A career in ophthalmology
Authors: Rakesh Jayasawal
Publication date: 18 Jun 2005
Few medical students have a true taste of ophthalmology. Amar Alwitry and Rakesh Jayasawal describe the work and career path of this diverse specialty
Owing to the enormous medical curriculum and the pressures of time for undergraduate training, ophthalmology teaching at medical school tends to be a short lived affair. Consequently, when medical students graduate and begin to consider their future careers, few have had a true taste of ophthalmology. The occasional clinic session spent fumbling with the ophthalmoscope, confidently saying you can see the disc margins clearly while being focused on an eyelash, may give a false and off-putting impression of this rewarding career.
What is ophthalmology?
Ophthalmology, from its Greek origins, is literally the science of eyes. During its development as a medical specialty it has grown to encompass the skin around the eyes, the globe, the orbit, and the nervous connections in the brain all the way back to the visual cortex. Pathology in this system and the management of systemic diseases that affect the eye are in the remit of the ophthalmologist.
“The eye is the window to the soul”
Ophthalmology requires a wide range of skills owing to the diversity of the specialty. It requires medical and surgical skills, and patient care ranges from the paediatric to the geriatric population.
There are few medical conditions that are not related to, or manifest as, eye signs. These features may well be the primary presentation of systemic disease.
Most ophthalmological care deals with a healthy elderly population. Patient care usually takes place in outpatient clinics, and most patients are extremely grateful for anything that you do for them. Often patients are followed for a long time, allowing a true rapport to develop. On the downside, these innumerable follow-up appointments account for very busy clinics.
Operations are usually undertaken on a day care basis and under local anaesthesia, which means few ward patients and minimal ward work.
Most ophthalmologists are concerned with both the medical and the surgical aspects of eye conditions. However, if you are averse to operating it is possible to specialise in medical ophthalmology. Ophthalmic surgery consists of fine microsurgery on the globe with the aid of an operating microscope, plastic surgery on the tissues around the eyes, anterior segment surgery (cornea and lens), posterior segment surgery (vitreoretinal), and orbital surgery.
Although the ability to use an ophthalmoscope remains an essential skill for ophthalmologists, in most of our clinical practice we use a slit lamp and lens to obtain a three dimensional view of the fundus.
This image is wider than that obtained by a direct ophthalmoscope, allowing much greater visualisation and appreciation of the structures at the back of the eye.
Ophthalmology training is divided into roughly three years' training as a senior house officer (SHO), during which the three postgraduate exams are taken, and four and a half years' training on a higher surgical training programme, at the end of which the certificate of completion of specialist training (CCST) is awarded.
The exams are set by the Royal College of Ophthalmologists (www.rcophth.ac.uk) and are divided into three parts.
Part I—No ophthalmic experience is required. This covers the basic sciences. A detailed understanding of anatomy and embryology (head and neck, neuroanatomy, and ocular), physiology (general, ocular, visual system, central nervous system), biochemistry, pharmacology, microbiology, pathology, and statistics is required. Obtaining this exam vastly increases your chances of obtaining your first job as an SHO in ophthalmology.
Box 1: Advantages and disadvantages of a career in ophthalmology
Mix of medicine and surgery
Grateful patient group
Civilised on-call commitments
Clean, delicate surgery
Rapidly advancing surgical techniques
Potentially monotonous workload
Work in dark conditions
People confuse us with opticians
Box 2: Personal attributes required for ophthalmology
Good fine motor skills
Adequate hand/eye/foot coordination
Stereoscopic depth perception
A degree of ambidexterity
Good communication skills
Box 3: Further information
How to get into ophthalmology
In the present system, once you have obtained full registration two options are available. You may attempt to get a job as an SHO in ophthalmology directly or undertake a post as an SHO in another specialty such as medicine, emergency medicine, plastic surgery, or neurosurgery. Wider experience of other branches of medicine, especially those related to ophthalmology, will only improve your chances of obtaining the first job as a senior house officer.
Taken further, a higher degree, such as membership of the Royal College of Physicians (MRCP), will greatly improve your chances of not only obtaining jobs as an SHO but also making the jump to higher specialist training. Most trainees begin in an eye unit in a district general hospital and then, after completing the part I exam, move to a teaching hospital rotation.
