Matching in Ophthalmology and then Succeeding in Residency: Pearls from Program Directors

By Rahul Khurana, MD

Ophthalmology is a wonderful subspeciality, but matching in this competitive field and succeeding in residency can be challenging. I had the invaluable opportunity to interview three Ophthalmology Program Directors at the finest Ophthalmology Residencies in the country to get the inside scoop and separate fact from fiction! Dr. Alfredo Sadun (AS) of the Doheny Eye Institute/University of Southern California, Dr. James Dunn (JD) at the Wilmer Eye Institute/Johns Hopkins, and Dr. Pratap Challa (PC) of Duke Eye Center were kind enough to share their insights on matching in ophthalmology and thriving in residency afterwards. For those who have not met these wonderful individuals, you should introduce yourselves to them at meetings as they are excellent educators in the field of Ophthalmology.

GETTING INTO RESIDENCY

1. What qualities and characteristics are you using to evaluate medical students in admission to residency program?

AS: The first quality we look for is evidence and a commitment to leadership. We want to train not only excellent clinicians but future leaders who will push our field forward. This leadership is often in academics through basic science or clinical research. But it could also be in policy or in politics through health care advocacy. The second quality we, and I think most programs look for, is evidence for being a team player. Residency classes are small and housestaff must work well with their supporting colleagues to maximize everyone’s educational experience. Someone who does not “play well with others” can compromise the entire residency.

JD: This is a very difficult question (Alfredo Sadun and I are actually writing an editorial (sort of a point-counterpoint) for the Journal of Academic Ophthalmology on the subject. Factors that may be considered include USMLE scores, college grades, caliber of medical school, basic science and clinical grades (including AOA if offered), Dean's Letter, letters of recommendation, personal essay/outside interests, and publications. Then there's the interview itself. Everyone has their own set of criteria that weight these factors differently. Programs also vary; places like Wilmer tend to take more M.D./Ph.D.'s (although there's very little evidence that a Ph.D. is more likely to go into academic medicine, and in fact I personally think that they're more likely to "burn out" from the years of training and may be LESS likely to do so). Other programs don't even consider Ph.D.'s because they think they won't be good clinicians.

I can give you my own preferences. I look for excellent USMLE scores (see Question 2 for more details). I think the Dean's Letter is useless and I don't even read it in most cases (plus, we interview in October and the Letters often aren't even available by that time). At Hopkins, for example, I can't tell from the Dean's comments the difference between the greatest and the worst student in a given class. Letter's of recommendation are critical, but it matters much more to me when they come from someone I know well, and from whom I know that I'll get an honest appraisal. Over the years, I've come to consider the interview less and less. For the most part, an applicant can sink themselves with a bad attitude (condescension toward the staff who organize our interview days is the kiss of death) or by appearing clueless about what is in their application (I've written off applicants who couldn't tell me about articles on which they were a co-author, and even had one applicant last year who, when asked about an intriguing-sounding article she had published in AJO just in the previous year, actually said, "Oh, that was a while ago; I don't really remember anything about that."). Simply by coming off as quiet or shy doesn't faze me if someone I know and trust has written that an applicant is exceptional; I will give much more weight to four years of performance in medical school than to a short interview. Over the years, I've been burned by applicants who are great interviews but disappointing residents. I guess if there's one "type" that I look for in an applicant, it's a smart, hard-working, team-playing student who looks like he/she has interests outside science in general and ophthalmology in particular. I worry about students who never took a humanities course in college, and I worry about students who do three or four or five months of ophthalmology electives as a fourth-year student, because I want residents who are physicians first and ophthalmologists second. I'm not necessarily worried if an applicant has shown promise in a different field (say, publications in cardiology or OB-GYN) but chooses to go into ophthalmology. To use a sports analogy, I look for the "best available athlete," rather than "drafting by need." When Ed Maumenee was chair here, he never gave a damn whether his residents got along; he selected residents he thought would become chairmen somewhere. I don't have that luxury in an era of duty hour rules; selfish residents make unhappy classes, and unhappy classes make more work for me AND generally make it harder to recruit the next batch of residents.

PC: Scholarship, commitment to the field, enthusiastic applicants, and ability to work well with peers. Leadership qualities and academic endeavors are also very important. Overall, I look for individuals with academic aspirations who would fit well into our learning environment.

2. How important are USMLE board scores? STEP I vs. II

AS: At Doheny, high USMLE scores are helpful but not essential. Our focus is on finding leaders in ophthalmology and board scores often do not reflect that quality. That being said, at least 50% of ophthalmology programs across the country use filters of at least 230 on Step I to screen applicants. And all things being equal, we would prefer those who know how to study and perform. Board scores are also important because they are probably a good predictor of OKAP scores. In the future, OKAP scores will be used to judge residency programs so poor scorers may not only jeopardize themselves, but may prove a liability to some programs.

JD: I look for excellent USMLE scores, but above a certain level it doesn't matter (i.e., I look for something in the 90th percentile or above, but it doesn't matter to me if they're 91st or 99th). I like to see Step 2 scores, because at least step 2 is clinically oriented, but most applicants don't have Step 2 scores so it isn't usually helpful for comparison.

PC: USMLE scores are part of the overall performance that we look at and we do not have a cutoff. All applicants have step I scores but only about one-half have step 2 scores. We look at all that are available.

