AAO 2017 Retina Subspecialty Day: IRIS Registry Retinal Detachment Outcomes
ASRS 2018: Women in Retina (WinR): How to Succeed in Different Practice Environments, From Academia to Private Practice. July 23, 2018. Course Organizer: Audina Berrocal, MD Faculty: Lisa Olmos de Koo, MD, MBA; Christina Weng, MD, MBA; Geeta Lalwani, MD; Aleksandra Rachitskaya, MD; Stephanie Vanderveldt, MD; Ashvini Reddy, MD; Alice Zhang, MD Stavros Moysidis, MD Associated Retinal Consultants, P.C. William Beaumont Hospital Instructional courses followed the PAT Survey and Global Trends talks after lunch on Monday, and it was difficult to choose from so many great options. Kourous Rezaei, MD, organized a Retinaws course entitled, “When the Going Gets Tough, the Tough Get Going - Challenging Cases in Vitreoretinal Surgery,” which boasted esteemed faculty discussants and surgeons: J. Fernando Arevalo, MD, FACS, Ehab El-Rayes, MD, PhD, Geoffrey Emerson, MD, PhD, Jose Garcia Arumi, MD, PhD, Stratos Gotzaridis, MBBS, MD, Timothy Murray, MD, MBA, Manish Nagpal, MD, FRCS (UK), Kirk Packo, MD, FACS, Stanislao Rizzo, MD, Homayoun Tabandeh, MD, and Charles Wykoff, MD, PhD. It was sure to be full of riveting surgical cases, challenges, and triumphs. Down the hall, one could enjoy a course organized by Andrew Barkmeier, MD, and Alan Franklin, MD, PhD, “Visualization in Vitreoretinal Surgery: Optimization, Technology, and Pearls” with renowned clinicians and vitreoretinal surgeons as discussants: Sophie Bakri, MD, Petros Carvounis, MD, Jorge Fortun, MD, Raymond Iezzi, MD, and Christopher Riemann, MD. Packed with a 3D-glasses-wearing audience, it looked like a scene out of Back to the Future, and guests were sure to leave the course knowing to see so well in the OR, that they too could predict the future. But it was the course in Room 118 that grabbed my attention: “Women in Retina: How to Succeed in Different Practice Environments, From Academia to Private Practice,” hosted by Audina Berrocal, MD. An inaugural course at ASRS, I had to check it out. With faculty discussants, Lisa Olmos de Koo, MD, MBA, Christina Weng, MD, MBA, Geeta Lalwani, MD, Aleksandra Rachitskaya, MD, Stephanie Vanderveldt, MD, Ashvini Reddy, MD, and Alice Zhang, MD, I knew I was bound to learn something useful, interesting, or both. It was awesome! [caption id="attachment_2355" align="alignnone" width="721"] Dr. Audina Berrocal[/caption] Dr. Berrocal, co-director of the surgical retina fellowship and professor at Bascom Palmer Eye Institute, started the session by sharing the secrets that guided her from fellow to professor at Bascom Palmer Eye Institute. She shared her insights, Ocean’s Eleven-style, with the help of Sandra Bullock in an orange jumpsuit, no less. #1 - Find your niche and pursue it with determination. Hers was a calling to the care of children with vitreoretinal disease, and countless families are fortunate it was. #2 - Attend important meetings and present your research. Choose the podium over the poster presentation. “Women tend to prefer poster presentations,” she said, and it’s a mistake. Ask to get involved on sub-committees. The way to get involved is to ask. #3 - Write, write, and write some more. Publish your work - both peer-reviewed and non-peer-reviewed. #4 - Be inclusive. Include the medical students who helped you as authors. “Being inclusive is good for everyone in the long run,” she said. #5 - Take care of your clinics. The schedule is so important to your success. Make sure your administrative assistant and everyone who works with you knows what’s important to you so that your schedule reflects that. Take great care of your patients. Look them in the eyes when they’re talking to you. #6 - Be available. If doctors in your department or the community call you at 6 o’clock about a patient, tell them to send the patient over to you. #7 - Belong to committees within your department and within the university. #8 - Take care of your staff. Be nice, but firm. Be consistent. If you’re unhappy with the level of focus or efficiency in clinic, speak to them directly about it, without scolding them. #9 - In the OR be courteous. Say please and thank you. Remember that everything that you say has been heard. Remain calm when complications arise. The perception of your surgical skill begins in the OR with the nurses. #10 - Find happiness in everything. Happiness comes from within. Don’t complain about your problems; find ways to make things better. [caption id="attachment_2356" align="alignnone" width="714"] Dr. Lisa Olmos de Koo[/caption] Dr. Olmos de Koo, director of surgical retina fellowship and Associate Professor at University of Washington, gave a crash course on