A Case of the Mondays

If you could return to the beginning of your medical training, would you still choose ophthalmology? Going back even further, would you still choose medicine? To many ophthalmologists, the answer is obvious – but is every ophthalmologist happy with the path they’ve chosen? In his work as a medical ethicist, John Banja has been lucky to get the opportunity to gain an insider’s look into the world of some anterior segment surgeons, and here he shares his observations on an important but sometimes overlooked topic amongst ophthalmologists: job satisfaction.

Are the work pressures different for younger and older doctors?

In the US, I’ve found that there is a great deal of dissatisfaction and disillusionment among medical professionals, including ophthalmologists. But it’s important to qualify this statement, as it’s something often seen among older doctors – those who have been in the field for at least 20, if not 30 or 40 years. I suspect it’s because these are the people who have seen their profession change considerably, and not always for what they believe is better. Younger doctors are often more in tune with the status quo, and seem predictably more satisfied with their profession. Of course, they have no basis to say “Well this is how we did things 30 years ago when it was so much better!”

What are the main sources of dissatisfaction?

Changes to the doctor-patient relationship, a lessening of autonomy and authority, and a tsunami of paperwork (even when it’s in electronic form) are three common themes when listening to complaints of seasoned but disaffected doctors. And, if you work in the US, this situation is further compounded by reimbursement problems and a growing corporatization of the clinic. US doctors are burdened with having to obtain authorizations from insurance companies so they can go ahead with the procedures their patients need, which often delays their patients’ care.

There are also the corporate demands of running any medical practice – which are particularly burdensome in ophthalmology. The business considerations involved in running a clinic are numerous: regulatory hurdles, hiring and managing staff, networking, affiliating yourself with optometrists to give you a healthy supply of referrals, and so on. These things introduce an element of complexity into the life of the ophthalmologist that he or she may not have conceived of during medical school. But at the same time, solo practices are becoming less common, and many ophthalmologists are now joining large, well-established clinics, which can also bring a lot of business responsibilities. There are productivity pressures too – surgeons might be in the clinic two or three days a week, 8–12 hours a day, doing a procedure like cataract surgery every 12–15 minutes. A lot of ophthalmologists also do pro bono and research work, and many would like to do more, but again, all these growing demands on their time can take them away from both the patients in their practice, and their worthy side-projects.

Do doctors feel compelled to keep up with the Joneses?

Another enormous challenge for today’s ophthalmologists is how technology-dependent the field is. Every new gadget that comes onto the market causes a buzz, and starts conversations among colleagues and contacts: “Should I invest in this; is it worth it?” But because ophthalmology is such a technology-driven, forward-looking field, the buzz often precedes the outcome studies. The femtosecond laser is an excellent example of this phenomenon. This technology can cost about half a million dollars in the US, but yet there is still debate around its value. Back in November, my wife had bilateral cataract surgeries, and her doctor used a femtosecond laser. The result was, in my opinion, spectacular – she now doesn’t need spectacles. But these kinds of remarkable outcomes are more and more commonplace in ophthalmology, with or without the latest gadget. Ophthalmologists have become, in a way, victims of their own success. Cataract surgery has become so safe and straightforward for the vast majority of cases, and the results are frequently fantastic. But this can leave doctors scratching their heads over new technologies, and wondering “Gosh, are they really all that much better? And how will I recoup my money on this thing?”

On the other hand, if you want to stay competitive, and you know the practice down the street has just bought a femtosecond laser and is advertising to potential patients that they’ve got the latest, cutting-edge technology, do you need to invest in a machine yourself to stay competitive? Is it worth it?

Could a robot do the job?

Another concern surrounding technology is increasing automation. A lot of veteran ophthalmologists have told me that they worry about the next generation losing their manual skills, because a perfect capsulorhexis can be made using the femtosecond laser – and what will these surgeons do when the inevitable complication arises, and the laser can’t handle it? And looking further down the road, as genetics, genomics and various innovative technologies will revolutionize healthcare, there is a concern in many fields of medicine that there will be fewer doctors and more technicians – for example, some disciplines question if a computer program might be reading and interpreting radiologic images and pathology slides in 30 years. Technology is going to continue to impose itself on the practice of medicine, and doctors will have to learn to rock and roll with the changes if they want to succeed.

How big is the problem, and what can be done?

Despite my own talks with ophthalmologists, I think far more data is needed before definitive conclusions can be drawn, and perhaps there is no data to prepare us for what is to come. More in-depth surveys of subgroups within medicine could yield a wealth of information, and give us a much better idea of the challenges different specialties face. It’s possible that the majority of ophthalmologists are absolutely tickled with their jobs, and that there are some who simply can’t wait to retire.

Unfortunately, if you dig your heels in and holler “I just want to treat my patients!” you won’t get far. And yet ophthalmologists shouldn’t become so concerned with these other things that they forget why they chose to practice medicine in the first place. An obvious step is to better prepare people during residency, so ophthalmologists are better equipped for tackling these responsibilities. Another is to surround yourself with an excellent team – office and business managers, assistants, and other staff that can help you minimize the other demands on your time.

Also, there are many aspiring entrepreneurs in ophthalmology who love to evolve new technologies, business practices and medical devices; people who have great business skills to complement their clinical skills, and who are eager to exercise them. Ophthalmology is often entrepreneurial and innovative by nature, but it’s important to ensure that these other potential pressures don’t result in some doctors feeling frustrated and dissatisfied.

What is your overall impression of the profession?

My interactions with ophthalmologists have impressed on me that ophthalmology is a magnificent profession, and the people I have met are outstanding human beings, who derive an immense amount of satisfaction from their work. To take a patient who is essentially blind, and 90 minutes later, they can see well, and a week later is seeing virtually 20/20? The gratification must simply be stupendous.

My impression is that if more can be done to support doctors, and if we can perhaps remove some of these regulatory, documentation, or business worries that some ophthalmologists have, and just let them do what they were trained to do, this will result in happier ophthalmologists. The last thing you want is a physician who is discouraged, miserable and frustrated. It is in the self-interest of every single patient who walks into a clinic to see an ophthalmologist who is healthy, well rested, happy, enjoying his or her life, and the work they are doing. We need further study on the pressures ophthalmologists face, and what might be done to alleviate them.

John Banja is a Professor at the Department of Rehabilitation Medicine, a medical ethicist at the Center for Ethics, Emory University, Georgia, USA, and the editor of AJOB Neuroscience.