Guide to Ophthalmology Residency Application

Overview

  • Introduction
  • Selecting a residency
  • Preparation for application to ophthalmology residency
  • The application process
    • The most important aspects of the application
    • San Francisco Match application service
    • Application timeline
    • Letters of recommendation
    • Personal statement
    • Central application service
    • Interviews
    • Rank list
  • Internship application
  • Conclusion and final thoguhts
  • Frequently asked questsions

Introduction

Ophthalmology is a great field!  Here are some of the specific reasons I enjoy ophthalmology:

  • A comprehensive ophthalmic exam allows you to diagnose 80-90% of your patients- it is objective and scientific in many ways.

  • Direct visualization of the pathologic process- it is amazing that ophthalmologists can see arterial venous crossing changes from hypertension and saccular dilatation of blood vessel wall of an aneurysm. 

  • Many systemic diseases have ophthalmic manifestation and it is clinical challenging and satisfying to assist other physicians with the diagnosis and treatment of difficult cases.

  • Ophthalmic micro-surgery is challenging but at the same time enjoyable and very satisfying.  It amazes me that we can manipulate the delicate ocular tissue and operate in such a small space- the intraocular content is only 5cc!  Successful surgeries can restore lost vision and make a tremendous impact in patients' quality of life. 

Selecting a Residency

Choosing a residency is a difficult process.  Most believe certain personality types fit with certain specialties in medicine.   A common generalization is that if you like to think and enjoy spending time with patients, you should go into internal medicine.  On the other hand, if you don't like to think or talk as much but enjoy working with your hands and getting things done, you should go into a surgery.  These generalizations may have a certain degree of validity, but it is really up to you to decide what specialty is the right fit for you after you have had first hand experiences on your clinical rotations.  How much you enjoyed a specific rotation- including the science and practice of that specialty, the patient population, and how well you get along with the residents and attendings- are all good indicators of how much you may enjoy that specialty as a career. 

Ophthalmology has both clinical and surgical components and may give you the best of both worlds.  There are multiple subspecialties within ophthalmology and the practice of each subspecialty can differ significantly from each other.  Neuro-ophthalmology, for example, mirrors medicine in that a thorough history is important and an initial consultation may take an hour to perform.  Comprehensive ophthalmology, on the other hand, may involve less history taking and more time spent on examination for glasses and detecting diseases such as cataract, glaucoma, and macular degeneration.

In order to enjoy and succeed in ophthalmology, you need the following two characterisitics:
  • Objectivity- as stated above, 80-90% of ophthalmic diagnosis come your office exam (pattern recognition).  You need to be able to look at  a cornea and diagnose fungal infection or examine a retina and detect macular edema from diabetes.  A good comparison would be radiology- you need to be able to look at films and objectively make your diagnosis.  Although there are ancillary tests, we still largely rely on our examination skills to direct us.  It is quite different from other specialties where you usually rely on ancillary tests (blood work) to guide your diagnosis and treatment.
  • Initiative- learning ophthalmology is a very difficult process initially.  Often times, I see medical students who are interested in ophthalmology not taking the initiative to examine the patients.  Instead, they confine themselves to shadowing residents and attendings.  These people will not do well in ophthalmology. Ophthalmic examination and surgery are difficult to teach.  When I use words to describe how to recognize a pathology or how to perform a surgical maneuver to you, it does not translate into you knowing how to perform the same tasks yourself (as opposed to teaching someone how to interpret blood work results).  Once you have gained a conceptual understanding of the process, you'll need to practice on countless number of patients and spend many hours in the microsurgery lab in order to perfect your skills.  You should start learning as much ophthalmology as you can in medical school because you wil be expected to quickly develop these skills with minimal amount of guidance when you become a resident.  Having the drive and initiative to perfect your clinical and surgical skills are prerequisites for someone to enjoy and succeed in this field.
Unfortunately, most medical students have very little exposure to ophthalmology- some may rotate on ophthalmology for only 1-2 weeks while others may not have the rotation at all.  If you think you may be interested in ophthalmology, I suggest you take an one month elective rotation as soon as possible.  You may have to make a special arrangement with you student affairs office- if you wait until all of your core rotations to be completed prior to taking your electives (May to June in most U.S. medical schools), you will not have adequate amount of time to prepare for your application (ophthalmology is part of the early match, see application below).

