Identification of Factors that May Predict Career Trajectory Among Neuro-Ophthalmology Fellows

Background: There is modest literature regarding fellowship applicant factors that may predict future career achievement. We aim to characterize neuro-ophthalmology fellows and identify and analyze characteristics that may predict future career trajectory. Methods: Data, including demographic information, academic background, scholarly activities, and practice information, were collected using publicly available sources, on individuals who completed neuro-ophthalmology fellowships from 2015 to 2021. Summary statistics describing the cohort were calculated. Prefellowship characteristics were compared with postfellowship characteristics to evaluate which prefellowship characteristics may predict postfellowship academic productivity and career achievement. Results: Data were collected on 174 individuals (41.6% men, 58.4% women). Sixty-five percent were residency-trained in ophthalmology, 31% neurology, 1.7% both, and 1.7% pediatric neurology. Fifty-eight percent completed residency in the US, 8% in Canada, 32% internationally, and 2% in multiple locations. Among those practicing in the US/Canada, 63.8% practice at academic centers, 35.3% private practice, and 0.9% at both. Thirty-one percent completed additional subspecialty training and 17.8% additional graduate degrees. Completion of additional fellowship training or graduate degrees, and publication of more papers before fellowship, correlated with later academic productivity. There were no significant correlations between completion of an additional fellowship or graduate degree with current practice environment or attainment of leadership roles. There were no significant correlations between total publishing productivity prefellowship and practice environment or leadership roles postfellowship. Conclusions: Additional graduate degrees/subspecialty training, and prefellowship academic productivity, correlated with later academic productivity among neuro-ophthalmologists, suggesting that these metrics may be helpful in predicting future academic performance among fellowship applicants.

Original Contribution Section Editors: Clare Fraser, MD Susan Mollan, MD Identification of Factors that May Predict Career Trajectory Among Neuro-Ophthalmology Fellows Aakash N. Patel, BA, Jing Tian, MS, Amanda D. Henderson, MD Background: There is modest literature regarding fellowship applicant factors that may predict future career achievement. We aim to characterize neuro-ophthalmology fellows and identify and analyze characteristics that may predict future career trajectory. Methods: Data, including demographic information, academic background, scholarly activities, and practice information, were collected using publicly available sources, on individuals who completed neuro-ophthalmology fellowships from 2015 to 2021. Summary statistics describing the cohort were calculated. Prefellowship characteristics were compared with postfellowship characteristics to evaluate which prefellowship characteristics may predict postfellowship academic productivity and career achievement. Results: Data were collected on 174 individuals (41.6% men, 58.4% women). Sixty-five percent were residencytrained in ophthalmology, 31% neurology, 1.7% both, and 1.7% pediatric neurology. Fifty-eight percent completed residency in the US, 8% in Canada, 32% internationally, and 2% in multiple locations. Among those practicing in the US/Canada, 63.8% practice at academic centers, 35.3% private practice, and 0.9% at both. Thirty-one percent completed additional subspecialty training and 17.8% additional graduate degrees. Completion of additional fellowship training or graduate degrees, and publication of more papers before fellowship, correlated with later academic productivity. There were no significant correlations between completion of an additional fellowship or graduate degree with current practice environment or attainment of leadership roles. There were no significant correlations between total publishing productivity prefellowship and practice environment or leadership roles postfellowship. Conclusions: Additional graduate degrees/subspecialty training, and prefellowship academic productivity, correlated with later academic productivity among neuroophthalmologists, suggesting that these metrics may be Medical College of Georgia (ANP), Augusta University, Augusta, Georgia; Division of Biostatistics (JT), Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore, Maryland; Division of NeuroOphthalmology (ADH), Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore, Maryland; and Department of Neurology (ADH), Johns Hopkins School of Medicine, Baltimore, Maryland. Supported by Wilmer Biostatistics Core Grant P30EY001765. A. N. Patel, J. Tian: no conflicts of interest to disclose; A. D. Henderson: Horizon Pharma, Springer Nature. Address correspondence to Amanda D. Henderson, MD, Division of Neuro-Ophthalmology, Wilmer Eye Institute, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Wilmer 233, Baltimore, MD 21287; E-mail: [e-mail] Patel et al: J Neuro-Ophthalmol 2023; 43: 303-306 helpful in predicting future academic performance among fellowship applicants. Journal of Neuro-Ophthalmology 2023;43:303–306 doi: 10.1097/WNO.0000000000001836 © 2023 by North American Neuro-Ophthalmology Society H istorically, the residency and fellowship selection processes have focused particularly on objective cognitive metrics (e.g., standardized test scores, grades). However, it has been suggested that over-reliance on these metrics emphasizes only one (medical knowledge) of the 6 core competencies (medical knowledge, patient care, systems-based practice, practice-based learning and improvement, professionalism, and interpersonal and communication skills) as defined by the Accreditation Council for Graduate Medical Education (ACGME). Emphasis on cognitive abilities does not clearly lead to the selection of clinically competent and successful future physicians. For example, studies of different surgical specialties found that excellence within a team sport or musical performance was the most predictive factor of positive faculty evaluations, that is, more so than cognitive factors.1–3 Evaluating applicants on a single data point, such as a test score, provides a narrow picture of the overall candidate. Further recognition and emphasis of noncognitive characteristics are essential in holistic review, which has been proven to increase diversity within graduate medical education (GME)4 and ultimately lead to improved patient care outcomes.4 However, data regarding precisely which characteristics to highlight when selecting fellows are lacking. There is a paucity of literature regarding neuroophthalmology fellowship applicant factors that may predict future career achievement. However, this information is needed not only to select top applicants from the existing applicant pool, but also to target recruitment strategies for potential future applicants (i.e., medical students and ophthalmology and neurology residents). Neuro-ophthalmology currently operates without a formal “match,” and each fellowship director and/or institution sets their own requirements regarding application materials, primary selection criteria, and fellow selection timelines. However, a formal match is currently under development, with a plan for implementation for fellows training in the 2024–2025 academic year. With the implementation of a centralized application process and uniform timeline for application, interview, and selection of 303 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Original Contribution fellows, programs may expect an increase in the number of applications for each neuro-ophthalmology fellowship position. This anticipated increase in the number of applicants for a given position corresponds with a greater need to enhance application review procedures before extending interview invitations. In this study, we aim to identify and analyze neuro-ophthalmology fellow characteristics that may predict future career achievement in our field. METHODS Former neuro-ophthalmology fellows who completed Association of University Professors of Ophthalmology (AUPO)-compliant neuro-ophthalmology fellowships between 2015 and 2021 were identified from AUPO/ North American Neuro-Ophthalmology Society (NANOS) records that are updated and published online annually (https://www.nanosweb.org/files/Fellowship%20Page/ AUPO_Compliant_Fellowship_Programs.pdf).5 The institutional review board of the Johns Hopkins University School of Medicine determined that this study qualified as exempt research (IRB00290652). Data regarding these fellows, including demographic information, academic background (e.g., neurology vs ophthalmology trained, medical degree type, additional graduate degrees, institutions of training, country of training), clinical and academic activities (e.g., current academic title(s), number and type of publications, h-index, surgical vs nonsurgical practice, whether additional subspecialties are practiced), and current practice environment (academic institution, private practice, or both) were collected. Publicly available data sources (e.g., PubMed, Scopus, Web of Science, online CVs, Doximity, LinkedIn, Google Scholar, and fellowship program and practice websites) were used to collect data, and data were inputted and organized in an Excel spreadsheet. Summary statistics describing the cohort were calculated. Prefellowship characteristics were compared with postfellowship characteristics to evaluate which prefellowship characteristics may be predictive of postfellowship academic productivity and career achievement. Continuous variables were evaluated using the Wilcoxon rank sum test. Categorical variables were compared using Chi-square or Fisher exact test. Ranked variables were compared using Spearman correlation. Statistical significance was set at P , 0.05. For the purpose of discussion in this study, academic productivity was defined by number and type of publications (case reports, review articles, original papers) and hindex. h-Index was calculated using a widely accepted methodology, based on an author’s list of publications in descending order of number of times cited. The index value equals the number of papers (N) in the list that have N or more citations. The Scopus database was used for these calculations. Career achievement measures also included attainment of leadership roles such as division chief, program director, or research director. 