Factors Affecting Ophthalmology Resident Choice to Pursue Neuro-Ophthalmology Fellowship Training

The number of ophthalmology-trained residents applying to neuro-ophthalmology fellowships has not increased despite a trend toward seeking fellowship training after residency. This study sought to identify factors affecting the choice to pursue or not pursue neuro-ophthalmology fellowship train- ing by graduating ophthalmology residents and recently graduated neuro-ophthalmology fellows

Original Contribution Section Editors: Clare Fraser, MD Susan Mollan, MD Factors Affecting Ophthalmology Resident Choice to Pursue Neuro-Ophthalmology Fellowship Training Alexander M. Solomon, MD, Vivek R. Patel, MD, Courtney E. Francis, MD Background: The number of ophthalmology-trained residents applying to neuro-ophthalmology fellowships has not increased despite a trend toward seeking fellowship training after residency. This study sought to identify factors affecting the choice to pursue or not pursue neuro-ophthalmology fellowship training by graduating ophthalmology residents and recently graduated neuro-ophthalmology fellows. Methods: An anonymous survey was sent to Association of University Professors of Ophthalmology residency directors to distribute to post-graduate Year 4 (PGY4) ophthalmology residents graduating in either 2018 or 2019. A second anonymous survey was distributed via the North American Neuro-Ophthalmology Society (NANOS) Young Neuro-Ophthalmologists listserv to ophthalmology-trained neuro-ophthalmology fellows. A total of 147 respondents, including 96 PGY4 ophthalmology residents not going into neuro-ophthalmology and 51 practicing neuro-ophthalmologists are included. Results: The most common reasons for residents to choose to not pursue further training in neuro-ophthalmology included a stronger interest in other fields, types of patients seen, no intraocular surgery, and the assumption that it is a nonsurgical discipline. The leading factors influencing graduated, ophthalmology-trained fellows to choose neuro-ophthalmology included interest in the clinical diseases treated, interaction with other specialty fields, and a supportive NANOS culture. Interestingly, despite perceptions of graduating residents, two-thirds of the neuroophthalmologists surveyed perform surgery. There were no differences between the 2 groups with respect to the degree Department of Ophthalmology (AMS, CEF), University of Washington School of Medicine, Seattle, Washington; USC Roski Eye Institute (VRP), Keck School of Medicine of the University of Southern California, Los Angeles, California; and Department of Neurological Surgery (CEF), University of Washington School of Medicine, Seattle, Washington. Support for this study is from unrestricted grants from Research to Prevent Blindness to the University of Washington School of Medicine and Keck School of Medicine of the University of Southern California. The sponsor or funding organization had no role in the design or conduct of this research. NANOS Annual Meeting, March 19, 2019, Las Vegas, NV. The authors report no conflicts of interest. Address correspondence to Courtney E. Francis, MD, Department of Ophthalmology, University of Washington School of Medicine, Box 359608, 325 9th Avenue, Seattle, WA 98104; E-mail: [e-mail] 56 of exposure to neuro-ophthalmology in medical school, presence of a dedicated neuro-ophthalmology rotation in residency, or timing of the rotation. Conclusions: There are a variety of factors influencing decisions regarding pursuing neuro-ophthalmology fellowship among ophthalmology residents. The perceived lack of surgical opportunities in neuro-ophthalmology is a deterrent for many. However, a significant number of neuroophthalmologists continue to perform surgery, including intraocular surgery. Repeated exposure later in residency may provide an opportunity to reconsider the field and to reemphasize opportunities to remain surgically involved as a neuro-ophthalmologist. Exposure to the practice patterns of recently graduated neuro-ophthalmologists offers residents in training excellent exposure to the contemporary practice of neuro-ophthalmology. Hence, ensuring trainees receive a balanced exposure to practicing neuro-ophthalmologists across the spectrum of seniority and scope of practice may promote greater interest among ophthalmology residents to pursue a career in neuro-ophthalmology. Journal of