Of the 654 applicants who applied to ophthalmology in 2009, 196 (approximately 30%) failed to match. Similar results were noted in the 2007 and 2008 matches, making ophthalmology one of the most competitive specialties.
We recently discussed the ophthalmology residency selection process with Dr. Andrew Lee, chairman of the Department of Ophthalmology at The Methodist Hospital in Houston, Texas and Professor of Ophthalmology at the Weill Cornell Medical College. Prior to becoming chairman, Dr. Lee was professor of ophthalmology, neurology, and neurosurgery at the H. Stanley Thompson Neuro-ophthalmology Clinic at the University of Iowa Carver College of Medicine. Following residency training at the Cullen Eye Institute at the Baylor College of Medicine, Dr. Lee completed a fellowship in neuro-ophthalmology at the Wilmer Eye Institute.
Dr. Lee is an accomplished author, having written two full textbooks on ophthalmology and over 260 peer reviewed articles. Presently, he is a member of the editorial board of 12 medical journals, including the American Journal of Ophthalmology and Eye. He is also the editor in chief of the Journal of Academic Ophthalmology. For his significant contributions to the specialty, he has received several prestigious awards from the American Academy of Ophthalmology including the Honor Award, Senior Honor Award, and the Secretariat Award.
In a survey of junior and senior US medical students who had chosen to pursue ophthalmology as a career, 13% entered medical school with the intent to become an ophthalmologist.1 How should students who have an early interest in the specialty proceed?
A junior medical student with an early interest in the specialty should concentrate on insuring that ophthalmology is the right career choice for that particular student. Many medical schools (including the University of Iowa) have an Ophthalmology Student Interest Group (OSIG) that can introduce the student to the field, provide networking opportunities with fellow students and access to busy clinical faculty, and can allow participation in an OSIG service project. The student should consider whether his or her personality matches the “ophthalmology personality type” (e.g., do they enjoy seeing the entire spectrum of ages of patients, taking care of mostly ambulatory healthy patients with focused eye problems, and having a patient mix of both surgical and medical problems). Shadowing both a private practice eye MD or an academic faculty member might allow the student an insider glimpse into the practice of ophthalmology, and can create a mentoring opportunity that could lead to an important and convincing letter of recommendation downstream. The bottom line is that the most important task of the junior medical student interested in ophthalmology is making sure that ophthalmology is the right choice for them.
Although some students enter medical school feeling certain of ophthalmology as a career choice, most do not make their specialty choice decision until after completing an ophthalmology rotation. In the aforementioned survey, 52% did not make their specialty choice decision until late in their third year or early in their fourth year. These students only have a few months to strengthen their application for a particularly competitive specialty. What can students do to make the most of the time that they have?
Once the student is convinced that ophthalmology is for them, then the important task for the student becomes convincing others that they are right for ophthalmology. Ophthalmology is a competitive specialty and an honors level performance on the required ophthalmology rotation and any subsequent eye electives is mandatory. Reading in advance of the rotation and on a day to day basis, coming early and staying late, asking relevant and insightful questions, demonstrating enthusiasm and passion for the job, and connecting with an interested faculty mentor are key differentiating features of the best applicants. Working on a short case report or case series can be an easy way for the student to acquire new knowledge and skills in ophthalmic research, and provides evidence and content for genuine interest and effort in the field at the time of future interviews.
In January 2009, the average USMLE step 1 score for applicants who matched into ophthalmology was 235.2 The average score for unmatched applicants was 212. Many applicants are concerned that their application might be screened out because of their score. What recommendations do you have for these applicants?
Ophthalmology programs receive far more applications than available positions. While it is true that most programs use the USMLE step 1 score as a “screening device”, the score alone neither guarantees acceptance nor rejection. This test was not designed for this purpose, but in the real world it is used as a screen. Applicants with a great score should not become overconfident, and applicants with a subpar score should do everything possible to demonstrate their value in other ways. Taking the Step 2 as early as possible to demonstrate a higher alternative score is one tactic. Another tactic is to tackle the problem head on in the personal statement and to highlight other alternative evidence of performance and intelligence in their record (e.g., honors grades, AOA, clinical proficiency). Getting the program to ignore a subpar score is challenging but not impossible. For applicants with scores towards the unmatched level, having a back up application plan is always a good idea. The bottom line is that if you have a good score don’t get cocky, because everyone else has a good score too, and if you have a less optimal score you must demonstrate to the interviewer or the screener that you offer something else in your application that can justify looking away from the score alone.
