The proportions of ophthalmology residents pursuing fellowships have been increasing steadily, reaching 81% in 2017 (Figure 1). The rate of subspecialty training has important implications for residency curriculum development and physician workforce planning. This study updates our understanding of factors affecting ophthalmology residents’ career choices to seek subspecialty fellowship training or to practice comprehensive ophthalmology. Our study found several factors that remained important in residents’ decision-making since the 2005 study by Gedde et al, including a desire to acquire special skills and lifestyle considerations.1 Retina, cornea and glaucoma continue to be the three most popular fellowship choices. On the other hand, our study found a few important changes in resident decision-making regarding post-graduate career choices. In 2005, male gender, prestige and perceived more favorable job market were significant predictors of a resident pursuing fellowship training. The present study did not find such associations. Instead, we observed several previously insignificant factors to be correlated with post-graduate career choices of recent residents including marital status, educational debt and interest in academic career.
Fellowship programs focus on the attainment of clinical and research expertise over and above the competencies of residency. The goal of subspecialty training fits well with the desire of fellowship-seeking residents to acquire special skills and to work with new technology. Therefore, these two factors remain among the top factors influencing residents to pursue subspecialty training. The constant popularity of retina, cornea and glaucoma parallels the higher numbers of fellowship positions available in these fields. In 2017, 97 subspecialty training positions were offered for cornea (14.1% increase from 2012), 148 offered for retina (21.3% increase) and 81 offered for glaucoma (24.6% increase). In contrast, 65 positions were offered for pediatric and strabismus ophthalmology (8.3% increase from 2012), 28 position offered for ophthalmic plastic and reconstructive surgery (33.3% increase), 17 positions offered for uveitis (21.4% increase) and even fewer positions for ophthalmic pathology or neuro-ophthalmology.
Lifestyle has remained an important consideration for residents choosing comprehensive ophthalmology since 2005. Work hours/lifestyle and preferred geographic area were both regarded as more important by residents planning to practice comprehensive ophthalmology than by residents entering fellowships. In the free-text response, several residents mentioned family as an influential factor in their decision to practice comprehensive ophthalmology. Studies have found that lifestyle considerations influence post-residency career choices of a range of medical and surgical specialties, including internal medicine, obstetrics and gynecology, radiology and orthopedics. 13 14 15 16 A study by Fang et al. found that lifestyle is among the top two factors influencing trainees’ career choice after ob/gyn residency.13
One factor that we found to be insignificant in influencing the decision of residents to pursue fellowship was gender. In recent years, there has been a push to achieve gender equity in medicine through promoting transparency, routinely assessing compensation equity, minimizing unconscious gender bias, establishing policies regarding family and medical leave and engaging leadership.1718 19 Although gender disparities are still noted in subspecialty training in some other fields of medicine,20 21 22 the present study did not find gender to significantly influence the decision to seek ophthalmology subspecialty training. Gender neutrality in motivations to pursue fellowship training was also observed in a recent study on general surgery residents in the U.S.23 The study concluded that both genders have similar considerations when it comes to fellowship decisions.
Our results suggest that there has been a change in the perception of the job market by graduating residents. Fifteen years ago, residents entering fellowship training rated perceived a favorable job market as more important in their career decision than residents planning to practice comprehensive ophthalmology, whereas the present study found that residents entering comprehensive ophthalmology regarded favorable job market as a more influential factor than residents seeking fellowships. One resident commented that he went on interviews for pediatric fellowship and comprehensive jobs at the same time, received good comprehensive ophthalmology job offers, and realized from fellowship interviews that “another year of training would potentially limit the range of my practice and marketability more than help it in the areas I was looking to practice”. Some residents entering comprehensive ophthalmology said good opportunities for comprehensive ophthalmology arose at the time of their graduation so they accepted the job offer.
