what went wrong and what you can change over the next year.

As we said, all you can really do (besides read every book and decide which you like) is ask those around you for their opinion. So, I asked as many people as I could to tell me what they thought was helpful and I’ll share that with you. I’ll also tell you about what they thought was not helpful.

First of all I’ll tell you a story about this guy that I know that rocked the charts with a 36% his first year. Now we all know that if you’ve gotten this far, you probably aren’t used to getting a 36% on anything except that Physics test in college where this would mean a B+. Needless to say this man was disturbed and wondered how this had happened. He tells me that he realized that he had a newborn baby when he started his residency. He also tells me that he had trouble early on organizing his time with a totally new life. Add to this the fact that he had no idea what to study come OKAP time and you get a poor showing followed by ridicule by the staff.

Now why am I telling you this? Good question. The answer is that this same guy scored a 94% the following year. No, he didn’t develop an elaborate Spies Like Us-esque scheme for beating the system. He did not sell his family to pirates and study 24/7 either (although he says he thought about it). What he did do is start early and make a plan. He set goals for himself and organized his time wisely. He says that he talked to as many people as he could and figured out which review books seemed to help the most when approaching the test.

Here is what he recommends:

Read for an hour every night no matter what. This guy did it after he put his kid to bed each and every night and made it a habit.
Reading willy nilly is great and all, but it’s just that…willy nilly. Make a plan for yourself and stick with it. A personal syllabus if you will.
Read the BCSC series throughout the year at least one year. If you can do that your 1st year then great. Try to read the book that correlates with the service that you are on if you can.
When it comes time to study for OKAPs then pick the books you will review and stick with it. Most find that buying 50 books and reading 1 chapter of each is less helpful than reading all of just a few key books.
In January, read Review Questions in Ophthalmology (Chern/Wright) the whole way through. That will hit the high points of what you’ve been reading over the last several months.
Starting in February, begin reading from Ophthalmology Board Review (Tamesis) and The Massachusetts Eye and Ear Infirmary Review Manual for Ophthalmology (Lamkin). He tells me that he would review one subject in the Board Review book and then work the corresponding questions from the Questions book. This is time consuming and will take a while to complete.
In April take a week to review optics and go through Last Minute Optics (Hunter).
Take a week to go through all of the questions in the back of each BCSC book. They are very helpful and you’ll surely see some similar questions on the test.
Use one week to review subjects that you were particularly weak in. This is also a good time to look at that embryology, review the genetics, etc. For some of us this would make for a long week…
Finally, the Secret-XJ2000-Trump-Card-Shock-and-Awe-Weapon. The night before, go cover to cover through Eye Pathology: Atlas and Basic Text (Eagle).

That’s one guy’s advice. I polled a few other folks from across the land as well. I made sure to ask some of my fellow future Cornea specialists because not only are they very wise, but it is a known fact that they give excellent advice. Here is what they said:

“I thought the Friedmann book was awesome. Chern and Wright question book was good. I thought the Mass Eye and Ear was too difficult and overwhelming but it’s a good book if you’re not the type that gets overwhelmed.”

“Ophthalmology Pearls are very good for OKAP”

“I like the Friedman Book, Chern Review questions, Ophthalmology Pearls, and Last minute optics.”

“I didn’t like any because I don’t like studying” later followed by “The Mass Eye and Ear questions were poorly worded to prepare you for this particular test. Ophthalmology Pearls, Chern and Wright Question book and the BCSC questions at the back of the book were most helpful.”

“I thought that the Chern and Wright questions were most similar to those that I saw on the test. I loved the Friedman review book. The Essential Optics Review for the Boards (Wilkinson) on MedRounds.org was great. I thought that the Mass. Eye and Ear questions as well as those from the MOC review were less helpful for OKAPs.”

“I used the Friedman Review book and the Chern and Wright questions and I smoked the test.”

“Mass Eye and Ear is not good. I stuck to the Chern and Wright books only”

“Pearls by Tamesis and Friedman are all that I use now. I thought that the Mass Eye and Ear questions were alright, but didn’t like them as much.”

