There is concern among many pediatric ophthalmologists that the subspecialty may be headed toward a crisis in the future. Many providers have found it difficult to maintain financial security and are forced to either subsidize their practice through accepting general ophthalmology patients and/or performing other procedures not covered by insurance such as laser in situ keratomileusis, facial treatments, and plastic surgeries. Additionally, some pediatric ophthalmologists have channeled their efforts into obtaining greater income by providing care in the neonatal intensive care unit. Other providers have even retired early, largely due to these financial issues, sparking a need for more fellows entering this field. All of these issues have resulted in reduced pediatric ophthalmology care.
Another issue is that both women and men in the United States are marrying later and having fewer children.1 This issue could certainly be a contributing factor to today's low birth rate, which was reported to be the lowest in 30 years by the Centers for Disease Control and Prevention in 2017.2 As fewer children are born, less pediatric ophthalmology care may be needed, reducing the number of patients and the demand for providers. Even if this is the case, the unequal distribution of providers will remain an issue, prompting general ophthalmologists to divert their attention from their specialty to care for children.
Simon et al.3 first identified the issue of declining interest in pediatric ophthalmology and strabismus in a 2007 study using data from the San Francisco Match Program. The authors found a decrease in resident participation in the fellowship match since 2002 and an increase in the number of fellowship positions by approximately 3% from 2000 to 2005. A survey was distributed in 2005 to U.S. ophthalmology resident graduates who chose not to pursue careers in pediatric ophthalmology and strabismus to identify possible reasons for not entering the subspecialty. Among the reasons, disinterest in the field, preference not to work with children, and inadequate financial compensation were the most common. Nearly half of the respondents revealed that they would have been inclined to pursue careers in pediatric ophthalmology and strabismus if there were higher salaries, because the salaries and reimbursements for pediatric ophthalmologists were lower than those of other ophthalmology subspecialists. To increase interest in this field, these residents proposed more individual faculty guidance and enthusiasm; earlier exposure to the field, specifically during the first year of residency; and improved instruction for preoperative management of strabismus.
The issue of inadequate pay as a major factor in the diminishing interest in pediatric ophthalmology and strabismus was supported by the results of a job satisfaction survey administered to 780 members of the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) by Simon et al.3 Although the majority of respondents reported satisfaction with their lifestyles, the variety of conditions they treat, and the respect they feel from the medical community, the topic of financial compensation received the most negative comments. Fifty percent of members in academic settings and 63% of members in private settings reported dissatisfaction with their salaries, indicating that inadequate pay is one of the major issues within this subspecialty. Additionally, in a questionnaire distributed to fellowship directors in 2006, Simon et al.3 found that 25% of fellows were international medical graduates who intended to practice in their native countries.
In addition to unfilled fellowship positions, inadequate distribution of providers remains an issue in pediatric ophthalmology and strabismus. Estes et al.4 reported that more than 24 million people living in 127 metropolitan statistical areas in the United States do not have access to pediatric ophthalmologists who are AAPOS members. More than 250,000 of these people living in 16 metropolitan statistical areas with more than 20% of the population younger than 20 years had no listed AAPOS member within their communities. Estes et al.4 identified a ratio of 2.7 AAPOS members per million individuals in the United States from 2005 to 2006. However, there were 27 AAPOS members per million individuals in Iowa but only 1.3 AAPOS members per million individuals in Las Vegas during this time. Additionally, there was no listed AAPOS member in North Dakota. The authors emphasized the importance of identifying areas of the United States with no listed AAPOS members and addressing the issue of inadequate distribution of pediatric ophthalmologists in these areas. As pediatric ophthalmologists retire and more pediatric ophthalmology and strabismus fellowship positions remain unfilled, there is concern that there will not be enough providers to meet the demands of this subspecialty, especially in under-served areas in the United States.
Dombrow and Engel5 argued that as pediatric ophthalmologists continue to retire earlier and fewer fellows Match, it is imperative to devise methods to increase interest in the field to prevent a possible shortage of providers in the future. Although there was no overall shortage of pediatric ophthalmologists in the United States as of 2007, the distribution of specialists remained unequal. Although there may be a shortage of providers in the future if interest continues to decline, these researchers projected an increase in the pediatric population at the time of this study, because the birth rate in 2006 was reported by the Centers for Disease Control and Prevention6 to be the highest in more than 40 years. However, by 2017, the birth rate had decreased by nearly 10% as people married later and had fewer children.1 Dombrow and Engel5 noted a 9% decrease in eye muscle surgeries from the 1970s to the 1990s and an even greater decline in procedures for those younger than 15 years in the United States. It remains uncertain how a decreasing birth rate will affect these numbers in the future.
