A few years back, I was guest lecturing to the residents at my son’s ophthalmology program. A well-meaning subspecialist faculty member approached me and said, “Your son is a really smart and capable resident. He definitely needs to do a fellowship.” The biting implication being that the smarter residents should subspecialize, and the lesser ones become general ophthalmologists. You know, like me.

And I wondered how we got to a point where some concluded that subspecialty training implied a higher calling, better suited to the more gifted among us.

SAYS WHO?

Back up just a bit. Like 50 years or so.

When I was a kid, everyone went to the local “GP” for medical care. If your kids got really sick, they went to the pediatrician. Same thing for adults, but they went to an internist. As time went on, these specialties evolved into primary care, which I suppose is just fine — to a point.

As time continued to pass, some people started self-referring directly to a medical subspecialist for almost everything.

Look at what’s happening now in eye care — I see parents who insist their children only see a pediatric ophthalmologist for normal, routine eye exams. Pressure 22? Off to a glaucoma specialist. Patients with very mild drusen insist on an appointment with retina. I’ve not yet had someone with 1+ guttata demand to see a corneal specialist, but give it time.

It occurred to me that in most residency programs, the overwhelming exposure of our residents is to subspecialists. And that makes sense, to a degree. But it leads to a self-perpetuating cycle of teachers becoming convinced that the better docs are subspecialists, since they make up most of the faculty at these prestigious halls of learning. Residents continue that cycle by being immersed in that same thinking, believing the general ophthalmologist only does basic eye exams and some cataract surgery.

COMPREHENSIVE, INDEED

The main point I want to make is that most general or comprehensive ophthalmologists can handle, well, most problems that present to them. In my practice, my son and I perform a variety of procedures, with most routine eye exams done by our optometrists. Surgeries include cataracts, oculoplastics, complex lens exchanges and glaucoma, including both MIGS and tube shunts.

We don’t do retina operations, although we do thousands of anti-VEGF intravitreal injections a year. No strabismus or corneal transplants, as the numbers would never be high enough to make us proficient.

I’m totally fine with the term “general ophthalmologist.” But the recently more popular term “comprehensive ophthalmologist” is perhaps better. Take time to reflect on that word: comprehensive. It is defined as “complete; including all or nearly all elements or aspects of something.”

That’s what we are doing at our practice. I’m thankful we have subspecialists — referring a patient out to one can often be in the best interest of your patient and is sometimes necessary. But that’s also true of being a good comprehensive eye doc and taking care of the patient yourself. OM

Larry E. Patterson, MD, is an instrument-rated private pilot. He is also the chief medical editor of Ophthalmology Management. On the side, he is the founding partner of Eye Centers of Tennessee. His e-mail is larryp@ecotn.com.