“Review books I would recommend are Review of Ophthalmology by Friedman, the question book by Chern, the Provision questions from the AAO, and Guyton's optics book.”

So there you have it. More opinions than you know what to do with. I got the general feel that people really thought that Review of Ophthalmology (Friedman, Kaiser, Tattler) was very good. What’s even better is that I’m just now finding this out with 15 days to go in my residency. I also found that people were on the fence about The Massachusetts Eye and Ear Infirmary Review Manual for Ophthalmology (Lamkin). I think that it’s very possible that this could be due to the sheer girth of this book and the difficulty of the questions. Once again, that’s nice to know now that I’ve looked at this for 3 straight years. You can take what you will from the rest and remember that we all study in different ways. One 99% test taker may read 12 books and the other read just 3. I think that the key to all of this is read consistently throughout the year and have goals. You will not only do well on your tests, but more importantly, you will excel in your treatment of patients. Remember, that’s why we’re here in the first place…

Pearls for Starting a Fellowship in Corneal Refractive Surgery

noreply@blogger.com (MedRounds Publications) — Mon, 28 Jul 2008 03:44:00 +0000

By George O. Waring IV, MD

Beginning a fellowship in corneal-refractive surgery can be an intimidating experience as residents often have limited exposure to this subspecialty during their training. Just like starting your residency in ophthalmology, the learning curve can be steep- but you will get there. Sit down with your preceptor on the first day and define the goals and expectations of your fellowship. The objectives of a corneal-refractive fellowship can broadly be divided into patient and procedure selection, surgical technique, and communication with refractive patients.

Patient and Procedure Selection

The primary considerations in patient and procedure selection for refractive surgery are assessing risk factors for the development or exacerbation of keratoectasia, providing optimal optics, and screening out certain personality types. First and foremost, the fellow should become facile with interpretation of corneal maps (keratometric, anterior and posterior elevation, and corneal thickness). This skill is largely pattern recognition, and therefore a beginning fellow should make it a priority read about the interpretation of the different types of corneal maps and then practice as much as possible.

A clear understanding of risk factors for the development or exacerbation of keratoectasia after corneal refractive surgery is imperative. The fellow should familiarize themselves with the many keratoconus risk factor grading scales, and develop their own systematic method of determing candidacy. Other preoperative considerations include, but are not limited to pupil size, pre-existing dry eye and blepharitis, anterior basement membrane, corneal scars, lens changes, amblyopia, nystagmus and systemic co-morbidities.

The refractive fellow should also understand how each procedure affects corneal curvature and overall optics. For example, a moderate hyperope with steep keratometry would not be a good candidate for corneal refractive surgery, but may be a good candidate for a refractive lens exchange. In recent years, many new excimer laser ablation profiles have been introduced which may correct or preserve higher order aberrations (HOA). An understanding of wavefront aberrometry and the indications for conventional, aspheric or custom profiles are important for addressing HOA. The refractive fellow should learn the optical and mechanical principles distinguishing different excimer and femtosecond lasers.

Finally, it is a good idea to avoid corneal refractive surgery in patients who have hyper-perfectionist, obsessive-compulsive or “type AAA” personality types. These traits can be subtle, and difficult to detect during a single preoperative exam. However, personality screening is an important consideration in patient selection.

Communicating with Refractive Surgery Patients

Communicating effectively with refractive surgery patients is an important skill. Patients seeking elective refractive surgery tend to have different “needs and wants” than many of the patients that we treated on a non-elective basis during residency, and the expectation level tends to be high. Most refractive patients have researched the procedures prior to presentation, and are in your office because of “word of mouth”. Whether it is dealing with healing after PRK, or neuroadaptation after monovision, patient reassurance is an integral part of refractive surgery. Clear communication regarding patient expectation and possibility of post-procedure treatments is important. A basic approach is to under-promise and over-deliver. Typically, this is best learned by direct observation from one’s preceptor.

