Ophthalmology residency training has traditionally consisted of 4 years, the first
of which (the internship, or first postgraduate year [PGY-1 year]) takes place in
non-ophthalmology fields of medicine such as general medicine or general surgery.
As the amount of ophthalmology knowledge and skills required during residency training
has continued to grow, in recent years, more consideration has been given to integrating
ophthalmology training into the intern year while still retaining training in general
medicine, as detailed in the 2016 Association of University Professors of Ophthalmology
(AUPO) white paper.[1] Prior research shows that historically, ophthalmology residents often chose their
internship programs based on quality of life, and that their acquisition of ophthalmology
knowledge was quite variable.[2]
In 2017, the Accreditation Council for Graduate Medical Education (ACGME) required
ophthalmology residency programs to provide a combined transitional or joint preliminary
program for PGY-1 ophthalmology residents, with enforced implementation by 2023 to
avoid citation. The intention of this change was to standardize the experience of
PGY-1 ophthalmology residents, and to facilitate acquisition of ophthalmologic knowledge
and skills during the PGY-1 year.[1] Since the addition of a combined transitional or joint intern year for PGY-1 residents,
it has not yet been assessed how the combined intern year has impacted ophthalmology
resident preparedness.
Research from prior to the combined intern year demonstrated that the transition to
ophthalmology residency is even more stressful than the transition to residency (intern
year) in general.[3]
[4] Prior to the integration of the PGY-1 year, the PGY-1 to PGY-2 transition has not
always been one for which ophthalmology residents are well prepared, with much of
their previous education and practical training geared toward general medicine.[3]
There is also early evidence that ophthalmology exposure during the intern year is
beneficial. For example, 8 to 12 weeks of clinical ophthalmology during the intern
year increased preparedness in formulating ophthalmic diagnoses, performing the ophthalmic
exam, obtaining adequate history, and proficiency with using electronic medical records
in one prospective study.[5] Additionally, Logothetis et al found that residents who felt confident at the start
of ophthalmology residency had more hands-on clinical ophthalmology experience than
residents who did not feel confident.[2]
Given the recent integration across U.S. ophthalmology programs and previous results
indicating a possible benefit of early ophthalmology exposure and integration, this
study aimed to survey ophthalmology residency program directors (PDs), postgraduate
year 2 (PGY-2) residents, and postgraduate year 3 (PGY-3) residents to evaluate characteristics
of the combined ophthalmology PGY-1 year.
Methods
This national, cross-sectional survey-based study was distributed to program directors,
current PGY-2 ophthalmology residents, and current PGY-3 ophthalmology residents in
U.S. residency programs. The AUPO Data Resource Committee reviewed the survey prior
to approval. The survey was then disseminated to the AUPO listserv of program directors
with the request of sending the survey along to current PGY-2 and PGY-3 residents.
The survey collection period was from July to August 2022. PGY-2 residents included
in the final analysis were those who self-reported a position in a combined transitional
(medicine and surgery) or preliminary medicine or surgery PGY-1 year that was either
integrated or joint with their residency. A second survey collection period was implemented
from April to June 2023 with the addition of a question regarding the number of years
an integrated ophthalmology internship had been available prior to the 2021 to 2022
academic year. There were an additional 10 program directors, 21 PGY-2s, and 21 PGY-3s
who completed the survey during the second survey collection period.
Study data were collected and managed using REDCap (Research Electronic Data Capture)
electronic data capture tools hosted at Mass General Brigham.[6]
[7] REDCap is a secure, web-based software platform designed to support data capture
for research studies, providing (1) an intuitive interface for validated data capture;
(2) audit trails for tracking data manipulation and export procedures; (3) automated
export procedures for seamless data downloads to common statistical packages; and
(4) procedures for data integration and interoperability with external sources.
The program director survey consisted of 29 questions on combined PGY-1 program characteristics
and perspectives on the program roll-out. The PGY-2 survey consisted of 32 questions
focused on demographic data and preparedness for core competencies, as well as perspectives
on how to improve the combined ophthalmology PGY-1 year. The PGY-3 survey consisted
of 28 questions on similar subjects and asked respondents to reflect back on preparedness
for the PGY-2 year.
This study received approval by the Mass General Brigham Institutional Review Board
and adheres to the principles set forth in the Declaration of Helsinki. Consent was
obtained from all individuals who completed the surveys used in this study.
