The Ultimate Guide to Ophthalmology Residency

Feb 13, 2020
27 min read
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First year, second year, third year, deciding whether to do a fellowship . . . ophthalmology residents are a busy bunch! Here's a comprehensive guide, year-by-year, with plenty of tips.

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Whether you’re getting ready to apply for ophthalmology residency, eagerly awaiting Match Day, or getting ready for your first day as a resident, you want to know what to expect. What do you need to know before your first day as an intern? What kinds of questions can you ask hospital staff? How should you interact with your faculty or older residents?

First, here are the facts about ophthalmology residency

Is ophthalmology a competitive residency?

Yes. In January 2019, 484 ophthalmology residents were filled from an applicant pool of 790 (a 75% match rate).

How many ophthalmology residency programs are there?

In January 2019 there were 485 positions for ophthalmology residents, 484 of which were filled. 53% of matched applicants matched with their first choice; 25% with their second choice and 22% with their third.

How many spots does each program have?

Most ophthalmology programs typically have only three to four spots.

How much do ophthalmology residents make?

The 2019 MedScape survey reported that ophthalmology residents earned $59,900 per year.

How long is ophthalmology residency?

Ophthalmology residency takes four years: one year of internship, followed by three years of ophthalmology-specific residency.

Starting this summer, the American Academy of Ophthalmology is moving towards an integrated four-year structure. This means that beginning with the January 2020 match cycle, ophthalmology residencies will now all include a PGY-1 year linked with the ophthalmology residency, or an integrated program with PGY-1-4 all run through a department of ophthalmology. This process will be fully implemented by the 2023 match cycle.

What that means is that wherever you match for your ophthalmology residency, that is where you'll be for the next four years. That same hospital is where you'll be doing your intern year, and incorporated into that intern year is three months of ophthalmology. So you'll spend nine months doing either internal medicine, family medicine, pediatrics, or general surgery, depending on the program arrangement.

This is a new process for ophthalmology; other surgical subspecialties, like ear, nose, and throat, plastic surgery, urology, and others have already operated in this model. When I applied to residency, it was a different process—I applied for my intern year separately from my ophthalmology residency.

I appreciated that I was able to do a transitional year residency close to home: I felt like a third-year medical student all over again. Each month I was on a different service—pediatric surgery, radiation oncology, ICU. I was able to pick rotations that I thought would have some overlap with ophthalmology—like radiation oncology, since a lot of times patients with brain tumors or optic nerve tumors get radiation therapy, which can affect their vision.

In the old model, you had a little more flexibility when it came to choice, but you weren’t guaranteed any ophthalmology training during your intern year. It was at the discretion of your program. With the new residency match model, applicants are saving money by not having to pay two sets of fees, go on two sets of interviews—not to mention the time saved by not having to write two separate sets of statements.

What to expect from the residency match process

When you’re applying to residency in your fourth year of medical school, the core components of the application are:

  • Board scores
  • Medical school transcripts
  • College transcripts
  • A personal statement
  • Three letters of recommendation

The recommended submission date is usually in August of your fourth year of medical school.

Once you’ve submitted your residency application, the interview process begins. These start in September and end in December, and are usually staggered by program. For instance, the Midwest programs usually start interviewing in September-October, but the rest of the programs hold interviews in November and December.

Once you’ve interviewed, your rank list is due along with the rank lists from the residency programs in early January. Then, SFMatch runs each of these lists through their algorithm, and releases the matches about a week later. The process is like a cross between the Sorting Hat and rushing a sorority or fraternity, but it’s said that the algorithm is weighted in favor of the applicant.

Then on Match Day, which for ophthalmology residency is in the second week of January, you discover where you’ll be spending the next four years of your life.

The cadence of the next four years: from internship to planning on fellowship

Your intern year is perhaps the most formative. You’ve just graduated medical school, and the very next day you’re a doctor. On my first day, I remember walking into the hospital, and having one of the hospital staff say to me, “Dr. Agarwal, what do you want to order for this patient?” Wait a second, I remember thinking—just yesterday I had a safety net!

But those nurses know that every year, on July 1st, comes a new batch of fresh-faced doctors. The people you work with from day one know that you’re young, still adjusting to this newfound responsibility, and will be by your side to support you for the next four years.