Surgical Technique

LASIK may look easy, but it is a surprisingly complex procedure. Approach corneal refractive procedures in a step wise manner, similar to cataract surgery, where each step builds on the prior. The Refractive Surgery volume of the Academy’s Basic and Clinical Science Course is an excellent basic reference and should be read before starting your fellowship. Surgical videos of corneal refractive surgery are an effective way to gain exposure to basic and new techniques. Also, reading the peer reviewed literature such as the Journal of Refractive Surgery is a sure-fire way to stay current on evolving techniques and technology.

Although there is a movement toward femtosecond laser flap creation, a well rounded fellow should also become facile with a blade microkeratome. In addition, the subspecialty of refractive surgery is quickly becoming more lens based, and therefore a fellow should invest time and energy into gaining exposure and experience with phakic IOLs, refractive lens exchanges (basic phacoemulsification for cataract surgery will hone these skills) and post-refractive IOL calculations.

There are many “tools in the tool-box” for vision corrective surgery such as conductive keratoplasty, Intacs® corneal inlays, and astigmatic keratotomy- try to get as much exposure to these surgical modalities as possible. The management of refractive surgery complications is important. The refractive fellow should learn to identify and manage post operative complications such as epithelial ingrowth, slipped flaps, striae, deep lamellar keratitis, transient light sensitivity, infections and keratoconus after corneal refractive surgery.

The treatment of presbyopia is an emerging “sub-sub specialty” and therefore a refractive fellow should become familiar with a reliable method of determining ocular dominance and the different surgical treatment options and indications.

Other Considerations

In addition to the basics listed above, there are other considerations when starting a cornea refractive surgery fellowship. Take advantage of any opportunity to complete laser and other refractive technology certification. Also, pay attention to laser operation and trouble shooting, don’t rely on the OR staff as the surgeon is ultimately responsible.

Try to identify special areas of interest and pursue research early on with the goal of submitting abstracts to conferences and/or the peer reviewed literature. Look for teaching moments and lecture opportunities with residents. Teaching refractive surgery is always appreciated by the residents who may have minimal exposure to this discipline, and teaching solidifies your knowledge base.

Fellowship training in the rapidly evolving subspecialty of refractive surgery is a rewarding experience. Clearly definining your goals early on will enhance fellowship training experience, and likely result in a satisfying and productive career in refractive surgery.

Pearls for Starting Ophthalmology Residency

noreply@blogger.com (MedRounds Publications) — Mon, 28 Jul 2008 03:38:00 +0000

By Don Sauberan, MD

You have finally made it through undergraduate education, 4 years of medical school, and 1 year of internship (which often seems longer than the 4 years of medical school!). Your ophthalmology residency is just about to begin. I will provide several pearls for your first few months as a new ophthalmology resident to have a gratifying experience?

1. Be eager to learn. Beginning an ophthalmology residency is like drinking through the proverbial fire hose. Most medical schools have very little training in ophthalmology, and even fewer require clinical experience prior to graduation. You have just spent the past year dealing with MIs, abdominal trauma, and end-stage renal disease. What ophthalmology knowledge you may have gleaned from medical school could be long-gone. The terminology and examination techniques are often completely foreign. Accept this initial ignorance, and dive in with eagerness. Ask lots of questions. Have techniques shown to you. Retinoscopy and scleral depression are two techniques which take time to master. Try to practice on as many patients as possible. No question is too small. If you don’t ask questions early, it becomes harder to ask later on when you “should know better”.

2. Read, read, read. The volume of information present on such a relatively small portion of the body can be overwhelming. As a new ophthalmology resident, you will receive the Basic and Clinical Science Course (BCSC) from the American Academy of Ophthalmology. This is a 13-volume series discussing all aspects of ophthalmology. Because it is the Academy’s own publication, it can be considered to be what the Academy wants you to know about the specialty that you are now a part of (this becomes important at OKAP time!!). It is much easier to read small amounts consistently than large amounts less frequently. Dedicate 1 hour (at least) per night to read. At the beginning of your residency, do not worry about other sources such as peer-reviewed journals, or more detailed textbooks. You will probably have some type of lecture series/OKAP review session. This can be subject-driven (e.g., all of oculoplastics lectures are in September), or, more frequently, are randomly arranged. If you have a more random lecture series, you may want to start with the Glaucoma book (Volume 10), as it is the smallest book. Finishing it often gives you a much-needed boost to continue your reading schedule.

