Columbia University recently published internal data showing a decreased percentage of graduating Columbia medical students choosing ophthalmology compared to 1976. To evaluate this trend and how medical educators can continue to foster medical student interest in ophthalmology, 3 experts in ophthalmology medical education share their thoughts.

Is the decreased interest in ophthalmology real?

Rukhsana Mirza, MD: The national numbers do not show a significant decline in interest in ophthalmology. According to the SF Match 2020 statistics, 737 individuals registered for the match showing a significant interest in the 496 available spots. While this is a decrease from 2019 (790 registered for 485 spots), the match rate is within the same range of fluctuation that we have seen over the past decade. This does not mean that we should not be proactive to protect and enhance our profession’s pipeline. Lack of exposure to an ophthalmologist or ophthalmology is the greatest cause for a potential decline in interest. Anecdotally, at Northwestern, our interest remains strong. In 2020, ophthalmology was the second most chosen specialty after internal medicine and the most pursued surgical specialty. These trends need to evaluated within the larger context and do vary year to year.

Yoshihiro Yonekawa, MD: I agree with Dr. Mirza. I spoke with Dr. Tara Uhler, the residency program director at Wills Eye Hospital, who had fantastic insights. There are many factors to consider here, and we cannot just look at one school at only 2 time points. There has been a small but steady increase in the number of ophthalmology positions offered, but does that really suggest that the chances of matching have increased? Or have the academic records of those who self-select into ophthalmology improved, and those without the strongest applications may have decided not to apply? What about the steadily increasing numbers of medical student graduates and the corresponding ratio of those who apply for ophthalmology? Anecdotally, at Jefferson we average 12 to 15 students per year applying for ophthalmology, but some years have seen as few as 8, and some years have seen as many as 22. Some students may take off for research, which can shift the numbers from year to year. There are also many external factors that contribute to the “popularity” of a specialty, for example, expansions of a department within a medical school, opportunities for students to interact with the field, curriculum changes, generational perceptions, and the job market.

What are the major factors that may contribute to a decreased interest in ophthalmology?

Dr. Mirza: There has been a steady decrease in curricular time dedicated to ophthalmology, especially in reference to required clerkships over the past several decades; however, more recent data show that this decline has stabilized.[1] Traditional class time and required clerkships are historically the way that students have made career choices, but this may not be the case today. Many schools still require ophthalmology content with a large shift to exposure during preclinical years. Other schools now rely on nontraditional teaching as adjunct methods for exposing student to ophthalmology. Examples include interest groups, community health screening, clinical skills training, research projects, partnerships with other specialties, and participation in clinical threads. Furthermore, schools with dedicated directors of medical student education in ophthalmology are more able to advocate for time in and out of the formal curriculum. As undergraduate medical curricula changes, methods of exposure to ophthalmology must change with it. Students need to interact with our specialty in as many different ways as possible from interest groups, to meet and greet sessions, clinical rotations, mentoring and advising, research and formal electives and curricula offerings.

Dr. Yonekawa: Ophthalmology is a fulfilling career and I think it remains an attractive field for medical students. I agree that we have challenges though. As medical school curriculums become shorter while more and more information needs to be taught, we need to make sure that ophthalmology is not neglected. As Dr. Mirza noted, ophthalmology departments should have directors for medical student education who can promote and advocate for ophthalmology exposure, and curate creative ways to engage students. From an ophthalmic society standpoint, I think ophthalmology, state, and subspecialty societies can consider student memberships as a membership type. There are not many societies that currently accept medical students as members, but I think the effects would be profound. The American Academy of Ophthalmology is spearheading this concept. Students will be empowered, have a sense of community and belonging, can contribute, and, most importantly, students will bring unique ideas and societies will be able to stay in touch closer with the future of our field.

What are the major obstacles to increasing ophthalmology exposure in medical school curriculums?

Jayanth Sridhar, MD: Significant ophthalmology exposure is not a core or required part of either the basic courses or clinical rotations at most US medical schools. I know from my own experience as a medical student that if we had not had a 2-week lecture course during the second year of medical school, I probably never would have signed up for a third-year elective and fallen in love with this field. Given the lack of exposure, I think it also may be difficult for medical students to visualize what a career as an ophthalmologist looks like on a day-to-day basis.

Many medical schools are shifting toward a 3-year medical school curriculum. What effect do you expect this to have on interest in ophthalmology and why? What should ophthalmologists do in response to changing medical school curriculums?

Dr. Yonekawa: We have to make sure that ophthalmology, at the least, maintains the current ratio within a medical school curriculum. I think it also makes sense to integrate ophthalmology into core clerkships so that every student has exposure to clinical ophthalmology. Nevertheless, I predict that more students will discover ophthalmology later than ideal in a shorter curriculum (for an early match also!). Some applicants currently take a year off for ophthalmology research, but we may be seeing more students take this route.

Dr. Sridhar: Personally, I do not think there will be a significant positive or negative impact unless there is increased exposure at schools with no protected ophthalmology times or decreased exposure at those schools that require some exposure during the second or third year.