the highlights of an MBA curriculum and how to effectively use those teachings in academic medicine. The core classes in the MBA curriculum include communications, economics, finance, marketing, and strategy. She found communications to be her most useful class in business school. She recommended Toastmasters International as a course in communication and public speaking for anyone shy or hesitant to come up to the podium to speak. She advised paying close attention to all the details of your presentation, including the font type. She recommended avoiding intricate or elaborate fonts and sticking to straighter, simpler, font types that are easier to read. Next, she discussed economics classes. One of her professors would stomp on the ground and yell, “there is no free lunch!” She stomped for effect, and the room shook. “Every time you make a decision, there is something else you’re not doing,” she said. “Be fiscally responsible,” she continued. Understand and follow your cash flow. Third, she highlighted insights from finance courses. She emphasized the importance of learning and unlocking the power of excel. She discussed net present value formulas for making financial decisions. Thinking of buying new equipment for clinic or the OR? Use the net present value function. Thinking of hiring a new associate or a scribe? Net present value has your back. Run the numbers and make smart decisions. Next, she discussed the importance of marketing. It’s not enough to be a great clinician and surgeon. She explained that one must work to “increase the amount of goodwill out there” for the good work that one does, whether it be for the practice, for the department, or the laboratory. Finally, she shared that strategy was her favorite class in business school. “Going from fellow to full Professor. That’s a huge journey. And you have to have plans along the way to get there.” She recommended reading the book, “Getting to Yes” to learn more about negotiating. And she advised learning to negotiate with another party in such a way that both parties win, without letting emotions cloud you. Leverage all these skill sets in your retina practice: Communications, economics, finance, marketing, and strategy. [caption id="attachment_2357" align="alignnone" width="764"] Dr. Christina Weng[/caption] Dr. Weng, director of the surgical retina fellowship and Assistant Professor at Cullen Eye Institute, Baylor, discussed how to navigate change when you’re starting out in practice. She pointed out that many of us in medicine aspire for control – to be captains of our ship – but that life is full of surprises. She described her personal experience with the unexpected. When she first joined the faculty, she had two senior and two mid-level retina attendings she could lean on for advice or discuss cases with. However, within a matter of months, two of these faculty left, leaving her at the helm of the retina fellowship program, perhaps earlier in her career than she would have wanted. At one point, her responsibilities had exponentially grown to include Q1 call coverage for 4 hospitals – a task that would have flattened most normal humans. But Dr. Weng is no normal human. She toughed it out and kept a positive attitude and soon she saw herself “turning the corner.” Now her retina division has grown again, and she is enjoying her role and the many hats she is wearing. She learned 3 lessons from this unexpected event: #1. Don’t be ashamed to ask for help. She discussed that we’re often nervous of showing our weaknesses when we start a new job - that we want to prove ourselves. She commented that this feeling may be especially pervasive among female retina surgeons starting out. She talked about how learning to ask for help improved her situation. She expressed her gratitude that her Chairman, Dr. Stout, generously agreed to cover her call to allow her to attend a meeting (It was just the one time. Ok, Baylor faculty? Don’t get any ideas…). Dr. Weng talked about the importance of having mentors and reaching out to them for advice. #2. Turn obstacles into opportunities. She never thought of taking over the fellowship program of her department. And now, she is enjoying her role, teaching and molding future vitreoretinal surgeons. #3. Every cloud has a silver lining. She thinks things have a tendency to get better, especially when we work hard. But she emphasized the importance of having a deadline in your mind for how much time an unsustainable situation is reasonable – about having a Plan B. Her final piece of advice to fellows pursuing a pathway in academic medicine is to be collaborative – to reach out to colleagues in private practice and find things to work