In this Higher Ed Careers interview, Andrew Hibel speaks with a group of neuro-ophthalmologists about how to overcome the challenge of filling fellowships, and ultimately full-time positions, in their field and other medical subspecialties. Provider shortages, no matter what field, put future patient care and well-being at risk.
Andrew Hibel, HigherEdJobs: Please share an introduction to the neuro-ophthalmology field.
Committee: Neuro-ophthalmology is a subspecialty that combines ophthalmology and neurology and requires one year of fellowship after either an ophthalmology or neurology residency. Neuro-ophthalmologists see patients with vision loss, double vision, pupillary or lid abnormalities, and abnormal involuntary eye movements (e.g., nystagmus) associated with disorders of the brain, thus playing a vital role in the diagnosis and management of vision-threatening and life-threatening disease. Neuro-ophthalmologists not infrequently diagnose disease that presents with visual issues yet have the potential to cause more widespread symptoms such as multiple sclerosis, stroke, brain tumors, and myasthenia.
Hibel: In a recent conversation with a neuro-ophthalmologist, we learned that many fellowships in this subspecialty go unfilled. Can you confirm or deny this? If it’s true, what are some of the challenges to filling them?
Committee: It has been estimated that one full-time clinical neuro-ophthalmologist can provide coverage for 1.2 million Americans.1 Despite this very large ratio of patients to neuro-ophthalmology providers, according to a recent North American Neuro-Ophthalmology Society (NANOS) membership survey,2 our country still falls far below this threshold with only eight states appropriately meeting this demand, and six states not having a single practicing neuro-ophthalmologist. This can be dangerous for patients because it can delay the diagnosis of serious conditions, such as brain tumors, systemic inflammatory diseases, and vascular stroke, dissection, or aneurysm.
Unfortunately, about one-third of neuro-ophthalmology fellowship positions have gone unfilled in recent years. In addition, many positions are filled by international graduates who will not remain in the United States to practice neuro-ophthalmology.
To determine why ophthalmology residents do not more often pursue a career in neuro-ophthalmology, a survey was recently sent to all graduating US PGY4 ophthalmology residents.3 Several of the most commonly cited reasons to not pursue a career in neuro-ophthalmology included 1) the perceived lack of surgery, 2) potential job opportunities limited to academics, and 3) low anticipated salaries. Interestingly, some of these perceived barriers to pursuing neuro-ophthalmology are outdated misconceptions. Although neuro-ophthalmology has traditionally been considered a medical subspecialty, according to a recent survey of neuro-ophthalmologists in the United States, over 50% of practicing neuro-ophthalmologists actively incorporate surgery into their practices. The survey also found that one-third of active neuro-ophthalmologists practice in a non-academic, private practice setting, often combining neuro-ophthalmology with general ophthalmology/neurology or other subspecialties, thereby diversifying clinical interests. Admittedly the salaries in neuro-ophthalmology can be lower than subspecialties that are more heavily surgical, but there is a wide range of salaries that can be competitive. In addition, neuro-ophthalmologists have a unique skillset that makes them valuable to a large practice or academic center and can increase patient volumes for the rest of the practice. Once the misconceptions about neuro-ophthalmic practice have been addressed, the benefits of being a neuro-ophthalmologist can be more fully appreciated.
Hibel: What can we be doing differently in academia to help fill these specialty fellowships and ultimately boost numbers in fields that are traditionally understaffed?
Committee: In addition to helping remove the misconceptions that are barriers to residents choosing neuro-ophthalmology as a field, medical schools can become more proactive at assessing current and future demand for physician services subspecialty by subspecialty.4 As they identify specialties/subspecialties in which a physician shortage is present or anticipated, the following actions could be implemented:
- All medical students could receive an annual list of specialties that are in short supply. Medical students should be urged to look at the disciplines with manpower shortfalls as potential careers because this will help offset the shortage, and the graduating medical student would be guaranteed more job security in entering a field that has high demand. Medical school dean’s offices should work with specialty/subspecialty societies to have a current list of administrative and physician leadership contacts so that interested medical students could have an easy avenue for learning more about these short-supply specialties.
- All medical schools could devote a day in the second semester of year one or the first semester of year two as the “Meet the specialties that are seriously needed” day. The AAMC can work with the relevant specialty societies to develop small speaker bureaus that would send speakers to meet with medical students on this day. The specialty societies could work with the AAMC to develop a website of current materials that could serve as reference materials for the students to learn more about these specialties.