Preparation for Application to Ophthalmology Residency

Ophthalmology residency takes four years- one year of internship in internal medicine or surgery or a transitional year followed by 3 years of training in ophthalmology.  The three years are usually divided as follows:
  • 1st year- general ophthalmology, emphasis on examination skills and diagnosis, limited to some exposure in subspecialty ophthalmology, limited exposure to surgery.
  • 2nd year- general and subspecialty ophthalmology, emphasis on diagnosis and management, limited to some exposure to surgery.
  • 3rd year- emphasis on surgery.
After three years of residency, you will have the opportunity to subspecialize or start practicing as a general/comprehensive ophthalmologist.  Fellowship takes an additional 1-2 years and the available subsepcialties are glaucoma, retina and vitreous, oculoplastics, uveitis, cornea and refractive surgery, cornea and external ocular diseases, pediatric ophthalmology and strabismus, and ophthalmic pathology.  

I have the following recommendations for you to prepare for your application to ophthalmology:
  • Perform a small research project during the summer after your 1st year.  Alternatively, perform a small research project during the regular academic year.  Select an ophthalmologist who you think will actually spend some time with you and write a strong letter of reference on your behalf.  It also helps if this ophthalmologist is well known across the country.  Academic ophthalmology is a relatively small community and many academic ophthalmologists know each other very well.  Members of  the residency selection committees often trust the recommendation of their colleagues and a strong letter of reference will carry you a long way.
  • Do well on your USMLE Step 1.  Ophthalmology is a competitive specialty and it will definitely help you get your foot in the door, especially the top programs, if you have a good score!
  • Rotate in ophthalmology as soon as possible to gain an exposure to the field to see it is the right field for you.  I would start with an one month rotation at a county or VA hospital where you can learn your examination skills with the residents.  Residents are often willing to teach you because you will help them see patients in busy clinics.  I would suggest you read the following books:
  • After you initial public hospital rotation, rotate with one or two ophthalmologists in their university-based or private clinics.  By this time you should have sufficiency skills to demonstrate you can examine patients and pick up some interesting findings to impress the attendings.  You will likely ask for a letter of reference from this rotation.
  • If your medical school does not have an ophthalmology department or has a small ophthalmology department, you should apply for an away rotation at a large academic institution.  Again, a letter of reference from a well-known ophthalmologist will carry you a long way!
  • Plan early because you need to have all of your application material ready by the end of August/beginning of September of your 4th year.  If you did not plan ahead and cannot get an ophthalmology elective until August, you will likely not have enough time to get the letters of recommendation.

The Application Process

The Most Important Aspects of the Application

Here are the most four most important parts of your application:

