Ophthalmology is one of the most competitive subspecialties in medicine, consistently ranked within the top ten. There are approximately 120 ophthalmology residencies in the United States, each with only a few seats.
In January 2021, there was an applicant pool of 677 people, with 498 positions filled (a 74% match rate). All but one seat was filled; 38% of applicants matched with their first choice; 19% with their second choice; and 10% with their third.
While the numbers sound fairly good, those that are applying to this specialty usually have a strong application to begin with.
Choosing which ophthalmology residency is the best for an individual is an important decision that requires one to carefully weigh a few factors. The weight of each factor is generally a personal decision but there are a few which are listed with an asterisk* that should be considered higher up on one’s scale. While some of this information is readily available online, some information can only be gathered from the program itself or current/prior residents.
There are several factors to look at when evaluating: program size, board pass rate, national reputation, research, location, integrated program, having various subspecialties and clinic sites, number of faculty, on-call volume, culture, surgical volume, didactics, facilities, and program accreditation status. We’ll explore each of these in detail below.
A survey of medical school applicants from the American Medical Association in 2021 showed these to be their top five considerations:
- Desired geographic location – 88%
- Perceived fit – 84%
- Reputation of program – 83%
- Academic medical center program – 68%
- Quality of residents in the program – 67%
I have always compared choosing a residency to choosing a meal
The vast majority of people would want a delicious, juicy “burger”. This means the on-call experience is extremely light, clinic patient volume load is non-demanding, facilities are extraordinary, situated in a prime location with outstanding benefits, and time for research or other extracurricular activities are abundant. The other side of the spectrum is the “salad”. This means that call duties will likely be very heavy with a huge clinical patient volume, demanding research or clinical requirements with limited time for research or other extracurricular activities. You are clinically very busy.
It may be obvious to the reader that the burger is tempting (just imagine getting a full night’s rest every night during residency). Your heart may really want it. But the truth is, it won’t make you the best ophthalmologist you can be. On the flip side, that salad doesn’t sound tasty at all. However, eating a salad is really good for you (and your future career). With all of that being said, what would make you the best and happiest ophthalmologist you can be? Find a burger with a side salad.
This means a program with a good blend of all the features above, which we will break down. You want a moderate on-call experience where you learn to diagnose and manage urgent and emergent eye conditions, an adequate clinic patient volume so you can see a wide breadth of “bread and butter” ophthalmology, good facilities to train in with good benefits, and just enough time to get involved with research while ensuring you have an appropriate amount of time scheduled for yourself.
What should you look for in an ophthalmology residency?
As an ophthalmology applicant, some of these points below may have been mentioned to you like things to look for in a program, but perhaps it wasn’t clear why these factors are important. It wasn’t for me at least. Let’s delve deeper!
Reminder: an asterisk* indicates factors that should be weighed highly.
Program size
This number can range from as few as two seats to as high as twelve seats per year. The average is around four to five. What does this mean for you? The number of seats should all be taken into context with regards to the number of sites a program has and how surgical experience would be affected. For example, if there is a program with a large number of residents among a large number of sites, chances are there will be adequate room for each resident to grow surgically at his or her respective site.
However, if there are a large number of residents with only a few sites, chances are that the surgical numbers may be compromised since the residents may have to share a caseload for their operating room (OR) day.
Board pass rate*
This is an important benchmark that is usually available to the program. It indicates what percentage of graduating residents have passed their boards. Obviously, you want to go somewhere where there is a high board pass rate. This program may emphasize didactics or give you adequate time to study for your boards. Lower board pass rates may signal the opposite, so something to be cautious about.
Reputation*
A program’s national reputation is largely influenced by patient outcomes, the prevalence of alumni publications, the prominence of house staff, board pass rates for residents, and funding for research.
“The decision to go into a highly reputable program depends on your goals in life.”
There is no doubt that you will have access to some of the more prominent thought leaders in the field with the ability to diagnose and treat rare ocular conditions. You may also have more access to perform cutting-edge research as well. It can help you in the future as you apply for fellowship positions as well as a job in an academic center. If these don’t align with your goals, then perhaps this shouldn’t be as high on your priority list. It is important to note that regardless of where you go, you will still have the ability to turn your career into a more ‘academic’ one if you choose to do so and can still pursue competitive fellowships.
