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Launching and Preparing for Careers in the Anti-VEGF Era

Part 3 of a 3-part series on medical and surgical retina.

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Retinal physicians still in their first years of practice, and those who are currently pursuing fellowships, have only ever experienced the practice of retina during the anti-VEGF era. Their perceptions of current trends are unique, and their responses to these trends intriguing — particularly because decisions they are contemplating now will shape the trajectories of careers likely to span decades. Here, 4 physicians, still in early stages of their careers in retina, speak with optimism about the future.

PRIVATE RETINA PRACTICE

Paul Hahn, MD, PhD, who completed a 2-year fellowship in vitreoretinal diseases and surgery at Duke University in 2012, and now practices at New Jersey Retina in Teaneck, New Jersey, says that he watched the anti-VEGF era gain momentum while he was still in medical school. He expected that medical retina would occupy more of his time, despite a personal interest in and focus on surgery during training. Indeed, Dr. Hahn says that a typical week for him now involves about 4.5 days each week in the office and approximately half a day in the OR, at his practice’s surgery center. Still, he regards reports of a steep decline in retinal surgery as perhaps misleading.

“Retinal surgeries have become faster and more efficient, so we may actually be doing more surgery than in the past,” says Dr. Hahn. “For example, in the past we had a very high threshold for performing membrane peeling procedures, but now, with more advanced and more efficient techniques, we might be more likely to peel membranes in an eye that still has relatively good vision. In my experience, the decline in surgery has not been of sufficient magnitude to cause me to have concern that people are not being adequately trained or are not able to maintain their surgical skills.”

While all of the specialists in his New Jersey practice are currently trained in both medical and surgical retina, the practice has not ruled out the possibility of recruiting a medical retina subspecialist in the future.

“Right now, our goal is to serve our patient and referral base by having retina specialists available to treat any medical or surgical retinal condition on an emergent basis and in a timely fashion,” says Dr. Hahn. “Our managing partners have considered recruiting a medical specialist, but have encountered some logistical challenges and complexities regarding scheduling. If our practice considers employing a medical retina specialist in the future, it will likely be in an office where a surgically trained specialist is present at the same time, and can serve as a back-up to the medical specialist.”

Before joining NJ Retina, Dr. Hahn was the founder and director of the Duke Center for Artificial and Regenerative Vision, and the first surgeon to implant the Argus II “bionic eye” in the southeastern United States. His expertise in a highly specialized type of surgery gives him a unique perspective from which to contemplate the possibility of increasing specialization among retinal surgeons.

“For the most part, retinal surgery is not yet subspecialized,” says Dr. Hahn, “but that may change as further posterior segment techniques are developed that require skillsets other than those traditionally taught. A common example of such subspecialization is IOL surgery. When needed, these will often be referred to a retinal surgeon comfortable with these procedures. Ocular tumor surgery and pediatric retinal surgery are other examples of subspecialization.”

Because he is the only retina specialist in his practice and in his region trained to perform Argus II implantations, he receives referrals from other retinal specialists, who would otherwise be friendly competitors, when evaluations for this procedure are needed. He also notes that referring ultracomplex retinal detachments and similar procedures to a surgeon known for handling such complex cases is fairly common.

RETINA WITHIN A MULTISPECIALTY PRACTICE

Roles for medical retina subspecialists within large multispecialty ophthalmology practices are currently more defined than in private retina practices. At the Riverside division of Kaiser Permanente in Southern California, Vincent Hau, MD, PhD, is one of 3 surgical retina specialists in a 19-person practice that also includes 1 full-time medical retina specialist.1

“People are often curious about the structure of our type of practice,” says Dr. Hau, “in part because with changes in Medicare, and the trend toward more hospital-based systems, the way that we practice here at Kaiser is considered by many to be the wave of the future.”

In the field of retina, hiring trends at Kaiser Permanente will likely take into consideration the growing need for providers who can perform injections.

“We are currently exploring several comanagement models, which incorporate roles for general ophthalmologists, as most residents graduating today are comfortable with and trained to do some basic medical retina,” says Dr. Hau. “The extent to which this model is adopted will determine our future ratio of medical to surgical specialists.”

Dr. Hau, who completed a 2-year vitreoretinal surgical fellowship at Texas Retina Associates in 2011, says that his fellowship provided him with a good balance of surgical and medical training. He believes that it is important to remember that a fellowship doesn’t necessarily mark the end of training.