During this year, you should not worry about ophthalmology. You have the rest of your career to practice. Focus on learning the flow of the hospital, EMR, and the administrative side of things in addition to the basics of medicine. For example, if I had completed my internship at my ophthalmology residency program, I would have struggled much less in figuring out how to set up social work for disabled patients, ordering outpatient IV steroids, and getting prior-authorization approval for medications.

Ophthalmology residency: year one

Your second year—the first year of your ophthalmology residency—is where things really start going. Now you’re a resident doctor in ophthalmology, and this is when you realize that you truly know nothing. The language of ophthalmology is a new one, and you have to pick it up quickly. You’ll feel slow, like you don’t know anything, but don’t worry—you’re learning more than you think.

In your first year as an ophthalmology resident, you’ll take a ton of primary calls and you’ll see a huge variety of pathology. Depending on your residency, it might be an ER call with local hospitals and potentially even a children’s hospital. Everything will be very new because you haven’t seen it all before—pay attention and keep learning!

There will also be a lot of eye trauma, especially if you are at a level one trauma facility. You'll be called in to consult with your colleagues from medical school in other departments who don’t know anything about the eye but know that you do. You’ll be figuring things out on the job, and learning that you know more than you think. You’ll keep doing exams, reading about central diagnoses, and practicing. You’ll be scared, thinking “Who is letting me, someone who has only been doing this for a few days or weeks, treat these patients?! What if they go blind because of me?!”

Keep in mind that you’ll always have your chief resident and your attendings guiding you through workups, plans, exam findings, and management. The goal of your first year is to get comfortable doing the complete eight-point exam, learning the basic management of eye emergencies, and getting the flow of managing clinic patients down.

Some programs will have scheduled operating room time for the first years, where you’ll start off with oculoplastics—trauma, eyelid lacerations, globe trauma, and the like or pediatrics. These are the kinds of gross ophthalmic surgeries where you’ll start off with. As you continue in your residency you’ll begin to do the more intricate microscopic surgery.

Depending on the program, you might also have the opportunity to start performing some routine in-office laser surgeries—such as for glaucoma or posterior capsular opacification. This gives you the opportunity to get more comfortable with the feel of microscopic procedures, without throwing you into the deep end of cataract surgery.

Year two: It’s time for subspecialties

In the second year of your ophthalmology residency, you start rotating on subspecialties. You’ll experience rotations in cornea, retina, pediatrics, oculoplastics, glaucoma, and neuro-ophthalmology. You’ll be working with fellowship-trained physicians, observing and sometimes participating in their cornea or retina procedures, and also seeing how they manage those patients in their clinics.

Residencies are structured differently in terms of how the subspecialty clinics are set up. Some have departments dedicated to specific subspecialties and others have rotations within private practices. This is when you build on your fundamentals from first year and start ironing out the details clinically and surgically. You’ll find your fund of knowledge has grown immensely, and the intricate questions your seniors were asking finally make sense to you.

In some programs, you’ll get a short introduction to cataract surgery in your second year. In some, you might be doing a graded approach, where you’re performing some of the steps. You will also have more hands-on experience with glaucoma, pediatric, cornea and globe trauma surgeries.

In most programs, slowly taper off taking primary calls or stop taking them altogether. At a select few, you might still be taking primary ER call and dealing with the same ER consults and coverage that were you were doing as a first-year resident, but functioning more autonomously clinically and surgically.

Luckily, you’ll be more comfortable with it because you’ve been doing it for a year. And then, before you know it, you’re a third-year resident.

Third-year residency: time for intraocular surgery

In your final year of residency, you begin to perform intraocular surgery. You might find yourself performing some glaucoma or cornea surgery, but your true bread and butter is cataract surgery. (Keep in mind that almost no programs will have third-year residents doing retina surgery, because those are really saved for fellowship.)

As a third-year ophthalmology resident, you’re also responsible for mentoring the first-year residents—showing them the ropes, seeing patients with them, being their backup on call, and helping them as you were helped in your first year. You’ll also be managing the inpatient service, overseeing the appropriate workups and treatments, as well as communicating with the attendings about what’s going on on the service. If the patients need to be rounded on with an attending, you may be part of that—it’s become your role to supervise and manage the service in addition to your clinic responsibilities and doing surgery.

Each year your responsibilities grow, but you also get more comfortable because now you know the language of the exam, and ophthalmology becomes more comfortable for you. The pathology is no longer as foreign or overwhelming, and you’ll find that you're able to teach and educate.

