How to choose a subspecialty in ophthalmology

Shub-ad¹ walked into the office of her department chair. It was the year 1745 BC and Shub-ad's residency in ophthalmology was almost complete. Always an excellent student, she had graduated in the top of her class at Baghdad University and then at The Hammurabi School of Medicine, allowing her to secure a highly coveted residency slot in this competitive specialty.

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A great resident and conscientious physician, she had a tremendous fund of knowledge, cared for each patient like he or she was a family member, was respected by the faculty, nurses, and her fellow residents, and (most importantly) had scored at the 90th percentile or higher each year on her OKAP examinations. Shub-ad loved ophthalmology, but was having trouble deciding on her subspecialty.  She knew her wise chairman, Pay-Dro, would help her think through the options.

Pay-Dro welcomed her warmly into his office. He liked Shub-ad very much. "If all my residents were like this young woman," he thought to himself, "being chairman would be the easiest job in the world." 

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Befitting his exalted position of chairman, Pay-Dro's office was richly adorned with fine carpets, golden statues, and various commemorative crystals and framed certificates from his numerous named lectureships along with the usual smattering of autographed photos of him with various politicians and celebrities.

Shub-ad began with the standard greeting of a resident to her chairman: "Greetings to Your Excellency, whose tireless efforts alone make all good things happen in this department but goeth unrecognized by so many."

"Arise, my child," responded Pay-Dro, "and let your chairman know how he may further thy career."

"Well here's the thing," said Shub-ad.  "I am having trouble deciding on a specialty. Cataract surgery restoreth sight to my patients quickly and is most gratifying. But oculoplastic surgery alloweth me to rid my patients of their ptosis and wrinkles, giving them back their youthful beauty. And it goeth without saying that injecting the miraculous anti-VEGF agents into the vitreous cavity all day is a joy. I love it all.  So what subspecialty shall I select? Also, there is the matter of repaying my student loans. Tuition and room-and-board in Baghdad are not cheap these days. As my chairman, I know thou art all-knowing and will not steer me wrong."

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Pay-Dro smiled. He remembered pondering these same issues as a resident. "Young Shub-ad," he replied, "you have great surgical abilities and are already an excellent cataract surgeon. Plus, our great King Hammurabi, whose enemies tremble at the sound of his name, issued his Code just five years ago providing professional fee reimbursement of ten shekels for successful surgery. Ten shekels is nothing to sneeze at³, as we chairmen like to say, and such a fee will allow you to quickly repay your loans and purchase fine luxury items like you see scattered around my office, and perhaps even a nice convertible chariot from Germany. Just be sure to document all elements of the history and examination on thy clay tablets to comply with meaningful use rules. So the path for you should be that of busy cataract surgeon. Plus, there is only the one downside."

A big downside

As already mentioned, Shub-ad was sharp as a tack and nothing ever got past her.  "Downside? What downside?" she inquired.

"Well, our great King Hammurabi, whose knowledge of health care policy exceeds that of all other policy wonks, has included in his reimbursement formula the caveat that if the surgery is unsuccessful and the patient loses his sight, the surgeon shall have his/her hands cut off."

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"You're kidding!" exclaimed Shub-ad, who had grown rather fond of her hands.

"Not at all," responded Pay-Dro. "Perhaps you have noticed that almost all of your senior faculty have no hands. My 5,000th cataract surgery patient regrettably developed postoperative endophthalmitis from a strain of multiple drug-resistant Staph. aureus and lost his vision. Statistically, a 1-in-5,000 rate of infection is pretty darn good and superior to what is published in the literature, but rules are rules, so my hands were cut off. So what do you say?"

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"I think neuroophthalmology seemeth like a good option. It is a very intellectually challenging field," responded Shub-ad, as she backed out of the office while being careful to constantly bow toward her chairma

References:

1. Shub-ad is the name of a queen and priestess historically documented to have lived in ancient Mesopotamia.  http://www.womeninworldhistory.com/lesson2.html

2. The sixth Babylonian King, Hammurabi, issued his legal system code around 1750 BC.  https://en.wikipedia.org/wiki/Code_of_Hammurabi

3. One shekel of silver equaled 180 grains or 5.5 grams of silver.  According to the Ishnuna Code of Law, a labourer received the monthly wage of one shekel plus his food.   http://www.ishtartv.com/en/viewarticle,35322.html