Residency in ophthalmology is getting tougher by the day. During the tenure of residency, one is filled with innumerable questions which they feel someone could help them with. This collated questionnaire is an effort in that front. It has a few relevant and common questions which a resident in ophthalmology faces every day. And whobetter than the heads of education of the top three ophthalmology institutes of the country to answer these questions. We have the three doyens of academics answering and guiding the basic queries during residency program.Dr. Venkatesh Prajna (DR NPV)began his career from Cornea department in 1993. He is the Chief of Medical Education of Aravind Eye Hospital & Post Graduate Institute Of Ophthalmology. Dr.N.V Prajna holds his DNB from National Board and has been awarded an honorary FRCS, Glasgow.Dr. Avinash Pathengay (Dr.AP)graduated from Stanley Medical College and went on to pursue his ophthalmology residency at Madras Medical College, following which he completed his fellowship at Sankara Nethralya in vitreo retinal surgery. He completed his FRCS (Glasgow) in 2001. He has pursued a one-year fellowship with Dr Harry Flynn at Bascom Palmer Eye Institute, Miami, Florida. He has been associated with LVPEI since 2001 and currently he is the Director of the GMRV campus and Director of Academics of LVPEI network.Dr. S. Meenakshi Swaminathan (Dr MS)obtained her M.B.B.S degree from the Madras Medical College in 1988, and M.S. (Ophthalmology) training from Postgraduate Institute of Medical Education and Research (PGIMER) in the year 1992. She then did a research fellowship in Cornea at the University of Texas at Houston, in 1994-95. She then did a mandatory Transitional Year Residency program at the Kettering Medical Centre, Dayton, Ohio followed by a three-year residency program in Ophthalmology at the University of Louisville, Kentucky, USA, which she completed in 2000. She then did a one-year fellowship in Paediatric Ophthalmology and Adult Strabismus in an AAPOS certified fellowship program at the University of Iowa, under Drs. William E. Scott and Ronald Keech. She passed her American Board of Ophthalmology exam in 2002. She is a consultant in the department of Paediatric Ophthalmology at Sankara Nethralaya since October 2001. She holds the position of the Director of Academics at Sankara Nethralaya since April 2006.
eOphtha:Most of us (before joining ophthalmology) thought that ophthalmology basically revolves around the eye and is very monotonous. Is that the case?
Dr NVP:Yes, ophthalmology does revolve around the eye, but is not monotonous !!!!!!
Dr AP:It certainly revolves in and around the eye! It was a thought process many years ago ophthalmology was a option for those who wanted to deal less with medical and surgical emergency, while that sort of thought process still continues because that’s what a majority of private practice in ophthalmology is all about. This has never been the case in academic and tertiary care institutes. Having said that there are various sub-specialty in ophthalmology like cornea, retina and to a certain extent oculoplasty who deal with more emergency than others.
So there is no monotony!
Dr. MS:Like everything in life Ophthalmology is a colourful speciality and you can make it that way. Subspecialities like Oculoplasty, Pediatric ophthalmology and Neurophthalmology and Uvea deal with many systemic conditions
eOphtha:The first question that students ponder upon after entering the course is what books to read during the residency term. What is your recommendation?
Dr NVP:1.Kanski 2. AAO series in subspecialties.These books would form the basics.
Dr AP:Read books that appeal to you, books that teach you, books which you feel like going back to again for a reference. This is the principle or philosophy that I would like the residents or the fellows to adopt.Let me give you my own example, when I was a resident my teachers used to always tell me read book authored Parsons and Duke Elder otherwise you would not pass exams. Somehow they did not appeal to me, started reading text books which had lot of images so that I could understand and start building on a strong foundation. Once I had my concepts clear moved on to text books which gave valuable information for me to become a good ophthalmologist and just not have proficiency in ophthalmic literacy. Once you are well versed in the basic fundamentals in ophthalmology move on and begin to question the authors who have written the chapters as well, always remember books are written by people like me and you
Dr MS:There are several excellent textbooks of ophthalmology which are comprehensive. Basic books like Parson’s and Kanski are mandatory reading because they really simplify the subject. It is best to then have one set of books that one should read over and over again supplemented by reference material, review articles etc.
eOphtha:What should our goals be for the 3 year course? And how should be plan on a yearly basis?