That’s when it’s time to decide whether you want to keep going—and apply for fellowship.

How to succeed in an ophthalmology residency

I had strong ties to my intern year hospital staff and personnel, and that’s something I wish I still had easy access to. When the pharmacists would call me, saying that I ordered something wrong, they would joke with me and educate me rather than scold me. They’re not mad: there are just a lot of checks and balances, thank goodness!

The nurses, the respiratory therapists and everyone else who makes up the healthcare team is used to these kinds of mistakes from interns. So it’s expected for you to be able to turn to them and say, “What do you usually do in this situation? You’ve been doing this longer than I have” or “I’ve never ordered that before, can you please show me how?”

During my ophthalmology residency, I felt like I had to start building these relationships all over again. But if you remember to be kind, humble and respectful to everyone around you—including the janitorial staff—you’ll realize they can help you out more than you can imagine. I often had times the ER secretary would hold on paging me for 30 minutes when she knew I had a busy night just so I could get a bit of sleep in. Similarly, I’ve had the OR bump my case ahead of scheduled cases because I was the “helpful doc” (helping transfer patients from stretchers, moving beds, grabbing supplies for the case, etc).

The most common mistakes made by residents

It’s actually expected for you not to know everything—that’s the point of being an intern, being a resident, and going through this process. If you already knew everything, then there would be no point in residency. Because of this, the three most common mistakes made by residents all have more to do with mindset than with a lack of knowledge.

Mistake #1: Procrastination

The biggest mistake residents make is procrastinating. With the advent of EMR, we all get bogged down in paperwork, charting, returning patient phone calls, etc. The best piece of advice I got from an attending was to do everything while the patient is in the room.

Patients want to know that you’re spending time on them. They don’t know any of the time you spend when you take your notes home; to them, you were in the room with them for two minutes. Not to mention the fact that when you take things home to work on at night, you’re going to forget details and feel more rushed.

So, do everything when the patient is in the room. Most importantly, tell the patient everything! Don’t just order a test, see that it’s negative, and not call them with the results. They’re worried and anxious! Help them understand why you are ordering these tests. I have found that discussing the care plan with a patient helps them be more engaged and motivated about their care and the outcomes are substantial. They take the initiative to get their medications filled and actually take them, labs drawn, and show up for follow up appointments. You can do all the work behind the scenes, but what’s it worth when the patient doesn’t follow through on any of it?

Do they need a note sent to their rheumatologist or primary care physician? Write that note in front of the patient, and make sure they know what you’re doing. Your patient will feel heard, and that leads to them being more confident in the care you’re providing. They’ll know that their doctor is doing everything you said you were going to do—and you’re getting it done.

This is particularly crucial for residency because of how busy you are, all the time. I have residents on my service who still haven’t written up their notes from the beginning of the year—and that leads to confusion for everyone. If patients call about their records or for instructions on their medication, the front desk staff won’t know what’s going on because the notes aren’t available. This is especially a faux-pas if another service is relying on your evaluation to make a treatment decision (i.e., Rheumatology, Neurosurgery, etc!)

If your colleagues don’t know what’s going on, you’re not being a good member of the team.

Mistake #2: Not asking for help

The second big mistake residents make is directly related to procrastination, and it’s not asking for help when you need it.

As a second-year resident and even as a chief resident, I had this idea that I’m supposed to know everything. I’ve come to realize that no, I’m still a resident—I’ve been doing this for barely two and a half years. I have the right to ask what I may think are “dumb” questions, but there’s no shame in that.

You should never feel ashamed to ask a question, to ask for advice, or to say that you don’t know. It’s better to admit that and ask the advice of the experts and the experienced practitioners around you, because this is your time to learn. That’s what this time is designed for. Hindsight is 20/20, and it’s not worth risking something going wrong because you were afraid to ask for help.

If I could go back in time and give myself advice before my first day of residency, I would tell myself not to be afraid. It’s going to be very hard to make a mistake that someone else isn’t going to catch, although it can happen! I felt a lot of personal pressure, because I wasn’t aware of all of these checks and balances. There are a lot of safety nets in place, especially if you vocalize you need help.

