I normally write articles for patient education but I thought I would write an article for ASOPRS fellows who are graduating. Recently at the Chicago ASOPRS meeting, I was fielded many questions about practicing as an oculoplastic surgeon in an oculoplastics only practice versus a multispecialty group. I have done both and am much happier in an oculoplastics only group or practice. An oculoplastics only practice is one where there are only oculoplastic surgeons in the practice. It can even be a solo practice. A multispecialty group is a group of ophthalmology specialists (cornea, glaucoma, general ophthalmology). There are certain advantages and disadvantages for both but from being in an oculoplastics only group there are major advantages compared to the other model. There are always exceptions to every situation but this is what I have found in my personal experience. This is obviously my opinion but I think many of my colleagues share this opinion.

Greater Overhead in a Multispecialty Group

In oculoplastic only groups or solo oculoplastics practice the overhead is between 38 and 42 percent on average. In ophthalmology groups the overhead can be as high as 75% but closer to 60%.. Therefore if you collect $1000 dollars in a month, in an oculoplastics group you would take home $600 whereas in a multispecialty group you are taking home $400. Do the math and you can see that the income in an oculoplastics group is roughly 50% more than being an oculoplastic surgeon in a multispecialty group. Why is that? Oculoplastics practices have less fancy ophthalmology equipment such as an OCT, visual field, tear film analyzer. On top of that, there are less technicicans needed because there is less ancillary testing and refraction work. Finally, the space that is needed (ie the rent) is lower because you need less space to hold all the fancy equipment and techs. The oculoplastic practice is not as dependant on higher volume necessitating lots of waiting room space, dilation areas etc.. as well. (ie less space for rent).

Limited Outside Referrals in Multispecialty Group

In an multispecialty group there will be zero outside ophthalmologists who refer into oculoplastic surgeon in the group. Why is that? Imagine a medical practice is a mom and pop hardware store. The multispecialty group is like Home Depot. If you needed a wrench that the mom and pop store didn’t have, the last thing they want to do is send you to Home Depot where you buy the wrench and think “what was I doing at that small place? Home depot is my new hardware store. An argument that is made by multispecialty groups is that “If you send the patient back other doctors won’t care”. That is totally false and should be responded with the question of “Do you send to solo oculoplastics doctors or doctors in multispecialty groups?’ Most often the doctor will tell you that they will send patients to the solo or group oculoplastics only doctor. The comprehensive group will want you to "garner referrals from non-ophthalmology doctors" but in my practice 90% of surgical patients are from ophthalmologists. I might get dermatology, endocrine and primary care referrals but that is relatively small.

The ratio of referrals that are true surgical referrals from ophthalmologists to their oculoplastics partners is roughly 125 to 150 to 1. That means an ophthalmologist will need to see between 125 to 150 patients to send one real patient to their oculoplastic colleague. For Optometrists referrals it is much higher because they tend to see younger, healthier patients. This referral by the way is a real surgical candidate…not someone who will need ptosis repair in 10 years ,blepharitis, chalazion. That is a good ratio to know. A private practice oculoplastic surgeon in an oculoplastic only group will see close to 10 new surgical patients on a clinic day. That means that ophthalmologists somewhere had to see between 1250 and 1500 patients for one clinic day of patients. In huge multispecialty groups where they see 3000 patients a week, that can produce a full oculoplastic surgeons clinical cases but in most multispecialty groups that is not the case.

One exception is optometrists. They may refer into multispeciality groups and oculoplastic only groups as it may not matter for them the difference. That being said, many savvy optometrists want their patients to go to the oculoplastics only group not multispecialty group especially if they have optical that competes with them.

