Entering a Residency in Ophthalmology: My Experience

By Florin Grigorian, MD

Second Year Ophthalmology Resident
University of Missouri - Kansas City

My journey began in my native country in Eastern Europe where I started a residency in ophthalmology. I realized then how extraordinary this field of medicine was to me. I discovered at the same time that I would like to practice ophthalmology at a higher level, one that would have been impossible with the training, technology, and health system available in my country. This is the reason why I decided to expand my training by pursuing a residency in the United States. There were many colleagues in my class that decided to further their education in the U.S. but none of them in the field of ophthalmology. My mentors in Romania were also very skeptical, even convinced that it was impossible to enter an ophthalmology residency when coming from Romania. Nonetheless, I was very determined to follow my goal and I began taking my first steps in completing this journey.

I realized that in order to succeed, I had to be close to perfection. The first bumps I had to meet were, of course, the USMLE exams. It was indeed very important to have good scores on these exams because my medical school, though prestigious in my country, did not mean anything in the U.S. My assumption was that a person evaluating my application paid more attention to my USMLE scores rather than the name of my medical school. These scores can open a gate: the FMG’s with excellent scores (95 or above) will find it easier to secure interviews. The foreign applicants with less than excellent scores will have a more difficult time in getting interviews, and will have to compensate for this perceived weakness in other areas to make their application stand out. Once I passed through this gate, I believe the weight of the USMLE scores diminished significantly. I was fortunate enough to have excellent scores, but I knew that this was not enough. My application needed more bells and whistles to draw more attention. I thought that my previous ophthalmology residency experience in Europe would be important, but in retrospect, I realize that this experience it is not as critical as I originally thought. Over the years, I met numerous people that graduated from ophthalmology residency programs abroad, but were unsuccessful in securing a residency position here. However, I did not meet a single person that completed a clinical fellowship in the United States that was not successful in securing a residency position afterwards.

Let’s take the example of Pediatric Ophthalmology Fellowship: my wife and I are both former fellows and now we are residents. The fellows that preceded us and those that followed us also got residency positions. The same happened with many other former pediatric ophthalmology-trained people that I met over the years at different meetings. There are no guarantees that one will enter a residency after a pediatric ophthalmology fellowship, but based on my limited experience, the odds are extremely high that one will be successful.

Next, I found myself ready to complete my first application, and I needed something more than my passion for ophthalmology, my previous residency experience, and my USMLE scores. So, I completed a six-week observership at the Wills Eye Hospital that provided me with some U.S. experience and more importantly, a letter of recommendation. Even though the letters of support that I received from Wills Eye were very laudatory and extremely helpful, they still were not enough, as I spent such a short time there. In order to secure a strong letter a recommendation, my advice is to spend enough time in a given place, while also involving yourself hands-on clinical activities. In this regard, a clinical fellowship is an ideal venue.

To summarize the strong points of my first application: USMLE scores, a completed ophthalmology residency, a letter of support from well-regarded U.S. ophthalmologist, and a short U.S. experience at a prestigious institution. Those were enough to grant me 4 interviews but not a position.

What are the reasons for the first failure? Some issues that I mentioned before, namely a lack of significant experience in the U.S. medical system, and also mild letters of support. Another important part of the application process that I believe I missed was participating in volunteer activities. While these are certainly not critical, I do believe they can be very useful. Regardless of my initial failure, I realized you must be willing to improve. Even if there are things of minor importance, continue to strive for the best, as the competition to enter this field of work is intense.

After the first mismatch, I had three options. First was to do an internship and be ready to jump on board in one of the vacancy positions. That was what I did and it gave me the advantage of having a more consistent U.S. experience, another letter of recommendation, some financial security, and an opportunity to exercise my English language.

Second, my option was to enter a clinical fellowship if qualified (ECFMG certificate and completed or near-completed residency overseas) in order to have an even more valuable letter of recommendation, support from more visible people, and more valuable U.S. experience. In other words, this provides a place and opportunity where you can prove yourself as a qualified ophthalmologist, and gain recognition and reward through strong recommendations. The disadvantage lies in that you cannot participate in the selection process for immediate vacancy positions. Ideally, you should combine the first two situations that involve mainly clinical work with a good research background, which can lead to some publications. Research, and especially publications, is a tremendous asset to your application.

Finally, the third solution was to start a research activity and that can take different forms: earn a doctorate, or obtain a basic research position or pre-residency fellowship (pathology fellowship, or other types of research or combined clinical-research fellowship). I considered the research position the best solution and I pursued this in two interviews. The first position was a pathology fellowship at a noted ophthalmology institution. I was very excited about this possibility, but unfortunately I was not successful. The second position was a basic research position, associated with another famous university, where I would receive training in the various techniques of molecular genetics but I chose to pass up this opportunity because I felt it would remove me from the clinic. I instead decided to pursue an internship possibility. I was not able to secure an internship position before the match and I did not want to risk and wait for an after match vacancy. As such, I did participate in the NRMP and I was selected for a categorical internal medicine position instead. That complicated my path quite a bit as I ended with this 3-year commitment.

While I was in my internship, I participated in the SF match process again and I had only one interview. I also applied for vacancies but I was not offered an interview. Both these facts showed me that although I envisioned myself a better candidate with significant progress in my English, more medical knowledge, and a better understanding of the system, I was not considered a good candidate for the selection committees around the country. My work situation, as I mentioned, as well as my family situation was also complicated. I decided to slow down a little bit without renouncing my dream of becoming a resident in ophthalmology in the United States. My wife entered a pediatric ophthalmology fellowship, had numerous interviews, and matched. She came to do the internship in the program where I was a second year resident.

During my second year in America, I faithfully applied for the SF match and for vacancy positions. I had two interviews in the match, but I was unsuccessful again. That showed that my strategy was not good enough and I needed to change it. So, after discussing with my mentors in the internal medicine program, I decided to pursue my ophthalmology dream instead of continuing in internal medicine. I then started applying for fellowship and research positions. My efforts were successful this time and I was invited for an interview for Pediatric Ophthalmology Fellowship and then offered the position that I gratefully accepted. Interestingly enough, a few days after I was offered this position, an e-mail came with an offer for an interview at another fellowship position in a program where I had applied for a residency position but did not get an interview. To me, this proved two things. First, that it is relatively easy to secure a fellowship position if you are reasonably qualified. The fellowship positions in some subspecialties are not as competitive as residency positions, and program directors are looking for suitable candidates outside of graduates from American residencies. Secondly, it shows that people pay attention to your application even if you are a FMG. Someone should have noticed that I completed a residency in Europe, that I had an ECFMG certificate, and that I did not match in ophthalmology.

While in my fellowship, I continued to apply in the match and for vacant positions. With my new CV and with my mentors help, I was able to secure multiple invitations for interviews. But once again, I did not match. I began wondering why this was so. I called and e-mailed members of the selection committees to find out what was holding me back and how I could improve. The unanimous answer was that my English needed improvement. I started English lessons and I was lucky to have a good teacher. I strongly recommend that you consider English lessons if you have even minimal difficulties in pronunciation or accent.

With the help of my mentors, with my improved English, with my significant experience in ophthalmology (fellowship in USA and residency in Romania), with my USMLE scores, and with a lot of luck I was invited to participate in an interview for a vacant position. I was successful this time and now I am in the second year of my residency in ophthalmology. It took a lot of effort, but it all paid off.