To compare and contrast how neuro-ophthalmology was practiced and how neuro-ophthalmologists were compensated in the United States as opposed to other countries represented within the North American Neuro-Ophthalmology Society (NANOS) membership, in the spring of 2016, an 18-question survey (see Supplemental Digital Content, Appendix E1, http://links.lww.com/WNO/A262) was sent to the international NANOS members.
The 2016 NANOS membership roster was used as the source of members to be surveyed with at least 1 member contacted from each country other than the United States. Where there were multiple NANOS members from a given nation, more than 1 was contacted in an attempt to maximize the number of countries represented in the survey. If responses were received from more than 1 person from a single nation, the first response received was used as the source data.
The survey (in English) was emailed to 47 NANOS members from 31 countries; several reminders were sent if no response was received. Ultimately, 20 responses were received representing members from 15 countries (see Supplemental Digital Content, Appendix E2, http://links.lww.com/WNO/A263). Where responses needed clarification, the follow-up email inquiry was sent; all of these received adequate response. In some cases, not every question was answered by each respondent.
The route of training in neuro-ophthalmology was predominantly through ophthalmology in all nations that responded (Fig. 1). The number of people who practiced a significant amount of neuro-ophthalmology ranged from 5–6 (Denmark) to 100 (India) (Fig. 2).
In terms of population data, I estimated that in the United States, there are approximately 0.8 clinicians/million people who practiced a significant amount of neuro-ophthalmology. Using 2015 population data from the World Health Organization (1), those practicing a significant amount of neuro-ophthalmology outside the United States ranged from 0.08/million (India) to 3.10/million (Israel) (Fig. 3).
The percentage of neuro-ophthalmologists who dedicated their practice exclusively to neuro-ophthalmology varied widely. In India, it was reported that no neuro-ophthalmologist practiced only neuro-ophthalmology, whereas in Denmark, 60%–80% of the neuro-ophthalmologists practiced it exclusively (see Supplemental Digital Content, Figure E1, http://links.lww.com/WNO/A250). Although 10/14 (71%) of respondents indicated that at least half of those practicing a significant amount of neuro-ophthalmology were at academic centers, the actual numbers ranged from 4% (United Kingdom) to 90% (France and Japan) (see Supplemental Digital Content, Figure E2, http://links.lww.com/WNO/A251).
The respondents were asked to characterize access to neuro-ophthalmology as being 1) adequate, 2) in short supply, or 3) a severe shortage. Two countries (Switzerland and Israel) were said to have had an adequate supply to allow appropriate access, whereas a shortage was found in 11/15 countries, and a severe shortage in 2 (Great Britain and Chile) (see Supplemental Digital Content, Figure E3, http://links.lww.com/WNO/A252). Those nations with adequate access also have attractive compensation models (see below).
The survey looked at where each country's neuro-ophthalmologists had received their training. In 9/15, at least 50% were home nation trained. In 5/15, at least half had received some neuro-ophthalmology training in the United States (see Supplemental Digital Content, Figure E4, http://links.lww.com/WNO/A253). However, the survey did not differentiate between active hands-on care vs observational training, nor did it ask the duration of such training.
Those surveyed were asked whether, for academic neuro-ophthalmologists, the prevailing compensation model was a fixed salary, fixed salary plus a productivity bonus factor, or purely productivity/collection based. In 12/15 countries, there was a fixed salary model, 2/15 used salary plus a productivity component, and 1/15 had a fixed blended formula of 40% straight salary and 60% salary/productivity component (see Supplemental Digital Content, Figure E5, http://links.lww.com/WNO/A254).
For nonacademic neuro-ophthalmologists, 4/14 used fixed salary, 1/14 used salary plus productivity bonus model, 8/14 used solely productivity-based compensation, and 1/14 reported both an exclusively productivity-based model and a mixed salary plus productivity compensation (see Supplemental Digital Content, Figure E6, http://links.lww.com/WNO/A255).
A question asked the source of funding for the academic neuro-ophthalmologist, specifically asking whether the government or the university provided the funding. The responses were complicated in that universities may have provided direct salary but, in some cases, the university may be government run/funded (see Supplemental Digital Content, Figure E7, http://links.lww.com/WNO/A256).