- Just as financial incentives were developed by CMS and others to encourage physicians to train in primary care; such incentives could be considered for specialties where there is a severe shortage of providers.
Hibel: What specific specialties/subspecialties (other than neuro-ophthalmology) are facing this challenge of recruiting doctors?
Committee: Several specialties, other than neuro-ophthalmology, are also suffering from current and projected physician shortages, including pediatric ophthalmology, uveitis and inflammatory ocular disease, and general neurology. These fields share similar barriers with neuro-ophthalmology in recruiting trainees into their specialty, while also having some of their own unique barriers.
According to Lee et al, a significant reason for the shortage in pediatric ophthalmology is the downtrending economic reimbursement in pediatric ophthalmology compared to other subspecialties.5 Pediatric patients require more lengthy examinations, and there may be opportunity costs related to the additional time necessary to thoroughly examine patients, particularly those with special needs. Additionally, the 2022 CMS fee schedule proposed sharp reductions for a number of the strabismus surgery codes, which are the main surgical procedures performed by the subspecialty. These economic factors undoubtedly affect fellowship selection, resulting in fewer ophthalmology residents pursuing pediatric ophthalmology as a subspecialty.
Similar to some neuro-ophthalmology practices, uveitis and ocular immunology are not a procedural specialty and therefore reimbursement for services is often less than the more surgical specialties in ophthalmology. In addition, they too share the challenges of longer visits as a result of highly complex patients with vision- and even life-threatening disease. General neurology suffers from similar challenges, caring for complex patients and having fewer options for procedural coding, with the exception of electromyography and electroencephalography. These economic changes can result in dissatisfaction amongst current practitioners, thereby resulting in overall disillusionment within the field which undoubtedly has an effect upon trainees. Other cognitive non-procedural medical specialties, such as cognitive neurology and rheumatology, experience similar difficulties.
Hibel: Do Medicare reimbursements play into students’ choices about what fields to pursue? Specifically, are lower Medicare reimbursements for diagnosis vs. treatment keeping people from going into diagnostic fields? And if so, what impact does that have long-term for patients and healthcare in the U.S.?
Committee: While data do not support a direct answer, we do have student opinion about specialty choice from the Graduation Questionnaire (GQ) published annually by the AAMC. The GQ is sent to all graduating medical school seniors and includes several questions on influences on specialty choice. Over the last five years, students’ specialty choices are most influenced by content of specialty and fit with personality, interests and skills, with role model influence and fellowship options also being high on the list. Income expectations are predominantly a minimal to moderate influence, but there has been a gradual rise in it as a major influence over the last five years (AAMC GQ report, 2022). Overall, this suggests that medical students are still choosing specialties based on their passions as opposed to their future compensation, although this may be a changing trend that bears watching.
Perhaps the more important question is what the factors are that influence ophthalmology or neurology residents-in-training subspecialty choice. As discussed above, according to a recent survey of recently graduated ophthalmology trainees,3 40% of ophthalmology trainees surveyed cited salary as a reason not to pursue neuro-ophthalmology fellowship, which was the third most commonly cited reason. A neurology survey is in development and will help understand the different factors affecting neurology resident subspecialty choices.
Further delineation of the reimbursement issues that affect neuro-ophthalmology providers has been explored by Dr. Frohman in his recent Hoyt Lecture.4 This highlights the significant limitations for the “cognitive specialties” reimbursements from CMS and the workarounds that individual providers resort to in order to support their neuro-ophthalmology practices in the academic and private sectors, which include secondary fellowships (frequently surgical or containing some interventional component) and/or retaining general ophthalmology/neurology practices. There is no doubt that these different factors play a significant role in the difficulty recruiting and then retaining full-time neuro-ophthalmologists. This difficulty in recruiting and retaining full-time neuro-ophthalmologists has led to and will continue to cause mismatch of supply to demand, with the average wait time for a new patient appointment most recently calculated at seven weeks.2 Without significant changes, the impact will be increasingly inadequate access to neuro-ophthalmologic care. And if people trained in neuro-ophthalmology devote only a fraction of their time to this discipline, the question of who will have adequate neuro-ophthalmic expertise to properly train the next generation of neuro-ophthalmologists is a concern.