304 RESULTS Sex Data were collected on 174 individuals who completed a neuro-ophthalmology fellowship between 2015 and 2021. Seventy-seven were men (41.6%) and 101 women (58.4%). Residency Type and Location One hundred fourteen (65.5%) neuro-ophthalmology fellows were residency-trained in ophthalmology, 54 (31%) in neurology, 3 (1.7%) in both ophthalmology and neurology, and 3 (1.7%) in pediatric neurology. One hundred one (58%) completed residency in the United States, 14 (8%) in Canada, 56 (32.2%) internationally, and 3 (1.7%) in US/ Canada and internationally. Fellows with international residency training were more likely to be ophthalmology-trained (89.3%) than fellows who completed their residencies in the US/Canada (55.7%) (P = 0.00003). For physicians practicing in the US and Canada for whom data were available, similar proportions of those who were ophthalmology- vs. neurologytrained were practicing in academic environments (63% vs 64%, respectively, not statistically significant). Additional Education and Training Fifty-four neuro-ophthalmology fellows (31%) completed additional subspecialty training. The most common additional subspecialty was pediatric ophthalmology (21), followed by oculoplastic and reconstructive surgery (18), neuroimmunology (7), ophthalmic pathology (2), vascular neurology (1), retina (1), neurophysiology (1), movement disorders (1), glaucoma (1), and cornea (1). Of the fellows, 31 (17.8%) completed additional graduate degrees. The most common graduate degree was a PhD (13), followed by MPH (6), MSc (4), MS (2), MHS (2), MBA (2), PharmD (1), and OD (1). Practice Environment and Leadership Roles Among those practicing neuro-ophthalmology in the US/ Canada, 74 (63.8%) currently practice at academic centers, 41 (35.3%) in private practice, and one (0.9%) in both. Seven (4%) of the former fellows evaluated currently hold leadership positions (residency program director, associate residency program director, division director, and/or assistant director of research). Correlations With Additional Subspeciality Training Those with additional subspecialty fellowship training published more papers overall (median 4 vs 2, P = 0.0019), more review articles (median 0 vs 0, mean 0.8 vs 0.3, P = 0.0205), more original research papers (median 2 vs 1, P = 0.006), and more case reports (median 1 vs 0, P = 0.0154) before their neuro-ophthalmology fellowships than those without additional training. They also had higher h-indices (median 4 vs 2, P = 0.004). Those with additional subspecialty fellowship Patel et al: J Neuro-Ophthalmol 2023; 43: 303-306 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Original Contribution training published more papers overall (median 6 vs 3, P = 0.0095), original research papers (median 2 vs 1, P = 0.0051), and case reports (median 2 vs 1, P = 0.0003) during/after their neuro-ophthalmology fellowships than those without additional subspecialty training. Whether or not additional subspecialty fellowship training had been completed did not correlate with current practice environment (academic center vs private practice) nor with attainment of leadership roles (P = 0.43). Correlations With Postfellowship Practice Environment Current practice environment (academic center vs private practice) did not correlate with number of papers (overall or any individual type) published before neuro-ophthalmology fellowship. Those currently practicing in academic centers published more papers overall (median 6 vs 2, P , 0.0001), more case reports (median 2 vs 1, P = 0.0017), more review articles (median 1 vs 0, P = 0.0073), and more original research papers (median 2 vs 1, P = 0.0008) during/after their neuroophthalmology fellowships than those in private practice. Correlations With Additional Graduate Degree(s) Those with an additional graduate degree published more overall papers (median 5 vs 2, P = 0.0004), more case reports (median 1 vs 0, P = 0.0265), and more original research papers (median 4 vs 1, P = 0.0002) before their neuro-ophthalmology fellowships, and they also had higher h-indices (median 4 vs 2, P = 0.0017). Those with an additional graduate degree also published more overall papers (median 7 vs 3, P = 0.0444), review articles (median 1 vs 0, P = 0.0405), and original research papers (median 2 vs 1, P = 0.0206) during/after their neuro-ophthalmology fellowships. Holding an additional graduate degree did not correlate with current practice environment nor with attainment of leadership roles (P = 0.63). Table 1 shows prefellowship characteristics that were found to correlate with postfellowship scholarly productivity. Correlations With Publication History In addition to the other characteristics reported, we found that prefellowship scholarly productivity correlated with later scholarly productivity. Total number of publications before fellowship correlated with number of publications during/ after fellowship (Spearman correlation: 0.42, P , 0.0001) and number of original research papers published during/ after fellowship (Spearman correlation: 0.29, P = 0.0001). Number of original research papers before fellowship correlated with total number of publications during/after fellowship (Spearman correlation 0.23, P = 0.0028) and with number of original research papers published during/after fellowship (Spearman correlation 0.40, P , 0.0001). CONCLUSIONS Training successful physicians is a key focus of every medical school, residency, and fellowship program. This study of 174 recently graduated neuro-ophthalmologists is the first to delve into career outcomes based on pre–neuroophthalmology fellowship characteristics and performance. An additional subspeciality fellowship was associated with more publications before and during/after fellowship, along with an overall higher h-index. These findings may be explained because fellowships often require formal scholarly activity during the program and also typically require additional time spent in an academic environment. Alternatively, it also is possible that physicians who complete multiple fellowships are more academically inclined. TABLE 1. Characteristics predictive of postfellowship scholarly productivity Median (Range) No Additional Subspecialty Training Additional Subspecialty Training P 1.0 (0.0–72.0) 2.0 (0.0–27.0) 0.0003 1.0 (0.0–26.0) 2.0 (0.0–20.0) 0.0051 3.0 (0.0–101.0) 6.0 (0.0–33.0) 0.0095 # of case reports during/after