With COVID-19 on the forefront of everyone’s mind this year, this symposium highlighted many of the factors involved with running a practice in this environment as well as the many effects of the pandemic on a professional and personal level. Chairs Sumit Garg, MD, and Nicole Fram, MD, hosted this symposium, which was sponsored by the ASCRS Young Eye Surgeons Clinical Committee and the Vanguard Ophthalmology Society. The discussions in this symposium provided key updates and perspectives for ophthalmologists of all ages. 

When Your Practice Burning to the Ground is Not Your Biggest Problem

While on vacation in Nicaragua with his wife in November, Tom Harvey, MD, received a frightening video from his daughter — his clinic was on fire. Fortunately, no one was harmed, but nothing in the building was salvageable. The fire resulted in more than a $5 million loss. However, some factors mitigated the loss: zero debt, a cloud-based EMR and excellent insurance coverage. 

The practice rented a nearby space and worked hard to reopen at the end of January. Only 2 months later, a now familiar scene unfolded: the practice was forced to close up shop once again, this time due to the coronavirus. Owners zeroed their salaries, and the practice saw only urgent and emergent patients until fully reopening again in early May. 

An unlikely benefit of the fire emerged, in that the experience helped Dr. Harvey prepare for what was to come with the coronavirus. “The advantage we had was we were really experienced having a quiet period, going dark then turning the lights back on to try to reengage with our patients, so that helped us,” he said. “I think the ultimate test will be to see how the practice continues to grow over the coming months.”

“What seemed like the worst thing in world actually prepared you to move forward in this new age,” added Dr. Fram.

Daniel H. Chang, MD, a symposium panelist, believes the strength of Dr. Harvey’s practice was its financial standing and preparedness, which will also dictate how well other practices survive in the coming months. “If you were in a lot of debt, living paycheck to paycheck so to speak, it would have been harder to recover. That’s going to be a similar situation coming out through this pandemic.”

How to Keep Your Surgical Skills Sharp When Volume Dries Up

Manjool Shah, MD, shared strategies surgeons can apply from home to develop their skills.

First, surgeons can watch videos of their previous surgeries. Dr. Shah recommended starting with a straightforward routine cataract case, taking notes and drawing diagrams. “Seek the ‘why’ behind every action and every inaction that may occur,” he said. Also, focus on the fundamentals, such as hand position and phaco position. 

Then pick a case where things did not go as planned, such as a dropped nucleus, and apply the same active watching principles. Find the root cause, find the cause before the root cause and imagine all the steps that went from initial event to complication and beyond, Dr. Shah said.

“We can use this opportunity to develop ourselves and be that much better for it when this crisis is over.”
Julie Schallhorn, MD, associate director of University of California, San Francisco’s residency program in ophthalmology, said the pandemic has taken a toll on residents and their ability to train, especially those at the end of their third year. “It’s a big year. This is really when they get churning in the OR, and everything is screeching to a halt for them.” To help mitigate the surgical volume loss, UCSF joined with other local residency programs and allowed attendings to take turns presenting cases and analyzing them in excruciating detail.

Naveen Rao, MD, another panelist, says that in some ways this situation has created good opportunities for teaching. “Before (the pandemic), to do a lecture I would have to go in from where I live downtown to do a talk,” he said. “Now, I can do it from home.”  

How COVID Has Affected Finding the Job of Your Dreams

Zachary Zavodni, MD, covered the current state of job searching for young surgeons. As it pertains to finding a job, Dr. Zavodni presented “more bad news than good news.”

Within the health-care world, Dr. Zavodni said ophthalmology has arguably been the hardest hit from an economic perspective, including the largest decline in patient volume. In addition, patients may have a hard time affording surgery or fear interacting with health-care providers. These factors are shaping the job market for young ophthalmologists, as some practices close and others put off hiring for expansion or growth. Some positives: older physicians may decide this is their opportunity to retire. Also, the potential for population redistribution may result in a need for eye-care providers in smaller rural communities.

To increase their standing for a potential job, Dr. Zavodni detailed a few key aspects that employers may be searching for. First, employers want creative problem solvers who have new ideas and are excited about implementing health care in new ways. Next, they want positive attitudes, those who will come to work daily and try to uplift their staff. Also, employers want flexibility and a willingness to work longer hours and weekends and potentially for less-than-anticipated levels of compensation. 

