Show notes
Session 78
Dr. Alex Voldman is an osteopathic (DO) physician who specializes in Ophthalmology as a cornea and cataract surgeon. Check out our latest episode to learn more. Also, check out all our other podcasts on MedEd Media Network. Please help us find a guest here on the podcast. Send me an email at ryan@medicalschoolhq.net.
[01:35] Interest in Ophthalmology
Alex didn't go to medical school thinking about such Ophthalmology Upon his path to being an orthopedic surgeon, presenting at a conference, he met an Ophthalmologist who encouraged him to spend a day at his clinic. Seeing their practice, he thought they're some of the happiest doctors he has ever seen in the years he spent as a student.
He thought it was an organized environment where doctors and patients were happy. And he thought they were happy. Wanting to be happy as well, he decided to jump to the bandwagon. He also found them to be working at reasonable hours. They also got surgery and played with cool toys and lasers. When he found it was competitive, this drew him even more as it was something that challenged him.
Thinking he was going to be a businessman, the father of Alex's friend called him and discouraged him from doing so. He was told that if he became an orthopedic surgeon, he was going to retire at 50 as a millionaire. It sounded great to him and thought the dad was great and living the life. So he literally switched his major and started taking science classes. He admits not really liking the business classes he was taking.
Nearing medical school, he realized that advice the worst he had ever gotten. He was glad though because it brought him to medicine but to tell somebody to go to medicine to become rich is absolutely wrong. Sure, you could do well and be rich if that's the goal but that's not the way to do it.
"To tell somebody to go to medicine to become rich is absolutely wrong."
When he got into medical school, he started exploring the orthopedic surgery lifestyle but the personalities he met didn't seem to flow with his, as he describes it. He found people to be a bit more aggressive than what he would have envisioned a classic doctor. Personality-wise, he saw he was more aligned with the Ophthalmologists who are dorkier and laid back.
[06:51] Traits that Lead to Being a Good Cornea Specialist
Alex explains you have to be very meticulous although you don't have to start being one. Instead, you'd be forced to be meticulous. All of their surgeries and procedures are visible in the patient's eye everyday. So whatever result they have, they're walking around with it. They're looking through it. And if you're off by a small fraction, then a patient sees that for the rest of their lives.
"Every calculation, whatever technology we're using... all have to be meticulously placed."
[08:00] Types of Patients
Although a cornea specialist, Alex also sees a lot of general ophthalmology. In reality, if you practice cornea in private practice, you're also more likely doing a lot of general ophthalmology because there's not that much cornea pathology to keep somebody all day long.
For instance, in a day, he may see young patients for routine eye exams. The majority of his patients are also elderly. Common cases would be cataract, glaucoma, macular degeneration. And from a cornea standpoint, there are corneal diseases related to surgery such as patients with previous eye surgeries, multiple surgeries. If you have a sick eye and has had lots of surgery, it causes damage to the cornea which often needs corneal transplant.
"If you have a sick eye and has had lots of surgery, it causes damage to the cornea which often needs corneal transplant."
Sometimes, people have infections that cause scarring and corneal disease. So he may see contact lens wearers with corneal ulcers that sometimes have scarring so they need corneal transplants. Rarely, they will see certain corneal diseases like dystrophies people are born with. And often, they'd see those with corneal ectasia, also called keratoconus, characterized by thinning or balling out of the cornea if people are born with corneal disease. Their corneas become thin and pointed so they become weak and would nee corneal care either in the form of specialty contact lenses or corneal surgery.
[11:20] Typical Day
Alex's day usually starts at 8 am as his first scheduled patient and then see between 10 and 20 patients. He's in private practice, working about half an hour from his house. He has great support at the practice. He has a scribe and technicians that work patients out for him. He'd describe it as a pretty fast-paced practice.
"To be able to get through 20 patients and make everybody happy around you, you have to be efficient."
He'd usually finish around noon and the next patient is scheduled at 1pm. So he gets to have his lunch break (although he doesn't eat but doing other things). Then he ends at 430-5 pm. This is a typical clinic day
For OR day, his first case starts at 7 and doing about 10 surgeries in a half day. He'd be done at noon, take a break, and then do clinic in the afternoon from 1-5 pm.
[13:02] Taking Calls and Work-Life Balance
In his practice, they have 7 physicians, they split their calls equally among 7 people. So he'd be called once a week and you're covering call for your practice only. It's usually light, too. Middle-of-the-night emergencies are rare and if they're happening, sometimes the person can be seen the next morning. He'd also cover call for the local university hospital occasionally where he gets to see trauma call with residents, which can be easy. They have the option to do it as much or little as they want so Alex is doing it one week a year only.
"Generally, ophthalmology private practice call is not really intrusive in your life."
When taking a call, it's very rare that he gets called in during the week since he can just see the patient the next morning. So he almost never has to go in during the week. On the weekend, he'd have a patient to bring every few weeks. So it's not very common.
Alex illustrates his lifestyle as being very predictable and he thinks this is one of the biggest draws of the specialty.
[15:22] The Training Pathway
You have to do ophthalmology residency and prior to that, do your internship. As of now, they're separated. So you do one year of internship of some kind. Most people do traditional medicine or transitional. Very rarely would you see surgery or peds. Then you do three years of ophthalmology residency. Then for Alex, he did one-year Fellowship on Cornea.
"Nothing is going to change the practice pattern so the lifestyle factor will always draw people and will make it competitive inherently because of that."