on together. She discussed that she invites colleagues to give lectures to fellows and residents and to teach them in the operating room, as well as collaborating on research projects together. Even though Houston has about 26 retina specialists within a very small area, she feels there is enough work to go around for everyone – that all can be successful. [caption id="attachment_2358" align="alignnone" width="722"] Dr. Geeta Lalwani[/caption] Dr. Lalwani, founder of Rocky Mountain Retina Associates, shared her pathway to success in private practice. After 5 years in academics, she decided to return home to Boulder, Colorado, where she started a successful solo-Retina practice, Rocky Mountain Retina Associates – a tremendous accomplishment in today’s healthcare landscape. With increasing medical student loans, increased regulation, and increasing costs of getting started, including the cost of Electronic Medical Records, the solo-startup is an endangered species. And yet now, almost 5 years later, Dr. Lalwani’s practice is thriving and she is interviewing new associates to join the growing practice. She said that the most important barrier to starting a practice is being ready clinically – “Medicine is what we do. You have to be very comfortable with the medical and surgical aspects of retina,” she said. She pointed to the steep learning curve to competency and that it takes each individual varying amounts of time to get there. Only then can one focus on the business aspects of retina. “Location, location, location” – she pointed to the practice location as a critical factor for success. After doing her homework, knocking on doors, and scouring the internet, she realized that there was an unmet need for quality retina care in Boulder, and thus she opened her doors and has been flying since. She advised the naming of a practice is critical – that one must have a vision for what she or he wants the practice to be like 5 or 10 years from now and name the practice accordingly. She envisioned her practice growing to multiple office locations, so she needed a name and a logo that fit that vision. She advised understanding your patient demographics. Miami, where her career in retina got started, had a very large population of patients with diabetic retinopathy, possibly 50% of her practice. For comparison, in Colorado, it’s closer to 12%. For that reason, it doesn’t make as much sense for a solo practitioner in Boulder to purchase higher end lasers for the office (PASCAL, etc), whereas it makes more sense in Miami. A physician must understand her or his patient population to understand the investments that are needed for the office. Next comes office size and design. She advised thinking about your current needs, but also your potential needs 5 years from now. While you don’t want to be paying for more office space than you need, you also don’t want to continue to repeatedly outgrow the space, if you can plan ahead. Plan for the present and the future. She suggested sharing office space with other ophthalmologists at some of your office locations to reduce your overhead. She pointed to EMR choice as an important one for the group. Since the Affordable Health Act Electronic Health Records mandate, EMRs have gone through several iterations and a consolidation, such that she feels the options available today have stood the test of time. Still – choose carefully, and consider all aspects of EMR cost – annual cost, training costs, cost for the patient portal bridge, for sending letters or faxes, etc. Equally important is the PMR aspect of the practice – or practice management system. When you don’t know something, you have to ask people and seek good advice. She recommended considering the ease of training staff, degree of integration with your EMR, and paying close attention to claim submissions – you’re responsible for the claims you submit. Medical insurance credentialing is a critical step for the practice. While Medicare allows for retroactive billing within one year, most other insurances do not allow submitting claims until a provider is credentialed with them. For malpractice insurance she recommended OMIC. She said the key to success was being available, and she made sure that every referral source within a 30-mile radius knew how to directly reach her. She pointed to one of the greatest barriers to entry is the management of intravitreal drugs. Luckily, the major companies, Genentech, Regeneron, and Allergan, all offer user friendly web portals to perform benefits analyses on patients, as well as significant personal support to educate staff. Finally, she said staff salary was the next greatest cost for the practice. She