Dr. Zavodni closed with some optimism. “I’ve painted a rather depressing picture for trainees coming out during a recession, but we should all continue to remember that the long-term outlook for anterior segment surgeons is positive. As baby boomers continue to age, there will be an increasing need for eye surgeons. With time, practices should come back to the days of thriving and efficient centers of excellence.”

With regard to flexibility, Dr. Fram related her experiences being hired in 2008 during a recession. Without many patients to see, she found other ways to contribute, including redesigning the practice’s website and learning how to run a clinical trial. Now, her younger associate is taking a similar role, which includes becoming the practice’s expert on implementing and billing for telemedicine services. 

Rethinking Clinical Care in the Era of COVID-19

Dr. Schallhorn started her presentation with a major difficulty in treating patients right now: a lot of COVID-19 patients are asymptomatic, says Dr. Schallhorn. “You have to treat everyone, including yourself, as potentially infected and take steps to protect people.” The difficulty is that ophthalmology is one of the worst specialties for social distancing, given the proximity at which doctors and patients typically interact, she said.

Dr. Schallhorn presented three keys to clinical practice in the COVID-19 era. First is to implement social distancing, including telemedicine. These services include checking visual acuity to motility and alignment exams based on photos taken by a computer or smartphone camera. Augmented telehealth visits include some aspects of an exam that still must be performed in person. At UCSF, this has included drive-through IOP checks as well as bringing in patients for necessary imaging, then discussing the results via a video conference afterwards to limit the doctor and staff’s exposure to the patient. 

Second, practices should implement appropriate screening methods for patients and staff. At UCSF, this includes telephone screenings 24 hours prior to a visit, a staff screener at the front door and multiple signs displaying restrictions and warnings. 

Finally, Dr. Schallhorn recommended implementing a variety of infection control measures in the office. UCSF patients wait in their cars until called. Exam rooms and imaging equipment are fully wiped down after each patient, and workflow was reconfigured to avoid patient-to-patient interactions. In the OR, patients undergo preop COVID testing, the practice employs breath evacuators under the drapes, and the staff predistribute postoperative instructions. 

Elizabeth Yeu, MD, shared an additional safety measure taken at Virginia Eye Consultants. Due to the proximity with each patient, her practice now utilizes a 0.2% betadine mouth rinse for patients, which has been found in dental literature to be an effective virucide.  

With regards to telemedicine, Dr. Rao expressed concern about how it might change patients’ mindsets about coming to the practice for an in-person exam. “Will this be the new standard that patients expect — web-based exams the way they do with web-based refractions? I hope not. I worry we’re going too far down this road too fast, and worry that it becomes an expectation that we can’t come back from.”

Looking Forward – Predictions on the New Normal

Dr. Yeu looked into her crystal ball to predict the “new normal.” Among her predictions, Dr. Yeu said that ophthalmologists will be more wary of seeing patients coming from nursing homes and incarcerated patients in other hospitals. Regarding testing, Dr. Yeu said dilated exams will be more limited, nonmydriatic fundus photography will likely increase and there may even be more automated remote controlled slit lamp exams if possible. In addition, Dr. Yeu forecasted surgical schedules and protocols will change, including more preoperative testing and a greater use of the ASC for surgical care. Finally, Dr. Yeu expected bilateral immediately sequential cataract surgery to increase along with fewer postop appointments, and the potential for more virtual postop day 1 routine cataract surgery follow-ups.

It Took a Pandemic for Me To ...

John Berdahl, MD, shared several lessons he learned during the last few months. Among his realizations, Dr. Berdahl started to apply “team first” principles, similar to the notions that “leaders eat last” and “the captain goes down with the ship.” 

Another similar lesson learned has been to elevate his team beyond their comfort level. “Everyone right now is beyond their comfort level, and you have to give your team opportunities and allow them to make mistakes so they can get better.” 

This helps with his next lesson: stop building upside down pyramids on yourself. Dr. Berdahl expressed a tendency to always say yes and volunteer for tasks, which he admits is not a sustainable growth-oriented model. “We have to elevate our leaders and teammates and empower them to make decisions.” They won’t be the same decisions you would make, he acknowledged, but in some cases they might even be better.

On a personal level, Dr. Berdahl learned that working less but also getting paid less is a desirable trade. While he loves working, Dr. Berdahl said the key is to find the right balance. “We want to serve the people who have needs, but we have a responsibility beyond just our profession — we have an obligation to our families. This is our one swing at life.” OM