Keywords
business of ophthalmology - practice management - residency education - malpractice
- negotiation
After 12 years of intense postsecondary education, graduates of ophthalmology residency
programs are finally ready to put their years of hard work to use as practicing ophthalmologists.
But while they are well prepared to care for patients, many struggle to navigate the
array of employment challenges encountered immediately following graduation, particularly
those related to the business of ophthalmology.[1]
To increase success in the business practice of ophthalmology and to avoid common
pitfalls, residents ought to have a formal introduction to the business of medicine.[2] Topics that could be covered include negotiation skills, basics of coding, and differences
in practice types such as private practices, academic medicine, and hospital employed
models. An introduction to entrepreneurship, risk management, and financial statements
would be useful for all early career ophthalmologists, especially those entering private
practice. Most residency graduates would also benefit from formal training in billing,
contract negotiation, noncompete clauses, and the nuances of malpractice insurance.[2]
[3]
Unfortunately, residency programs have yet to meet these needs.[2] A survey of 269 ophthalmologists who had been in practice for less than 5 years
found that 63% felt their residency program poorly prepared them in coding and reimbursement,
and 70% felt poorly prepared in practice management skills.[1] These results are not limited to ophthalmology, as residents across specialties
feel unprepared for the business of medicine.[2]
[4] In a study of general surgery program directors, 87% agree that residents should
be formally trained in business and practice management, as discussed by Lusco et
al.[5] Yet finding time in an already busy didactic curriculum with the clinical and procedural
needs of residents is tough. Even more challenging is locating available and experienced
faculty to teach specific business topics.[2] However, there are programs in anesthesia, general surgery, plastic surgery, internal
medicine, and urology that have implemented practice management training with promising
results.[2]
[3]
[6]
[7]
[8] Other graduate training programs such as dentistry and optometry have long recognized
the importance of including these topics in their curricula.[9]
[10] Still, the literature lacks any formal residency education models specific to the
business of ophthalmology.
Noting this need for business education in our residency program, the Vanderbilt Eye
Institute (VEI) began annual lectures for trainees on the business of ophthalmology
in 2014. After positive feedback from participants, the education committee instituted
a formal business of ophthalmology course. We conducted surveys to assess the value
of this program in preparing trainees for the business side of ophthalmology in 2020.
Methods
Business of Ophthalmology Course
The business of ophthalmology course consisted of 11, 1-hour sessions covering 10
of the most relevant topics for ophthalmologists in training. These topics are summarized
in [Fig. 1]. The coding cases topic was split into two sessions to allow for additional practice.
All sessions were delivered virtually due to the coronavirus disease 2019 pandemic,
and formats included traditional lectures, case-based sessions, and question and answer
panels. Lecturers and panelists included content experts both at VEI and across the
country. The course ran from June 8, 2020, to June 29, 2020.
Fig. 1 Business of ophthalmology course topics.
Study Population and Surveys
This study was approved by the Vanderbilt University Institutional Review Board (#201146).
We developed two web-based, voluntary surveys, which were delivered before and after
the course. The study population included VEI ophthalmology residents and Vanderbilt
medical students interested in ophthalmology. The course was a component of the resident
lecture series, so lecture attendance was mandatory for all residents and voluntary
for medical students. The precourse needs assessment gathered information on attitudes
and previous exposure to business topics. The postcourse satisfaction and outcomes
survey focused on the level of satisfaction with the course and the change in knowledge
and skills in fundamental business domains. The survey item format included 5-point
Likert scale questions, multiple choice questions, and free response questions for
general comments.
Data Collection and Analysis
The voluntary surveys were e-mailed to all attendees of the business of ophthalmology
course. All responses were anonymous, and data were stored in a secure survey account.
Descriptive statistics and a one-tailed t-test were employed for analysis of survey responses.
Results
Twenty-four trainees completed the presurvey, and their training levels are broken
down as shown in [Table 1]. Few trainees reported previous training in business of medicine domains during
medical school ([Fig. 2]). 96% of respondents had no previous training in contract negotiation, 88% lacked
training in lawsuits, and 88% had no training in liability insurance. 96% had no inpatient
coding education, and 88% had no outpatient coding training.
Fig. 2 Presence of previous training during medical school in practice management domains
(N = 24).
Table 1
Training level of survey respondents
|
Presurvey (N = 24)
|
Postsurvey (N = 17)
|
|
Medical student
|
5 (21%)
|
3 (18%)
|
|
PGY-1
|
3 (13%)
|
0 (0%)
|
|
PGY-2
|
4 (17%)
|
5 (29%)
|
|
PGY-3
|
5 (21%)
|
4 (24%)
|
|
PGY-4
|
4 (17%)
|
5 (29%)
|
|
PGY-5 or higher
|
3 (13%)
|
0 (0%)
|
Abbreviation: PGY, postgraduate year.
