Ophthalmology has been one of the fastest growing specialties in the world. The advances in the field in the last three decades has been astounding. In the early 1980s, a cataract surgery required a 10 day hospital stay with a few nylon/steel sutures to the eye and yet have sub-optimal visual outcomes. Today the same cataract surgery can be done as a day care procedure of about 10 minutes duration with just topical anesthesia (anesthetic in the form of eye drops), through a pinhole probe and no sutures at all. The post operative outcomes have risen to give patients 6/6 vision and sometimes they don’t even need spectacles after surgery.
Today the field has expanded into sub-specialized eye care with many sub-specialists in
- Cornea & Refractive Surgery
- Retina & Vitreous,
- Strabismus and Neuro-Ophthalmology
- Ophthalmic Plastic Surgery & Ocular Oncology
- Uvea and Immunology
- Ocular Pathology
These are some questions you need to answer to yourself first before deciding on what to do after residency :
- Where will you be practicing- a major city or small town ?
- Are you really interested to become a sub-specialist or you are just following the herd?
- Do you want to work in a medical college or in a private eye hospital or a charitable hospital ?
- Whether you want to have your own set up or you prefer to have a salaried job or you want to be on your own working in several hospitals ?
- Whether finances are a problem and you need to immediately start earning after your residency?
These above questions are very important for your career path.
Decide on where you want to practice
If you are going to be working in a small town an exclusive sub-specialty practice will be difficult if not impossible. If you are going to be practicing in a metropolitan city a single Ophthalmologist clinic is not going to be a viable option because the initial investment required to attract patients is too high. Ophthalmology is a machine intensive field so unless you can invest a large amount of money opening your own eye hospital is tough especially in a big city.
Make sure you know what you want to do by the end of residency
General Ophthalmology is a viable option if you want to start earning soon as you finish residency. Income wise it’s not going to matter a lot in the long run. Doing a sub-specialty sometimes restricts income avenues as well as it takes longer to train. Good fellowships in India pay poorly and that would not even be enough to take care of yourself. Remember that the longer you train, the longer it is before you can start practice.
Doing a Sub-speciality has it’s pros and cons. Practicing a subspecialty like Retina requires expensive equipment for diagnostic and treatment purposes which are available only in big eye hospitals. Oculoplasty is a completely referral based practice because people usually do not know about this subspecialty. For a Cornea practice the support of good in house Eye bank is the most important requisite. A lot of the Sub-speciality practice is possible only in big hospitals who can afford to spend on infrastructure, high end machines and have enough patients to justify the expenditure. If you do general Ophthalmology and cataract surgery along with your sub-speciality practice, your sub-speciality practice can get diluted. If you are a retina surgeon doing cataract surgery, you may not get many referrals from cataract surgeons. This is especially true in big cities in the south of India.
Get good skill sets before you start your practice.
By the end of your residency, one should be able to do a cataract surgery independently- ideally Phacoemulsification too. That really is the basic minimum in an Ophthalmology residency. Unfortunately 80% of Ophthalmologists who clear their final year exams in India are not trained enough in this basic surgery independently. If you haven’t been taught in that institute, don’t stick around hoping you’ll get training someday. Don’t waste your time. Move to different places and do fellowships to learn cataract surgery. There are just too many centers in India to learn cataract surgery from. It takes more time and effort but that’s just required.
If you were reasonably trained in in cataract surgery during residency it is important that you either get better at that or start sub-specialty training in good institutes. I was lucky that my institute (RIO- Kolkata) gave me very good training in all sub-specialties of Ophthalmology. I was not keen on doing only cataract surgery for a living and was keen to add more variety to my work.
I wanted to sub-specialize either in Oculoplasty or Cornea & Refractive Surgery. Eventually I ended up doing both fellowships. I did not plan it that way but it so happened by fate.
If you were reasonably trained in in cataract surgery during residency it is important that you either get better at that or start sub-specialty training in good institutes. Try to get into the best fellowships available and be willing to work hard for it. If you want a good fellowship and did not get through in the first round of interviews in the fellowship of your choice don’t settle for less. Say you want to do Retina in a premier institute and you didn’t get through the interviews- Try to get a research position or a clinical observer position in the same institute instead of joining some underpaying job. Show them that you are genuinely interested in working there. Get involved and make some sacrifices.
Find a good mentor
This is especially hard in India. Many big surgeons in India have a god complex. Many of them don’t really want to impart training but rather they want minions around them to do their bidding and ghost research in their name. Many expect you to be subservient to them all your life just because they trained you. Many may start to see you as a competitive threat and may try to cut your wings off. You will in all probability encounter many such persons during your long career. Be careful to avoid such people or make exit at the correct time.
I found an amazing mentors first during residency and then in Singapore during my fellowship- mentors who treated me like a colleague. Much of what I am today is because of them. There are many great teachers who are willing to mentor young Ophthalmologists even in India but they are too few and too far in between. This is a difficult part of building a career but also one of the most important parts.
Do not get obsessed with Cataract Surgery. There’s more to Ophthalmology than Cataracts.