Dr AP:Founder chairman of LVPEI Dr GN Rao would always mention to become a good doctor inculcate 3 H’s ...good Hands, best Head and greatest Heart.Your goals should revolve around to explore the curiosity, creativity and inherent talent in you.Once you have written the goals keep looking at it often and keep playing it in your mind so that you reach there. There would be many obstacles in your path but don’t lose sight of your final destination that is your goal.WORK HARD.PLAY HARD.
Dr MS:Simply stated one must acquire enough skills to pass the exam while also focusing on becoming a competent and compassionate ophthalmologist. ICO curriculum has nicely stated the goals for each year.
eOphtha:Selecting an institute is no easy task. Considering most of us get into places on merit, what are the criteria you think one should keep in mind while selecting an institute?
Dr NVP:Usually, the situation is that the entrance criteria would determine this. For fellowship, the best thing would be to ask the concerned person who is undergoing the course. Each department in an institution would be different.
Dr AP:Getting into an institute is also not an easy task!
Once you are selected that means you’re good or better than the rest. Now every institute has its certain philosophy on which they expect their fellows to work. The fellows should have clear understanding before joining them.
Always remember the institute will not change their ideology because their success has been time tested so the residents or the fellows have to quickly mould and get into the groove or endure.
Dr MS:An institute that offers a rigorous academic program, good faculty, respects the postgraduates, ensuring that they come out well trained both clinically and surgically-these are the basic criteria for a good institute.
eOphtha:Most institutes only give exposure to cataract surgeries. Apart from that, which other surgeries should a postgraduate be acquainted with (hands-on) by the end of the course?
Dr. NVP:Pterygium, corneal tear repair, assist keratoplasty, assist RD surgery, do Laser PHC, do Laser PI, trabeculectomy
Dr. AP:Other surgeries which could also be considered are Pterygium, trabeculectomy, horizontal squints, intravitreal injections, laser photocoagulations, cryopexy, DCR and DCT, corneal-scleral-lid tear repair.
Dr MS:Minor procedures such as tarsorraphy, canthotomy especially what will come in handy during an emergency, are important to learn. Many types of lasers which are again vision saving like YAG laser peripheral iridotomy, or panretinal photocoagulation are also good to know.
eOphtha:The ICO guidelines for a residency program are indeed exhaustive. Do you think we can implement that? Or can we come up with a version for our students?
Dr NVP:The ICO curriculum is too elaborate and not practical. Individual institutions can take a call.
Dr AP:I understand its exhaustive but a good one, we can certainly implement it otherwise we have to keep reinventing the wheel again and again.
Dr MS:The ICO curriculum is designed for adaptation to your program and needs. It appears exhaustive but offers you a good comprehensive list and hence one doesn’t have to reinvent the wheel.
eOphtha:Writing up an article or publishing is something quite a few of us would be interested in. But most of us have had no exposure in our undergrad. How should we go about it? What is its importance?
Dr NVP:The best way is to take a short term course conducted by institutions like Aravind and CMC on research methodology. Today, it is not very important. However, in the future, it would be mandatory.
Dr AP:None of use read any books for cycling or swimming. The best way to go about is to jump into it and find a good mentor. In a day and age where the information on how to publish is available on the web, the onus is on us how badly we want it.
I don’t have to mention about the importance because you can feel it in when your name appears in print, there is not many ways by which a CV can be made impressive.
Dr MS:Writing articles and publishing helps in many ways. As a postgraduate you tend to become more aware of literature, research methodology etc. It is also very important when applying for a fellowship or an academic career, to have publications. There are many online courses to improve one’s knowledge of research methodology.
eOphtha:Conferences and CME’s happen almost every month. How do we decide which ones to attend?
Dr NVP:Ideally CMEs are better than conferences. Conferences are to get together and to buy instruments
Dr AP:Attend the ones where learning is involved, if not don’t waste time in attending another CME.
Dr MS:As a postgraduate, it is best to attend those that are of special interest, for e.g. if you are interested in a particular subspecialty. It also depends on the quality of the speakers and sometimes relevance to the exam
eOphtha:Do you think institutes could make it compulsory for students to present one paper and publish one article as a pre requisite for the completion / degree? (OPTIONAL for individual institutes?)
