Ophthalmology's Challenges: An Expert Interview With Paul Sternberg Jr, MD

Linda Roach

January 14, 2013

Editor's Note: This month, Paul Sternberg Jr took office as the 116th president of the American Academy of Ophthalmology. He was elected to the 1-year term by the Academy's 32,000 members.

Dr. Sternberg is a nationally known retinal specialist and leader in ophthalmic education and research. Since 2003, he has been the G.W. Hale Professor of Ophthalmology and chairman of the Vanderbilt Eye Institute at the Vanderbilt University School of Medicine, in Nashville, Tennessee.

In a telephone interview with Medscape Medical News, Dr. Sternberg discussed some of the salient issues in ophthalmology today.

Paul Sternberg Jr, MD. Source: Vanderbilt University Medical Center Photography Service

Medscape: What steps should government and leaders in the ophthalmic profession be taking to ensure that there are enough ophthalmologists to meet the eye care needs of the rapidly increasing elderly population in this country?

Dr. Sternberg: I am more concerned, and I think we all should be more concerned, about the availability of primary care physicians in the future. That's where as a nation we will have more of a gap.

But I do think that we still need to think about how to provide eye and vision care in the future with the whole global world of eye care providers. We have ophthalmologists and optometrists and opticians and technical staffs, and together we can solve this problem with team-based care.

We are going to have to work together. I don't think the solution is to expand the scope of practice of other eye care providers into surgery. And as someone who for many years has worked on training new ophthalmologists, I know that it takes a long time. So even if we tried, there's no way we could ramp up the number of ophthalmologists in time to make a meaningful difference to the amount of eye care available.

If we're trying to make the assumption that ophthalmologists are going to provide all of the eye care to our aging population, there's no way we can ever increase our training programs enough to do that. But we can provide patients with the eye care they need if we make the most of our human resources, through team-based care.

Medscape: Some states have begun licensing optometrists to perform limited surgical procedures. From the patient's standpoint, why does this dispute about "scope of practice" between ophthalmology and optometry matter?

Dr. Sternberg: Surgery is not something to be taken lightly, and frankly I am incredulous at the concept of legislating surgical privileges. As ophthalmologists we are very busy, and we will continue to be busy in the future, but the solution to meeting Americans' eye care needs won't come from having other members of the eye care team doing surgery.

As someone who works to train new surgeons every day, I know the enormous commitment of time and effort it takes to train a skilled eye surgeon. It requires not just time with patients but time in a wet lab, and there are a lot of issues related to knowing the indications for surgery, knowing how to manage the complications of surgery.

This is a quality and patient safety issue. The public wants to know that their surgery is being done by someone who knows how to do it safely. This is not something you can learn with a weekend course at a Holiday Inn.

Medscape: After seeing the Earth from space more clearly than he ever had, a US astronaut called his cataract surgery miraculous. Do the eye surgeons who perform this "everyday miracle" many times every year feel underpaid by Medicare and undervalued by the public, and if so why?

Dr. Sternberg: Probably not undervalued. We are very fortunate to be in a profession where we help patients and they are appreciative, whether it's for a good pair of glasses, a cataract operation, or now, treating their [age-related] macular degeneration (AMD).

But underpaid? Probably. In the 1980s Medicare paid the surgeon more than $2000, and now--while it varies by state--it pays around $600.

As we got better at it and the outcomes became better, and we learned to use newer and better types of implants, reimbursement has gotten less, even though we restore sight and provide dramatic improvements in quality of life for millions of Americans.

So if you really talk about value, as I said this past November at the opening session of the Academy's Annual Meeting, Every day we perform miracles at dollar-store prices.

We have a healthcare system that reimburses ophthalmic physicians based on how much time they spend. We are paid based on how long something takes, not on how much value it brings to the patient. So if you get better at a procedure and you give the patient better outcomes, you get paid less. Yet at the same time a very elderly patient with congestive heart failure will be hospitalized and given a very expensive ventricular assist device, and then will be rehospitalized repeatedly before dying several months later.

In one case we have a procedure that costs the system hundreds of thousands of dollars to give someone a poor quality of life for a matter of months, and in one case a procedure that gives someone excellent vision and a good quality of life for 10, 20, 30 years, and we pay the surgeon less than $1000. This is not good stewardship of our financial resources.

Medscape: As a vitreoretinal subspecialist, how do you view the recent buzz that treating age-related macular degeneration off-label with a less expensive vascular endothelial growth factor inhibitor (bevacizumab; Avastin, Genentech) might endanger patients compared with the approved drug (ranibizumab; Lucentis, Genentech)?

Dr. Sternberg: I think that since [results from the federal study that found them equally effective] came out there are more ophthalmologists willing to use Avastin, with me being one of them. I was very hesitant to use an off-label drug that whose safety and efficacy had not been demonstrated when there was a [US Food and Drug Administration–]approved drug available. But now I am using both those agents, and I use Eyelea (aflibercept; Regeneron) as well. I use all 3.

I think we have an obligation to tell our patients that there are several drugs that are available and to discuss with them the options, and then together, as a physician and a patient and/or patient's family, come up with a treatment plan that we are all comfortable with.

We are fortunate to have all these options. I lived in the world for many decades where there was nothing I could offer these patients. So the fact that we even have one option, no less 3, is remarkable.

So, at this point, I don't lose a lot of sleep over the potential differences between Avastin and Lucentis. I think that, if there is a difference, it's going to be really subtle. And when you get differences that subtle it seems to me it's almost idiosyncratic. How can you really make a decision based on such subtle differences? It's going to be a matter of individual patient response.

Medscape: Is there anything else that you would like to tell our physician readers?

Dr. Sternberg: It's important for medical readers to know that ophthalmologists are medical doctors, and we take our relationship with the house of medicine very seriously. Our medical colleagues may see us as isolating ourselves, with our outpatient surgery centers and our Lasik centers, but at the end of the day, we must be viewed as colleagues.

We went to medical school with you, we did our rotations with you, we are physicians too. And we know how important it is that we continue to be part of the medical community. That means taking call, coming in when a patient in the hospital has an eye problem, helping treat babies with ROP [retinopathy of prematurity], partnering with internists and endocrinologists to provide the best possible care for our diabetic patients.

I want both our doctors and the general medical community to remember that we are one, and we have to support each other in identifying and advocating for proper scope of practice. Today, we're talking about ophthalmologists and optometrists. Tomorrow, they are going to have their own versions: psychiatrists and psychologists wanting to prescribe medicine, anesthesiologists and nurse anesthetists, primary care physicians and advanced-practice nurses.

The solution in all of these is partnership, working together. The solution is not legislative battles. Clear heads have to prevail, and we all have to work together. Because I think that if we are unified at the house of medicine and understand that these areas of concern in each discipline really all roll into the single overriding concern, which is how do we together provide quality care for an increasing population need, we'll move forward.

So I want medicine to know that ophthalmology and ophthalmologists wants to work with them, and I want our doctors to know that we need to make our efforts to remain members of the medical community. One of the personal accomplishments which I'm most proud of as chief medical officer of Vanderbilt is that, as an eye doctor and educator who really hardly spent any time in the hospital as a provider, I now lead a large multispecialty medical group and am dealing with all these issues on a regular basis.

Dr. Sternberg has disclosed no relevant financial relationships. Linda Roach writes articles for American Academy of Ophthalmology publications.