Research
You may hear the question: “Is it research-heavy or clinically-heavy?” This question is asking if the program is a strong academic center focused on research or if it is a smaller program focused more on seeing a large volume of patients. Importantly, these are not mutually exclusive. There are many programs that have both attributes.
If you enjoy research and foresee yourself wanting to publish a lot during residency and beyond, finding a program that has a strong research focus may be important for you. Finding programs that have faculty that publish often or have ongoing research projects will be the way to go. By doing more research, you’re also setting yourself up to be competitive for the fellowship process, should you choose to go that route.
Location*
This one is obvious and will totally depend on your own circumstances. Perhaps you want to be in a big city with the world at your fingertips. Maybe you have family or a significant other that you could be closer to. Or, maybe you’ve never lived on the west coast, and want to try something new for one of your last moves during your training process. Urban areas will also cost a lot to live in, and the salary may be disproportionate.
Contrastingly, a rural location may pay moderately well especially given a more affordable cost of living.
“Whatever the reason you have, location is a huge factor in the decision-making process, at least from a quality of life standpoint.”
Call shifts**
This one is big. The nature of call can make or break your residency experience.
Here are a few questions to consider:
- How busy is call?
- How often do you get to sleep at night?
- How many sites do you cover?
- Do you get a post-call day or a few hours off the next morning? How often am I on call?
- How does call change as I advance during training?
- Am I performing surgery (i.e. globe ruptures) on-call overnight?
- What kind of support do I have when I am on-call?
Every residency is unique in its structure of call and the answers to the above will vary significantly. I would highly advocate for going to a program where there is at least a moderate call volume. This will prepare you to triage non-emergent ocular conditions and to diagnose and treat urgent/emergent ocular conditions that you may not otherwise see in your outpatient clinic. While it sounds nice to go to a program where call is extremely light or barely existent (think: burger), it is ultimately not going to make you the best ophthalmologist you can be.
Culture**
The culture in a residency is the shared learning, beliefs, values, behaviors, and traditions among participants. It is hard to gauge a residency’s culture without actually being in residency for some period of time, but it is a huge factor that should be explored to the best of your ability. This will likely influence your “satisfaction” with your residency experience and whether you would do it again.
The topic of residency culture is huge, but overall can be answered by a few questions:
- Do I find my work meaningful and satisfying?
- Do I feel like I am growing in my role? Does the program encourage me to make positive changes and to be a leader in medicine?
- Is the program leadership committed to my success and professional development? Is there mentorship?
- What is the quality of the relationship between my residents? Am I in a trustworthy, authentic environment?
- Do my personal values match that of the residency? Do I feel any ethical or moral distress in my day-to-day?
- How much are my opinions and thoughts considered in decision-making?
- Are residents respected? Is there any bullying?
These are just some questions that a resident can answer to understand a program’s culture. Nonetheless, culture is dynamic and culture can be built. Culture can be created by your attitudes and the attitudes of those around you. The one mainstay in determining culture, however, is leadership. It is important to have a program director and/or department chair that demonstrate that they care for their residents and will make changes where appropriate. The above questions should all be answered positively.
On the day of your campus visit, try to understand from current residents what the culture is like. Ask them a few of those questions if you have the chance. Or simply ask: “What is the culture like here?” You’ll be able to gain a lot of insight from that.
Joint/integrated program
All ophthalmology programs in the 2023 match cycle will have an integrated/joint program. As such, it is no longer a unique point to explore. It goes without saying but having additional time during your intern year to learn ophthalmology at your respective program really eases the learning curve come July of your PGY-2 year.
Specialties*
This one is more important than you might realize. Having all the major specialties (including Oculoplastics and Neuro-Ophthalmology) in your residency is important. It enables you to learn more broadly about the visual system. It also allows you to take care of your patients within your own health system in a multidisciplinary fashion, and you can follow through with the patient’s care, which inevitably enhances your learning. Finally, the exposure to all the various specialties will allow you to determine if you enjoy the field enough to consider it for fellowship.
