Having trained residents and fellows for more than 25 years, I am very excited for our education and career issue. At this time of year, the end of a year of hard work is in sight, and the excitement is palpable. However, the world our graduating retina fellows face is very different than the world that I entered. Private equity, declining reimbursement, increased rules and regulations, and the uncertainty of our economy weigh heavy on new retina specialists’ minds.

Private equity is an interesting dilemma; firms are now targeting retina practices, having already targeted other high-revenue medical practices in dermatology, cardiology, radiology, anesthesia, and orthopedics. Judging from history, in retina, older partners will leave practices having cashed out at a level they could hardly have imagined. The remaining physicians will see an increased volume of patients compared to non-PE-owned practices. Nonpartner employees of the practice will be forced to sign onerous noncompete clauses and be forced to produce. With often no choice in the matter, they lose autonomy and say in the direction of the practice. Paid well at first, these employees are expected to increase EBIDA year after year, as if patients are widgets that can be made faster. High-revenue elective procedures will also increase.

The appropriately named Retina Consultants of America (RCA) was formed by Webster Equity partners, with 5 acquisitions totaling $350 million. It goes without saying that the investors in Webster’s Fund IV expect to see a hefty return on that investment, as articulated in Webster’s mission statement of “delivering optimal outcomes for our investors.” Private equity follows the money, and retina practices are the most appealing of all of ophthalmology. The fund that backs RCA has also funded 11 other companies including fertility centers, hospice care, autism services, orthotics, GI services, and rehab services from the $875 million in committed capital in the fund. Although I certainly am envious of my close friends’ ballooning bank accounts, and the decision to sell was a no-brainer (like buying Gamestop in December), I am concerned about what this means for our new graduates and young retina specialists who have long careers ahead of them.

For retina fellows, the clear path used to be considering joining a large practice based on its reputation, in the hopes of one day becoming a partner. Now, that approach may not be the smartest, because it is likely that a nationally recognized practice will be sold to PE, and young retina specialists may have to leave the practice or sign a noncompete that locks them out of a geographic area. The best option for graduates in 2021 may be to look at smaller practices that offer the chance to be autonomous and maybe even become a future partner.

Like others, I am concerned about where our specialty goes with PE entering our business. The goal of PE is making money for their investors, which is not always in the best interest of patients. Although many PE-owned practices state that they are physician-owned or -operated, in reality the holding company that includes the practice is controlled by the parent company. Also, lest we forget, the investors in the PE funds have a timeline for their return. What happens when the bill comes due? At some point, PE needs to sell. Maybe then the nonpartner employees will be able to actually become partners. We will see. RP