Neuro-Ophthalmology 2022;42:56–61 doi: 10.1097/WNO.0000000000001239 © 2021 by North American Neuro-Ophthalmology Society O phthalmology-trained neuro-ophthalmologists are at risk of becoming an endangered species. Despite a trend toward an increase in the proportion of ophthalmology residents applying to fellowship over the past decades (1), there remains a dearth of ophthalmology-trained applicants to neuro-ophthalmology fellowships. We sought to determine the underlying factors contributing to ophthalmology residents’ choices regarding the decision to pursue training in neuro-ophthalmology or not. METHODS Anonymous surveys were sent to 2 different groups. The first survey was sent out via the Association of University Professors of Ophthalmology (AUPO) residency director listserv to reach all graduating post-graduate Year 4 ophthalmology residents who chose not to pursue fellowship in neuro-ophthalmology. The survey was sent out Solomon et al: J Neuro-Ophthalmol 2022; 42: 56-61 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Original Contribution twice to capture residents graduating in either 2018 or 2019. The initial question of each survey included a statement of informed consent to present and publish the anonymous results. We received 96 responses. There may have been a selection bias with respect to which program directors chose to forward the survey to the relevant residents. The second survey was distributed via the North American Neuro-Ophthalmology Society (NANOS) Young Neuro-Ophthalmologists (YONO) listserv to reach recently graduated ophthalmology-trained neuro-ophthalmologists, with 51 responses. Of the respondents, 65% had completed fellowship within the past 5 years, representing the newest members of the profession. Because the survey was sent to subscribers of the YONO listserv, we may have not captured ophthalmologists who completed a neuroophthalmology fellowship but are not actively practicing the subspecialty. Both surveys posed questions regarding the impact of early exposure to neuro-ophthalmology, timing and quality of residency rotations, and details regarding neuroophthalmology faculty, in addition to questions regarding motivation for career choices and factors that appealed to or discouraged the respective groups from applying for neuroophthalmology. The survey distributed to neuroophthalmologists included a 5-point Likert scale for rating the importance of various factors contributing to their choice of neuro-ophthalmology as a career. Outcomes in this study included dichotomous choices regarding exposures during neuro-ophthalmology training rotations in residency. We also asked for explanatory variables, which could be classified as intervals (i.e., number of full-time faculty), ordinal (i.e., postgraduate year for decision making and Likert scale responses), and categorical (i.e., particular types of surgeries performed on rotation). These explanatory variables were assessed using two-sample independent tests for interval variables, the chisquare test for ordinate variables, or the Fisher exact test for either categorical variables or dichotomous choices. A twosided P value of ,0.05 was considered statistically significant. All analyses used IBM SPSS Statistics for Windows, Version 26.0. (Armonk, NY: IBM Corp). RESULTS Resident surveys were completed by 51 graduates in 2018 and 45 graduates in 2019. Surveys of neuroophthalmologists had 51 responses including 33 who had completed fellowship in the past 5 years. Of the graduating residents, 74% were electing to pursue fellowship, and by design none of these included neuro-ophthalmology. Survey responses were received from residents going into all other subspecialties and comprehensive ophthalmology practices with the exceptions of oncology and pathology, including 25 comprehensive (26%), 22 surgical retina (23%), 18 Solomon et al: J Neuro-Ophthalmol 2022; 42: 56-61 glaucoma (19%), 15 cornea (16%), 11 pediatric ophthalmology (11%), 9 oculoplastics (9%), 3 uveitis (3%), and 3 medical retina (3%). A comparison between responses obtained from the 2 surveyed groups is depicted in Table 1. There was no difference between the 2 groups regarding exposure to neuroophthalmology in medical school, the number of respondents with dedicated neuro-ophthalmology rotations, exposure to surgical neuro-ophthalmology during neuroophthalmology rotations, or the timing of the rotation. There was