Medical students often wonder if they should do an audition elective in ophthalmology. In a recent survey of 46 program directors, audition electives were ranked 12th among a group of sixteen residency selection criteria.3 What are your views on the role of audition (away) electives in the ophthalmology residency selection process?
The official party line is to discourage “audition electives”. The real goal of an away elective is to gain new knowledge and to experience ophthalmology in a different setting. Having said that, however, the away elective offers the applicant the opportunity to shine at a prospective institution and introduces the student to the faculty at that specific institution in a real world setting that can create a relationship that leads to an interview or even a higher ranking for the match. Ranking a “known” quantity with a personal track record and a letter of recommendation from an insider is always a great relief, especially for risk averse programs. In addition, if the choice is between two applicants with similar credentials, the known applicant obviously has the edge. My recommendation for a student doing an away elective is to use the time wisely, read in advance, make a great impression, talk with the residents and the faculty, and make yourself memorable in a good way. The goal is to “stand out,” however, not “stick out”.
In your article, “Re-engineering the resident applicant selection process in ophthalmology,” you wrote about “common but overused themes” in personal statements, including “a personal experience with a vision disorder, having a relative with an eye problem or requiring eye surgery… or some type of dramatic epiphany regarding the intricacies of the anatomy or physiology of the eye.”4 How would you advise applicants toapproach the personal statement?
Your personal statement is your chance to “talk” to the evaluator in a special way and to make your case for acceptance into the ophthalmology “club”. Thus, the ultimate purpose of the personal statement from an applicant’s perspective is to get an interview. The message should be clear but concise, and should emphasize that information which is not apparent from the credentials and scores in the application. The personal statement would ideally highlight what is unique or novel about a particular applicant and the “storyline” should emphasize a quality or anecdote or credential that is based upon a credible, genuine and personal experience. As a reader, I am looking for evidence of leadership potential, altruism, sincerity, or scholarship potential. The best personal statement to me is one that is memorable, unique, exciting and demonstrates an applicant’s intangible qualities (e.g., passion, humanity, charisma, enthusiasm, motivation, or future academic potential). At the end of reading a great personal statement the reader should want to meet the writer in person (i.e. for an interview).
In a 2006 survey of ophthalmology residency program directors done to determine the prevalence of residents who experience difficulty mastering surgical skills, nearly 10% of residents were found to be surgically challenged.5 Types of problems encountered included poor hand-eye coordination and poor intraoperative judgment. In the survey, 20% of participating programs (11 total) were found to use vision testing during applicant screening and 4% used some form of dexterity testing. In the future, do you feel that testing of vision, stereopsis, and hand stability will be a routine part of the selection process?
I believe that validated metrics for determining baseline hand-eye coordination skills in ophthalmic surgery are needed before routine testing can be advocated for resident selection. Testing of vision, stereopsis, and color vision are already required in some professions (e.g, pilots, military) and some jobs require pre-employment testing for dexterity with basic hand-eye coordination instruments. The difficulty lies in correlating performance on such examinations with the actual job description and surgical performance. I believe that these types of performance evaluations probably should be taking place at the medical school level and not as part of applicant screening, where presumably it would be too late for the applicant to do anything about a failing performance. Many applicants already self direct themselves towards or away from surgical specialties based upon their own self assessment of ability. Unfortunately, one unintended consequence of such screening might be to deter applicants who envision a career as a non-surgical or medical ophthalmic specialist (e.g., neuro-ophthalmology) from pursuing ophthalmology residency.
In your article, you wrote that extracurricular activities “might provide evidence for non-cognitive attributes that may predict resident success.” Which attributes do you feel are important to ophthalmology residency program directors?