Dr AP:Allow me to blow hot and cold over this issue. If we force it would work as long as that someone wants to listen to you but it would fail terribly on those who don’t want to. For this to be successful an environment has to be created to make them publish and they know why there are doing it.
Dr MS:Definitely as a fellow, this should be a pre requisite. As a postgraduate I think it is less important. It is more important to develop competence.
eOphtha:Most students have difficulty in the practical aspect of the exams. Why do you think it is? What tips/ suggestions do you think can work for students to overcome this fear?
Dr NVP:Present as much as possible, but the practical exams still invoke a lot of fear, mainly because the exams are not standardized
Dr AP:This happens when the reading becomes virtual and practical application of what one has read, falls short of acceptable standards.Let me make you understand with a hypothetical example. A resident reads hours and hours on microbial keratitis but when he encounters a real patient sitting in front of him he finds it difficult to write a plan of management or even a simple correct prescription. The reason is the disconnect between the theory and practical. When it happens there will be certainly fear because he or she does not know what they are doing, isn’t it. Bridging the gap would be useful. Practical exams should be like any other day in your clinics where you don’t have to read separately and just do what you practice.
Dr MS:Regular presentation during clinics and classes to the senior residents, fellows and junior faculty will be a big help to prepare students for the real thing.
eOphtha:In today’s era of sub-specialty, how essential do you think is it to pursue fellowships? And what are the places where students should apply to?
Dr NVP:It is essential. But even more essential, is that the students do atleast 2-3 years of general ophthalmology before applying for fellowship
Dr AP:Pursuing fellowship is for those who have interest or passion in that sub-specialty what they want to pursue and it is not a compulsion.It’s important to do a adequate research before deciding with which group one aspires to do fellowship, it has to match your expectation.
Dr MS:Students should apply to institutes that offer good teaching and mentoring. Decision to do a fellowship depends on the individual’s career plan.
eOphtha:Any suggestions for those of us who do not have sub-specialty branches in their institutes.
Dr NVP:Some of the institutes have a tie up with institutes which have them
Dr AP:Then it is not an institute in a true sense!
Dr MS:You can still develop your interest and focus it on any subspecialty of your choice. Being a comprehensive ophthalmologist is equally challenging and rewarding.
eOphtha:The moment you enter the residency program, you hear people preparing for other exams like FICO, FRCS, FRC Ophth, FAICO and other exams. What is the significance of writing these exams and how do these exams help the students?
Dr NVP:Most significantly, it helps benchmark the students with an international recognition
Dr AP:It’s a very good question which every individual should ask themselves, before taking one. One usually takes the above mentioned exams for additional qualification, license purpose and /or learning. If it does not benefit you in any way my suggestion would be “don’t waste resources”.
Dr MS:These exams helps one methodically study the entire course. They also may give opportunities to go abroad for short term fellowships.
eOphtha:What websites, forums and platforms are there for young ophthalmologists to learn more, express their thoughts, and be involved in the process of delivering better eye care?
Dr NVP:No comments
Dr AP:Various ophthalmic societies, institutes, groups are present in the web which educate residents or fellows but my suggestion would be select the ones which are interactive in nature.
eOphtha:Time management is where most of us falter. Any suggestions Sir/Madam on how we should allocate our time for studies, classes, postings, CME’s, etc?
Dr NVP:All of us are pretty weak in this aspect
Dr AP:Time management is important for people who multitask. Prioritizing is very important for time management and for it to be effective it’s important for one to differentiate between “important and immediate” . Nevertheless spend 70% of time on horizontal learning and 30% on vertical learning.
Dr MS:It is absolutely mandatory to read up anything you have seen in the clinic or come across at surgery. That will stick well. Most trainees tend to waste a lot of time on Sundays, sleeping in. That is the best time to have a protected 4-5 hours to prepare for the forthcoming week and the classes.
eOphtha:How different is our system and program as compared to the ones abroad? What is it that we here in India can incorporate as postgraduate students at the least?
Dr NVP:Each one has its own advantages and disadvantages. It also depends on where you want to settle down.
Dr AP:The best academic institutes in India are head to head with the best training programs in the West. The grass is always greener on the other side.
Dr MS:The residents there are very hard working. They are quite driven to learn the speciality well, are not afraid to ask questions, free with the faculty but also respectful. They also often will go beyond what is expected of them thanks to their curiosity.
eOphtha:Would you recommend us to go abroad for further studies? If so, what are the options and benefits?