Repka7 further stressed the increasing demand for pediatric ophthalmology and strabismus specialists in his 2007 review of these previous research studies. He explained that financial compensation must be increased to grow the field and proposed three ways to improve salaries for providers. Repka7 explained that care should be made available to populations without access to insurance, while providing adequate reimbursement to physicians caring for these patients. He suggested that Medicaid reimbursements should be made similar to those of other health care programs. Additionally, he argued that the challenging task of caring for pediatric populations should be taken into account in determining salaries for pediatric ophthalmology and strabismus providers because working with children was one of the main reasons why fellows chose not to pursue careers in pediatric ophthalmology and strabismus.3
Dotan et al.8 found a decrease in the number of residents participating in the pediatric ophthalmology and strabismus Match compared to those for the glaucoma, cornea, and retina subspecialties, based on the results of the San Francisco Match Program from 2000 to 2015. Interest in the field of pediatric ophthalmology and strabismus has remained low despite improved mentorship and teaching conditions because reimbursement rates have not yet been increased. Of those Matching to pediatric ophthalmology and strabismus, international medical graduates comprised a greater percentage of fellows in this field than in other ophthalmology subspecialties. International medical graduates submitted more fellowship applications for pediatric ophthalmology and strabismus than U.S. graduates from 2013 to 2015, accounting for 31% of fellows during this time. Although 27% of pediatric ophthalmology and strabismus fellows from 2010 to 2014 were international medical graduates, only 24% of graduating international medical graduates intended to practice in the United States. Dotan et al.8 suggested that international medical graduates should be encouraged and allowed to practice pediatric ophthalmology and strabismus in the United States to increase the number of providers.
These authors also found that pediatric ophthalmology graduates continued to receive lower salaries than graduates in other subspecialties. For example, retina specialists can earn twice as much as pediatric ophthalmologists after a few years of practice. With an average debt of $181,000 for U.S. medical graduates in 2017 that will likely continue to increase over time, it is understandable why ophthalmology residents may have the incentive to pursue subspecialties with greater financial compensation rather than those with lower salaries such as pediatric ophthalmology and strabismus. Financial compensation for pediatric ophthalmology and strabismus providers continues to be an unresolved issue and therefore must be increased to attract more graduates to this field.
The future of pediatric ophthalmology is of concern because residents have opted to pursue careers in other ophthalmology subspecialties rather than pediatric ophthalmology and strabismus. Possible reasons for this discrepancy include disinterest in the field itself and/or reluctance to work with children. Additionally, pediatric ophthalmology care may decline as providers pursue other avenues of revenue, which detracts from their current practice and contributes to the shortage of providers in this field. As pediatric ophthalmology and strabismus fellowship positions remain unfilled and pediatric ophthalmologists retire, there may be an inadequate supply of providers if this trend continues. Therefore, it is imperative to address and ameliorate the conditions that deter fellows from pursuing this subspecialty.
A major factor to be considered is the lower financial compensation for pediatric ophthalmology and strabismus providers compared to other ophthalmology subspecialties. Many pediatric ophthalmologists accept Medicaid patients, which further decreases compensation because reimbursement rates are typically lower than those of private insurance. Because many medical graduates face an overwhelming amount of debt, they may choose to pursue subspecialties with higher salaries and reimbursements. Why are the reimbursements in pediatric ophthalmology lower than those of other subspecialties? Unless this question is addressed, it does not seem possible that the field of pediatric ophthalmology will advance.
- Arnett JJ. Emerging Adulthood: The Winding Road from the Late Teens Through the Twenties. New York: Oxford University Press; 2004.
- Hamilton BE, Martin JA, Osterman MJK, Driscoll AK, Rossen LM. Births: Provisional Data for 2017. Hyattsville, MD: Center for Disease Control and Prevention, U.S. Dept of Health and Human Services; 2018. https://www.cdc.gov/nchs/data/vsrr/report004.pdf Published May 2018. Accessed July 19, 2019.
- Simon JW, Bradfield Y, Smith J, Ahn E, France TD. Recruitment and manpower in pediatric ophthalmology and strabismus. J AAPOS. 2007;11(4):336–340. doi:10.1016/j.jaapos.2007.04.004 [CrossRef]
- Estes R, Estes D, West C, Zobal-Ratner J, Droster P, Simon J. The American Association for Pediatric Ophthalmology and Strabismus Workforce Distribution Project. J AAPOS. 2007;11(4):325–329. doi:10.1016/j.jaapos.2006.08.014 [CrossRef]
- Dombrow M, Engel HM. Rates of strabismus surgery in the United States: implications for manpower needs in pediatric ophthalmology. J AAPOS. 2007;11(4):330–335. doi:10.1016/j.jaapos.2007.05.010 [CrossRef]
- Martin JA, Hamilton BE, Sutton PD, et al. Births: Final Data for 2006. Hyattsville, MD: Center for Disease Control and Prevention, U.S. Dept of Health and Human Services; 2006. https://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_07.pdf Published January 2009. Accessed July 29, 2019.
- Repka MX. Pediatric ophthalmology and strabismus of the future. J AAPOS. 2007;11(4):323–324. doi:10.1016/j.jaapos.2007.06.005 [CrossRef]
- Dotan G, Karr DJ, Levin AV. Pediatric ophthalmology and strabismus fellowship Match outcomes, 2000–2015. J AAPOS. 2017;21(3):181.e1–181.e8. doi:10.1016/j.jaapos.2017.01.004 [CrossRef]