Results
Combined Ophthalmology PGY-1 Program Characteristics
Forty-two program directors started the survey, but only 26 program directors completed
the survey out of a total of 128 program directors on the AUPO listserv (completed
response rate: 20.3%). Of the 42, 15 (35.7%) represented programs in Midwest, 12 (28.6%)
from the East Coast, 11 (26.2%) from the South, and 4 (9.5%) from the West Coast.
Most programs (n = 37, 88.1%) reported 3 months of dedicated ophthalmology during the PGY-1 year,
and four (9.5%) reported 4 or more months. During the second survey collection, respondents
were asked about the number of years an integrated ophthalmology had been previously
implemented prior to the 2021 to 2022 academic year. Among the 10 program directors
who completed the survey during the second cycle, 60.0% reported that 2021 to 2022
was the first year an integrated ophthalmology internship had existed at their program
([Table 1]).
Table 1
Characteristics of the integrated ophthalmology PGY-1 year
|
n
|
%
|
|
Geographic region (n = 42)[a]
|
|
East Coast
|
12
|
28.6%
|
|
Midwest
|
15
|
35.7%
|
|
South
|
11
|
26.2%
|
|
West Coast
|
4
|
9.5%
|
|
Number of months spent on ophthalmology during PGY-1 year (n = 42)[a]
|
|
2
|
1
|
2.4%
|
|
3
|
37
|
88.1%
|
|
4+
|
4
|
9.5%
|
|
Number of years an integrated ophthalmology internship had been implemented at the
institution prior to the 2021–2022 academic year (n = 10)
|
|
0
|
6
|
60.0%
|
|
1
|
3
|
30.0%
|
|
2
|
4
|
40.0%
|
|
3
|
0
|
0.0%
|
|
4
|
0
|
0.0%
|
|
5+
|
1
|
10.0%
|
|
10+
|
2
|
20.0%
|
|
Wet lab sessions (n = 26)
|
|
Cataract (i.e., EyeSi, wound creation, capsulorhexis, phaco, lens insertion)
|
13
|
50.0%
|
|
Cornea (i.e., corneal suturing, penetrating keratoplasty, corneal gluing)
|
8
|
30.8%
|
|
Glaucoma (i.e., conjunctival suturing, trabeculectomy, tube placement, MIGS)
|
5
|
19.2%
|
|
Retina (i.e., port placement, sclerotomy suturing, intravitreal injection, scleral
buckle, laser simulation)
|
4
|
15.4%
|
|
Oculoplastics (i.e., lid laceration repair, tarsal strip, canthotomy/cantholysis)
|
11
|
42.3%
|
|
Other
|
6
|
23.1%
|
|
Resources available (n = 26)
|
|
Basic and clinical science course series
|
18
|
69.2%
|
|
Lectures/didactics
|
24
|
92.3%
|
|
Slit lamp exam training
|
21
|
80.8%
|
|
Indirect ophthalmoscopy training
|
21
|
80.8%
|
|
Standardized patient experiences
|
1
|
3.8%
|
|
Minor procedure training
|
10
|
38.5%
|
|
Refraction training
|
18
|
69.2%
|
|
Patient testing/tech-ing training
|
18
|
69.2%
|
|
Other
|
3
|
11.5%
|
Abbreviations: MIGS, minimally invasive glaucoma surgery; PGY-1, first postgraduate
year.
a A total of 42 PDs responded to the demographic questions regarding their programs.
In addition, 26 PDs completed the survey.
Most combined PGY-1 ophthalmology programs included exposure to comprehensive clinics
(n = 22, 84.6%), inpatient ophthalmology consults (n = 19, 73.1%), and comprehensive ophthalmology operating rooms (n = 18, 69.2%). Half of the programs reported time in ophthalmology emergency department
consults (n = 13, 50.0%). Few programs included rotations in retina operating rooms (n = 7, 26.9%), glaucoma operating rooms (n = 7, 26.9%), pediatric ophthalmology operating rooms (n = 7, 26.9%), or ocular pathology (n = 7, 26.9%). A minority of programs offered rotations at Veterans Affairs hospital
ophthalmology operating rooms (n = 7, 26.9%) or clinics (n = 10, 38.5%) ([Fig. 1]).
Fig. 1 Distribution of ophthalmology clinic and operating room exposure during the combined
ophthalmology PGY-1 year among U.S. ophthalmology residency programs. PGY-1, first
postgraduate year.