He still thinks the specialty is highly competitive until now. He points out that the nature of the lifestyle is always going to draw people to it. To be competitive in matching, like any other field, you need to really know you want it and be able to show that you want it. The only way to do that is be involved - whether in research, clinical experience, shadowing, volunteering. These are all just ways to figure out whether you like it or not. Then build connections throughout the entire process and those connections are what can help you. You'd be able to get better letters of recommendation from people you spend a lot of time with.
"You need to really know you want it and be able to show that you want it. The only way to do that is be involved."
Undoubtedly, the first thing residency programs are going to screen you on is going to be your school and Step 1 that's going to get your foot on the door. Otherwise, it could be an uphill battle - not impossible, you could definitely do it.
Next, is how well you interview. Ophthalmologists work tightly together and in a clinic environment side by side with your attending physicians, and a lot of times, with their private patients. So they want somebody they'd feel comfortable around patients. Lastly, Alex says that research always helps.
For cornea fellowship, it's not as competitive. Good programs at anything are always going to be competitive. The same reason you could say that family medicine isn't competitive. But pick the best program in family medicine and it's going to be very competitive. Ultimately, in terms of competitiveness in ophthalmologic fellowships, it's probably middle of the road.
[19:35] Other Sub-specialties
There are new ones every couple of years. But for now, there are subspecialties like a 2-year fellowship in Retina or a 1-year or 2-year fellowship in Oculoplastics, a 1-year or 2-year fellowship in Oculoplastics, 1-year fellowship in Glaucoma and 1 year in Cornea. You could also do 1 year in Uveitis, 1 year in Pediatrics. You can also do Pathology or a special fellowship for Refractive Surgery.
[20:35] Negative Bias in the Field and
Alex explains that even as a DO the bias doesn't come up among his patients. The bias rather comes up when you're trying to apply for residency programs. The program directors of MD programs are not going to look at you first. You have to do something special to stand out among the MD applicants.
"The bias undoubtedly is going to come when you're applying for residency programs because the field is so competitive."
[21:27] Working With Primary Care and Other Specialties
His advice to primary care physicians to refer early and don't just treat red eyes. The differential diagnosis of a red-eye when he sees one
"Refer early and don't just treat red eyes."
The exams he does and all the things he looks for are extensive. A lot of times, primary care docs see patients and they say it's probably a pink eye. Then they'd give somebody an antibiotic. Then send him his way.
So he urges primary care physicians to refer early. Less is more. And don't just treat. Because a lot of times, this could make Alex's job a bit more difficult when they get to him and he's not sure where to really start.
Other specialties he works the closest with include Anesthesia, Primary Care (as they manage a lot of diabetics), Neurology (taking care of patients with vision loss, cranial nerve palsies, etc.) He may also work with a Rheumatologist (autoimmune inflammatory eye diseases that need systemic management.
[23:12] Special Opportunities Outside of Clinical Medicine
One may get involved in the industry of surgical devices, doing trials, and testing new devices. You can also always be a business owner.
[24:08] What He Wished He Knew that He Knows Now
In one aspect, he has enjoyed building long-term relationships with patients. But as a practice, he is pretty tied to his geographic location because he's getting his self and name out there in building a patient base. So he can't just leave and decide in another part of the country, which is something other specialties can do such as Anesthesiologist or Emergency Medicine doc.
"The private practice of Ophthalmology is much more community-centered."
The best part of his specialty he describes is the one-day post-op where the patients come in and there's a smile in their face because they can see much better. On the flip side, one of the things he likes the least is the fact that he not infrequently does he have to talk to patients about money. For instance, he may prescribe eye drops that can't be covered by their insurance or offering different services not covered by insurance.
[26:30] Working with Optometrists
There's a lot of uproar being seen right now with optometrists requesting and pushing for more and more ability to do procedures and things. In his experience working alongside optometrists throughout medical school up to his private practice, he thinks the majority have not been interested in getting involved in surgical intervention. He doesn't blame them because a lot of them actually went into optometry because they didn't want to be surgeons. They want their predictable lifestyle and hours and don't particularly want to go out of the scope of what they're comfortable with.
"There's a push for some optometrists to have a piece of the surgical pie and I've seen mistakes made and I've seen things that were missed."
Alex says he had seen mistakes made by optometrists. However, it has nothing to do with them being an optometrist, but it just had something to do with them not having years of surgical training and not actually knowing what you could be looking for, let alone, missing it. This makes him a bit nervous. It's scary for patients to walk in the door because half the time, they might not know who they're talking to and who's actually doing surgery on them. So for patient's safety, Alex believes it can be dangerous for optometrists to get involved surgically.
[29:23] Major Changes in the Field of Cornea Surgery
Particularly in the field of corneal transplantation, they used to take donor tissues and sew them into place. They hope that in the future, they will be able to take individual cells and replace just the damaged cells instead of the tissues. This is in the effort to have lower rejection rates, faster recovery, and better outcomes for the patients.
Other things in the cornea sphere, specifically from the refractive side (getting better vision), technology is like lens and plans they put in during cataract as well as better techniques to do cataract surgery. Currently, they're doing laser cataract surgery. Lastly, Artificial Intelligence (AI) is already in Ophthalmology to help them make better clinical decisions.
Finally, if he had to do it all over again, Alex says he would still do it. His advice to students who might be interested in this specialty, spend some time with enough ophthalmologists.
"Anybody that wants any specialty always gets in eventually. I've never met anybody that really wanted something that just never got it. Whether it took more time or a different approach or using different tools, somehow they got there. So do not give up!"
Links:
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ryan@medicalschoolhq.net
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