Don’t make mistakes intentionally, obviously, but if you do, there are people around to help. The most important thing you can do to set yourself up for success in your residency is to establish yourself as someone who is reliable and communicative. You have to be able to collaborate with other people, otherwise, you will not be delivering quality care. Own what you know, own what you don’t know, and don’t be afraid to ask for help.

Mistake #3: Forgetting self-care

The final big mistake that I made and learned from was not prioritizing my own well-being. It’s very easy to get bogged down and feel like there aren't enough hours in the day. You feel like that one hour you do have free in the day should be spent studying or doing clinical work. However, it’s very important to schedule time for yourself to say, no, I'm going to work out, or I’m going to cook myself dinner.

I lived the first few years of residency thinking that every hour I wasn’t spending studying or doing clinical work was an hour lost. I thought I was slacking off, but I wasn’t realizing how unproductive that time actually was. If I was sitting in the library for 16 hours, only five of those hours were truly productive. Now, I’ve reprioritized my sleep, exercise, and eating, and what used to take me five hours to complete takes me two—because I’m rested, clear-minded, and energized by the time I took to prioritize my well-being.

Your physical health affects all aspects of your life. If you’re tired, you’ll make mistakes and forget things. Taking care of yourself improves your mood, your perspective, and your memory—it’s just as important as studying and practicing surgery.

A lot of the fear that drives these three mistakes comes from the anxiety and pressure that we put on ourselves. But it’s expected that you don’t know everything. This is the point of being an intern and being a resident: if you already knew all of this, you wouldn’t need to go through the process.

Build those relationships!

Showing up and being engaged is more than half the game. You can know everything, but if you don’t have the work ethic, the camaraderie and teamwork-focused attitude to work with your nurses, attendings and fellow residents, you’re not going to deliver the best possible care you can for a patient. Communication is key. Being able to be reliable, to follow through on things, is key. Just because you have great board scores or got honors on all of your tests, doesn’t automatically make you superior to your colleagues. You have to show that you are more than just numbers on a page—and it takes more than just knowing all of the answers.

I can’t overemphasize how important communication is: even the simple motion of telling a nurse that you’re going to order a medication or a test, because if you forget, there’s another person who can follow up with you. Your coworkers are an important resource, and it’s part of your job to rely on them to support you, and vice versa.

Finding mentors during your residency is another way you can set yourself up for success in your career down the line. And that starts with, again, communication! Just talking to your attendings early on, you’ll get a feeling of who shares your mindset and would be a good mentor.

This is the part where many residents miss an opportunity: not everyone is going to be the perfect mentor. Just because someone is in a prominent position in the department doesn’t mean they’re going to make a good mentor for you. Instead, look for someone you feel will give you honest advice about your career and shares a similar mindset with you.

Also, don’t wait until you’re struggling to ask for help or to reach out for guidance from a mentor. Start early once you’ve realized that these are people you’ve clicked with, and have real conversations with them. Many of the attendings will have stories to share, and you can learn so much just from listening. Ask them how their practice is going, and later you’ll realize just how much you were learning from those conversations!

Fellowship or the job market?

Just like it’s never too soon to start looking for mentors, it’s never too soon to be thinking about life after residency. Are you going to go straight into practice, or will you apply to fellowship? There are so many paths residents can take, so it really depends on finding which one is right for you.

I’m an atypical representative of the fellowship path. Usually, what most residents experience is one of the following: you come into ophthalmology residency knowing that you’re going to pursue a specific fellowship, you’re leaning towards a comprehensive practice, or you have no idea and are just happy to have matched into ophthalmology.

Many times, you’ll find yourself drawn to a particular subspecialty because you’ve had a brilliant mentor in that field. Sometimes you find this mentor or this field in your second year by getting exposure to the subspecialties and realizing you enjoy this subject both clinically and surgically.

Additionally, many residents start to think about lifestyle and family, and that has a strong impact on your decision to pursue fellowship or not. Fellowship is another one to two years of study, and if you have a family that can add additional pressure. At this point, you’ve been in school for eight years beyond college, so another two years can seem like asking a lot when instead you could settle down with your family and start taking in that ophthalmology salary.

It’s all about what is right for you and your career. And this is also when talking to your attendings and mentors about their work-life balance can help you make your future decisions.

I came to an anterior segment fellowship through an atypical path: I entered residency thinking I was going to do oculoplastics. I was set on it! And then I started my residency and realized that oculoplastics was very different than I thought it was. I hadn’t planned on the trauma aspect, and oculoplastics is partly an emergency specialty.

