With more than 50 applicants for every open residency position in 14 AOA-approved programs, ophthalmology is one of the profession’s most competitive specialties.
Many programs will not consider candidates with scores lower than the 90th percentile on the Comprehensive Osteopathic Medical Licensing Examination of the United States (COMLEX-USA), says Carlo J. DiMarco, DO, the executive vice president and CEO of the American Osteopathic Colleges of Ophthalmology and Otolaryngology—Head and Neck Surgery (AOCOO-HNS).
Enchantment with the eye, one of the most complex and cherished organs of the body, accounts for much of the field’s appeal.
“I have always been fascinated by the intricacy of the human eye and how it works,” says Dr. DiMarco, the AOA’s 2008-09 president, who directs the AOA-approved ophthalmology residency at Millcreek Community Hospital in Erie, Pa. “Just 24 millimeters in size, eyes are amazing in what they do.
“In Genesis, God said ‘Let there be light.’ But light has no function without eyes to process it.” Because of early recognition of eyesight’s importance, ophthalmology eventually developed into the first medical specialty, he says.
As someone who relishes intellectual challenges and loves to fix things, Dr. DiMarco enjoys his occupation’s balance between clinical medicine and microscopic surgery.
“Because most systemic diseases present with ocular findings, ophthalmologists get to aid in the diagnosis and treatment of cardiac disease, kidney disease, central nervous system pathology and many other conditions,” he says.
The son of an optometrist, Michael Keil, DO, had early exposure to eye care. But his passion for ophthalmology developed after he entered medical school.
“When I rotated in ophthalmology as a student, I fell in love with the specialty,” says Dr. Keil, the director of the AOA-approved ophthalmology residency at Metro Health Hospital in Wyoming, Mich. “I picked up an ophthalmology text and actually read it cover to cover, which was a first for me. When I rotated in other specialties, I couldn’t bring myself to read the textbooks—I just wasn’t interested enough.”
Millcreek’s chief resident in ophthalmology, Geremie Palombaro, DO, didn’t discover his enthusiasm for the field until he was an intern in anesthesiology.
“I did an ophthalmology rotation and was hooked after watching some of the surgeries, so I ended up switching fields,” Dr. Palombaro says. “The surgeries are very detailed, very precise and very clean. And I liked the variety, from cornea to retina procedures.”
Ophthalmology is also less stressful than many other medical specialties, says Robert L. Peets, DO, who directs the AOA-approved ophthalmology residency at Grandview Hospital and Medical Center in Dayton, Ohio.
“Our specialty provides a great combination of office-based care and surgery, so we have a nice lifestyle,” Dr. Peets says. “We do take call. But for the most part, call is not horrible.” Many ophthalmologists are in group practices, so they share responsibility for treating trauma patients who have ocular emergencies after hours.
The pay for ophthalmologists is decent as well. Ranked 10th among 25 medical specialties, ophthalmologists make an average of $270,000 a year, according to a 2012 Medscape survey. Completing fellowship training in such subspecialties as ocular plastics and vitreoretinal diseases adds to an ophthalmologist’s earning potential.
Applicants need outstanding credentials to secure spots in ophthalmology residencies, which are four-year programs that include a linked internship year. Generally, students match into ophthalmology from their fourth year of medical school, though transfers from other programs are not unheard of.
Because most fourth-years who try to match into ophthalmology fail to do so, many graduates try to match from rotating internships, a year spent in research or a pre-residency fellowship, or residency programs in other specialties.
At Millcreek Community Hospital, Dr. DiMarco limits his residency candidates to those with solid grade point averages who score in the top 10% on COMLEX-USA. “Ophthalmology is one of the most intellectually challenging areas of medicine,” he says. “You need a strong knowledge of all of the body’s organ systems and of clinical medicine to excel in this field.”
But not all residency directors like to use board scores as the primary screening tool.
Noting that most applicants for ophthalmology spots have high COMLEX scores, ranging from the mid-600s to the mid-700s, program director Glen Hatcher Jr., DO, says he prefers to use other criteria in selecting candidates for his AOA-approved ophthalmology residency at Valley Hospital Medical Center in Las Vegas.
“I have found over the past 30 years that high board scores do not necessarily translate into being a good resident or practicing physician,” Dr. Hatcher says.
Dr. Peets’ residency, which has one opening a year, considers only applicants who have passed Levels 1 and 2 of COMLEX-USA on the first attempt. But he doesn’t use a specific score or percentile to winnow down his initial list of candidates.