  • Letters of recommendation- this is the key to a good application.  As stated previously, in the small academic ophthalmology community, academic ophthalmologists know and trust the opinions of their colleagues.  Good letters from well-known ophthalmologists will help you overcome weaknesses in your application and make you a very competitive candidate.  I think the reason for this phenomenon is that academic ophthalmologists will have to work closely with you as a resident in both clinics and operating rooms.  Therefore, they have vast amount of interest in obtaining residents that not only look good on paper, but also function well in real life.  They rely on those who have worked with you to tell them you are capable of handling the high demands that will be placed upon you as a resident.
  • USMLE score- a good number here will get you past the initial screening process and get you interviews to the top institutions.  It may also help you overcome weaknesses in your medical school academic records.
  • Interviews- unlike medical school interviewers who you probably have never seen again after the interview, attendings that interview you for residency will work very closely with you for three years.  In addition to the information from letters of recommendation, they want to find out more about you as an individual- your personality and work ethics are going to be very important to them.  They want to know that you are someone who is intelligent, hardworking and responsible.  After you have been selected for an interview, the interview itself will be key to your successful match.
  • Reputation of your medical school- unfortunately, the reputation of your medical school and its associated ophthalmology department factor in considerably to the selection process (I do not agree with this, but the reputation of your school will matter).  If you are from a smaller medical school or a school with a small ophthalmology department, you need  to do an away elective and obtain a letter of recommendation to strengthen your application.
Here are the much talked about but less important aspects of your application:
  • Honors- it's good to have some honors in your 1st-3rd year classes and rotations but you don not need to have honored in every class to be a competitive condidate.
  • Alpha-omega-alpha honor society- this is another nice addition to your resume, but as long as you have good USLME scores and some honors, it may not be crucial to be part of AOA.  All of your academic accomplishments will be considered together as a whole and weakness in one part can be off set by strength in another.  Peope often think one needs to number one in all academic endeavors to match into ophthalmology.  As long as you have solid academic records, you will be a competitive candidate.
  • Dean's letter- programs rely much more on letters from ophthalmologists than the generic Dean's letter.
  • Publication- research allows you to get the letter of recommendation.  You should finish and publish your research if possible but publication is not a key aspect of the application.

The San Francisco Match Service

SF Match is the primary application service for ophthalmology (like AMCAS for medical school).  The application is done through CAS, or the central application service.  Residency match is different from medical school application because both the applicants and the residency programs rank their choices in order from first to last and the match service will generate a match report giving the most appropriate match between the two parties.  Therefore you will only have a single match, unlike medical school, where you may have had multiple acceptances to choose from.  Ophthalmology is an early match specialty.  The match occurs on January 15 instead of March.  Check out the SF Match site for more information- you can get statistics on previous matches to help you determine if you are competitive as a candidate.  It also has a suggested application timeline.

Application Timeline

Here is my suggested timeline for the application process:

1st-3rd Year

  • Perform a small research project with a mentor from ophthalmology- be realistic and choose something that can potentially be completed within a reasonable amount of time.

3rd Year

  • April-May: rotate through a public hospital to learn examination skills the residents.
  • June-July: rotate through 1-2 private rotations to work with 1-2 attendings.  Don't work with too many attendings because they will not get to know you well enough to write you a letter of recommendation.  Start your personal statement and work on your application at this time.

4th Year

  • August-September: complete and turn in your application to SF Match.  The ideal time to submit your application is toward the end of August and beginning of September.
  • October-December: interviews are conducted for ophthalmology.  Complete and turn in your regular match application for your internship.
  • November-February: interviews are conducted for internship and transitional year.
  • January: early match results released.
  • March: regular match results released.
  • April-June: after you finish your requirements for graduation, it's time for a little R&R!

Personal Statement

The personal statement for residency is similar to the one you have done for medical school. I suggest you write directly and succinctly. It is important to write separate statements- one for ophthalmology and one for internship or transitional year. See the personal statement section for medical school for additional tips on how to write a personal statement as needed.

Letters of Recommendation

Once again, the letters of recommendation are crucial to your success (see the most important aspects of the application).  This section deals with the logistics of these letters only.  CAS requires 3 letters of recommendation and it is important to realize your application will not be forwarded to residency programs until it is complete- this includes your 3 letters!  Therefore, you need to do your research and ophthalmology rotations early in order to have the letters ready in time- don't forget to allow approximately one month for your letter writers.  This means you should have completed all of your rotations by the end of July.

For your 3 letters, you will need 2 letters from ophthalmology and 1 letter from another specialty (i.e. medicine, surgery).  Most programs allow you to send in additional letters directly if needed.  I suggest you get at least 2 ophthalmology letters and 2 general letters- you will then be covered for both ophthalmology and internship applications.

CAS Application

CAS is the central application service provided by SF Match.  Once you have registered with SF Match, you will have access to the database that contains all the residency programs in the country. Complete the applications and fill out the distribution list.  All ophthalmology programs participate in the match service.  See SF Match for more details.