advised keeping the staff number low, allowing for some redundancy, but keeping them happy. You want to hire good staff and try to keep them – staff turnover is negative advertisement for patients and referring offices. Be fair, but firm with your staff. [caption id="attachment_2359" align="alignnone" width="744"] Dr. Aleksandra Rachitskaya[/caption] Dr. Rachitskaya, Assistant Professor of Ophthalmology at Cole Eye Institute, Cleveland Clinic, gave a great talk on “Self-help for young women in retina. What I learned in the last couple of years.” She started by showing her ophthalmology class residency photo from her 3rd year of residency and joking that only two people were wearing pink and only one of the two was not wearing a tie. The point was crystal clear to me – we should all drop the tie (it’s bad for circulation in the neck). And so Dr. Rachitskaya guided the audience through the challenges of being a woman in retina – only to hear her describe it, it was not so much challenges, but opportunities, the way she looks at it. She focused her talk on mentorship, the imposter syndrome, leadership, and importance of getting involved. First, she showed a quote from Sheryl Sandberg saying that, “I realized that searching for a mentor has become the professional equivalent of waiting for Prince Charming… Once again, we are teaching women to be too dependent on others.” Dr. Rachitskaya pointed out that she respectfully disagreed with that mentality. In retina and ophthalmology, mentors are very important for growth and success. She suggested looking for multiple mentors, and even in unusual places – you can learn something from everyone. She pointed to senior mentors and department chairs as being instrumental in her growth, but that perhaps one of her best mentors when she started at Cole, was her administrative assistant, Sandy Wong, who guided her through getting accustomed to working in a new department. Next, Dr. Rachitskaya discussed shedding the feeling of Imposter Syndrome, that somehow we don’t belong or we don’t deserve what we have – something she feels could be particularly a problem for women. She showed that women tend on average to wait until they have 100% of qualifications for a position before applying for it, while men tend to apply without hesitation even if they don’t have all the qualifications. Sometimes the imposter syndrome manifests in much milder forms. She watched an old video of herself saying multiple times how lucky she was to be in the position she is in and was surprised in self-reflection as to how she was coming off. “We worked hard, and we got what we deserved. We were not lucky. We worked for it,” she said. That is an important mentality to adopt to be successful. Next, she talked about leadership, about the importance of being a good leader – the kind who knows herself and those she leads. She described how she adapted her behavior after learning about her weaknesses of micromanaging from the ophthalmology technicians. She advised surrounding yourself with people you admire and having common goals. For instance, in research, you want to work with collaborative people and not people with whom, for example, you might argue with over authorship. Finally, she recommended getting involved. She pointed to her own reluctance to initially get involved with women’s groups – worrying that they would be meetings of “pedicures and wine,” while she prefers meetings about “concrete goals and leadership.” She said asking to be involved in leadership, showing interest and initiative is critical. When one senior hospital member met her request for leadership by offering her a position on a women’s-only committee, she insisted on a more diverse role and approached her Chairman, again asking for leadership opportunities. Now she is the youngest person on the committee to advise on hospital affairs, because she asked, because she persisted. She also became involved with women’s groups at her institution, and she has realized that their goals and ideas aligned with hers. And that is why Dr. Rachitskaya’s star shines so brightly, so early in her career, because of her hard work and perseverance. [caption id="attachment_2360" align="alignnone" width="710"] Dr. Stephanie Vanderveldt[/caption] Dr. Vanderveldt, partner at Georgia Retina, shared her insights on a hot topic in our field, private equity, in her talk titled, “partnering your practice with private equity.” Georgia Retina, most Retina Roundup readers may know, famously partnered with private equity a year ago, EyeSouth Partners, a portfolio company of Shore Capital Partners – a lower middle market healthcare private equity firm. Dr. Vanderveldt conveys