The first priority of a residency selection committee is insuring that the applicant does not wash out or cause trouble during their time in the program. This is sometimes referred to generically as “fit”. Everyone wants a team player who is unselfish and working towards a common goal. Leadership skills demonstrated by being an officer in extracurricular activities or being an Eagle scout, or a leader or founder of a new organization or club are all looked upon favorably. The second goal is to look for evidence of noncognitive attributes that might make a superior ophthalmologist (conflict resolution, team work, leadership ability, communication skills, performance under stress, maturity, seriousness of purpose, prior scholarly activity). Finally, programs are looking to graduate (and thus select) residents who will make the program proud.
Many programs encourage applicants to attend a social event (e.g., pre-interview dinner) to learn more about the program. Through these events, programs also learn more about applicants. How do programs use these events to evaluate candidates?
Every part of the application process is important. The applicant needs to present their best face and be on their best behavior throughout the process. Treating every person in the application process with respect, dignity, and courtesy is important. Likewise, the social event is a chance for one to shine, make new friends, network with the other applicants, and most importantly make a good impression. The residents and fellows are looking for someone with whom they can work for three years, and not necessarily the smartest or the most academic applicant. Their vote counts, and while I encourage people to be “themselves” I would caution applicants that being on your best behavior is a good idea. Although these events are a great opportunity to learn more about the program, it is also a chance for the program to get to know you. You should treat the social events as seriously as the rest of the interview process.
What impresses you most about an applicant during an interview?
I am looking for three things in a resident interview. First, eliminate the people who may have looked “great on paper” but are terrible in person (e.g., psychopathic or sociopathic types, hermits or hotdogs, socially inappropriate duds, or selfish, arrogant jerks). Second, elevate the people who look mediocre on paper but are superstars in person (e.g., charismatic, engaging, enthusiastic, well spoken, and passionate). Third, and perhaps less tangible, I am looking for philosophical and personality “fit”. Applicants should understand their own, as well as the prospective program’s, learning environment, institutional culture, and teaching philosophy. Hard work, intelligence, teamwork, leadership, communication and interpersonal skills and professionalism are welcome attributes in most programs, and demonstrating these qualities can be a challenge in a short conversation. I am most impressed by applicants who are comfortable with themselves and with emphasizing their achievements in a credible manner, who can communicate clearly and concisely their career goals, and who can make the interview time “fly by” and who make me want to keep talking with the person beyond the assigned time.
Applicants who fail to match often wonder how they should spend the year before they reapply. What recommendations can you offer to these applicants?
The best chance for a match in ophthalmology is as a first time US senior medical student. The match rate drops off precipitously after this first application. The second application needs to be better than the first application if the second time applicant is to be successful. This means demonstrating perseverance, passion, and persistence through a research year in ophthalmology (e.g., a clinical or bench project), a pre-residency fellowship (e.g., ocular pathology), or an observational fellowship combined with the above. The “brick walls” in the process are meant to keep the other people out (i.e., those who don’t want it as badly or who fail to make a significant improvement in their application).
References
1Nissman SA, Kudrick NT, Piccone MR. Motivations and perceptions of US medical students pursuing a career in ophthalmology. Ann Ophthalmol 2002; 34(3): 223-229.
2Data from the San Francisco Ophthalmology Matching Program. Available at www.sfmatch.org.
3Green M, Jones P, Thomas JX. Selection criteria for residency: results of a national program directors survey. Acad Med 2009; 84(3): 362-7.
4Lee AG, Golnik KC, Oetting TA, Beaver HA, Boldt HC, Olson R, Greenlee E, Abramoff MD, Johnson AT, Carter K. Re-engineering the resident applicant selection process in ophthalmology: a literature review and recommendations for improvement. Surv Ophthalmol 2008; 53(2): 164-76.
5Binenbaum G, Volpe NJ. Ophthalmology resident surgical competency: a national survey. Ophthalmology 2006; 113(7): 1237-44.
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As a faculty member at the Baylor College of Medicine, Dr. Samir Desai has educated and mentored medical students, residents, and international medical graduates, work for which he has received numerous teaching awards. He is an author and editor, having written books that together have sold over 250,000 copies worldwide.