also no significant difference in the total number of faculty neuro-ophthalmologists within their residency, with an average of 2.2 for neuro-ophthalmology fellowship graduates and 2.6 for residents who eventually chose another field. All respondents were more likely to rate the exposure to neuro-ophthalmology research to be inferior to other specialties; however, recent neuro-ophthalmology fellows were significantly more likely to feel that research, clinical exposure, and quantity of time in neuroophthalmology were inadequate. Of note, there was also a significant difference in the timing of subspecialty choice, with the final decision being made later for neuroophthalmologists, whose average post-graduate year of decision was 3.1 compared with 2.0 for residents selecting other specialties. Moreover, those who pursued neuroophthalmology fellowship were significantly more likely to have had exposure to cataract surgery as part of their neuroophthalmology rotation and, interestingly, less likely to have exposure to optic nerve sheath fenestrations. Fellowshiptrained neuro-ophthalmologists perceived their rotations to be shorter than other subspecialties and were more likely to think that the didactics and clinical exposure were inferior. Factors that accounted for the decision to not chose neuro-ophthalmology are represented in Table 2, whereas those that influenced a choice to pursue neuroophthalmology for former fellows, measured using a Likert scale, are shown in Table 3. The most common reasons graduating residents chose another field were interest in another subspecialty, types of patient seen, a lack of intraocular surgery, and a lack of surgery in general. Salary and restriction to primarily academic positions were noted as concerns to a subset of respondents, and a minority also felt that the field was too difficult. Few to none were worried about a paucity of jobs or the lack of a formalized matching process (i.e., SF Match or equivalent). By contrast, the clinical diseases treated was the most important reason neuro-ophthalmologists selected the field followed by interaction with other medical specialties such as neurosurgery and neurology as well as NANOS culture. Absence of surgery or intraocular surgery followed distantly by the types of surgery were rated as the least important factors in the decision-making process. Finally, Table 4 demonstrates the surgical practices of the neuro-ophthalmologists surveyed. The majority of 57 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Original Contribution TABLE 1. Training exposure and characteristics NeuroGraduating Residents Ophthalmologists (n = 51) (n = 96) Timing of subspecialty choice MS PGY1 PGY2 PGY3 PGY4 Timing of excluding neuro-ophthalmology MS PGY1 PGY2 PGY3 PGY4 Would consider neuro-ophthalmology if combined with another field (i.e., pediatrics, oculoplastics, or glaucoma), or did another fellowship Had exposure to neuro-ophthalmology in medical school Dedicated neuro-ophthalmology rotation in residency Year of neuro-ophthalmology rotation in residency PGY2 PGY3 PGY4 Quantity of time spent on rotation relative to other specialties Less Equal More Quality of clinical exposure to neuro-ophthalmology Inferior On par Superior Quality of didactics to neuro-ophthalmology Inferior On par Superior Quality of research exposure to neuro-ophthalmology Inferior On par Superior Average number of neuro-ophthalmology trained faculty Average neurology trained Average ophthalmology trained Neuro-ophthalmology faculty performing surgeries at residency institution Exposure to surgery during neuro-ophthalmology rotation Cataracts Strabismus Orbital Lid Glaucoma Temporal artery biopsy Optic nerve sheath fenestration Stastical analysis used for P-values: a = chi-square test; MS, medical school; PGY, postgraduate year. b = Fisher exact test; respondents perform surgery, and of those, the most common surgeries performed were temporal artery biopsies. Despite a general impression among residents that there is a lack of intraocular surgery, many practitioners performed cataract surgery and/or strabismus surgery. Orbital, oculo58 c 11 (12%) 5 (5%) 22 (23%) 45 (48%) 2 (12%) 1 (2%) 2 (4%) 8 (16%) 18 (35%) 22 (43%) N/A P ,0.001a 16 15 39 25 0 43 (45%) N/A N/A 56 (58%) 78 (81%) 27 (55%) 42 (82%) 0.863b 1.000b 70 (73%) 65 (68%) 16 (17%) 32 (63%) 23 (45%) 13 (26%) 0.259b 0.013b 0.276b 0.001a 24 (25%) 63 (66%) 9 (9%) 31 (61%) 15 (29%) 5 (10%) N/A 0.010a 12 (13%) 47 (49%) 37 (38%) 16 (31%) 15 (29%) 20 (39%) 0.066a 8 (8%) 42 (44%) 46 (48%) 11 (22%) 21 (41%) 19 (37%) 36 (38%) 52 (54%) 8 (8%) 2.6 (1.4) 1.0 (1.1) 1.7 (1.1) 57 (59%) 44 (46%) 7 (13%) 33 (62%) 8 (15%) 3 (6%) 1 (100%) 32 (60%) 29 (55%) 29 (57%) 17 (33%) 5 (10%) 2.2 (1.6) 0.7 (1.0) 1.6 (1.1) 27 (55%) 26 (51%) 13 (46%) 19 (68%) 3 (11%) 3 (11%) 0 (0%) 18 (64%) 8 (29%) 0.048a 0.159c 0.184c 0.485c 0.487b 0.605b 0.002b 0.618b 0.740b 0.411b 1.000b 0.731b 0.035b = two-sample independent test. plastics, and glaucoma surgeries were among the least common procedures performed by neuro-ophthalmologists. Of note, the respondents were also asked if they had pursued further subspecialty training beyond neuro-ophthalmology. Of the 51 respondents, 33 (64.71%) had not completed Solomon et al: J Neuro-Ophthalmol 2022; 42: 56-61 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Original Contribution TABLE 2. Factors influencing decision not to pursue neuro-ophthalmology Graduating Residents (n = 96) Salary Lack of jobs No surgery No intraocular surgery Perceived difficulty of the field Type of patients seen Stronger interest in another field Lack of participation in SF match Jobs primarily in academic departments 38 7 55 63 19 62 65 1 31 further fellowship training, and of the remaining respondents, 9 (17.65%) sought additional training in pediatrics, 5 (9.8%) in oculoplastics, 3 (5.88%) in glaucoma, and 1 (1.96%) in medical retina. These results demonstrate that not all neuro-ophthalmologists performing surgery required additional subspecialty training. Surgical practices can be maintained with only a neuro-ophthalmology fellowship, particularly if a program’s training is robust and facilitates continued learning and practice of surgical techniques. CONCLUSIONS Although there has been a general increase in the proportion of ophthalmology residents applying to fellowship, this trend has not extended to ophthalmology-trained applicants to neuro-ophthalmology fellowship programs. A variety of factors may contribute to the choice of pursuing one ophthalmic subspecialty over another. Previous publications have aimed to determine underlying factors leading residents to pursue additional glaucoma (1) training and pediatric ophthalmology (2) fellowships. This survey sought to (40%) (7%) (57%) (65%) (20%) (65%) (69%) (1%) (32%) determine attitudes toward neuro-ophthalmology, both of graduating residents choosing other fields and recently graduated neuro-ophthalmologists. Although no single survey is able to completely define attitudes and preferences that lead to the selection of a fellowship, the current study provides some insight regarding the factors young ophthalmologists are using to parse through their subspecialty options. Neuro-ophthalmology is a field that thrives on the diversity of its practitioners’ training. As a fundamentally hybrid subspecialty, the practice, growth, and development of neuro-ophthalmology is uniquely enhanced by contributions and perspectives from both core ophthalmology and neurology-trained neuro-ophthalmologists. The decrease in ophthalmology-trained applicants jeopardizes this unique aspect of the field; continued investment and improved understanding of potential candidates’ assumptions and motivations is crucial. The disparity in surgical experience, the practice of surgery within neuro-ophthalmology, and attitudes toward surgical practices of graduating residents need to be considered further. 67% of neuro-ophthalmologists who TABLE 3. Factors influencing former fellows’ decision to pursue neuro-ophthalmology Neuro-Ophthalmologists (n = 50) except as Noted by*† Interest in the clinical diseases treated Research areas Patient demographics* Interaction with other medical specialties NANOS culture Lifestyle Types of surgery performed No surgery No intraocular surgery Job availability Jobs primarily in academic† departments Not Important Slightly Important Somewhat Important Moderately Important Very Important 0 10 14 0 8 11 19 25 26 15 12 0 14 12 5 6 7 4 1 3 3 8 1 10 11 7 9 20 6 5 4 16 12 4 6 5 16 12 7 8 2 4 11 11 45 9 6 22 12 5 7 2 3 5 8 Survey Question: Rate the following factors on a scale of 1–5 (with 5 very important and 1 not important) in terms of how much they influenced your decision to pursue fellowship in neuro-ophthalmology. *n = 49 (participant skipped factor). † n = 51 (an additional