I see the trend in Ophthalmology practice today is getting concentrated around cataracts. Ophthalmology conferences in India are filled with symposiums after symposiums about cataract surgery. I know cataract surgery practice is very lucrative and has become very simple to gain surgical skills in it. There is definitely skill involved that you need to master for doing a good cataract surgery. Today there is very little difference between an excellent cataract surgeon and an average cataract surgeon. In cataract surgery you reach your peak surgical skills very early in your career so in a few years there will be younger hungrier surgeons who are just as good as you are and cost lesser for a hospital to hire. Your career is going to plateau after a few years if you depend only on cataract surgery to earn your monthly salary. This is especially applicable in major cities where the saturation is already visible. If you can make other surgeons work for you, that’s another story. Have more skill sets than just cataract surgery. Laser surgery, Refractive surgery, Medical Retina, Uveitis, Glaucoma management , etc are very valuable skills for a general ophthalmologist to have other than knowing cataract surgery. Develop them! Don’t be a one-skill pony!
Do not handle something you are not trained for
Don’t try to do retina surgery if you are a cornea surgeon. It’s ok to refer to your colleagues. If you do, they may refer some patients back to you. Even if they don’t- at least you won’t end up with an unhappy patient. Many things seems simple in theory but they are not when you actually do it. I do get a fair share of patients who’ve had complications because the general ophthalmologist tried a surgery he saw on YouTube or a conference and tried to replicate it. YouTube and conferences are great learning resources but they are no substitute for actual hands on training in surgery and experience.
Don’t sell yourself cheap and learn to negotiate.
Move out of the student mentality once you are ready for practice. Don’t sell your skills for cheap. Hospitals are always trying to screw doctors over. Do not agree to work for low salaries just because you are starting your practice. When you agree to whatever they offer, you are valued less by them. The best salaries are given to doctors who can negotiate well and these are not necessarily the doctors with the best credentials or surgical skills.
Also know that women are generally paid less than men in any hospital because women tend to agree for lower salaries. Sometimes there are other factors in this disparity like men putting in more hours or work than the women hence justifying the higher salaries. But for equal amount of work done the general trend is women are paid far lesser. The damage here is two fold, when women work for lesser salaries, hospitals hire more women and the average salaries offered to either gender tends to go down. Due to this trend I see that starting salaries in many corporate eye hospitals have decreased to abysmal levels despite increasing inflation.
If you are in independent practice don’t do surgeries at dirt cheap prices especially in private practice. When you lower the value of your surgery you are lowering your own opinion about your skills. Patients notice that! You are fine doing things for less compensation in charitable and government hospitals where there is actual need. It is often seen that the type of intraocular lenses are given more value than the skill of the surgeon. Patients would rather pay more for a costlier implant than pay more to a good surgeon. The ophthalmologists themselves are responsible for that.
Make sure that you are selling your surgery and not the implant!
It’s easier said than done. But don’t be that person who can only think of money bags when a patient walks in. Don’t advise surgery just because your boss is asking you to meet your monthly targets. Don’t have an unholy nexus with the pharma companies to prescribe eye drops that your patients don’t need. Don’t advice a particular test just because you spent a fortune buying a new diagnostic machine. You’ll see this happen around you, but don’t be that person!
Teach Ophthalmology whenever you can It is not only important to learn
Ophthalmology but also important to teach it. Teach your patients, teach the general public and teach your juniors. It is important that you teach and train younger residents and medical students because this will ensure that you will remain abreast of the latest in medical literature. What you learn during your residency can fast become obsolete in a 5-10 years. What endures is teaching others and in the process yourself. The student in you should never leave you.
Make philanthropy a part of your career and don’t treat it as an extra chore
In the midst of establishing a career people forget that philanthropy is also part of our profession. You need not become the richest Ophthalmologist in your city to volunteer regularly for free to some charitable institutions and causes. In Ophthalmology we have the ability to create a lot of impact on people with quite minimal resources. Imagine restoring sight to a daily labourer whose livelihood would be restored with restoration of eye sight following cataract surgery. There are many NGOs working in India which need skilled Ophthalmologists to work in remote places. Volunteer. Establish eye clinics or work in centres where access to ophthalmic care is minimum to nil. Spread awareness about eye donation where ever you are. Try to set up eye banks in your own locality, town or village. Don’t always think in terms of monetary profit when you are working as an Ophthalmologist. Be a valuable citizen to your community.
Challenge yourself at every step of your career.
Don’t get too complacent doing what you do. Constantly try new things. Learn from other surgeons and even spend a few days in their practice and operating theatre seeing how they go about it. Even when you practice a sub-specialty don’t be scared to take on difficult and complicated cases. Get out of your comfort zone once in a while but in the same vein know the limits of what you can achieve. Think of every patient that you treat as your own family member. “Under-promise and over-deliver” should be your life long mantra!
The 15th-century England’s attributes of an ideal surgeon holds true to this day : “the mind of Aesculapius, the eye of an eagle, the heart of a lion, and the hands of a woman.”