Overshadowed by the likes of General Medicine, General Surgery, Obstetrics and Gynaecology - Ophthalmology as a subject, during MBBS often falls under the road less travelled, not getting the due exposure it requires to leave a lasting impression on the young medical student’s mind. Hence, quite naturally, deciding on opting for a residency in the subspeciality is a perplexing decision to make.
This is a brutally honest guide to help you objectively decide whether a residency in Ophthalmology (in India) is something you should consider. Conversely, if you have already begun residency, this should serve as a checklist of what to expect from your programme.
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 shining a torch into your patient’s eye, hoping to see that godforsaken reflex everyone talks about.
Some general information about Ophthalmology 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 primarily 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 a 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 relatively 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, riddled with 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 (especially in medical colleges) 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 avenues.
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. The 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 canclick hereto 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 offering them that. Also, since most surgeries today are day-care procedures, your patients don’t sit in the ward, without good reason.
5. Further learning
There is adequate scope in clinical and surgical specialities to, raise the bar, so to speak, in both knowledge and technique. The trend throughout Ophthalmology is to make surgical procedures as minimally invasive as possible and diagnostic procedures as non-invasive as possible. You are entering this sub-specialty on the verge of this very trend going viral.
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. In Ophthalmology, that’s one headache you do not have to endure. Also, most procedures being elective, you do not operate on unstable patients which saves you from the clutches of the anaesthesia department and their pre-anaesthetic 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 you 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 branch
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. It is prudent for you to have your own direct ophthalmoscope, indirect ophthalmoscope, 20D, 90D/78D lens, gonioscope, retinoscope – the cost when combined, will set you back considerably. Indian manufactures do soften the blow, but not by much.
A lot of things in the eye happen over a very miniscule area. Precision is everything. Even removing a simple foreign body from the cornea requires a firm, steady and precise grip, logical manoeuvring and just the right amount of force, failing which you essentially are adding fuel to the fire.
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. Taking cataract surgery into consideration, a part of the country is performing SICS (or even ECCE), while another part of it has moved onto bladeless, laser cataract removal. You may find yourself struggling to find a middle ground.
5. Hands-on exposure
- I’ve intentionally 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, for the most part. Minor surgeries, and your exposure to them, depend on the interest you take.
- Your chances to scrub in for speciality surgeries entirely depend 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 (or an exception). However, ideally 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 give 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/senior residency 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, for whatever it is worth. Keeping in mind that exceptions cannot be examples, a MS degree has an overall better pass percentage as well as a better public perception. The latter is bound to change over the coming years. Regarding the former, in my humble opinion, though both examinations are well above standard, there is some degree of leniency seen in state universities, while there is no scope for the same in DNB.
- It is no secret that though the sheer variety (though the number may not be) of cases in a MS institute are more, while the structure of DNB is more tailored. The same holds true for Ophthalmology. Additionally, the access and exposure to the latest in patient management and technology are more in a DNB institution.
- Since all MS institutes are attached to a hospital set-up, you train more in becoming a comprehensive ophthalmologist (with more exposure in systemic ophthalmology, neuro-ophthalmology, uvea, paediatric ophthalmology 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, which serves as a learning opportunity for yourself.
- Ultimately, knowledge, skill and acumen are individualistic, and one should always make it a point to make the most out of the resources presented to them, irrespective of them being in a MS or DNB institution.
- 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 financial backing in this branch more so than any other branch.
- Do not 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.