Published in Refractive Surgery

Should I Pursue Refractive Surgery? A Guide for Ophthalmology Residents

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11 min read
Are you an ophthalmology resident interested in refractive surgery? Learn from the wisdom of renowned surgeon and thought leader Dr. Blake Williamson.
Should I Pursue Refractive Surgery? A Guide for Ophthalmology Residents
Blake Williamson, MD, MPH, MS is a nationally recognized refractive surgeon and third-generation ophthalmologist currently serving as President and Managing Partner of Williamson Eye Center in Baton Rouge, Louisiana. He holds master's degrees from Columbia University and Johns Hopkins University, and he finished his medical training and residency at LSU and Tulane University, respectively. Dr. Williamson completed a fellowship in refractive, cataract, and advanced anterior segment surgery and is now in private practice, where he specializes in vision correction.
He is a chief medical editor at MillennialEYE and sits on the refractive board for the magazines CRSToday, Eye World Magazine, and Ophthalmology Management. Dr. Williamson also serves as the YRSA Chair of the Refractive Surgery Alliance.
As a well-respected thought leader and early adopter of new technology, he is frequently amongst the first surgeons in the United States to launch new refractive technologies. He has participated in many clinical trials and is widely published in the peer-reviewed literature. Dr. Williamson has served as program director and section chair of numerous ophthalmic symposia and has lectured worldwide.
Eyes On Eyecare was lucky enough to sit down with Dr. Williamson to discuss his major passions, vision correction surgery, and the future of the specialty. Keep reading for his advice on what makes this specialty great and what ophthalmology residents can do to get involved.

When did you specifically develop your passion for refractive surgery?

Williamson: As a teenager, I remember going out with my family, and people would come up to my dad and say, “Hey, you probably don't remember me. I know you see a lot of patients, but you changed my life,” and that stuck with me. It was almost like being related to a celebrity but someone famous for doing something meaningful. I was able to see that one person really could make a large impact.
Once I got into ophthalmology, it was very clear to me that refractive surgery was by far the most fun and the most exciting subspecialty to be practicing. Happiness surrounds it. The refractive surgeons generally were the happiest attendings I saw, and the refractive patients seemed to be the happiest patients I would see in the clinic. It solidified what I had felt all those years ago as a teenager: that this could be a fulfilling career.

What do you think draws ophthalmologists to refractive surgery?

Williamson: Most refractive surgeons tend to be tech-oriented people. Many of us are pilots, musicians, or are into computers. Refractive surgery is all about new technology all the time, and that’s very exciting. We tend to be good with our hands and enjoy doing what we can to improve the lifestyle of our patients.

In many cases, we can take someone who is completely blind without correction and make their vision better than perfect overnight.

It’s totally life-changing, and I think refractive surgeons enjoy being the ones who can make that difference in someone’s life. It really is performance surgery, meaning we are making someone better than they ever have been.
Most of us are also entrepreneurial, and we like the cash-pay component of this lifestyle surgery, similar to plastics or dermatology. It's nice to be outside the wheelhouse of insurance telling you how much you are worth (and continuing to reimburse less and less each year it seems). In refractive surgery, we decide what our surgery and expertise are worth, and it keeps going up.

Why is it important to grow the refractive surgery specialty?

Williamson: There are so many myopes—and there are more coming out every year. Myopia is an epidemic. So there's no shortage of work, and there's constantly new technology coming out: it’s very exciting.
The most important thing to understand is that there are just not enough refractive surgeons. Only a small percentage of doctors in the United States are ophthalmologists, and when you look at those who are purely refractive surgeons, it's a very low number. Why is that?
The reality is that we're not teaching true refractive surgery in many of the fellowship programs and certainly not in residency. Even in many of the “corneal” fellowship programs in this country, we're not teaching “elective” refractive surgery.
It's often called a “corneal refractive fellowship,” and that means you're doing corneal transplants, DSEK, and DMEK (and probably taking a lot of backup calls and staffing open globes on the weekend in some cases). You're not doing a bunch of LASIK, SMILE, and custom lens replacements. Most of the academic “refractive” fellowships in this country are not truly refractive—they're more focused on hard-core cornea.
Many of the busiest refractive surgeons are in their sixties or seventies. We need an influx of new refractive surgeons, as the older ones are starting to retire and slow down. This is why so many private fellowships have popped up around the country; it’s what many students need.

I believe that if we're going to control the myopia epidemic, we need to make refractive surgery the default primary care solution for eligible candidates.

We need surgeons to do that, and we just don't have enough right now. I'm one of the believers that refractive surgery should be the primary care for myopia and astigmatism. That's a lot of cases! We need surgeons to treat those cases, which is why it's so important that young doctors consider refractive surgery as a subspecialty.

What makes a great refractive surgeon?

Williamson: Above all else, I would say a great refractive surgeon likes dealing with people. So much of this specialty is about people and their lifestyles. When choosing between the different refractive options, you want to know something about what the patient does.
Being able to have that conversation and set expectations is about being a people person. So much of what we do involves managing expectations; if someone isn't perfectly happy with how they do, you have to be able to walk them through that and give them their options. All that goes back to social awareness and being a good people person.

Secondly, you have to be meticulous; you have to be someone who tends to ‘measure twice, cut once.’ A lot of what we do is dependent on diagnostic measurements, so your surgical approach has to be meticulous.