“The assistant program director and myself plus one of the other attendings and all of our residents take part in the interview process,” Dr. Peets says. “A few years ago, we decided to blind everyone to the candidates’ board scores.” Only after the interviewers agree on a short list of potential residents do they look at applicants’ COMLEX scores.
“I think board scores are important, but what we use them for is to help us differentiate between excellent candidates,” Dr. Peets says.
All ophthalmology residency directors prefer applicants who have rotated in their programs. This lets program directors see whether a candidate would be a good fit and has what it takes to succeed.
First, Dr. DiMarco gauges whether students on rotation seem intelligent enough to master the field of ophthalmology in a four-year residency program. Second, he assesses whether they are hard-working and dependable.
“You can see whether the students volunteer to do extra work and whether they are willing and eager to be called in the middle of the night if there is an emergency,” Dr. DiMarco says.
Because of the unpredictability of medicine and surgery, it can be difficult for residents to adhere to a predefined schedule. “Residents have to know that they can depend on one another to take up the slack if there are multiple challenges occurring at once,” he says.
Third, Dr. DiMarco evaluates the interpersonal skills of students on rotation. “We see if they are personable with patients, residents and staff,” he says. “We specifically ask our staff how the students interact with them because some students have been condescending.
“Residents work closely with other residents and staff for four years, so it is extremely important to see that potential candidates mesh well with the rest of our team.”
Because ophthalmologists develop longitudinal relationships with patients of all ages and backgrounds, an engaging personality is essential, Dr. Palombaro says. “You definitely have to be able to communicate with all types of people,” he says.
Rotations also allow students to decide whether they like a particular institution and location.
“It is important for someone who is interested in a specialty to spend time at different residency programs because otherwise you won’t really know what a place is like,” Dr. Keil says. “You may not like the program, the people or the town or city the institution is in. If you don’t like these things, it will be hard for you to do well.
“At Metro Health Hospital, we like people to rotate with us because we want to know if they like us as much as we want to find out if we like them.”
In addition to rotating with a desired residency, students should find ways to stand out among their stellar peers. Research experience in ophthalmology is a big plus, as is clinical volunteer experience involving vision assessment and eye care.
Fine motor finesse
But a sharp mind, winning personality and impressive curriculum vitae are not enough. Residency candidates must demonstrate that they have the motor finesse and hand-eye coordination needed for ophthalmology.
“Fine motor skills are very, very important because we deal with very, very small measurements, and the majority of our surgeries are done under a microscope,” Dr. Palombaro says.
Because eye surgery is so intricate and precise, students on rotation in ophthalmology don’t get a chance to do any cutting and suturing in the operating room. Program directors must look for other indications that someone can make the cut in ophthalmologic surgery.
“During the interview process, we have candidates demonstrate manual dexterity in a mock surgical set-up,” says Valley Hospital’s Dr. Hatcher. “I have found that because they are so well-versed in the new technologies—iPhones and iPads, as well as video games—they generally perform well.”
Dr. Keil, however, questions the effectiveness of using a surgical simulator to evaluate someone’s manual skills because it creates an artificial environment.
“In a surgical specialty, you never know if someone has great hands until you observe him or her in the operating room,” Dr. Keil maintains. He values letters of recommendation from other surgeons, not limited to ophthalmologists.
Another predictor of manual dexterity is an individual’s hobbies since childhood, says Dr. Keil, who enjoyed building with Legos and constructing and painting models from kits as a kid. Those who play a musical instrument or are adept at needlepoint often make skilled surgeons.
Opportunities are bright and varied for general ophthalmologists and subspecialists, say leaders in the field.
Many areas of the country have a shortage of ophthalmologists, Dr. Hatcher notes. “There is definitely a need for our services,” he says.
Dr. Palombaro is excited to begin his two-year fellowship in ocular plastics come July. “In this subspecialty, we deal with orbital cancers, eyelid dysfunction, lacrimal system dysfunction, and trauma in and around the eye,” he says.
Desiring to distinguish himself from other ophthalmologists in Grand Rapids, Mich., Dr. Keil found his niche in LASIK surgery, a subspecialty amenable to running a cash-based practice.
“I don’t bill insurance. I don’t participate in Medicare or Medicaid,” Dr. Keil says. “I do things the way I think they should be done and don’t have to worry about third-party payers.”
Whatever one’s subspecialty or practice type, ophthalmology is a rewarding career in large part because of the high level of patient satisfaction, Dr. Peets says.
“Patients come to us with a well-defined problem—they can’t see well,” he says. “And when they leave, they see beautifully. These are very happy patients. That is why the field is so gratifying for me.”