A question was asked of the ophthalmology-trained clinicians whether they could estimate the annual income of the “typical neuro-ophthalmologist” as a percentage of the typical comprehensive ophthalmologist, retinal surgeon, glaucoma specialist, and pediatric ophthalmologist. In Denmark, the United Kingdom, and Japan, all ophthalmologists were paid the same regardless of subspecialty. In India, neuro-ophthalmologists were paid “very much less,” perhaps the reason why India had the lowest number of clinicians/million people doing a significant amount of neuro-ophthalmology (Fig. 3). In no country were any of the subspecialties paid lower than neuro-ophthalmologists (see Supplemental Digital Content, Figure E8, http://links.lww.com/WNO/A257).
As to the source of consultations, in 9/14 countries, at least 50% of consult requests came from ophthalmologists. Only in Turkey and Chile did more requests come from neurology than ophthalmology. In Chile, the most common source of referrals was from neurosurgery (see Supplemental Digital Content, Figure E9, http://links.lww.com/WNO/A258).
The survey asked whether approval was needed before a neuro-ophthalmology consultation could be performed. The response from all 15 nations was “No” with the exception of Hong Kong, where the patient had to see a neurologist or ophthalmologist before being seen by a neuro-ophthalmologist.
The survey inquired about requisite approvals for neuroimaging (computed tomography and magnetic resonance imaging [MRI]) being requested by the neuro-ophthalmologist (see Supplemental Digital Content, Figure E10, http://links.lww.com/WNO/A259). They were not required in most countries. In Chile, they were required, but approval was from the chief of neuro-ophthalmology. In Israel, if one used the national health maintenance organization (HMO), approval was required; outside this health care model, it was not. In Canada, a routine scan did not require authorization, but to expedite the study approval was required by a neuroradiologist. In Brazil, authorizations were only required if the patient did not have health insurance.
The waiting time to obtain an MRI was assessed, inquiring separately about patients with insurance/financial resources to cover the expense, as opposed to those who did not have these resources. For those with insurance or financial resources, in the United Kingdom, a scan deemed urgent by the neuro-ophthalmologist could be obtained on the same day. In Chile, Hong Kong, Switzerland, Israel, Denmark, Turkey, Brazil, and Canada, scans could be obtained within a few days, although in Denmark and Canada, this was for urgent, not routine scans. In Japan, urgent scans were available; routine scans could take a couple of weeks. In Israel and Australia, the wait was much longer if one had public insurance/HMO coverage (see Supplemental Digital Content, Figure E11, http://links.lww.com/WNO/A260).
In the United Kingdom, Switzerland, Denmark, Japan, and Israel, all citizens had some form of insurance, so there was no distinct response for the wait for an MRI in a patient without financial resources or insurance coverage. In Chile, if the patient happened to go to a hospital that had an MRI machine, they may have been able to obtain the scan on the same day. Hong Kong had the longest wait, which might have been a year. France reported a 45–60-day wait. Turkey reported a 2–4-week wait; Australia had a 1–2 week wait if urgent, and 6–8 weeks if routine. Canada reported up to a 7-day wait if urgent, but a 4–6-month wait if routine. Those using governmental public insurance in Brazil found a wait of several weeks to a few months, and Singapore dealt with this on a case-by-case basis through a social worker (see Supplemental Digital Content, Figure E12, http://links.lww.com/WNO/A261).
To the question, “Are there impediments to practicing neuro-ophthalmology in your nation that you think are not seen by physicians in the United States?”, the response from South Korea was that neuro-ophthalmology was not yet established as a subspecialty, and that there was low insurance compensation for a neuro-ophthalmology consultation. From Hong Kong, it was noted that for those patients cared for at public hospitals, there is a long waiting time for visual fields, optical coherence tomography, electrodiagnostics, and neuroimaging. From Australia, it was noted that neuro-ophthalmology was not completely accepted as a specialty, and that the geography (large country and less dense population) was a challenge. In Brazil, a larger percentage of the population lives in poverty and these individuals were only covered by governmental insurance. The response from Japan noted it was difficult to start a practice that was exclusively neuro-ophthalmology because of a fee schedule that reimbursed uniformly for all subspecialties. A number of other interesting comments also were reported (see Supplemental Digital Content, Appendix E3, http://links.lww.com/WNO/A264).
In considering access to neuro-ophthalmic care, it is important to interpret the data in the context of each country's investment in health care. I looked at per capita gross national product (GNP) and what percentage of the GNP is allocated to health care (Fig. 4). High GNP does not insure access to neuro-ophthalmic care. Singapore, Switzerland, and the United States had the 3 largest per capita GNPs; yet only respondents from Switzerland reported adequate access to neuro-ophthalmologists. Switzerland also had the second highest density of those practicing a significant amount of neuro-ophthalmology. Devoting a large percentage of GNP to health care also did not guarantee access to neuro-ophthalmologists. The United States, Switzerland, and France devoted the largest portion of their GNP to health care; yet only Switzerland reported adequate access.