newfound popularity at cocktail parties, where many vitreoretinal surgeons come up to her to ask about the “horrors” of private equity. And so, she set out to dispel “common myths about private equity.” As an introduction, she shared that in 2014, a handful of ophthalmology practices were aligned with private equity groups. By 4th quarter 2017, there were over 60. She anticipates that in the future, this will increase to about 20% of practices. Here are some common myths about private equity, she says: #1- It’s only beneficial for older doctors. As one of 14 physicians at Georgia Retina (now hiring a 15th associate), she pointed out that only one physician is older than 60 and a handful are over 50 years of age. She feels that the acquisition has been good to all involved. #2- You will lose practice autonomy. She says that 1 year out, her autonomy and that of her partners has not changed. The C.E.O. of EyeSouth Partners tells the doctors that “good medicine is good business.” And so Dr. Vanderveldt has felt supported when it comes to the administrative aspects of her day to day work. She feels they have continued to operate autonomously within the group. #3- Disruption of referral patterns. A concern that she hears repeatedly voiced is that joining private equity will scare away doctors that were previously referring to the group. The day the merger was announced, all the partners at Georgia Retina called their referring doctors to let them know about the merger and to emphasize that nothing would change in their practice or referral patterns – that they could count on a business as usual philosophy. #4- Recruiting top talent. She discussed the concern that accomplished vitreoretinal surgery fellows and attendings might be reluctant to join Georgia Retina after the acquisition. She feels this will not be the case for several reasons – there is now a faster track to the partnership buy-in, which she suggested would also be more affordable in a landscape of steep buy-ins, and that there are new opportunities for leadership within the umbrella company. She has become co-chair of the physicians advisory board of 65 doctors. She concluded by saying that reimbursements are declining and overhead is increasing, and that there is power in numbers to negotiate with payers. While private equity may not be for everyone, it represents a new opportunity in the field of retina, she concludes. [caption id="attachment_2361" align="alignnone" width="738"] Dr. Ashvini Reddy[/caption] Dr. Reddy, Assistant Professor of Ophthalmology at Wilmer Eye Institute, Johns Hopkins, started the discussion of the final topic, “Practice Patterns of Women in Retina.” She noted that there are a growing number of women in ophthalmology, and growing interest in salary differences between women and men. Women are paid approximately 56 cents on the dollar compared to men, in ophthalmology. This represents a greater disparity relative to other fields in medicine. But what is at the root of these differences? The study was performed using anonymized data from PAT survey 2016 and ANOVA and chi-squared tests were performed. The study could not account for whether a provider was full time or part time in practice. Dr. Reddy suggested that more work remains to be done on this topic and highlighted that industry payments to men have been greater than to women. Furthermore, a 2015 analysis of 671 original articles and 89 editorials from three major ophthalmology journals between 2000 and 2010 found that most articles were written by men as first authors, though the percentage of original articles with a woman as first or last author had increased significantly. [caption id="attachment_2362" align="alignnone" width="721"] Dr. Alice Zhang[/caption] Dr. Zhang, Assistant Professor of Ophthalmology at the University of North Carolina in Chapel Hill, closed the session by sharing gender-related practice patterns through an analysis of the PAT survey among US retina specialists. Women were more likely to pursue a fellowship in medical retina than surgical retina. There were no differences in geographic practice setting between men and women. Proportionally, there were more men in retina-only group private practices, whereas proportionally, there were more women in academic settings. There were fewer women than men who have been in practice for over 25 years. Overall, she summarized the survey by highlighting the similarities in clinical decision-making by women and men in the management of neovascular age-related macular degeneration and diabetic macular edema. This course was packed with great stories, honest advice, and an incredible array of topics. See you at ASRS 2019!