The field has a growing demand of care, and dropping rate of new specialists. The solution can start at medical schools.
Tejus Pradeep, BA
The rate of medical students joining the ophthalmology field is a key determinant of the outlook of the profession. Estimates by the Association of American Medical Colleges (AAMC) project a shortage of ophthalmologists by the year 2025.
While many factors play a role in this shortage, the central crux of this issue stems from a supply and demand imbalance.
Increasing future demand for eye care services has been well-characterized, driven by the aging Baby Boomer generation, demographic shifts in the US population, and the increasing incidence of secondary causes of eye disease including diabetes and hypertension. An aging population needs eye care, and the most rapidly growing population bracket is senior citizens older than 85 years old.
The supply side of the equation is driven by professionals who can provide care. And while there are a range of professions that may play a role, this is mostly driven by how many individuals decide to become ophthalmologists. The trickle-down effect is that our medical schools and curricula play a tremendous role in molding which specialties students choose to pursue.
As a rising fourth year medical student interested in ophthalmology, I have observed firsthand how rare it is to gain adequate exposure to the field without seeking it out. There is a self-selection process where those who apply into ophthalmology are ones that either already knew they were interested, or ones that accidentally stumbled upon it during a third-year elective. From my experience, any brief exposure to ophthalmology usually came from first-year basic science lectures teaching visual pathways in a neurology course. These courses are often taught by PhDs who place a disproportionate emphasis on niche areas of research interest—which may seem less interesting to students who seek a clinical correlation.
Despite these factors, ophthalmology remains an extremely competitive residency. This is due to its appeal as a surgical subspecialty with a balanced combination of clinic and operation, fair compensation, controllable lifestyle, and opportunities for public health, global initiatives, and research.
To me, it represents the perfect field: offering a bit of everything, and the opportunity to focus on one of the most elegant areas of the human body. Moreover, restoring vision in an at-need patient is profoundly impactful and the ultimate privilege.
Naturally, I was shocked that very few of my classmates knew anything about the field, and often dismissed it without much consideration. In a study of fourth year medical students who did not choose an ophthalmology residency, a research team lead by Adrienne Scott, MD, a retina specialist at Johns Hopkins Hospital, found that the top 3 reasons students did not pursue the field were insufficient interest, lack of exposure, and a feeling that the field was too specialized.
Furthermore, the lack of underrepresented minority (URM) students in ophthalmology is especially striking. As primary author Marguerite Linz wrote in their paper titled, “Evaluation of Medical Students' Perception of an Ophthalmology Career,” none of 16 observed URM students chose ophthalmology—which is consistent with the 1.3% to 2.4% of URM students nationwide that chose the field from 2005-2015.
Compared to non-URM students, there was a significantly greater proportion of URM students who believed that there were insufficient same-race role models in the field. For URM students especially, this lends itself to a vicious cycle where URM students through lack of perceived mentorship fail to enter the field, leading to fewer URM mentors in the future.
In my opinion, the solution to all these issues lies in the form of a grassroots approach — one that captivates the undifferentiated first year medical student with the depth and breadth of the field, in a clinically-oriented way. While student organizations like ophthalmology interest groups and local community outreach programs like Sightsavers are a great place to start, change also needs to occur from an administrative and course-design standpoint.
I remember asking an ophthalmology mentor involved in curriculum design why his efforts to increase early exposure in medical school had been rejected so often. His answer was that medical schools are usually run by internal medicine and general surgery-based faculty, not subspecialists. His answer was interesting, but revealed a profound reality. Unfortunately, with such limited time and a vast amount of knowledge that medical students need to cover, a disproportionate emphasis is placed on preparing for Step 1 board examinations, with content that heavily covers the core medicine specialties, and barely scratches the surface of fields like ophthalmology, dermatology, otolaryngology, or other specialized fields.
Thus, real systemic change needs to occur such that students can prioritize exploring fields of interest and cultivating their passions, rather than overcommitting to test preparation at the cost of a well-rounded medical exposure.
It is no wonder that misconceptions about the field persist. I once believed the field was too narrow in its focus, with a lack of sufficient ‘medicine.’ Just 1 week into my ophthalmology rotation, I was floored by the depth of systemic manifestations of eye disease, the subtle nuances of the physical exam, and how an ophthalmologist could serve to screen and prevent disease, prescribe plans for medical management, and be a surgeon offering tangible solutions with often immediate results. Not many fields offer this balance, and not many students are aware of this early in training.
I wish I had been shown videos early in my education of cataract surgery, corneal transplantation, and a plethora of other elegant ophthalmic surgeries, involving technical microsurgical approaches and awe-inspiring precision.
I am confident that if students gain early exposure, the allure of the field will organically lead to higher rates of entry. But it can sometimes be difficult to distance ourselves from what we already know and put ourselves in the minds of an undifferentiated student. We may often take for granted realities about the profession that students may not be aware of.
For a field like ophthalmology, which is already notoriously underrepresented in medical school, being keenly aware and conscious about educating our peers becomes far more than just a thought exercise—the future of the field and health of our patients depends on it.
Tejus Pradeep is a rising fourth-year medical student at Johns Hopkins University, School of Medicine in Baltimore, MD. In 2016, he graduated from Rutgers University with a Bachelor of Arts in cell biology and neuroscience, and a Bachelor of Arts in psychology. After graduating medical school, Tejus would like to pursue a career in the field of ophthalmology. The piece reflects his views, not necessarily those of the publication.Health care professionals and researchers interested in responding to this piece or similarly contributing to MD Magazine® can reach the editorial staff by submitting a request here.
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