Once I came to the realization that I wanted to focus on intraocular surgery, I considered focusing on cataract surgery—which meant I wouldn’t need a fellowship. But then, as I saw more patients, I realized that many patients come into the clinic wanting the latest and greatest procedures. Cataract procedures combined with minimally invasive glaucoma surgery, LASIK, refractive surgery—a lot of newer specialty surgeries that residencies don’t offer a lot of exposure to, but certain fellowships would.

That’s when I found the small but growing field of anterior segment—which is doing exactly what I described. There are only a handful of programs out there, and I’m excited to be heading to one of them this year.

For me, fellowship is a way to grow that foundation of knowledge and build on what I’ve already developed in residency. This way I will know that when I’m in practice, I’m offering the best care possible to my patients, from a position of formal training.

Wondering what to do after fellowship? Check out this article on establishing yourself as a new ophthalmologist!

How to prepare for your ophthalmology career

When you’re working with mentors throughout your residency, you should always make sure to ask them about their experience running a practice. That’s where this is all heading, right? They’re a resource of knowledge and experience—whether that’s the headaches of dealing with an EMR system or dealing with the fact that the billing protocols are changing. By talking with your mentors, you’ll learn about these things—and you’ll know that if you run into a problem in the future, you can reach out to ask for their advice.

Towards the end of your second year of ophthalmology residency, you should start thinking about what you want to do after your residency is complete. This can be as simple as thinking about where you want to practice—a particular area of the country such as a city, rural or urban, and so on. If you're trying to go into a competitive market or competitive location, how badly do you want to be in that area? Does it seem like that area is saturated and so competitive that you need a fellowship to get your foot in the door?

You don’t need to—and probably shouldn’t—think of what your ideal job is, but start asking your attendings what they think about the various modes of practice. What do you think about private equity taking over practices? What do you think about being a private equity-owned practice? What do you think about being in private practice? All of these questions are best answered by the people who are living them. Getting a wide range of perspectives will help you make the most informed decision.

I recently learned that 80% of ophthalmologists leave their first job within three years. That’s a huge number, and should absolutely affect how you think about accepting your first job, particularly when it comes to contracts and non-competes. If you’re picking an area where you want to settle down, you have to consider whether you’ll still be in that first job in three years—and what it will mean if you’re not and your contract includes a non-compete clause?

Furthermore, if you’re thinking about getting a job straight out of residency, it's not too early to start looking in your second year. Many practices are willing to wait for graduation, because they understand the timeline.

All of this comes back to finding your mentors and talking to them. Ophthalmology is a small community, and asking for advice will help you make the best decisions. Whether that means asking your mentors to help you review contracts or sharing what you’re looking for just in case they know someone who happens to be looking to hire—these are reasons why your ophthalmology faculty are there to help you.

Having those people who've experienced this before mentor you through that process is also very, very valuable. You do not have to reinvent the wheel. The idea of becoming a partner in a practice is now changing. The idea of owning a practice is now changing. It’s never too early to just start talking to people and looking for jobs on job posting boards if that is the direction you want to go.

You may feel overwhelmed by all this information and that is normal. This is meant to be a comprehensive guide for you to reference at all stages of your career and details I wish I had known before entering the field. Try to absorb as much as you can from your patients, colleagues and faculty members and most importantly, enjoy your time during this journey!

References

  1. “Ophthalmology.” American College of Surgeons, www.facs.org/education/resources/residency-search/specialties/ophthal.
  2. “Questions to Ask Yourself.” American College of Surgeons, www.facs.org/education/resources/residency-search/position/questions.
  3. “Residency Match Basics for Ophthalmology.” Residency Match - American Academy of Ophthalmology, www.aao.org/medical-students/residency-match-basics.
  4. “Section III: Surgical Specialties.” American College of Surgeons, www.facs.org/education/resources/residency-search/specialties.
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About Kanika Agarwal, MD

Dr. Kanika Agarwal, MD is an ophthalmology resident physician with a strong background from an Ivy League University in research, engineering, and business. While primarily interested in Ophthalmology, Dr. Agarwal is also interested in pursuing endeavors involving consulting for biotechnological/pharmaceutical companies and philanthropically driven biotechnological initiatives for developing countries.


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