That only Switzerland and Israel reported adequate access to neuro-ophthalmologists is no surprise, as they also reported the highest number of clinicians per capita practicing a significant amount of neuro-ophthalmology. In both Switzerland and Israel, the discipline is well recognized, and in these nations, the variance between the lowest and highest paid ophthalmic subspecialties was less than in most countries (see Supplemental Digital Content, Figure E5, http://links.lww.com/WNO/A254). Perhaps, this minimized the impact of those intellectually drawn to neuro-ophthalmology from selecting another specialty. In Switzerland, a respondent commented that “10 years ago, a sophisticated reimbursement system was implemented that is quite unique. It is not technical procedures, but rather time that physicians spend with their patients. For neuro-ophthalmologists, this represents a major advantage.” Yet in nations where all ophthalmologists are paid the same amount (United Kingdom, Denmark, and Japan) Japan and Denmark were reported to have inadequate access to neuro-ophthalmologic care, and Great Britain reported a severe shortage. Thus, it is not just levels of reimbursement that may impact access to neuro-ophthalmologists. A clue may come from a response from Japan, where it was pointed out that although the payment may be the same for a visit in any ophthalmic subspecialty, the work load for each visit was higher in neuro-ophthalmology.
Other publications have reported similar issues regarding attracting people to enter the field of neuro-ophthalmology. In Brazil, Simao (2) found 3 issues interfering with developing an adequate supply of neuro-ophthalmologist; lower compensation, inadequate sites for training in neuro-ophthalmology within Brazil, and a lack of support for the discipline by the public health system. Although we did not receive a survey response from a member based in Germany, Hos et al (3) reporting on a survey of German ophthalmology residents found that the only subspecialty where they perceived a lack of sufficient training was in neuro-ophthalmology.
A weakness of this survey was the intentional use of the word “significant” in Question 2, “How many people does your nation have who practice a significant amount of neuro-ophthalmology?” There was no way of identifying, let alone surveying, every neuro-ophthalmologist in each country. Given that we were asking a NANOS member about others in their country, I thought this term would better capture the best estimate of “committed practitioners” than trying to use a threshold percentage of effort and have them guess about how many colleagues met it. Another limitation was relying on information that was the personal knowledge of only 1 respondent from each country without the ability to assess how knowledgeable this person was. There is no way to determine whether this person was basing their responses on data that they had access to or whether their responses were anecdotal impressions.
In conclusion, individual national health care systems and compensation models have had a profound influence on the rewards and challenges that face neuro-ophthalmologists. There seems to be a relationship involving recognition of the subspecialty, financial rewards of neuro-ophthalmic practice, conditions that permit full-time neuro-ophthalmic practice, and patient access to care. Greater health care expenditure/GNP did not seem to insure an adequate supply of neuro-ophthalmologists. Regardless of levels of compensation, in some countries, there are barriers making it difficult for patients to access a neuro-ophthalmologist, and once that access is achieved, there are impediments to efficient delivery of neuro-ophthalmic care. Failure to address these issues will have a profound effect on the future of neuro-ophthalmology throughout the world.
The authors acknowledge those NANOS international members who kindly took the time to respond to the survey: Australia: Drs. Clare Fraser, Christian Lueck, and Isla Williams; Brazil: Dr. Mario Monteiro; Canada: Dr. William Fletcher; Chile: Dr. Cristian Luco; Denmark: Dr. Steffen Hamann; France: Dr. Caroline Tilikete; Hong Kong: Dr. Andy Cheng; India: Dr. Kumudini Sharma; Israel: Drs. Shlomo Dotan and Hadas Kalish; Japan: Dr. Satoshi Kashii; Republic of Korea: Dr. Hyosook Ahn, MD; Singapore: Dr. Sharon Tow; Switzerland: Drs. Francois Borruat, Klara Landau, and Misha Pless; Turkey: Dr. Tulay Kansu; and United Kingdom: Dr. Michael Burdon.
1. World Health Organization. Available at: www.who.int/countries/en
. Accessed January 24, 2017.
2. Simao LM. Neuro-ophthalmic training centers in Brazil: are there enough? Int J Ophthalmol Clin Res. 2017;4:070.
3. Hos D, Steven P, Dietrich-Ntoukas T. The situation of residents in ophthalmology in Germany; Results of an online survey. Ophthalmologe. 2015;112:498–503.