A decreased interest in academic medicine is associated with lower odds of going into fellowship training. Some residents choosing comprehensive ophthalmology in our study pointed out in the comment section that burnout from the academic environment deterred them from entering subspecialty training. On the other hand, fellowships might be a good training opportunity for residents interested in future practice in academic institutions. Studies found that academic surgeons who have received fellowship training are less concerned about professional confidence, express greater career satisfaction,24 have more grants proposal submissions, more grants funded, more publications and higher academic ranks than physician-faculty without fellowship training.25 Mentorship is also found to increase the odds of residents pursuing subspecialty training. Studies in other specialties have also found mentorship to be influential in residents’ post-graduate career choices.26 27 28 In addition, a study by Rubeck et al. found that the importance of mentorship is rated higher by physicians who have chosen academic primary care medicine than by physicians who decide to work in nonacademic primary care settings.29 Therefore, mentorship in residency is important for the future distribution of physician workforce.
Educational debt has become a more important factor associated with lower odds of seeking fellowships in our recent analysis. Medical school tuition and student debt levels continue to climb during the past two decades.30 31 The median educational debt for 2003 medical school graduates was between $100,000 and $135,000 depending on public or private medical school.30 In 2018, the median educational debt of medical school graduates was reported to be $195,000,32 a 44% to 95% increase from year 2003. In comparison, the consumer price index increased 40% from 2003 to 2018,33 34 meaning rise in medical trainee debt level has outpaced inflation. In our study, residents entering comprehensive ophthalmology rated earning potential as a more important determinant in their decision-making than their peers seeking fellowship training. One possible reason is that residents seeking fellowship training are more likely to go into academic medicine and the salary difference in academic versus private practice can reach more than $100,000.35 Indeed, studies have shown that higher educational debt is negatively correlated with a career in academic medicine.36 37
One limitation of our study is the suboptimal response rate with the potential selection bias. Although we sent the survey to all residency program directors in the country, only a small percentage of them informed us that they had forwarded the survey to their residents. However, the response rate in our study is within the range of response rates of survey studies in the field of ophthalmology (10%-51%), albeit on the lower end of the spectrum.1 38 39 40 In addition, the survey respondents in our study are a representative group of ophthalmology residents in the U.S. The demographics of our survey respondents are similar to the 2014 data from GME Track for all ophthalmology residents (female 49.0% vs. 44.3%, male 51.0% vs. 55.7%, P = 0.266; Non-Hispanic white 54.9% vs. 55.0%, Asian 33.3% vs. 31.8%, Hispanic 5.2% vs. 5.1%, African-American 1.9% vs. 2.4%, other 4.6% vs. 5.7%, P = 0.968).41 Seventy-seven percent of our respondents were pursuing subspecialty training. This number is comparable to the SF Match data (81%) in 2017. Moreover, the geographic distribution of the residency programs of our survey respondents is comparable to the data from Accreditation Council for Graduate Medical Education (ACGME) for all U.S. ophthalmology residents (northwest 32.0% vs. 30.9%, Midwest 28.1% vs. 24.8%, southeast 17.7% vs. 21.0%, west 17.0% vs. 13.4%, southwest 4.6% vs. 9.8%, P = 0.198). Despite the low response rate, our study results are reasonably generalizable to all U.S. ophthalmology residents.
There are several other limitations of our study. Our survey determined whether a resident enters fellowship or comprehensive ophthalmology based on the match results, which might not be the resident’s original intention. The survey did not ask residents entering comprehensive ophthalmology if they had failed to match for fellowship. According to the SF Match data, 32% of graduating residents failed to match in Ophthalmic Plastic & Reconstructive Surgery fellowships in the 2017 match, and 10% of graduating residents failed to match in other ophthalmology fellowships in December 2018. However, some residents applied to more than one subspecialty fellowships, complicating the interpretation. Additionally, as the survey was distributed after the fellowship match, it is unknown if the match results affected what residents thought about the various factors influencing their career choices.
In conclusion, this study updates our understanding of the decision-making process of ophthalmology residents regarding their career plans. A desire to acquire special skills, working with new technology and mentorship are associated with the decision to enter subspecialty training, while a decreased interest in academic career, higher education debt, anticipated lifestyles and being married are considerations in the choice to practice comprehensive ophthalmology. Through multivariable analysis, our study found that gender, prestige, and perceived favorable job market were no longer significant factors in the choice to enter fellowship training. This study may provide useful information for the improvement of residency and fellowship education and for the planning of physician workforce to meet the vision care needs of the U.S. population.