In the postsurvey, 17 trainees completed questions on the course's effects on their
competency in the business of ophthalmology. Statistically significant improvements
in confidence ratings were found in all domains including coding, malpractice claims,
and building a practice ([Table 2]). In addition, 88% of trainees reported that the course improved their ability to
code ([Fig. 3]). Finally, 100% of trainees agreed that the course improved their understanding
of lawsuits, their ability to negotiate a contract, and their understanding of the
business of ophthalmology.
Fig. 3 Postcourse survey on practice management domains (N = 17).
Table 2
Survey on practice management competencies
|
Prompt: How would you rank your knowledge or skill to do the following? Rate your
level both before and after the course on a scale of 1–5, with 5 being the most confident
|
|
Domain
|
Precourse mean
|
Postcourse mean
|
p-Value
|
|
Keys to retirement saving
|
2.81
|
4.13
|
< 0.001
|
|
The first rule of coding
|
1.94
|
4.59
|
< 0.001
|
|
Malpractice claims and payouts
|
1.27
|
3.60
|
< 0.001
|
|
Building an online reputation
|
1.86
|
4.21
|
< 0.001
|
|
Leadership and financial skills for building a practice
|
1.69
|
3.81
|
< 0.001
|
Discussion
The top priority of any residency program is, first and foremost, training skilled
clinicians and surgeons in the safe and effective practice of ophthalmology for our
patients. However, success in a career in medicine depends on more than just clinical
and surgical skills. In 1999, the Accreditation Council for Graduate Medical Education
(ACGME) created the core competencies for residents in training, including domains
such as interpersonal and communication skills, professionalism, and systems-based
practice, recognizing the needs of education beyond clinical and procedural learning.[11] Though formal business in medicine education fits under the systems-based practice
domain, it is not required by the ACGME, and there are few examples in use today.
This reality has left a gap in current ophthalmology resident education, and we sought
to change that with this course.
Measured by our results, our course achieved its goal of improving basic knowledge
of the business of ophthalmology. Although our surveys published in this report are
only from 2020, our education committee has seen value in this lecture series ever
since its inception in 2014. Our 2020 results validated this sentiment, as they showed
improvements in trainees' competencies across a variety of business of ophthalmology
domains.
During our lecture series, it became apparent that much of the business education
that currently occurs in ophthalmology is part of the “hidden curriculum” of residency.
Our lecturers and panelists repeatedly encouraged the trainees to reach out to mentors
or recent graduates to learn about different types of practice, job opportunities,
and contract negotiations. During their own graduate medical education experience,
they learned the business of ophthalmology informally and individually through interactions
with different mentors as well as by trial and error.
The literature supports this reality. Melendez found that one-fifth of ophthalmologists
who left their first job in the first 5 years of their career was significantly less
likely to have sought advice from other physicians before signing their contract.[12] Thus, the informal and unstructured nature of business education increases the risk
that some graduates, especially those who lack access to experts or formally trained
or business-minded mentors, are at a disadvantage when reviewing a contract or managing
a practice, further emphasizing the need for standardized business education in residency.
Recently, some medical students and medical graduates have met this need by completing
formal business education through master of business in administration (MBA) programs
either through devoted time or via executive MBA type curricula. Although an MBA may
have value for certain physicians, an understanding of basic business concepts is
likely essential for all early career ophthalmologists. Instead, a targeted, abbreviated
business course in the resident curriculum is a practical and efficient method of
teaching these concepts.
Finally, we observed that technology enabled our course to overcome the barrier of
finding qualified and available faculty. Due to the coronavirus disease pandemic of
2020, this year's course was delivered via Zoom, an online videoconferencing system.
Though we may have missed out on in-person interaction, the virtual format enabled
us to have 15 guest lecturers and panelists from across the country, each bringing
a specific area of expertise. It also allowed residents and trainees in different
locations to participate in a way that would not have been possible with an in-person
format. In addition, remote lectures enabled our residents to ask specific questions
to national experts with the added benefit of networking opportunities. Ironically,
the candor of the virtual format made it easier, not harder, to discuss topics traditionally
absent in the residency curriculum.
Conclusion
We conclude that a formal, targeted business of ophthalmology course improved the
knowledge of trainees on essential business concepts, preparing them for success as
young ophthalmologists and beyond. This course can serve as a model for ophthalmology
residency programs across the country that are looking to meet the need of basic education
in the business of ophthalmology.
