The Future of the Academic Ophthalmologist

FRANCO M. RECCHIA, MD · BRIAN R. CARLSON, MBA · PAUL STERNBERG, JR., MD

In ancient Athens, the sacred grove of olive trees in which Plato gave his lessons was called the Akademia, and any place of learning has since become known as "academic." In modern American medicine, the "academic mission" was expanded to encompass clinical care and research in addition to teaching, and it has become synonymous with the academic medical center (AMC). The modern vitreoretinal specialty grew out of the AMC through the development of vitreoretinal surgery at the Bascom Palmer Eye Institute at the University of Miami. While some of the first experts, such as Steve Charles, MD, or Connor O'Malley, MD, were in the private sector, the field primarily evolved from Robert Machemer, MD, at Bascom Palmer, Thomas Aaberg, Sr., MD, at the Medical College of Wisconsin in Milwaukee, and Ronald Michels, MD, at Johns Hopkins in Baltimore. Early on, therefore, the vitreoretinal specialist interested in treating complicated cases, conducting basic or clinical research, or training fellows, was most likely to be at an AMC.

THE MOVE AWAY FROM ACADEMIA

Times changed. Machemer moved to Duke (Durham, NC), Aaberg moved to Emory (Atlanta), and both programs flourished as strongholds, while prominent programs started to emerge both at other universities and in private practices around the country. A confluence of technological developments, socioeconomic factors, and changes in healthcare delivery and conduct of research gradually allowed for the provision of high-quality care by skilled specialists outside of universities. Several large retina group practices became active in clinical research. The formation of the Vitreous Society (later renamed the American Society of Retina Specialists) was a critical crossroads for the specialty, providing a forum for all fellowship-trained retina specialists, irrespective of academic productivity or affiliation, to meet and learn from each other. Thus, the vitreoretinal specialist in private practice could participate in scientific meetings, clinical research, and fellowship training. Thus, more of the top "academically" oriented fellows began to join private practices.

History has shown that academic productivity (or, more broadly, contribution to the field) is not determined by the address of one's office or source of one's paycheck. Significant contributions continue to be made by specialists in private practice, and many university-based physicians lack meaningful peer-reviewed publications. Many university departments have become primarily multispecialty practices, often run less efficiently than their community counterparts, with retina specialists employed ostensibly to provide specialized clinical services and resident supervision. But while there are isolated examples of successful clinician-scientists in practice, these are greatly outnumbered by those at universities. And while there exist excellent vitreoretinal fellowship training programs in private practice, they are still outnumbered by those at universities.

WHAT NOW?

What then is the future of the university retina practice? What does it offer that private practices do not? Many potential advantages exist. With their priority on scholarly productivity, AMCs can dedicate resources to support research and reward effective teaching. Philanthropy from grateful patients and community supporters has helped endow professorships to underwrite protected time for laboratory research, clinical trials, and mentoring. The academic department provides greater opportunities to build a "niche" practice to treat subspecialities, such as uveitis, ocular oncology, retinal degenerations, or pediatrics. It is harder to see an adequate number of patients to build a meaningful private practice in subspecialities, but it has been done successfully at many AMCs due to their regional bases for referrals. Also, the nature of the university department of ophthalmology allows close interaction with other specialists for the interdisciplinary management of complicated cases.

As scientific research has become more sophisticated, the AMCs provide easier access to high-level core facilities, thereby allowing opportunities for innovative, basic, or translational research. Of course, the university remains the home base for most residency and fellowship training programs, and such endeavors are part of the daily life of the AMC-based retinal specialist. It is hoped that the members of a department of ophthalmology have a shared commitment to the intrinsic value of academic contribution, although in private practice, this commitment is likely to be highly variable.

There may also be unanticipated economic benefits. If properly leveraged, the large AMC-based multispecialty practice can have considerable negotiating power for insurance contracts. This can result in better reimbursements for services. In addition, the academic department is often part of an integrated healthcare system that can both generate reserves and be well positioned to borrow money on advantageous terms. This can allow the AMC practice greater access to capital for acquisition of expensive equipment or to acquire practices to provide a network for referrals.

THE DOWN SIDE

These benefits are balanced by several potential disadvantages. Academic practices often have higher overhead. Departments are commonly charged a "dean's tax," a percentage of collected revenue that is used to help support the academic mission of the medical school. Also, many AMC-based practices are not run as efficiently as a private practice due to additional bureaucratic requirements and inefficiencies. This will result, in general, in lower physician compensation. In fact, when one combines the increased overhead with the fact that most university-based physicians devote less time to clinical practice, the 50th percentile salary for a vitreoretinal specialist at an AMC is $284,000 (based on the Physician Compensation Report of the Association of University Professors of Ophthalmology, February 2007), while the 50th percentile for vitreoretinal specialists overall is $452,648 (as reported in the Medical Group Management Association's Physician Compensation and Production Survey, 2007).

The academic retina specialist also has considerably less control of administrative aspects of the practice. This has become particularly apparent in the area of industry-based clinical research. While the clinical trial used to be the exclusive province of the university, most patient recruitment for multicenter trials now comes from the private sector. Medical school investigational review boards take considerably longer to approve a clinical protocol than those outside the university. In addition, contractual negotiations can become quite protracted when dealing with the university's lawyers, due to concerns about rights to intellectual property and liability for adverse outcomes.

Finally, the academic vitreoretinal specialist has considerably greater responsibility. In addition to building a clinical practice, maintaining proper relations with referring physicians, and staying up to date with rapidly evolving clinical care, he or she is often required to teach residents and/or fellows, be active in clinical and/or laboratory research, and publish. These factors combine to increase the risk for burnout.

CONCLUSION

Overall, however, a university-based retina practice has the rewarding potential to be a unique center of excellence and a great home for the individual with a sincere interest (the "fire in the belly") in teaching, research, and advancing the field. The university medical center lends itself most naturally and easily to certain pursuits, such as complicated cases requiring interdisciplinary management, basic and translational research, and comprehensive resident and fellow education. However, the decision to join and contribute to a productive university-based retina practice requires honesty and self-appraisal on both sides. Physicians must be clear about their career goals and motivations and, if a university is the best venue to pursue them, be willing to make certain sacrifices in order to earn the satisfactions of academic success.

Universities, through their department chairs, deans, and administrators, must also be honest about the expectations of their retina specialists and be willing to demonstrate their commitment to the academic mission by making efforts to retain talented and promising specialists. It is critical that the leadership emphasize 2 important areas: protection of time for academic pursuits and creation of a compensation plan that links salary with desired activity, appropriately rewarding research and teaching.

To ensure the success of academic vitreoretinal specialists, the institution must encourage scholarly endeavors by making sure there are other retinal surgeons available to cover walk-in patients and emergency surgeries during the time set aside to write or perform experiments. In addition, if compensation is completely linked to collections or relative value unit production, then faculty's incentives are to increase clinical productivity and not to teach or write. If a faculty member earns a research grant that provides salary support, there must be some increase in compensation; otherwise, they will be rewarded for doing more surgical cases, but not for doing meaningful research.

Ongoing advancements in biotechnology, changes in healthcare delivery, and economic pressures, coupled with an aging population and a greater need for retinal services, will present unique opportunities and new challenges for the academic mission. The creativity, innovation, and leadership that engendered the field of vitreoretinal surgery will be needed to respond to these challenges and allow us to continue to improve the quality of life of millions of people. With the right seeds and the right soil, olive trees can continue to thrive. RP