Medical specialties hit by pay gap

NEWARK, N.J. (WSJ) – As a neuro-ophthalmologist, Larry Frohman diagnoses unusual visual problems and many complex nervous disorders that often baffle other doctors. He’s also part of an endangered species.

Over the next decade, roughly 140 of the country’s remaining 400 neuro-ophthalmologists – specialists trained to detect and treat visual problems connected to the brain – will have reached retirement age, according to an analysis of the North American Neuro-Ophthalmology Society’s membership roster. Yet only 20 medical residents have opted to enter the field in the past four years, according to the society.

Why? ”The compensation just isn’t there,” says Roman Shinder, a senior ophthalmology resident at New Jersey Medical School, who says money was one factor that led him to pursue a surgery specialty instead.

A discipline built on spending time with patients to gather clues for a diagnosis, neuro-ophthalmology could become another casualty of a medical payment system that favors high-tech procedures over low-tech exams. The median income of a neuro-ophthalmologist at a teaching hospital is $200,000, according to the North American Neuro-Ophthalmology Society. That’s a third less than most general ophthalmologists, who undergo less training but can see more patients, and do more pricey procedures, in a given day.

Many in health-policy circles have focused on how the current health-care payment system is helping create shortages among primary-care doctors, internists and others on the front lines of medicine. But often lost is how the system is endangering some of the country’s most highly trained specialties as well.

Endocrinologists, rheumatologists and pulmonologists – specialties that also don’t involve performing many procedures – face acute shortages. Many of the severest deficits affect children. Though nearly 300,000 children in the U.S. are diagnosed annually with juvenile arthritis, lupus or other complex rheumatic diseases, there are fewer than 200 pediatric rheumatologists to take care of them, according to the U.S. government’s Health Resources and Services Administration.

Not everyone believes the future of such specialists is in jeopardy. Some doctors point out that shortages in medical specialties often correct themselves on their own. ”We don’t have (a neuro-ophthalmologist) on every street corner, but maybe we shouldn’t,” says Marco Zarbin, chairman of the ophthalmology department at the University of Medicine and Dentistry of New Jersey, where Dr. Frohman practices and teaches. ”It’s a sub, sub-specialty.”

Critics, though, say the decrease in specialists can hurt patients in need of proper diagnosis and treatment. Five years ago, when her 5-year-old daughter Kaitlyn was diagnosed with a connective tissue disease called juvenile scleroderma, Tammie Fishel says she was told to see a pediatric rheumatologist right away. But her daughter first would have to see a dermatologist in St. Louis – a four-hour drive away – and the first available appointment was in two months.

In its severe forms, juvenile scleroderma can weaken limbs and damage internal organs. Terrified her daughter could suffer brain damage, Ms. Fishel says she broke down crying on a voice message system. The dermatologist relented, but Kaitlyn had to wait another month before she could be seen by the pediatric rheumatologist. ”It was a very long month,” Ms. Fishel says. Now stable, Kaitlyn is regularly making the drive to St. Louis for treatment.

The shortages also contribute significantly to the relentless rise in health-care costs, say health-policy analysts, as both patients and physicians are driven into more expensive, procedure-driven care.

For two years, 68-year-old Al Purdon says he searched for a diagnosis for his persistently drooping eyelid. A visit to an optometrist led to a referral to an ophthalmologist and six more doctors, including an endocrinologist and a plastic surgeon. (Optometrists complete a four-year postgraduate program; ophthalmologists have a medical degree.) Several scans, a surgery and a biopsy later, Mr. Purdon says his eye still drooped, his Medicare had spent $10,850 on bills and there was no diagnosis.

Frustrated, Mr. Purdon and his wife went in early 2007 to Dr. Frohman. Dr. Frohman ”took one look and said, ‘I think I know what it is,”’ Mr. Purdon’s wife, Johannah, says. A series of seemingly basic tests, some questions and a blood sample later, Dr. Frohman diagnosed Mr. Purdon with myasthenia gravis, an auto-immune condition that impedes signal transmission from nerves to muscles throughout the body, but often first in the eyes. Medicare paid $220 for the visit, and Dr. Frohman said he’d continue to monitor the condition.

Mr. Purdon’s prior treatments may pose another risk. Because myasthenia can go into remission, doctors say the eye-lid surgery Mr. Purdon had can sometimes overcorrect the lids and make them appear to bulge.