3. Lean on your senior residents. They have “been there, done that.” They can help with clinical acumen, logistical questions, and deciphering your various staffs’ personalities. Initially, they see patients with you on-call, so right from the beginning they are helping to craft how you react to patients. Pick their brains on knowledge, technique, and survival strategies. Learn from their mistakes.

4. Be a team player. Residents spend more time with each other than with their own families. Thus, a quality relationship with your fellow residents (both senior and otherwise) can be the difference between enjoying residency and simply surviving it. The best way to foster a good relationship with other residents is to have a good work ethic. Don’t disappear when the last consults are waiting to be seen. Keep your senior residents informed about what is going on. Do not have an “attitude” with other services. If there is an ophthalmology consult, you as a first year are not the one who should be talking to the staff internist about why it isn’t warranted. You want to avoid getting a bad reputation. No reputation is better than a bad reputation.

5. Don’t forget about your family. For those with a family, they have probably sacrificed greatly for you to get to this point. However, residency is a stressful time, and families can often feel the brunt of it. Do not forget about them, and lose yourself in ophthalmology. Make sure you plan for “non-ophthalmology” time, whether it is simply a trip to the park, or a real vacation during one of your weeks off.

6. See as much as you can. Ophthalmology is a very visual specialty. Much of what we diagnose, we diagnose by visualization. There is an old adage, “you only see what you look for, and you only look for what you know”. If someone has an interesting case, make sure you go take a look at it. Examine all the patients at grand rounds. Many things in ophthalmology will only come around a few times, even in a teaching hospital with a residency program. A good ophthalmology atlas (such as Spalton’s Atlas of Clinical Ophthalmology) can supplement your clinical experience with pictures of many ocular diseases.

7. Learn to love the Wills Eye Manual. The Wills Eye Manual is the Washington Manual of ophthalmology. It has all of the vital information on nearly everything that you would see walking in to clinic, including differential diagnosis and treatment. It also has a good section on presenting signs and symptoms in ophthalmology. As a new ophthalmology resident, you will only know what symptom brings your patient in for a visit. The Wills Eye Manual lets you begin to learn how to craft a differential diagnosis based on symptoms.

8. Remember to have fun. This is what you have waited to do for some time. Despite the lack of sleep and the seemingly endless reading, remember how enjoyable the field of ophthalmology is. Remember how lucky you are to be training in a specialty that can help your patients so much. And remember that when you are finished in 3 years, you will have had a wonderful experience, both personally and professionally.

George O. Waring IV, MD

noreply@blogger.com (MedRounds Publications) — Mon, 28 Jul 2008 03:14:00 +0000

Dr. Waring served as Administrative Chief Resident of Ophthalmology at the State University of New York (SUNY), Downstate Medical Center in Brooklyn, New York. He was the first resident to be named Resident Physician of the Year by the faculty two years in a row. He was the Chairman Representative for over 900 residents to the Graduate Medical Education Section of the University, and received the distinguished Award for Outstanding Service to SUNY Downstate Medical Center. He is completing his fellowship training in Cornea and Refractive Surgery with Daniel S. Durrie, MD in Overland Park, KS.

Dr. Waring has been active in clinical research with a series of peer reviewed publications and national presentations to his credit. In addition, he has received multiple research travel grants and a national research award. His research interests include confocal microscopy and he developed the “Four Dimensional Confocal Microendoscopic Fly Through” imaging technique of the human cornea. He is also the co-author of LASIK and Other Vision Correction Surgery for Dummies.

Dr. Waring is a member of American Academy of Ophthalmology and an instructor for the Laser Refractive Surgery Course taught at the annual meeting. He is also a member of the American Society of Cataract and Refractive Surgery and a candidate member of the Cornea Society.

Lee Thurber, MD

noreply@blogger.com (MedRounds Publications) — Mon, 28 Jul 2008 03:13:00 +0000

Dr. Lee Thurber is a board certified ophthalmologist in Nebraska.