“I recommend that fellows join a practice that offers significant mentorship, particularly during the first few years of practice,” says Dr. Hau, who has co-chaired both the ASRS Fellows-in-Training and Early Career section programs. “During those early years, you are still learning about running a practice. And perhaps one of the most important things you can learn is when to ask for help. ”

Is it possible that specialists trained in surgery will experience a lack of career satisfaction — and perhaps even boredom — if they find that three-quarters or more of their practice involves imaging and the delivery of injections?

“I can’t imagine becoming bored with all of the expanding opportunities in the field of retina today,” says Dr. Hau, who recently launched a prospective clinical research program, as well as an educational program for professionals in his practice.

EXPANDING OPTIONS FOR FELLOWS

The remarkable midcareer transition by Mary B. Kansora, MD, FACS, from general ophthalmology to medical retina illustrates just one of many emerging educational and career paths in the field of retina. Nearly 20 years ago, during a residency at the Greater Baltimore Medical Center, then affiliated with Johns Hopkins, Dr. Kansora explored a personal interest in retina during several rotations, and even considered pursuing a retina fellowship. Ultimately she decided instead to build a private general ophthalmology practice with her husband in Fayetteville, NC, and put her love for retina on a back burner.

Her interest in retina never subsided, however, and now in her 40s, she has begun a medical retina fellowship at Bascom Palmer. Dr. Kansora says that her decision to pursue a medical retina fellowship does not fit into a mold for women pursuing careers in medical retina to secure more flexible lifestyles.

“Macular degeneration, in particular, has always been an interest of mine, for personal and professional reasons,” says Dr. Kansora. “I wanted to pursue a rewarding career that would allow me to treat patients with this condition.”

As a comprehensive ophthalmologist, Dr. Kansora says she knew that she was qualified to administer anti-VEGF treatments, but still she wanted to pursue a retina fellowship.

“If I am going to perform a procedure,” she says, “I should be able to confidently decide on the appropriate treatment, perform the procedure with superior skill, and follow my patients with an in-depth knowledge base that always keeps their best interests and prognosis in mind. Without this training, I do not think I would feel that I was giving my patients the level of care they deserve.”

Shilpa Kodati, MD, who started a 2-year surgical retina fellowship at Baylor College of Medicine last year, is also excited about future career options. After completing an ophthalmology residency at the University of Pittsburgh Medical Center in 2016, she completed a 1-year fellowship in uveitis and ocular immunology at the National Eye Institute, with the goal of pursuing a surgical fellowship afterward.

“My fellowship at NEI, like many uveitis fellowships, incorporated a significant amount of medical retina training. I’ve always hoped ultimately to practice in an academic setting, and eventually I hope to incorporate both the treatment of uveitis and surgical retina in an academic clinical practice.”

She believes that her current surgical fellowship, which she describes as well balanced regarding the amount of time devoted to surgical and medical retina over 2 years, will prepare her for the realities of daily practice.

“The way that our fellowship is structured,” says Dr. Kodati, “surgical training is integrated across the 2 years, although the first year is more medical and the second year more surgical. But even now, when I am not in the OR, I find that the time that I spend in clinic seeing pre-op and post-op patients — evaluating patients and learning when to operate — is a very valuable part of my surgical training.”

TRENDS IN RETINA PRACTICE

“With the increasing breadth and complexity of retina, I think we will see more subspecialization, and many of us will likely try to carve out a niche,” says Dr. Kodati. “Some of my colleagues who are also undertaking surgical fellowships have either completed prior fellowships or are considering additional fellowship training after surgical training in complementary fields such as uveitis or ocular oncology, so that they will be able to incorporate those skills into their practice.”

With greater subspecialization, she anticipates that there will be more referrals of all kinds among surgical and medical specialists, and greater collaboration rather than competition.

“If in the future we can offer our patients better care by referring them to other retina subspecialists, when indicated, that will only be a plus. Ultimately we are here to provide the best possible care to our patients, so the more we can learn from one another, and benefit from the skills of our retina colleagues, the better.” RP

REFERENCE

  1. Abelson R. The face of future health care. The New York Times. March 20, 2013. Available at http://www.nytimes.com/2013/03/21/business/kaiser-permanente-is-seen-as-face-of-future-health-care.html?mcubz=3 .