Private refractive clinics claim young specialists as public waiting lists grow in Canadian eye surgery

Pippa Wysong
in Toronto

OPHTHALMOLOGISTS switching to laser surgery are not the threat to Canada's health care system they were once thought to be, but there is still palpable concern about the ‘brain drain’ from hospital practice to privately run, for-profit clinics.

Gordon Guyatt, MD

Graham Trope PhD, one of the study authors, recalls that back in 2000 there was a boom in laser surgery in Canada, with practices attracting patients from not only Canada but from the US and abroad. Since then, the numbers appear to have stabilised, though Lasik practices are still fairly busy. The business of Lasik surgery is affected by a number of factors including the economy, explains Avi Wallerstein MD, from the Lasik MD practice group.

“In Canada, the economy has been doing quite well and we've been less affected than the US,” he said.
Lasik MD has a total of five clinics in Canada and surgeons perform between 20,000 and 25,000 procedures annually.
Canadian clinics are also often able to attract patients from the US, in part because of a favourable exchange rate and because technologies used in laser surgery are frequently approved for use in Canada before they are approved in the US. The new technologies and extensive surgical experience of Canadian surgeons continues to pull patients in from the US and other countries, he said.

For instance, Canadian surgeons have had the Zyoptix wavefront-guided Lasik system available for the past two years. LADARWave, a similar wavefront system produced by Alcon, was only approved by the FDA for use in the US about a month ago. It is the first wavefront technology approved ‘south of the border’.
Dr Wallerstein emphasises that he thinks that wavefront technology is still in its infancy. He stressed that it is not indicated for all patients. He is also cautious about the use of all-laser Lasik. He feels the technology, although interesting, has some limitations.
Omar Hakim MD, FRCSC, of the TLC Laser Eye Centres, said that overall there has been a drop in surgical volume for refractive surgery in Canada. The early to mid-1990s saw a boom in business for Canadian clinics before ophthalmic giant Visx received approval in the US.

To exploit the patient flow, some laser eye centres were opened near the Canada-US border to provide easier access for US patients.
“Because of the differences between US and Canadian regulations, I think we will always have the ability to use technology that is not yet approved in the US," Dr Hakim said. While business seems to have stabilised, not everyone is happy about having some of Canada's ophthalmologists working in for-profit clinics. Indeed, there are some ethical problems, according to clinical epidemiology and biostatistics professor, Gordon Guyatt MD.

Ophthalmological labour which has shifted into doing these select procedures is "labour that's not available for other ophthalmology procedures such as cataracts,” he said. And waiting lists for cataract surgery are an appreciable problem in Canada.
He questions whether physicians who have been trained largely with public dollars have a responsibility to make their services available to the general public with more severe medical needs. He argues that physicians are in a sticky ethical realm when offering for-profit services.“What doctors should be trying to do is present an objective view of the risks and benefits of alternative courses of action. If you are making money off a particular procedure, and are trying to stimulate the market for that procedure, you are in a profound conflict of interest,” he said.

Omar Hakim, MD

Dr Hakim agrees there are some worries when surgeons choose to move out of the public system and into for-profit clinics. But he points out that many eye surgeons feel there is an imbalance between how well they are compensated for publicly funded procedures such as cataract surgery, which can dramatically improve a patient's quality of life, and privately paid procedures like refractive surgery.

“If governments were funding procedures such as cataract surgery in a way that was fair they would be less likely to lose physicians to non-insured medical care.
“The problem is the difference between what the private market is telling ophthalmologists they are worth in Canada and what the public system is telling them they are worth,” Dr Hakim said.

His impression too is that surgeons who switch to refractive surgery tend to be younger, more progressive and keen to try out new technologies.

As older ophthalmologists working in the hospitals retire, some of the younger ones will not be there to replace them, which will lead to shortages of eye surgeons in the near future. Right now, the average age of ophthalmologists in Canada is the mid-50s.
Dr Hakim points out that people who need cataract surgery have to wait between six and 18 months to get to an operating room. By the time people get their cataracts removed, it has become a real quality of life issue, with many unable to drive any more and forced to significantly adjust their lifestyles to cope with the loss of vision.

But increasing or decreasing the number of ophthalmologists may not make any real difference, according to Dr Trope. Canadians already face difficulties accessing surgical eye care and there are several reasons for this.
A key one is decreased access to operating rooms as a result of plummeting hospital budgets. Over the past 10 years, there has been close to a 45% cut in the number of operating hours available to surgeons.

The hospital Dr Trope works at in downtown Toronto closes the operating room at 3.30 p.m. He notes that if it was open until 5.30 or 6.00 p.m., six more patients could be seen to.
Fewer eye surgeons are being trained. While the numbers of positions in medical schools has risen over the past few years, positions for specialty eye training have not.

Graham Trope PhD
University Health Network, Toronto, Canada
Email: graham.trope@uhn.on.ca

Omar Hakim MD, FRCSC
TLC Laser Eye Centres, Toronto, Canada
Email: ojhakim@aol.com

Gordon Guyatt MD
Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
Email: guyatt@mcmaster.ca

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