Is neuro-ophthalmology in jeopardy?

What is the difference, my friend likes to ask, between a neuro-ophthalmic examination and a regular ophthalmic examination? After a few seconds comes the punch line: About an hour.

This invariably gets a good laugh from a group of comprehensive ophthalmologists who have adapted to the era of managed care by promoting efficiency and by focusing their efforts in the clinic. From department chairmen and many neuro-ophthalmologists, the reaction is silence, a shaking of the head, and worry. Some, like me, wonder if the field of neuro-ophthalmology, as we have known it, will come to an end. And that's no joke.

Why the gloom? In each of the last 2 years, I am informed, two fellows have matched for training in neuro-ophthalmology in the United States. With 125departments of ophthalmology in the United States and only two new neuro-ophthalmologists each year, many who retire will not be replaced.

If your residency experience is typical, the neuro-ophthalmologist in your department is among the faculty most interested in teaching. Unlike so many of us ophthalmologists who get focused on our little part of the eye (cornea, retina, etc.), neuro-ophthalmology faculty deal routinely with the rest of the nervous system, as well as with endocrine, inflammatory, and infectious disorders. They tend to be among the ophthalmology department faculty most known and appreciated by faculty in other departments, with whom they closely interact on many patients. Not having a neuro-ophthalmologist would be quite a blow to the teaching and patient-care functions of most departments. At this rate of two new neuro-ophthalmologists being trained per year, the field eventually may cease to exist.

Fewer opt for the specialty

Why are ophthalmology residents voting with their fellowship matching forms to stay away from a career in neuro-ophthalmology? Is it because a business model in which examinations take an hour longer but are compensated the same is no longer viable? Is it that most residents seek a career with a significant component of surgery, and most neuro-ophthalmologists do not operate? What can we do to change this trend?

If the problem is purely financial, why don't department chairmen just subsidize their neuro-ophthalmologists? Historically, in the era of $2,500 per cataract extraction, this is exactly what happened. High-volume surgeons in academia would generate enough professional fee revenue to pay both their own salaries and a significant percentage of the salaries of their neuro-ophthalmic colleagues. The ability to have their complicated and baffling cases cared for by neuro-ophthalmologists, plus the excellent resident teaching, made the subsidy worth it.

As we all know, times have changed. Progressive cuts in reimbursement have made it a challenge for many to pay their own bills, let alone subsidize their fellow faculty. Just as changes have been made in private practice, most academicians have also had to make changes, such as the way they see patients, make teaching a part of the clinic day, hit the lecture circuit, and find time for academic pursuitsóall in response to the economic realities.

Some departments are lucky. Philanthropic dollars from appreciative patients or from grateful, generous, and successful alumni have created endowed professorships, insulating some lucky faculty from the real world. In my department, James Gills, MD, the famous anterior segment surgeon, funded the Frank Walsh Professorship, named after the person widely considered ìthe father of the field of neuro-ophthalmology.î

Most departments are not so fortunate, however. Department chairmen must be on the lookout constantly for discretionary funds from the hospital or elsewhere that they can use to fund this important area. Any way you look at it, in most departments, it is difficult for a traditional neuro-ophthalmologist to feel secure financially. Does this make the field attractive to a brilliant young ophthalmology resident who might be the next Frank Walsh?

What are neuro-ophthalmologists doing to adapt? Some are becoming dually trained to perform both oculoplastic and orbital surgery. Others are devoting major time to the laboratory, with funding from National Institutes of Health grants to help support these clinician-scientists.

An unusual approach is the one described by Barrett Katz, MD, MBA, professor and chairman, The George Washington University Medical Center, Washington, DC. He related how he changed his practice to scheduling patients every 15 minutes, because if he couldn't figure out the problem in the first 6 minutes with the patient then he would probably not figure it out at all. His history and examination became much more focused, his letters to the referring doctors are a couple of paragraphs long instead of three or four pages, and, he said, everyone wins.

My belief is the threatened demise of neuro-ophthalmology as a career option for ophthalmology residents is an unintended consequence of the changes being forced upon our U.S. health-care system. It will be fascinating to see how the leaders in this field respond to the challenges they face. If they fail to find solutions, resident training and patient care will suffer. So we all have a stake in their success.