Deciding how many programs to apply to can be difficult.  Work with mentors, student affairs office, 4th year medical students, and ophthalmology residents at your institution.  Look at the SF Match website to see how competitive you are as an applicant.  You want to aim for 8-12 interviews to get at least one match (most believe the magic number is 8).  It is generally better to be conservative- you can always apply to more than you need and decline interviews later if you have too many of them.  Here is a general guideline:
  • Outstanding candidates (USMLE 235+, honors, great letters of recommendation, top 25 medical school): apply to 15-20 programs, include a few less competitive programs.
  • Good candidates (USMLE 220+, some honors, good letters of recommendation, good medical school): apply to 20-30 programs and include more less competitive programs.
  • Average candidates (USMLE 205+, few honors, OK letters of recommendation, from smaller medical school): don't give up yet!  This is a generalized guideline and many applicants may only have weaknesses in one area but otherwise have a great application.  Apply to at least 30 programs and include some top choices as well!

Interview

The interview process is similar to what you have done for medical school and if you have made it this far, no additional preparation is needed.  If you still need some tips on how to conduct an interview, see the medical school application section for suggestions.

You will likely have multiple interviews with several faculty members- this a chance for them to get to know you and for you to get to know them.  Here is what you need to find out about every residency program.  Don't forget to take notes and meet the residents!

  • What are the affiliated hospitals and facilities- public hospitals (county and VA) are where you will acquire most of your clinical and surgical experiences.  Beware of weakening affiliations that may end during your residency or out-of-state affiliations that will require you to travel.
  • Surgical volume- how many cases do residents graduate with?  Unless you will be subspecializing in retina, oculoplastics, neuro-ophthalmology, pediatrics/strabismus or pathology, the most important procedure is cataract surgery.  Other numbers may also play a role but they are less important. 
    • Cataract surgery- the ACGME requirement is 90 but it is not enough to make you a good surgeon.  There has been an increasing trend for residents to do general/comprehensive ophthalmology fellowships after residency because they do not do not feel comfortable starting on their own.  This is especially prevalent in cities where there are multiple programs (i.e. New York, Chicago).  At least 120 is needed and 150 or more is desirable.
    • Laser surgery- glaucoma and retina laser can easily be incorporated to most practices and it's important you get significant exposure to these.  You should have at least 20 focal lasers and 20 pan-retinal photocoagulations (for diabetic retinopathy), 10 YAG-capsulotomy (for capsular opacification after cataract surgery), and 10 of YAG peripheral iridotomy and argon laser trabeculoplasty (for glaucoma).
    • Plastic surgery- it is a good idea to be able to do some simple plastic procedures such as blepharoplasties or ptosis repair.  Some comprehensive ophthalmologists incorporate these into their practices.  You should feel comfortable with about 15-20 of these procedures.
    • Refractive surgery- it is difficult to get an adequate refractive surgery (LASIK) experience in most residencies but inquire whether you can be certified for these procedures.
    • Glaucoma and cornea surgeries (cornea transplant)- these are of variable importance.  As a general ophthalmologist, you can choose to refer these to speciallists because the postoperative care can be more complicated than the surgeries themselves- the amount of clinic time invested may not be worth the reimbursement. 10-20 of glaucoma filtration surgeries (trabeculectomy and tube shunt) and 5-10 of corneal transplants will give you a good exposure to these procedures.
    • Retina surgery and strabismus surgery- not important unless you plan to be a specialist in the area.  You will get most of the training from your fellowship.
    • Trauma surgery (open globe repair, corneal laceration repair, eyelid laceration repair)- only important if you will go into academics or if you plan to cover emergency rooms as a private physician.  5-10 of open globe and corneal laceration repairs and 5-10 eyelid laceration repairs will give a good exposure to these procedures.
  • Attending coverage in clinics- it is important for public hospitals to be staffed by attending physicians for education purposes, otherwise you will just be doing busy work.
  • Didactic programs- what are the didactic teaching schedules.  Are there review courses to help you study for the OKAP (Ophthalmic Knowledge Assessment Program) exam (mock board exams).
  • How happy are the residents- talk to the residents to find out the strengths and weaknesses of the program.
  • How are the first year residents- they are going to be your senior residents and they will be the ones supervising and teaching you most of the time.  Try to meet all of them if possible, you can have the best or the most miserbale residency experience because of them.
  • How strong are each of the subspecialties- especially if you may already have an interest in a specific subspecialty.  Well-known attendings in the department will help you out tremendously when you apply for fellowships.
  • What is the reputation of the program- this will help you if you plan to go into academics or if you want to do fellowships.  Be careful in choosing based on reputation alone because some of the most reputable programs actually have lower surgical volume.  You can check Ophthalmology Times (put in best residency in the search) to see the annual ranking of the top ophthalmology institutions and residencies.
  • Other miscellaneous but important issues:
    • Call schedule
    • Vacation schedule
    • Pay
    • Allowance for attending national meetings
    • Research availability and requirements