Dr NVP:Maybe, you can go after completing your fellowship, something like a finishing school
Dr AP:Like I have mentioned earlier if your training has been good in India going abroad would be for those with a focused purpose which would add value to ones expertise.
Dr MS:I wouldn’t recommend repeating a residency program abroad. However a fellowship abroad, either research or clinical or studying for a year in a public health program will add immense value.
eOphtha:Students are often afraid to speak to senior consultants for advice. How do you think students and consultants both amend their ways to make communication and learning easier?
Dr NVP:It has got a lot to do with individuals and there is no generic advice on this
Dr AP:Isn’t that a problem with eastern culture? Communication should be spontaneous so also appreciation and this would enhance the mentor – mentee relationship.
Dr MS:It would be nice to approach the senior through an associate or junior consultant. There can also be informal meetings where the senior consultants put the trainees at ease and then they feel easier to interact and ask questions.
eOphtha:Presentations and seminars are not the strong points for most of the students. What do you think should we do in our early days to get better at it?
Dr NVP:Try and copy good presenters amongst your own faculty. You can have good and bad examples in your own set up.
Dr AP:Keep presenting again and again ! Also learn effective ways of presentation and you would reach there.
Dr MS:Attend CMEs. There you will see how the stalwarts hold the audience. One can learn the tricks of a powerful presentation from such opportunities.
eOphtha:It is often the case that students either land up having only textbook knowledge by the end of the course or focusing only on surgeries, and forgetting about the basics. How can this gap be bridged?
Dr NVP:There is no other way than to get exposed to as many patients as possible. If your institution does not offer it, maybe you should choose one which gives you a lot of this in the fellowship period
Dr AP:Applied basic sciences are absolutely important for effective learning.
Dr MS:Supervised patient interaction where the student is encouraged to see the patient on his/her own and come to a conclusion and plan is the best way to apply the book knowledge so that it sticks. Students should do this every day of their course.
eOphtha:Like any other field, monotony must set in at some point in the course. What do you do to beat the same?
Dr. NVP:This is our job and responsibility. You can afford to get depressed depending on some days, when your surgeries could go wrong, but there is no reason to feel monotonous.
Dr. AP:Develop hobbies and also look beyond your profession for being a well-rounded person.
Dr. MS:Residents and fellows keep monotony at bay. Changing the broad goals may also help. Every 5 years change roles, for e.g. become more involved in charity and volunteering, publish more, take on management roles, and so on.
eOphtha:What is the ONE key takeaway you would give us to have successful careers in our fields?
Dr. NVP:Take one step at a time. After you reach the next step, take time to assess the view and then take the next step. Too quick running will make you gasp at the end of the staircase, but more importantly, you would have missed the view.
Dr. AP: Hard work!
Dr MS:Always keeping in touch with the current literature and If we begin and end each day with gratitude, gratitude for the opportunity to help others, teach others, speak kind words, solve problems, you will always be successful.
eOphtha:How important do you think values and ethics are in today’s day and age, considering the competitive chaos we live in?
Dr NVP:They are very important. These are non- negotiable.
Dr AP:It has been important yesterday, today and will be tomorrow as well. These are non- negotiable.
Dr MS:That makes it even more important that these be taught separately and also through role modeling.
eOphtha:It is said that private practice and institute based practice is different. What is your take on it?
Dr NVP:Yes it is. It will always be.
Dr AP:Yes the philosophies are different. Choose the one which impresses you the most .Don’t think about money as the reason why you have to choose one over the other. Either way you would have earned enough bank balance where you did not have time to spend the earned money in your lifetime!
Dr MS:The actual practice details may be different. Ethics and values and professionalism should be the same.
eOphtha:For people who do not have an ophthalmic background, would you suggest them taking up the field considering the competition and what would be your advice to them?
Dr NVP:There is space for everybody. People who have background may have a higher chance of burnout.
Dr AP:Outside competition will always be there in any field and has to be considered. It’s also important to consider the uniformity of competition in a given state, city, town or an institute. It is good to start practice where the competition is not there but it better to start where healthy competition exists but never start your practice where there is too much of competition.
Dr MS:There are so many choices these days that one can take up this specialty with the confidence that he/she will find a niche for themselves without worrying about any lack of family background.