Having a bit of a pioneering spirit is also important. A lot of the time, as refractive surgeons, we get new technology where there haven't been many procedures done using it in the United States. You have to be a bit of a pioneer to say, “You know what, I'm gonna make that work. I'm gonna figure out how to make things work.”
Lastly, these are not medically necessary procedures; these are elective cash-pay procedures, so people expect excellent results. It is important to be unflappable because when you have a complication in surgery, you have to be able to stay calm and fix it.
Being a people person, being meticulous, having a pioneering spirit, and, overall, being calm in the face of adversity are all things that make up a good refractive surgeon.

What extra training do you think aspiring refractive surgeons should seek out?

Williamson: Use every resource you have where you are. At Tulane, where I trained, we had access to LASIK. I was able to do several LASIK and PRK cases before I graduated. We had access to toric lenses and multifocal lenses, and I tried as hard as I could to do as many of those as possible. Find out what resources you have in your program. Chances are, if you push, you can find ways to do refractive cases.
In the age of social media and accountability, if you're going to be a functional refractive surgeon, a residency isn't enough for most graduating residents.

You can't come out and just start doing LASIK if you've never done LASIK before. You need some type of fellowship or, at the very least, a mentorship with a more senior surgeon in the practice you’re joining.

That doesn't mean you have to go to a formal fellowship at a big academic institution. I would advise you to avoid that if your goal is to get comfortable performing laser vision correction, ICL, and custom lens replacement. If your goal is to do mostly vision correction procedures and not focus on the cornea, you should seek private fellowships.
If you just want to start working right away, you could join a practice that has a legacy surgeon who does a lot of refractive surgery and would agree to take you under their wing as a mentor. That way, you can have your own private fellowship while also working and earning money. Either seek out a private fellowship or join a practice where you have the possibility of mentorship under the watchful eye of an experienced refractive surgeon who doesn't mind teaching you their skills and helping you.

What are your tips for residents considering refractive surgery, and what are some pitfalls to avoid?

Williamson: Get ready because you're about to have a lot of fun. Being a refractive surgeon is the most rewarding decision I ever made in my life—so much so that if I couldn't do exactly what I do, I would probably not practice. I would go into marketing or something; I would leave the practice of medicine. That's how much I love refractive surgery.
If you're young, one of the advantages is that you're open to new things. That can be used in your favor while you're training. It's so important that you find those refractive-minded attendings and fellows and be a sponge. Find out as much information as you can. Go to meetings to network with other like-minded people.

The biggest tip that I could give to someone who wants to be a refractive surgeon is to spend some time with a busy refractive surgeon.

That was one of the best things I ever did when I graduated residency; I called it my Texas Tour. It was like a mini fellowship where I drove around the state of Texas and visited five surgeons over the course of about 2 months and spent 1 or 2 weeks with each of them.
I learned what they said and did, and I watched how they treated their staff. I watched how they held their instruments, what technologies they used, and how they talked to patients about refractive cataract surgery or LASIK. I was able to compare and contrast all of their different styles.
I took some stuff to heart and use it to this day. Other stuff I left on the shelf, and by doing that, I could make my own style. I learned more in those 6 weeks than I would have learned in any academic fellowship in a year because it was so specific to what I wanted to do.

Lastly, and most importantly, when you do join your new private practice, avoid trying to make everything about you.

Instead, you should try to make everything be about everybody else. This is why you have to be a good people person. This is a people specialty.
Finally, be careful to be kind and authentic with your staff when you get started—you only get one chance to make that good first impression. People will never forget how you make them feel, so when you get out there and start practicing, think of ways to have fun with your team and keep the day interesting and light. That will lend a more positive atmosphere to your refractive practice.
Blake K. Williamson, MD, MPH, MS
About Blake K. Williamson, MD, MPH, MS

Dr. Blake K. Williamson, MD, MPH, MS is a third-generation eye doctor who continues the legacy of his family, which has been taking care of the great people of Louisiana for nearly 70 years. Within a few short years of private practice, Dr. Williamson has established himself as a nationally recognized surgeon, thought leader, and lecturer in the fields of advanced cataract surgery, laser vision correction, and micro-invasive glaucoma surgery. Dr. Williamson was born and raised in Baton Rouge and has placed a strong emphasis on education and academic achievement throughout his life, first as a graduate from the Episcopal School and later going on to earn Master’s degrees from both Columbia University in New York City as well as the world-renowned Johns Hopkins Medical Center where he completed an ophthalmology capstone. With a goal of taking care of the people of his home state, Dr. Williamson returned to Louisiana completing his medical school and ophthalmology residency training at LSU and Tulane respectively. While training at Tulane, Dr. Williamson quickly developed a reputation as a skilled surgeon and he would go on to perform the most phaco cataract surgeries in the history of the residency program, which dates back 100 years. Innovation and using the latest techniques was also a strong focus, and Dr. Williamson was one of the first resident physicians from the United States to perform all bladeless femtosecond laser cataract surgery on the Catalys prototype in the Dominican Republic. He was also the first resident physician in the Southern United States to become certified using iStent, a novel surgical device for the treatment of glaucoma and the smallest FDA-approved medical device in the world at that time.

Blake K. Williamson, MD, MPH, MS
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