Cataract wet labs (EyeSi, wound creation, capsulorrhexis, phacoemulsification, lens
insertion) (n = 13, 50.0%) and ophthalmic plastic and reconstructive surgery wet labs (lid laceration
repair, tarsal strip, canthotomy/cantholysis) (n = 11, 42.3%) were most often offered to PGY-1 residents. Retina (port placement,
sclerotomy suturing, intravitreal injection, scleral buckle, laser simulation) (n = 4, 15.4%) and glaucoma (i.e., conjunctival suturing, trabeculectomy, tube placement,
minimally invasive glaucoma surgery) (n = 5, 19.2%) wet labs were the least frequently offered to PGY-1 residents ([Table 1]).
Resources most commonly made available during the PGY-1 year included lectures/didactics
(n = 24, 92.3%), indirect ophthalmoscopy (n = 21, 80.8%), and slit lamp training (n = 21, 80.8%) ([Table 1]).
Program Director Perspectives
When asked about how prepared the PGY-1 residents who went through the combined year
are for the PGY-2 year, 16 (61.5%) program directors responded “well prepared.” When
program directors were surveyed about how PGY-1 residents who went through the combined
year are prepared for the PGY-2 relative to the prior year's class, 16 (61.5%) responded
“better prepared.”
Program directors felt that the strengths of the combined year included early exposure
to fundamentals, such as slit lamp and indirect exam training, systems-level familiarity
with clinical workflows, and integration of residents with one another and faculty.
Weaknesses included the lack of a formal curriculum, insufficient time on specialty
ophthalmology rotations, operating room exposure, and effectively simulating PGY-2
responsibilities. Consistently, program directors remarked that a more formal rotation
schedule, backloaded rotations toward the end of the internship year, and increasing
the number of dedicated ophthalmology months during the intern year would be preferred.
PGY-2 Perspectives
Responses were received from 41 ophthalmology PGY-2 residents out of a total number
of 498 matched residents from the January 2021 cycle (response rate 8.2%).[8] Twenty-one PGY-2 residents (51.2%) were male and 20 (48.8%) were female with a median
age of 27 (interquartile range [IQR: 26–28]). Fourteen residents identified as Asian
(34.1%), 16 (39.0%) as white (not Hispanic, Latino, or Spanish), and 7 (17.1%) as
white (Hispanic, Latino, or Spanish). Most residents reported enrollment in East Coast
programs (n = 18, 43.9%) and in a combined transitional year program (n = 21, 51.2%) as opposed to a joint preliminary PGY-1 year in medicine (n = 15, 36.6%). Over sixty percent (n = 26) reported 3 months of dedicated ophthalmology during their PGY-1 year and only
5 (12.2%) reported 4 months ([Table 2]).
Table 2
Characteristics of current ophthalmology PGY-2 residents (n = 41)
|
Characteristics
|
Median/n
|
IQR/%
|
|
Age
|
27
|
26–28
|
|
Gender
|
|
Male
|
21
|
51.2%
|
|
Female
|
20
|
48.8%
|
|
Race/ethnicity
|
|
White (Hispanic, Latino, or Spanish)
|
7
|
17.1%
|
|
White (not Hispanic, Latino, or Spanish)
|
16
|
39.0%
|
|
Non-white Hispanic, Latino or Spanish
|
1
|
2.4%
|
|
Black or African American
|
2
|
4.9%
|
|
Asian
|
14
|
34.1%
|
|
Other
|
1
|
2.4%
|
|
Geographic region
|
|
East Coast
|
18
|
43.9%
|
|
Midwest
|
10
|
24.4%
|
|
South
|
8
|
19.5%
|
|
West Coast
|
4
|
9.8%
|
|
Missing
|
1
|
2.4%
|
|
Position
|
|
Non-joint preliminary or integrated PGY-1 resident
|
1
|
2.4%
|
|
Joint preliminary PGY-1 resident (Medicine)
|
15
|
36.6%
|
|
Joint preliminary PGY-1 resident (Surgery)
|
2
|
4.9%
|
|
Integrated transitional year PGY-1 resident
|
21
|
51.2%
|
|
Missing
|
2
|
4.9%
|
|
Number of months spent on ophthalmology during PGY-1 year
|
|
0
|
1
|
2.4%
|
|
1
|
2
|
4.9%
|
|
2
|
2
|
4.9%
|
|
3
|
26
|
63.4%
|
|
4
|
5
|
12.2%
|
|
Missing
|
5
|
12.2%
|
Abbreviations: IQR, interquartile range; PGY-1, first postgraduate year; PGY-2, postgraduate
year 2.
