Deciding a residency in Ophthalmology: Here’s what you need to know

This is a guide to help you decide whether a residency in Ophthalmology (in India) is something you should consider.

Full disclaimer: I have been brutally honest with my sentiments. You will not find a more, call a spade a spade guide.

Lets begin!

If you are reading this, you’ve probably cleared some ridiculously structured post-graduate entrance exam and you deserve a pat on the back! First and foremost, congratulations! Residency is going to be a very exciting phase of your life. I’m here to help you objectively decide if that residency is going to be in Ophthalmology, going over some pros, cons and anecdotal advice sprinkled in-between.

Whether you loved or hated Ophthalmology during your undergraduate days, what you learnt back then is really just an eye-wash (pun intended). Gone are the days of shinning a torch into your patient’s eye hoping to see that godforsaken reflex everyone talks about.

Some general information about Ophthalmogy you should know

It is a medical as well as a surgical branch.
It is an end-branch and doesn’t act as a feeder branch for any other super-speciality.
Emergencies are relatively sparse in this branch.
There are two types of post-graduation degrees - MS or DNB. Both have their individual pros and cons.
After your residency you are a comprehensive ophthalmologist. You may take up senior residency or a fellowship (6 months to 24 months). Fellowships offer further targeted medical and surgical training.

What are the pros?

1. Enormous patient inflow

Ophthalmology the only speciality where a patient comes to the doctor while he/she is well. Cataract (clouding of the lens) and refractive errors, the two most common culprits, are both physiological ageing changes of the eye.
The former, treated by surgery, is the bread and butter of an ophthalmologist. Here’s an anecdote. Once you’re a practicing ophthalmologist, let us assume a male patient comes to you at the age of 50 for cataract surgery of one eye. If you do a good job, he will come to you at 55 for the cataract of the other eye. Thereafter, when he is 60 he will bring his wife or a relative for the same and the tale goes on. You have the opportunity to make a family of lifelong happy patients.
For the latter (refractive error), should to choose to become a refractive surgeon, the world is your oyster. Refractive surgical options are advancing at an exponential rate.

2. Fixed hours, few emergencies

Not everyone is about that 12am life and midnight shifts. A lot of you would be looking for a good work-life balance. Despite being a surgical branch, ophthalmic surgeons have fixed work hours. Being attached to a hospital does require you to be on emergency calls and night shifts. However, the calls are mainly to aid your medical and surgical colleagues in coming to a diagnostic decision. Should you thrive for emergencies - orbit, oculoplasty and ocular trauma are untapped specialities.

3. Advancing treatment regimens and guidelines coupled with newer technologies

Ophthalmology is one of the few branches that is advancing every year. It is a fact that the regimens or guidelines followed now are vastly different from those even five years back. That is something you cannot say for many specialities. Scope for research and innovation is tremendous. This is primarily because of the fact that it is an end-branch and not a feeder branch. Most diagnoses can be augmented and confirmed with machine based precision. Artificial intelligence in Ophthalmology is just a couple of years away. You can click here to watch Sundar Pichai (the CEO of Google) talking about using AI for diabetic eye disease… way back in 2016!

4. Patient satisfaction

Patient satisfaction in any sub-speciality is of prime importance. Ophthalmology excels at it. Perfect vision is a right for every patient and you are almost always giving them that. Also, your patients don’t sit in the ward for days on end.

5. Further learning

There is adequate scope in clinical and surgical specialities to, raise the bar, so to speak, in both knowledge and technique. Ophthalmology is quickly striding towards non-invasive treatment compared to other specialities.

6. Non-dependent branch

I cannot stress how important this is. Try to remember your general surgery, orthopaedics, obstetrics and paediatric postings during internship and how harrowing it was to get your sister department to sign off on a procedure. Also, in Ophthalmology, most procedures being elective, you do not operate on unstable patients which saves you from the clutches of the anaesthesia department and their pre-anesthetic check-ups.

What are the cons?

I would be remiss if I didn’t stress on the cons as well.

1. Steep learning curve

There is a significant learning curve both in clinics and surgery. Not all structures and diseases can be seen with the naked eye, so will have to train yourself to use microscopes and lenses. Handling them, mastering binocularity and stereopsis is a six month affair. Understanding depth perception for ophthalmic microsurgery is also a considerable challenge.

2. Expensive

It is not only an expensive branch to get started in, but also an expensive branch to continue living in. Ophthalmoscopes and lenses are costly. They also require regular maintenance.

3. Dexterity

A lot of things in the eye happen over a very tiny area. Precision is everything. Even removing a simple foreign body from the eye requires a firm, steady and precise approach.

4. Too advanced

Though it may sound contradictory, you might often find yourself using prehistoric procedures for patient management which are obsolete in another part of the country/world.

5. Hands-on exposure

I’ve purposely kept this for the end. Please do not ask this as the first question for any surgical residency. Though you will see 101 types of surgeries being performed (depending on the institution you choose), your hands on training will only be in cataract surgery.
Your chances to scrub in for speciality surgeries entirely depends on your department and hospital. If a senior tells you that he/she has done vitrectomies or keratoplasties, either they have ridiculously lenient consultants or it is a bluff. However, you should get a chance to observe them. That is, the hospital you are choosing to join should have a functional unit in the speciality. Hands-on experience in that speciality, is what fellowships are for.
Coming back to cataract surgeries, without naming institutions, the best of the best gives their residents somewhere between 300-600 cataract surgeries (over three years). The average around the country is 150-200, while institutions with poor surgical opportunities are around 50. This is something you may enquire for while choosing an institution.
However, I am going to make my most important point now. Residency trains you to perform a cataract surgery. Fellowship trains you to be a cataract surgeon. Focus on tasting everything during residency. Your fellowship is for fine tuning your skills.

MS or DNB?

This is something that seems to be plaguing philosophers for centuries. I will try to add some clarity.

An MS degree has an overall better pass percentage as well as a better public perception.

It is no secret that though the sheer variety of cases in a MS institute is more, while the structure of DNB is more tailored. DNB makes you more meticulous. The same holds true for Ophthalmology. Additionally, the access and exposure to the latest in patient management and technology is more in DNB.
Since MS institutes are attached to a hospital set-up you become more of a comprehensive ophthalmologist (more exposure in systemic ophthalmology, neuro-ophthalmology, uvea, pediatric etc) just by the sheer number of referrals you get from the other departments. Additionally the institutes are attached to a medical college so you’re often posted teaching undergraduates.

Takeaways

If you are looking for a speciality with reasonable working hours, equal medical, surgical and research opportunities, while at the same time relatively free from emergencies, the hum-drums of other departments - choose ophthalmology.
If you have a background in music, art or anything that involves dexterity and precision - ophthalmology will be a suitable fit.
It definitely helps to have a friend, family member, well-wisher and a financial backing in this branch more so than any other branch.
Don’t take a decision based on your undergraduate understanding of the subject.
Not everything meets the eye in ophthalmology, and there is a bit of meandering involved. But once you see it, it is easy to fall in love with the subject.

My name is Dr. Anujeet Paul. I am a final year MS resident in Ophthalmology. I sincerely hope I have helped you in deciding whether Ophthalmology is/isn’t the speciality branch for you. You may take me up on any point I have made and I would be willing to provide any clarification.

If you enjoyed the read you may also check out the blog post where I dissect residency and provide a guide for incoming first year residents: Dissecting Residency - A guide to thrive for first-year residents

Please get in touch with me, to share your thoughts or even contribute: contact@anujeetpaul.com

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