participant ranked this factor). Solomon et al: J Neuro-Ophthalmol 2022; 42: 56-61 59 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Original Contribution TABLE 4. Surgical practices of neuro-ophthalmologists Neuro-Ophthalmologists (n = 51) No surgery Cataracts Strabismus Orbital Lid Glaucoma Temporal artery biopsies Optic nerve sheath fenestrations responded to this survey maintain surgical practices, including 33% who perform cataract surgery. Taken overall, this is consistent with the exposure graduating residents and eventual neuro-ophthalmologists received during residency to surgical neuro-ophthalmology faculty (59% vs 55%). However, 57% of graduates reported that absence of surgery was a reason for not selecting neuro-ophthalmology. This discordance may partly be attributable to the fact that only 46% of graduates were exposed to surgical neuroophthalmology during their rotation—hence, actually involving residents in the surgeries performed by neuroophthalmologists may be important. In addition, it is important to note that only 13% of graduating residents choosing other fields were exposed to cataract surgery within their neuro-ophthalmology rotations, in comparison to 46% for those who eventually chose neuroophthalmology fellowship. Hence, it seems that maintaining some form of surgical exposure during the neuroophthalmology rotation, regardless of type of procedures performed, may have an impact on the trainee’s perception of neuro-ophthalmology as a “surgical” discipline. It should also be noted that in further comments provided by respondents, one response specified that the number of surgeries was insufficient—future surveys may consider exploring whether differences between no surgeries and insufficient surgical numbers may be factors contributing to this perception. A similar number of recent fellows had a dedicated neuro-ophthalmology rotation compared to graduating residents pursuing other subspecialties. Although it logically follows that this would provide an opportunity to fully engage in all aspects of the rotation, it is interesting to note that on, average neuro-ophthalmologists tended to feel their rotations were shorter with less satisfactory clinical and didactic exposure compared with other fields. By contrast, residents choosing to pursue other career directions felt their clinical and didactic exposure to neuro-ophthalmology was at least on par with other subspecialty areas. However, graduating respondents did feel that exposure to research within neuro-ophthalmology lagged behind other areas, potentially contributing to sentiments among this group that they had a stronger interest in other fields (65%). Although personal interests will always vary, exposure to 60 16 17 17 6 9 3 23 12 (31%) (33%) (33%) (12%) (18%) (6%) (45%) (23%) innovation and advances in the field and the impact this may have on future career choices cannot be underestimated. Some graduating respondents commented on the perceived lack of curative interventions as a factor dissuading them from pursuing a career in neuro-ophthalmology. Wherever possible, increasing exposure to cutting-edge research developments within neuro-ophthalmology and neuroscience in general may increase appeal among aspiring young ophthalmologists. This study was limited by timing and constituency of both groups surveyed. First, a relatively small proportion of graduating residents over the course of 2 years responded to the survey, which could make it less generalizable to the experience across training programs throughout the United States, particularly given that some of these residents represented 2 consecutive classes from the same programs. Graduating residents inherently can only evaluate a potential career in neuro-ophthalmology based on limited experience and their perceptions and expectations of their chosen subspecialty or practice modality. The timing of the survey cannot capture the possibility that some graduating residents may choose to pursue further training in neuroophthalmology after completing an initial fellowship or time as a comprehensive ophthalmologist. However, this group is assumed to be relatively small. As mentioned previously, a survey designed to increase granularity regarding types, volumes, and settings of potential surgical practices may provide more useful information. Fellowship-trained neuro-ophthalmologists are frequently exposed to the field in medical