Limited Cross Coverage in Multispecialty Group

In a multispeciality group, the other ophthalmologists know minimally about how to manage oculoplastic cases, especially post operative cases. The multispecialty group will expect you to take general ophthalmology call and cover their patients. That being said, if they are on call and one of your post operative patients calls, they will just call you or give the patient your number. In short, you will never be “off-call” in the practice. In an oculoplastic only group you will obviously have cross coverage if you are out of town, busy in the OR or doing something else. In the multispeciality group, the patient will have wait until you are done in the OR or are available. Worse, will be if your multispeciality colleagues in the group attempts to treat or manage a post operative patient doesn’t recognize that needs to be done (i.e taking the conformer out of a post-op evisceration patient, not recognizing stent issue). When you are on call you will be covering post operative endophthalmitis, lasik complications and other diseases that you haven’t treated in two years. Are you managing those cases well? Probabily not. All in all, the call coverage is not good if shared in this model. That being said, if you are doing your own call, why are you in a group?

Some multispeciality groups have their oculoplastic surgeons do general ophthalmology. It boggles my mind how someone can master something as difficult and challenging as oculoplastic surgery by also doing general ophthalmology. They may believe “I am mastering everything” but as we know in the modern era of ophthalmology that is fantasy. I like focusing on my speciality and really trying to master the craft as much as possible without side distractions. If you are doing only 25% oculoplastic surgery and 75% general, I believe it will be difficult for that to happen. If you look at the ASOPRS preceptors who train the oculoplastic surgeons, the majority are oculoplastics only. By doing that, they were able to reach surgical competence and volume to a level that the national organization felt they could train others. Something to think about as your start your first job.

Limitation of Income in Multispecialty Group

Because of lower outside referrals and higher overhead, oculoplastic surgeons who are in multispecialty groups will earn less than their oculoplastic colleagues who are solo or in an oculoplastics only group. How much different? It can be almost half in some situations. In other situations it can be more. Income is not the most important thing but after two years of specialized training, is that worth it?

Difficulty to compete for Cosmetic Patients in Multispecialty Group

In multispeciality groups, often the cosmetic set up of the practice is nowhere near the appearance or setup of an oculoplastic practice. In those practices that are only oculoplastics, the exam rooms have a cosmetic appearance of beautiful chairs and art. There are no messy ophthalmic lenses or bulky equipment in the room. Remember, an oculoplastic surgeon competes with plastic surgeons, facial plastic surgeons for cases. The appearance and setup of these offices matter for these patients. The appearance of staff matter as well. These are emphasized in an oculoplastic practice. It will be hard to convince your ophthalmology colleagues to have a cosmetic setup.

More Difficulty getting new oculoplastic technology in Multispecialty Group

One of the biggest complaints of oculoplastic surgeons in Multispecaility groups is that it is extremely difficult to get new oculoplastic equipment especially stuff that is expensive. If you want a 100K CO2 laser or Coolscultping machine it is most likely that your ophthalmology colleagues in the group are not going to want to take the risk to get it. They will lack the control in its usage, won’t understand how that plays a role in treating functional oculoplastic patients and be very skeptical if it is needed. This is one of the most common frustrations that oculoplastic surgeons in groups have. The CO2 laser has less bleeding and better healing than a blade but an ophthalmology colleague may not care about that difference. At the end of the day, your patient may suffer.

Better for patient care

I firmly believe that oculoplastic patients who see oculoplastic surgeons in an oculoplastics only group have better care. I believe their surgeons are more experienced, they have better cross coverage by other oculoplastic surgeons, and have a better experience with better technology. I think it reflects that oculoplastic surgeon only groups have more cosmetic patients because of that experience.

More Security in Multispecialty Group

This where the oculoplastic surgeon in a multispecialty group has an advantage. In a group you will have set referrals from your doctors. You will get all their referrals. You don’t have to meet other doctors, have particularily great outcomes or be nice to patients. It is guaranteed. In my mind freedom is always better than security but some doctors many have comfort in being in a group and guaranteed to have all the referrals. You may want to be in a certain town and there are no other options..it may be better. I feel that there are large costs for this personally but each person has to make their own life decision.

I hope this was helpful. I wish someone had broken it down to me before I joined a multispecialty group and eventually realized all these things on my own. Largely the multispecialty group doctors don't know these things either so they may not understand "why you aren't getting busy enough" or "only doing 5 cases a week". It is not their fault but it is good to have this information out there so young oculoplastic fellows know what they are getting into when they do join a multispecialty group.