3. Is there a minimum USMLE Step I board score needed in admission to your residency program?

AS: No. Our focus is on finding leaders in ophthalmology and board scores have little to do with that! But anyone applying with less than very strong scores had better bring other evidence of their excellence and distinction.

JD: See above. There are some people on our committee that make this a true "linear" criterion (e.g., a candidate with a score of 251 is better than someone with a 249, which makes no sense to me). I do think the USMLE correlates with OKAP scores to some extent, in that applicants who score poorly on the USMLE tend to do poorly on the OKAP (the reverse certainly doesn't always hold), and I think that just reflects standardized test-taking ability. The USMLE (and OKAP) scores do NOT necessarily correlate with clinical skills.

PC: See above.

SUCCESS IN RESIDENCY

1. What are the qualities of successful ophthalmology residents in your program?

AS: “THAT THEY NOT HUNKER DOWN!” I used that phrase often to distinguish between those that react to complex and challenging situations by stepping up and grasping the opportunity, versus the common reaction of keeping your head down and trying to just survive. Those who do the former, will become great. I encourage our residents to see every challenge as an opportunity to add difficult experiences as deposits to their intellectual savings accounts. During the three short years of a residency, every difficult case should become part of the resident’s armamentarium. Each resident should embrace the pathology that comes his way. Each time they see something new or difficult, they should use that to stimulate themselves, to ask the faculty for help and then to go home and read and research the condition. Successful residents use the thrill of learning and discovery as an antidote for the demands of hard work. And if they do, not only will they learn a great deal, not only will they enjoy the experience of residency, but they will go on to retain this invaluable attitude of absorbing something from every challenging experience. Keep Learning. Stay stimulated.

JD: The same as those that I look for in applicants- passion, hard work, intellectual curiosity, team spirit, the ability to learn from mistakes, and an enjoyment for teaching and assisting junior residents and staff. They play nice with others in the sandbox and clean up after themselves. In our program, you have to be a self-starter; residents who require hand-holding do not thrive here. At the same time, I don't want cowboys; I want residents who WANT to learn from their colleagues and faculty and who know their limits and when to ask for help. It's important to me that residents leave something behind in residency; the best ones strive to leave a program better than when they came in, whereas the unproductive ones have an, "I got mine" attitude.

PC: Enthusiasm is the most important quality. These are the most teachable residents and ones who get the most out of their training. You can tell who they are because they always want to know more about all aspects of the field.

2. What are qualities of unproductive residents?

AS: Unproductive residents are those that see an ophthalmology residency as a credentialing process instead of a valuable, educational experience. They are just trying to get through it with minimal effort. They not only miss out on the learning, they also miss out on a lot of the fun.

JD: More and more, I see residents with a "9-5" attitude (they have little interest in their patients if they're off shift) who don't care to develop their skills. They show up in the O.R. without having prepared appropriately, expecting the attending to walk them through the case without any real thought on the resident's part. They don't go the extra mile to help out colleagues in clinic. They dump emergency patients on their colleagues rather than taking of the problem then and there. They ignore their administrative requirements (not keeping up with duty hour and surgical logs, so that other people have to expend valuable time and energy getting them to do it). They blame others (patients, staff, colleagues) for their own flaws and inadequacies.

PC: Ones with a sense of entitlement who aren't willing to put in the required time to read and practice on their surgical skills.

3. What advice would you give to current residents to maximize their ophthalmic educational experience during residency?

AS: See everything as a Learning Opportunity. Ask questions in lecture. Read current papers. Question article and book chapters if they do not make sense and follow up with a Faculty member to clarify them. Learn as much as you can from every patient.

JD: Read, read, read- but NOT during clinic!!!! The more patients you see, the better. THEN you read up on them. Stay busy. If you're in clinic and you have an unexpected cancellation, go see who else is out there. If you're in the OR and have free time, go watch someone else operate. Teach others. Nothing reveals your own lack of understanding of a subject than a junior resident who simply asks, "Why?" when you say something. Listen to your colleagues. Chances are they've seen something fascinating just recently. Ask them about it.

PC: Read from multiple texts to get a fundamental knowledge base, then rapidly transition to reading journals in the field. Ones who are enthusiastic and available are the ones who will have the best residency experience.

4. What role does research have in ophthalmology residency training?

AS: Research is the process of making new knowledge. Knowing this process teaches invaluable critical thinking skills that are essential during and after residency. Being involved in research also makes one appreciate how challenging research can be and how much work goes into the papers they read. It also allows the resident to analyze the current literature and determine which studies are poorly designed and which ones they should rely on. There are many poorly conducted studies that are published and the trick is choosing what to believe.

JD: I think it's critical that residents learn ABOUT research, primarily in the ability to appropriately dissect a journal article and recognize well-written ones from the bad ones. We certainly encourage research, but in the current climate it's unrealistic to expect that any of them will do bench research unless they have a strong background in that area already. We have less than 33 months (counting vacations) to teach ophthalmology, and there is more than enough to learn clinically. However, I think that clinical research, be it submitting case reports, chart reviews, or original clinical papers, is very valuable, and I strongly encourage residents to do something along those lines.

PC: This is an important and fundamental part of any field that rapidly evolves. The ability to ask a question and find a way to answer it teaches very important skills for continued career-long learning. Doing research teaches a different skill set that is needed to not only add knowledge to our field but also to critically evaluate new knowledge- i.e. to be able to evaluate journal articles, studies, etc.