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    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

    Peter J. McDonnell, MD
    He is director of The Wilmer Eye Institute, The Johns Hopkins University School of Medicine, Baltimore, and chief medical editor of ...

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