fellowship # of original research papers during/after fellowship # of publications during/after fellowship # of original research papers during/after fellowship # of publications during/after fellowship # of review articles during/after fellowship h-index Patel et al: J Neuro-Ophthalmol 2023; 43: 303-306 No Additional Degree Additional Degree P 1.0 (0.0–20.0) 2.0 (0.0–26.0) 0.0206 3.0 (0.0–101.0) 7.0 (0.0–40.0) 0.0444 0.0 (0.0–13.0) 1.0 (0.0–9.0) 0.0405 2.0 (0.0–17.0) 4.0 (0.0–15.0) 0.0017 305 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Original Contribution Likewise, our study finds that graduates who practice neuro-ophthalmology in academic settings published more during and after, but not before, fellowship, when compared with peers who entered private practice. This finding indicates that, interestingly, in our group, prefellowship scholarly productivity did not correlate with the later choice to remain in academic medicine and is consistent with the idea that exposure to the academic environment during the fellowship itself may contribute significantly to the ultimate choice of practice environment. Our finding is similar to that reported in a previous study evaluating neurosurgeons.6 Additional studies on characteristics that predict choosing a career in academic neuro-ophthalmology would be helpful for fellowship directors who are seeking to train future academic neuro-ophthalmologists. When examining a different metric of academic inclination, our study found that the number of publications before fellowship was predictive of number of publications during and after neuro-ophthalmology fellowship, suggesting a true correlation between past and future scholarly productivity among our group. A prior study reported that scholarly activity was ranked sixth of 25 characteristics in terms of importance with regard to ophthalmology resident selection,7 and our finding suggests that use of this metric may be appropriate when considering the potential for an individual to make lasting contributions in academic medicine. Our study further finds that fellows with additional training, in the form of a graduate degree in addition to an MD or an additional subspecialty fellowship, had significantly more publications before and during/after their neuroophthalmology fellowships. This finding may be partially explained by the formal research requirement of many graduate and training programs. However, with the evidence of continued scholarly productivity, it also is likely that those who pursue additional education may do so to develop research skills and because they enjoy performing scholarly work. Strengths A key strength of this analysis is that it includes all neuroophthalmology fellows who graduated from AUPO-compliant neuro-ophthalmology fellowship programs from 2015 to 2021, and the results are therefore generalizable and can inform neuro-ophthalmology program directors nationwide. Our study can help guide program directors when/if applicant numbers for each individual fellowship position rise with the implementation of the formal match process. To our knowledge, this is the first study of its kind within neuro-ophthalmology, and other studies in different specialties were often single institution or limited by institutional or program ranking. Limitations There are several limitations to our current study. The study cohort only includes recently graduated neuro- 306 ophthalmologists, resulting in a relatively short follow-up on outcomes such as leadership positions, which often take considerable time to attain. Likewise, long-term follow-up would better inform which characteristics predict long-term scholarly achievement. Further study of this and other cohorts in years to come will be required to address these issues. In addition, our study relies on publicly available data sources that were limited in some cases, particularly for those neuroophthalmology fellows who trained or practiced abroad. Some online sources may also misattribute journal articles to those with similar names. Although we tried to account for this in our h-index calculations with manual review of the attributed articles, it is possible that there were some residual misattributions. Moreover, the temporal delay in research and publication of a manuscript may inaccurately describe when such scholarly activity actually occurred. Our outcome criteria such as publication count, practice environment, and leadership positions do not necessarily encapsulate the successful career for every individual. Others may consider different or additional factors, such as patient outcomes, financial compensation, job satisfaction, and awards, when defining a successful career. Further study is needed to address these issues. STATEMENT OF AUTHORSHIP Conception and design: J. Tian, A. D. Henderson; Acquisition of data: A. N. Patel, A. D. Henderson; Analysis and interpretation of data: A. N. Patel, J. Tian, A. D. Henderson. Drafting the manuscript: A. N. Patel, A. D. Henderson; Revising the manuscript for intellectual content: J. Tian, A. D. Henderson. Final approval of the completed manuscript: A. N. Patel, J. Tian, A. D. Henderson. REFERENCES 1. 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Preresidency publication number does not predict academic career placement in neurosurgery. World Neurosurg. 2017;101:350– 356. 7. Nallasamy S, Uhler T, Nallasamy N, Tapino PJ, Volpe NJ. Ophthalmology resident selection: current trends in selection criteria and improving the process. Ophthalmology. 2010;117:1041–1047. Patel et al: J Neuro-Ophthalmol 2023; 43: 303-306 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited.