Traditionally, uveitis patients were managed in academic centers, but recently, more uveitis specialists feel comfortable treating patients in a private practice setting. Here, Uveitis Corner editor Sruthi Arepalli, MD, talks with uveitis specialists in private practice: Sherveen Salek, MD, with Kaiser Permanente in the Seattle area, and Akshay Thomas, MD, with Tennessee Retina in Nashville. This discussion highlights the benefits of practicing uveitis in an HMO or private practice setting.

Sruthi Arepalli, MD: Thank you so much for joining us. Could you tell us what your work week is like, and what percentage of your practice is uveitis?

Sherveen Salek, MD: I do both retina and uveitis in our practice, and we work 4 10-hour days a week. Typically, that means a half day of OR each week and then three-and-a-half clinic days. In terms of the clinic mixture, it’s probably about 80% retina and 20% uveitis.

Akshay Thomas, MD: We have 4 days of clinic and one day of OR on average per week. I’d say my split is about 65% retina and 35% uveitis, a ratio I am hoping to maintain.

SA: You both have clearly built a solid foundation for your uveitis patients. For our colleagues who are looking to establish their own uveitis practice, what kind of ancillary support do you have?

SS: Kaiser is a large organization, so I’m not as responsible for the hiring, but there is a lot of training for the staff. Kaiser is unique because it’s both an insurance and a health care provider, so you don’t have to deal as much with prior authorizations the same way that you do in private practice. However, there are different types of coverage, so I sometimes have to go through prior authorizations paperwork. It is nice to work for Kaiser where I don’t have to deal with those challenges day in and day out. It also helps for a staff member at each office to take ownersip of paperwork and fielding patient issues.

AT: Your uveitis patient workflow and needs are going to be very different from the rest of your patients. For that reason, it’s extremely important to have appropriate ancillary staff. When I joined my practice, we didn’t have a dedicated uveitis specialist. Over the last couple of years, we have trained three technicians to be uveitis coordinators. We try to keep the uveitis patient load most heavy at our main location, so when I have those clinics, I have 2 or 3 of my uveitis coordinators with me. They understand the workflow for specific subtypes of uveitis; for example, which patients need an anterior chamber check prior to dilation. They’re trained to do that on their own if necessary, and I’d say they function at the level of a resident in that regard, after more than a year’s worth of training. Our uveitis coordinators handle prior authorizations, send out aqueous samples, field emails from uveitis patients, send in prescriptions for uveitis medications and teach patients how to administer adalimumab.

We have a separate lab coordinator who does an excellent job at making sure patients have gotten the appropriate labs and who follows up on the results to make sure they get to me.

There are also a lot processes you have to streamline early on to establish a successful uveitis practice; for example, contracting with specialty labs handling aqueous samples for PCR testing, establishing a relationship with infusion centers, and establishing a network of rheumatologists, neurologists, gastroenterologists, dermatologists and infectious disease specialists for patients needing co-management.

SA: This is all fantastic advice. Another thing I wanted to talk about is how it can be isolating to practice uveitis in a private practice. How do you form connections with ancillary services, market yourself, and build a referral network?

AT: If you’re joining a practice where there’s not an existing uveitis service, you will want to market that because your referring doctors may not have traditionally sent those patients to that practice. You can do that with continuing education events. Also, you want to be available. If it’s a challenge for a referring doctor to get a patient to you, it will disincentivize them from sending you future patients.

SS: At Kaiser, referrals come internally from our optometrists and comprehensive ophthalmologists. We do have continuing education events, which are a great venue to get to get to know them. We have an integrated medical record, but I still communicate with referring physicians, because often in might be easier for intermediate visits for the patient to go back and see the physician who sent them over.

I trained at places were uveitis doctors managed immunosuppression themselves, as well as settings where we referred to rheumatology. At Kaiser, we have great rheumatologists available, so they usually take care of managing the labs and obtaining the prior authorizations for TNF blockers or other biologics. The integrated medical record makes it easy to coordinate with them.

SA: Speaking of building or expanding a uveitis presence, for those interested in joining a group, what advice would you give someone on negotiating a contract and establishing a presence in research and clinical trials?

AT: Remember that you’re providing a service that not a lot of doctors can provide but that might not generate a ton of revenue. You can argue that because you’re managing complicated patients, that clears up the schedule for your partners to see, perhaps more “bread-and-butter” patients, or maybe it increases the overall number of referrals to your practice. You want to establish up front what percentage of retina vs uveitis patients you’d like to manage, as the uveitis portion can quickly grow.

Another part of contract negotiation centers around ancillary and support services. If you’re in a practice where each physician pays their own overhead, adding technicians and a lab coordinator is not necessarily feasible right away. You may not need significant ancillary staff initially but as your practice grows, those ancillary staff will be critical. A third part of contract negotiation is compensation, which you might not have much say in. Depending on the compensation model you may find yourself looking for an additional uveitis specialist to join your practice so that your retina-to-uveitis ratio is maintained.

Regarding research, the demographic of uveitis specialists is changing in that we have a lot more uveitis practitioners going out into places like Kaiser or private practices. These sites are becoming more popular as uveitis clinical trial sites because of very successful recruiting from some of our colleagues.

SS: When I started, there was a huge volume of retina patients. For me, the challenge was making sure that when I was seeing uveitis patients, my staff knew to block out an appropriate amount of time in my schedule. Something I changed in the beginning was to set aside more time for the workflow — for the staff to be trained in the beginning but also set aside the time to do the imaging and history taking and examination.

I also agree that there’s huge opportunity for uveitis specialists in private practice or as part of an organization like Kaiser to see patients in trials, because that’s really where the patients are.

SA: This is all wonderful advice. For those starting out, what advice do you have about communicating and continued education within the specialty? Dr. Thomas has a wonderful uveitis podcast that I’d like to highlight, called “Headlight in the Fog.” What other resources have you relied on?

SS: There are both formal and informal networks. There are online forums like American Uveitis Society where we can email challenging cases to get input from our colleagues. And then there are informal networks like peer-to-peer interaction at meetings. It is extremely helpful to communicate with each other regularly, informally, about challenging cases.

AT: I echo what Dr. Salek said. When you start out you will be managing some of the most complicated patients in your practice and at times you will need help. Humility goes a long way in uveitis. The networks Dr. Salek mentioned are spot on. They are safe spaces to ask questions.

Definitely reach out to your mentors when you’re in a pinch. And reach out to your colleagues; this is a small field, we all know each other. We all know the growing pains. RP