Rank List

After all of your interviews, you need to put together your rank list.   I have already discussed the important aspects you need to consider above.  Surgical volume, the people you will be training with (residents and attendings), and and the reputation of the institution should factor heavily into you decision making process.  It is important for you to NOT rank a program if you do not want to go there (there was one program that I didn't want to go and I felt the interview was a complete waste of my time) because if you match there, you are obligated to go under match rules.  Turn in your rank list early if possible so you can get a confirmation that it has been received.

Internship Application

Internship application is processed through the Electronic Residency Application Service (ERAS) as part of American Association of Medical Colleges (AAMC).  The logistics should be straight forward and I will not go into details about it here. 

The most common question people have is what type of internship to apply to- medicine, surgery, or transitional?  The answer is it doesn't really matter.  You should choose one that will you allow you to enjoy your year the most.  There is really no point to do a hardcore intern year because the knowledge you gain is not going to be extremely useful to you.  However, I would recommend electives in rheumatology, neurology, or neuro-imaging/radiology (CT/MRI) because knowledge in these areas do come in handy.  Some of the grunt work you do- writing admit orders, getting used to prescribing medications, etc. will also be useful as a resident. 

Conclusion and Final Thoughts

In summary, ophthalmology is a challenging, exciting, and rewarding field of medicine.  Residency application is competitive and early preparation with focus on USMLE score and letters of recommendation will give you the best chance to succeed.  Choose your residency program carefully because you will acquire the knowledge and skill you need to become a competent ophthalmologist from the institution of your choosing.  Finally, remember to enjoy yourself after the match.  You deserve it after all the hard work you have put in to make it happen!

Frequently Asked Questions

I come from a school with a well known ophthalmology program.  Do I need to do an away rotation?

No, the letters from your home institution will carry you for your application.  You may choose to do an away rotation in your top choice residency program.  However, it is a double edged sword- depending on if you are well liked or disliked, it can increase or decrease your chance of acceptance tremendously.

Since ophthalmology is very competitive, should I apply to a back-up residency program?

It is too much work and I do not recommend it.  You will likely match into an internship and you can then request to stay in the same program to complete your training or apply for ophthalmology again next year.  Some people have been able to successfully obtain an ophthalmology residency position outside the match because a matched person decided to go into a different specialty during their internship training.  SF Match provides the information on open residency positions.

When should I take my USMLE Step 2? Does it matter for my application?

You should not take Step 2 until after the application process.  I would only consider taking it early if your score was low on Step 1. 

Once you have made it to the interview, do the numbers stlil matter?

No, once you have been invited for an interview, you have already made the number cut off for that institution.  At this point, it depends mostly on your interview.

I am trying to couples match, should I tell the programs about it?

No, you should not tell the programs.  Some programs react negatively to such a disclosure.  I believe they should not inquire about your marital status or whether you have children.  I would not voluntarily disclose the information.  

More FAQ will be added- please leave your questions in the guest book and they will be incorporated into this section. 

Revised June, 2007.