Number of faculty
Having a large number of faculty allows you to learn from more ophthalmologists. They all offer different perspectives medically and surgically. Ideally, a high faculty-to-resident ratio should be sought. Conversely, sometimes learning too many different techniques can also be a problem as you don’t get the chance to master any one technique (though this is rarely a problem).
Various clinical sites*
Having various clinical sites is important as each site attracts a specific patient population with certain ocular disorders. For example, having a VA clinic and a county clinic provide a varied and unique experience to your educational tool belt, both medically and surgically. You may also rotate in private attending clinics, which will give you yet another perspective. At my residency program, we also rotated at the navy base for a month, where we performed refractive surgery on the military. Having such a varied experience will leave you well-rounded after residency, which should be your primary goal!
Surgeries and types of surgeries*
I remember interviewing and asking every program about their “surgical numbers.” I knew it was important but I didn’t know why. When you leave your ophthalmology residency, you want to be equipped to perform the functions of a comprehensive ophthalmologist who doesn’t need additional training. Even if you are planning to pursue an additional ophthalmology subspecialty, the things you will learn during your surgical and procedural experiences will shape your learning curve.
You want to ensure you will have all the experiences required by the ACGME. Oftentimes, a program can (and should) show you an average of the surgical volume obtained by residents by the time they graduate. You want to clarify if all of these numbers were as “primary surgeon” and what “primary surgeon” actually means in that residency. Did the resident simply scrub in and watch the case? Did they do parts of the case? Or did they do the whole case?
Obviously, doing a full case would provide you with greater benefit. The exception here is with cornea surgeries (refractive surgery and transplants) as well as retina surgery where it is expected you may only be an “assistant.” That is because these are subspecialist—or fellow-level surgeries which are usually not performed by a general ophthalmologist. Of course, if you can get primary surgeries in this field, the better!
Overall, you want to make sure you are getting adequate volume in all the fields outlined by the ACGME: (https://www.acgme.org/globalassets/pfassets/programresources/oph_caseloginfo.pdf)
Particularly important for most residents is their cataract volume. You want to ensure your program is at least somewhere in the 50th percentile to have a good surgical experience. If you do more surgery, you will inevitably have more opportunities for mistakes or postoperative complications, all of which you want to ensure you learn how to manage ideally while in residency. As you learn more and do more, naturally this complication rate should go down.
Didactics*
OKAPS is the ‘in-service’ exam that is taken by all residents yearly. They are a reflection, generally, on how one will perform on the real board exam. The material is taken from the Basic and Clinical Science Course (BCSC). Having dedicated didactics time is important to be able to review this material. Of course, there will still be a tremendous amount that will need to be self-studied at home. Your residency experience should have a balance of structured didactic time and time to study on your own (again, usually at home after clinic hours).
Program accreditation status*
This one may seem obvious, but going to a program that is accredited ensures that they are likely meeting all of the standards set by ACGME for an appropriate training experience. Some programs may be on “probation” or can “continue with changes” which all speak to the level of intervention set by ACGME to ensure an appropriate training environment for residents. This information is usually available publicly online.
Facilities
While a brand new building, new flooring, and an aesthetic atmosphere are nice (again, think: burger), it is not nearly as important as all of the prior things we talked about. What is important, however, is having access to modern diagnostic technology or the latest and greatest surgical equipment. You want to be trained to be an ophthalmologist in the 21st century, who is familiar with all the latest technology so that patients can get the best care possible when you become an Attending.
Conclusions
Everything we discussed above is something to consider when choosing your ophthalmology residency. Every applicant will weigh which factors are more important to them, which will dictate where you apply, interview, and rank. You may want that “burger” even though a “salad” is what is best for you. In other words, it will make you the best ophthalmologist you can be. To have the best of both worlds, order a burger with a side salad (easier said than done!).
Ophthalmology is an incredibly rewarding field that is constantly evolving. Only you can determine how much you make of your experience. Good luck!