All questions should be directed to the BMJ Careers website (www.bmjcareersadvicezone.synergynewmedia.co.uk/).
Part II—Twelve months' experience as an SHO in ophthalmology is required. This covers optics and refraction and clinical assessment methods. The exam concentrates on the refractive physiology of the eye, spectacles, and lenses. An appreciable amount of physics is involved, so an A level understanding of the properties of light may be a distinct benefit.
Part III—Eighteen months' experience as an SHO in ophthalmology is required. This part of the exam is mainly clinical but it includes a structured exam in pathology and microbiology. The medical exam is the usual stumbling block for the part III candidate as it requires an in-depth understanding of the numerous medical and neurological conditions that may affect the eye and a high degree of clinical competence in exam skills.
The exams can be taken via the Royal College of Ophthalmologists, London (MRCOphth), or the Royal College of Surgeons, Edinburgh (MRCSEd). Once part II and part III have been obtained you may undertake work with a dispensing optician, which is a valuable boost to your income.
Basic specialist training
At least two years must be spent as a senior house officer in a recognised ophthalmology post. During basic specialist training, the trainee should acquire the general clinical skills of an ophthalmologist and gain a basic knowledge of the conditions covered by the specialty. Trainees must have attended the Royal College of Ophthalmologists' course in basic microsurgical skills before attempting intraocular surgery.
Higher specialist training
Higher specialist training takes four and a half years. To enter this training programme you must have obtained the certificate of eligibility for higher specialist training (CEEHST) from the Royal College of Ophthalmologists, which is granted when you have completed at least two years of recognised ophthalmology training posts and after you have passed the MRCOphth or equivalent. At the end of this period of training it is common to undertake a fellowship in your chosen subspecialty anywhere in the world before taking up a consultant post. Trainees are awarded a CCST on successful completion of their exit assessment.
Non-career grade ophthalmologists
Numerous opportunities exist for non-career grade doctors (clinical assistants, staff grades, associate specialists) with varying clinical commitments. Completion of basic surgical training in ophthalmology is usually necessary before entering these posts, but exams are not always required.
The table compares the current system and the proposed run through grade.
Modernising Medical Careers—proposed run through specialist training programme
With the first foundation years starting in August 2005 and the run through specialist training programmes due to start in August 2007, the current training programmes will be replaced (see table). It is proposed that after two foundation years trainees will be eligible to apply for a seven year run through specialist training programme. Whereas the previous bottleneck during training was entry into the specialist registrar grade, the new system will potentially shift this bottleneck further down the training grade to the entrance to these run through training programmes.
Selection for entry to these programmes will be done objectively via a series of tests and will be deanery based. The overall training period will be of similar length, but part I will be taken after two years. Currently, all exams are taken at a relatively early stage.
A maximum of three attempts will be allowed and failure to pass part I will result in exclusion from the training programme. Part II (the clinical exam) will be taken after a minimum of four years on the programme, and there will be no limit to the number of sittings for this exam. There will be no exit assessment. The result will be a certificate of completion of training (CCT). Further specialist training via a fellowship or an ASTO (advanced subspecialist training in ophthalmology) is planned before the CCST is awarded.
Entry into ophthalmology has been tough for many years despite there being over 470 SHO posts in the United Kingdom. The appeal and attractiveness of this specialty to many serves only to make the competition harder. With the new run through training schemes starting in August 2007, competition will get tougher as there will be only 80 entrance places a year for these schemes.
In the ever changing climate of the NHS, no one is really sure what the future holds. However, one thing is certain. With an ageing population, the demand for ophthalmology will continue and the job opportunities will always be there.
Trainees are formally represented by the Ophthalmic Trainees Group (OTG), which has representatives from each region who sit on committees within the Royal College of Ophthalmologists and continually ensure that trainee voices are heard within the college. OTG representatives are available to help trainees within their regions with anything that affects their training.
Ophthalmology continues to need bright, intelligent, and enthusiastic people. Give it a chance—come in and sit in on a few clinics and see what we are really about. And don't be put off by the tough competition. After all, there must be a reason why it is so popular. ■
Go to web extra at bmjcareers.com/career focus for a day in the life of an oculoplastic surgeon
Rakesh Jayasawal specialist registrar in ophthalmology Department of Ophthalmology, Eye, ENT Centre, Queen's Medical Centre, Nottingham NG7 2UH