Dr. Mirza: To avoid the unpredictability that Dr. Sridhar outlined, ophthalmologists need to advocate that understanding eye disease is relevant to all medical students and essential for a well-trained physician. There are core principles and skills outlined in a recent editorial.[2] This is important not only for the pipeline of our profession, but our role in educating our medical students about what we do and when to refer to the knowledge and skills specific to our field. Patients’ outcomes will benefit in the process.

Underrepresented minorities (URMs) are underrepresented in medicine, and ophthalmology is no exception. Why do you think this is and what can be done about this?

Dr. Mirza: Ophthalmology is a competitive match and a relatively small specialty. Some medical schools do not even have formal departments of ophthalmology. This can be intimidating unless there is strong mentorship and advising early in the process. The American Academy of Ophthalmology’s Minority Ophthalmology Mentoring program, along with local measures such as open houses, engagement in the curriculum, and dedicated faculty who mentor students may be a first step. Faculty participating in committees, and curriculum in nonophthalmology topics may also be useful to make ophthalmologists more available to interested individuals. Furthermore, many URMs may want to return to serve their own communities. Often, primary care specialties are perceived as the best way of doing this. It is important to emphasize the role of ophthalmology as primary care for visual health, which is essential. Without this care, there can be devastating effects on opportunities and productivity of working age individuals as well as independence for the elderly.

Dr. Yonekawa: It’s critical for our specialty, our patients, our society, and our future, that we increase the number of those underrepresented in medicine (URiM) in ophthalmology. It’s a vicious cycle that needs to be disrupted. We all have mentors who have generously helped us get to where we are today, and I think being able to connect and identify with mentors is key. In order to increase the interest of URiM students in ophthalmology, one important piece, is having URiMs as faculty mentors. It’s a matter of ophthalmology departments prioritizing this important issue when recruiting faculty and considering mentoring responsibilities. This, of course, will be more achievable with more URiM students becoming ophthalmologists. Patient-physician race and gender concordance has been shown to improve outcomes, so improving the racial, ethnic, and gender gaps is not only a social issue — it may be better care also.

Dr. Sridhar: This is an extremely important and relevant issue. As Dr. Mirza commented, the American Academy of Ophthalmology has made this a priority via the Minority Ophthalmology Mentoring program to try and recruit more URMs to apply for ophthalmology residency. While this is a multifactorial issue, I also agree with Dr. Yonekawa that the biggest reason for a lack of URMs is a lack of role models, resulting in fewer URMs getting adequate mentorship and guidance toward an ophthalmology career. By making active efforts to engage URMs both in the pre-application process and to cultivate diversity in resident selection, I do believe we can make in-roads here over the next 5 years to 10 years by fostering a generation of young URM ophthalmologists who can serve as role models.

How do you think the COVID pandemic will affect residency specialty choice?

Dr. Mirza: Ultimately, students pursue ophthalmology because of features that resonate with them and are not experienced in other fields. I have seen that “aha” moment when a student looks through a slit lamp for the first time, sees an optic nerve, or interacts with our grateful patients. If there is a decline in these experiences in the COVID era and the time that follows, we may see a dip in the interest. However, mentoring students even virtually can have a big impact on this outcome. There is also the possibility that COVID will inspire other students to pursue fields with more immediate overlap with widespread illness such as public health, infectious disease, and intensive care medicine.

Dr. Yonekawa: On the other hand, Dr. Mirza, health-care workers have been the heroes during the current pandemic, and there are some suggestions that this may have increased an interest in medicine in general. There will hopefully be even more passionate students entering medical school to help better society, and I think that’s a win for all specialties, including ophthalmology.

Dr. Sridhar: Great question, and I think that no one, not even the medical students who will define the data points, knows the answer. As Dr. Yonekawa pointed out, I would hope that COVID-19 motivates more bright, curious minds to pursue medical careers and medical school, which will help all fields of medicine overcome predicted upcoming medical provider shortages with a rapidly growing and aging population. Short-term, we may see a rise in ophthalmology applications as applicants prioritize work–life balance and outpatient specialties over hospital-based careers; conversely, Dr. Mirza is correct that it is very possible that the efforts of first-line providers during the pandemic inspire this next generation of physicians to pursue fields such as emergency medicine and critical care. Stay tuned!

Any final thoughts on promoting ophthalmology interest in medical students?

Dr. Sridhar: Get out and reach them! If formal exposure is not possible within a medical school curriculum, organize lunch or evening events where students can speak to residents, fellows, and younger attendings and get a sense of what ophthalmology is like and (in my biased opinion) why it is the most dynamic and innovative field in all of medicine. Then, once you get them in the door, you can work on getting them to choose retina as a career!

References

1. Moxon NR, Goyal A, Giaconi JA, et al. The state of ophthalmology medical student education in the United States: an update. Ophthalmology. 2020;127(11):1451-1453. doi:10.1016/j.ophtha.2020.05.001
2. Graubart EB, Waxman EL, Forster SH, et al. Ophthalmology objectives for medical students: revisiting what every graduating medical student should know. Ophthalmology. 2018;125(12):1842-1843. doi:10.1016/j.ophtha.2018.08.032