Most PGY-2 residents felt “somewhat prepared” to “well prepared” to perform basic
clinical skills and very few felt “not prepared” ([Fig. 2]). Similar trends were observed for preparedness for program engagement ([Fig. 3]).
Fig. 2 PGY-2 perspectives on preparedness for the PGY-2 year: clinical skills. PGY-2, postgraduate
year 2.
Fig. 3 PGY-2 perspectives on preparedness for the PGY-2 year: program engagement. PGY-2,
postgraduate year 2.
PGY-2 residents indicated early clinical and surgical exposure, as well as familiarizing
themselves with co-residents, staff, and the electronic health records, as strengths.
They reported a lack of feedback and a lack of a formal PGY-1 ophthalmology curriculum
as weaknesses and opportunities to improve.
PGY-3 Perspectives
Thirty-three PGY-3 residents responded from a matched class of 495 in the January
2020 cycle (response rate 6.7%).[8] Among those surveyed, with a median age of 27 (IQR: 26–29), 13 (39.4%) were male,
and 20 (60.6%) were female. Thirteen residents identified as Asian (39.4%) and 12
(36.4%) as white (not Hispanic, Latino, or Spanish). A third of PGY-3 residents reported
enrollment in an East Coast program (n = 11, 33.3%). Most PGY-3 residents had some ophthalmology exposure during their PGY-1
year (n = 26, 78.8%), and 5 (15.2%) reported more than 3 months of ophthalmology exposure.
Access to educational and training resources was limited ([Table 3]).
Table 3
Characteristics of current ophthalmology PGY-3 residents and their PGY-1 years (n = 33)
|
Characteristics
|
Median/n
|
IQR/%
|
|
Age
|
27
|
26–29
|
|
Gender
|
|
Male
|
13
|
39.4%
|
|
Female
|
20
|
60.6%
|
|
Race/ethnicity
|
|
White (Hispanic, Latino, or Spanish)
|
3
|
9.1%
|
|
White (not Hispanic, Latino, or Spanish)
|
12
|
36.4%
|
|
Non-white Hispanic, Latino or Spanish
|
1
|
3.0%
|
|
Black or African American
|
1
|
3.0%
|
|
Asian
|
13
|
39.4%
|
|
Other
|
3
|
9.1%
|
|
Geographic region
|
|
East Coast
|
11
|
33.3%
|
|
Midwest
|
9
|
27.3%
|
|
South
|
5
|
15.2%
|
|
West Coast
|
8
|
24.2%
|
|
Number of months spent on ophthalmology during PGY-1 year
|
|
0
|
7
|
21.2%
|
|
1
|
5
|
15.2%
|
|
2
|
2
|
6.1%
|
|
3
|
14
|
42.4%
|
|
4
|
5
|
15.2%
|
|
Resources available
|
|
Basic and clinical science course series
|
11
|
33.3%
|
|
Lectures/didactics
|
22
|
66.7%
|
|
Slit lamp exam training
|
18
|
54.5%
|
|
Indirect ophthalmoscopy training
|
19
|
57.6%
|
|
Standardized patient experiences
|
5
|
15.2%
|
|
Minor procedure training
|
8
|
24.2%
|
|
Refraction training
|
12
|
36.4%
|
|
Patient testing/tech-ing training
|
17
|
51.5%
|
|
Other
|
6
|
18.2%
|
Abbreviations: IQR, interquartile range; PGY-1, first postgraduate year; PGY-3, postgraduate
year 3.
When asked to reflect on preparedness for the first year of ophthalmology residency,
many PGY-3 residents felt “not prepared” to perform basic clinical skills ([Fig. 4]), but there was an even distribution of reported preparedness when asked about program
engagement ([Fig. 5]).
Fig. 4 PGY-3 perspectives on preparedness for the PGY-2 year: clinical skills. PGY-2, postgraduate
year 2.
Fig. 5 PGY-3 perspectives on preparedness for the PGY-2 year: program engagement. PGY-2,
postgraduate year 2.
When asked what would be beneficial to ease the transition to the PGY-2 year, PGY-3
residents consistently suggested exposure to clinic, operating rooms, and consults,
as well as hands-on practice with basic exam skills and patient encounters.
One third (36.3%, n = 12) of PGY-3 residents, the class preceding the mandated integration of the intern
year, reported they had gotten to know their co-residents “very well” prior to starting
their first year of ophthalmology residency, whereas 74.2% (n = 23) of PGY-2 residents, the class that was a part of the first year of the combined
ophthalmology intern year, reported this ([Fig. 6]).
Fig. 6 PGY-2 and PGY-3 perspectives on familiarity with co-residents.
Discussion
This is a national, survey-based study on the recently combined ophthalmology PGY-1
year, as well as program director and resident (PGY-2 and PGY-3) perspectives on the
integration. We found that the way residency programs across the country have designed
their curriculum is highly variable. However, based on data from 16 institutions,
there is a clear focus on exposure to comprehensive ophthalmology clinics and operating
rooms, as well as inpatient consults. Wet lab sessions offered to residents primarily
covered cataract surgery and ophthalmic plastic and reconstructive surgery procedures.
Most programs include basic ophthalmology skills (indirect ophthalmoscopy, slit lamp,
and refraction training) in the PGY-1 curriculum. The fact that these shared features
can offer a strong foundation for early ophthalmology trainees transitioning to the
PGY-2 years is evidenced by a relatively higher self-reported clinical preparedness
among PGY-2 residents than PGY-3 residents.
Responses from program directors and residents who underwent the combined PGY-1 year
indicate several benefits attributed to the integration. The overwhelming benefit
cited is early exposure to the unique set of clinical and technical skills that ophthalmology
demands. From a systems-level perspective, the combined PGY-1 year allows trainees
to gain a sense of clinical workflows, the electronic health record, and familiarity
with faculty. These opportunities enhance the professional development of trainees
and integrate them into the program as productive and meaningful participants in clinical
care.
Residency class comradery and community was evaluated in this survey by asking about
familiarity with co-residents. We found that nearly twice as many PGY-2 residents
knew their co-residents “very well” relative to PGY-3 residents. This is an important
finding because burnout is common among medical professionals and negatively affects
both physicians and patients.[9] While much of the literature has focused on individual characteristics that protect
against burnout, peer support, community, and a sense of belonging are important factors
that contribute to resilience during residency.[10]
[11]
Integration of the PGY-1 year is not without challenges or opportunities for improvement.
Most program directors suggest increasing the number of months spent on ophthalmology
rotations during the PGY-1 year. This is supported by the ACGME requirements of the
urology PGY-1 year mandating a minimum of 3 months and a maximum of 6 months on urology
rotations.[12] A counter-argument to increasing the number of months on ophthalmology is the loss
of medicine or surgery instruction that could become the responsibility of the ophthalmology
departments themselves. Furthermore, less time on non-ophthalmology rotations could
lead to weaker cross-specialty professional collaborations. Additionally, PGY-2 residents
suggested that ophthalmology program directors should work closely with their non-ophthalmology
counterpart program directors on selecting PGY-1 year rotations that are the most
educational and pertinent, while eliminating those that are less relevant. Most respondents,
both program directors and residents, also advocated for a formal curriculum for PGY-1
ophthalmology residents that focuses on dedicated didactics and simulation of PGY-2
responsibilities.
There are several limitations to this study. Due to the survey-based design, our data
are subject to selection and recall bias. Due to the low number of respondents, our
results have limited generalizability. However, respondents across the three surveys
did represent significant geographic diversity. Furthermore, nearly a year passed
since the PGY-3 residents first started their PGY-2 year and their recollections may
be error prone. Additionally, about one-third of PGY-3 residents indicated 3 or more
months of ophthalmology exposure during their PGY-1 year. This is likely because there
were ophthalmology residency programs with combined PGY-1 years prior to the ACGME
mandate which may contribute to an overestimation of preparedness and resources available.
Even so, the results of our survey results indicated generally less preparedness of
PGY-3 residents surveyed than PGY-2 residents surveyed for the first year of ophthalmology
residency. Future studies of the needs of early ophthalmology trainees are necessary
to further refine the combined PGY-1 year, as well as studies on the long-term effects
of the combined PGY-1 year on career advancement.
Our study demonstrates that there are many benefits of the combined ophthalmology
residency program to the professional development of ophthalmologists. We have also
outlined many opportunities to improve the experience for trainees. Ophthalmology
residency programs should evaluate, optimize, and standardize the combined PGY-1 year
to benefit future interns entering the field.