school leading to an early interest which continues through residency. Although the majority of neuro-ophthalmologists practice full-time neuro-ophthalmology, this includes surgery for a large subset of current practitioners. There is an important discordance between the perceived lack of surgical opportunities within a neuro-ophthalmic career and reality. This may represent an opportunity for programs and NANOS to improve education in this regard because our survey indicates that this erroneous perception serves as a deterrent for many residents. It may be worthwhile to simply emphasize to our trainees that one does not need to abandon surgery, including cataract surgery, if they choose a career in neuro-ophthalmology. To improve recruitment Solomon et al: J Neuro-Ophthalmol 2022; 42: 56-61 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Original Contribution of ophthalmology residents into neuro-ophthalmology, we need to continue early exposure and foster interest in medical students while promoting the varied surgical and research opportunities within our field to ophthalmology residents. Repeated exposure later in residency may provide an opportunity to reconsider the field and remind them of the clinical, research, and surgical aspects available within the discipline. Emphasizing these aspects, a plethora of job opportunities, while benefitting from a supportive subspecialty society, may be effective strategies to improve recruitment of graduating ophthalmologists into neuroophthalmology. We need to continue to advocate for young neuro-ophthalmologists early in their career as they provide the most direct example of the practice of neuroophthalmology to residents in training, and serve as excellent ambassadors to the field. Our survey supports the commonly held belief among trainees that compensation as a neuro-ophthalmologist lags behind other subspecialties. Although heavily procedural, high-volume disciplines are generally better compensated than cognitive specialties across medicine, it is important to emphasize that surgical opportunities can coexist within a neuroophthalmic practice, and this in turn would have a positive impact on salary. Department or practice leaders can factor in surgical revenue for such faculty, potentially contributing to a compensation level more in line with other subspecialties. Increasing opportunities for neuro-ophthalmology fellowship training combined with related disciplines such as orbit/oculoplastics or pediatric ophthalmology and strabismus may be worthwhile exploring. This would of course require interest and support from our colleagues in other subspecialties, but establishing such training programs at institutions where there is interest and expertise may prove Solomon et al: J Neuro-Ophthalmol 2022; 42: 56-61 fruitful. In addition, as an increasing number of recently trained neuro-ophthalmologists are “dual-fellowship” trained, or at least have some form of a surgical neuroophthalmology practice, supporting these individuals and institutions in establishing such fellowship training opportunities may help invigorate interest among trainees to pursue a career within which neuro-ophthalmology is a fundamental component. For those fellowships without specific neuro-ophthalmologic surgical training, creating an avenue to allow trainees to continue performing cataract surgery during fellowship would provide opportunity to maintain surgical skills, preparing them to continue a surgical practice after training. STATEMENT OF AUTHORSHIP Category 1: a. Conception and design: C. E. Francis and V. R. Patel; b. Acquisition of data: C. E. Francis; c. Analysis and interpretation of data: C. E. Francis, V. R. Patel, and A. M. Solomon. Category 2: a. Drafting the manuscript: A. M. Solomon; b. Revising it for intellectual content: C. E. Francis, V. R. Patel, and A. M. Solomon. Category 3: a. Final approval of the completed manuscript: C. E. Francis. ACKNOWLEDGMENTS The authors thank Leona Ding, MS, for her assistance with statistical analysis. REFERENCES 1. Gedde SJ, Budenz DL, Haft P, Lee Y, Quigley HA. Factors affecting the decision to pursue glaucoma fellowship training. J Glaucoma. 2007;16:81–87. 2. Hasan SJ, Castanes MS, Coats DK. A survey of ophthalmology residents’ attitudes toward pediatric ophthalmology. J Pediatr Ophthalmol Strabismus. 2009;46:25–29. 61 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited.