A career in medical ophthalmologyBMJ 2008; 336 doi: https://doi.org/10.1136/bmj.39532.573113.7D (Published 19 April 2008) Cite this as: BMJ 2008;336:s139
- Catherine M Guly, specialty registrar in medical ophthalmology 1,
- John A Olson, consultant ophthalmic physician1,
- Graeme J Williams, consultant ophthalmic physician2
Catherine Guly, Graeme Williams, and John Olson take a look at the role of the ophthalmic physician and career opportunities in medical ophthalmology
Ophthalmic physicians, or medical ophthalmologists, specialise in the diagnosis and management of medical conditions affecting the eye, orbits, and visual pathways. More than 50% of new ophthalmic referrals present with a medical rather than a surgical problem, so medicine comprises a large portion of the workload in ophthalmology.1
The start of a new specialty
In 1995, the Royal College of Physicians and the Royal College of Ophthalmologists jointly established a training programme for medical ophthalmology, which incorporated internal medicine and ophthalmology, resulting in medical ophthalmology becoming a specialty in its own right.2
The role of the ophthalmic physician
Ophthalmic intervention alone is often not enough to prevent visual impairment in many systemic conditions that affect the eye, such as diabetes, hypertension, atherosclerosis, inflammation, infection, and malignancy. Ophthalmic physicians, with their additional training in internal medicine and focused ophthalmic training, have a specialist role in a number of areas of ophthalmology.
Ocular inflammatory disorders may be the first manifestation of systemic disease and it is important that the whole patient is investigated and treated, not just the presenting organ. Ophthalmic doctors may, for example, be involved in managing diabetes retinal screening programmes or in identifying–and reducing–the risk of cardiovascular and cerebral vascular events.
Therapeutic procedures performed by ophthalmic physicians include laser therapy and intraocular, periocular, and botox injections. Intraocular injections of antiviral and antimicrobial drugs are used in infective uveitis, and antivascular endothelial growth factor agents have revolutionised the treatment of age related macular degeneration.
Who is suited to medical ophthalmology?
Medical ophthalmology welcomes trainees who have a keen interest in all aspects of internal medicine and who wish to work in a specialist field. Communication, diagnostic, and management skills are essential, and the ophthalmic physician needs to be able to work closely with a team of other professionals including ophthalmic surgeons, physicians, nurses, optometrists, orthoptists, and photographers. Good corrected visual acuity in both eyes is required, and stereopsis is important for examination of the fundus.
The training programme
The training programme is overseen by the Royal College of Physicians and the Royal College of Ophthalmologists under the auspices of the Joint Royal Colleges of Physicians training board. After the foundation years, trainees complete two years of core medical training or acute care core stem. They then enter the medical ophthalmology training programme at specialty trainee (ST) 3 level and undergo four years of medical ophthalmology training.
Surgical ophthalmologists who wish to change to medical ophthalmology may count ST1 and ST2 of ophthalmic training towards medical ophthalmology training, but they would also need to complete core medical training.
Assessment of trainees
Trainees are expected to have membership of the Royal College of Physicians and obtain competences in core medical training during ST1 and ST2. There will be a specialty examination later in training.
Current and projected numbers of posts
Medical ophthalmology is expanding and the Royal College of Physicians calculates that one ophthalmic physician per population of 263 000 is required to meet patient needs (www.jrcptb.org). The Royal College of Physicians’ census in 2006 recorded 10 ophthalmic physicians in the UK, four of whom are women, and there was one appointment in 2007. Three other posts were advertised in 2007 but were not filled by ophthalmic physicians because of a lack of suitably qualified applicants.
There are currently five registrars in the United Kingdom, with one foundation post in Aberdeen. There are plans to add three specialty registrar training posts to the programme in Scotland between 2008 and 2010, and at least three deaneries in England intend to create new specialty registrar training posts.
Statements from doctors in the specialty
Wai Siene Ng, foundation year 2 in medical ophthalmology, Aberdeen Royal Infirmary
Before starting my four month placement in medical ophthalmology I had not been familiar with what this specialty entails or of the training pathways. I have had the chance to experience a wide range of diseases, from neurology, endocrinology, and rheumatology with ocular manifestations. I learnt to approach the patient not only from an ocular aspect but also to include other aspects of their health in my management plan. It is very satisfying to diagnose an embolic ocular event and sometimes reveal insidious potentially fatal causes like atrial fibrillation, carotid artery stenosis, or diabetes. Exposure to immunosuppressive therapy added to the learning experience of the job as I learnt to monitor side effects of treatment as well as to carefully administer cytotoxic infusions. I have thoroughly enjoyed my medical ophthalmology block as it is a very rewarding and fascinating specialty.
Srilakshmi Sharma, specialist registrar in medical ophthalmology, Bristol Eye Hospital (currently doing research into gene expression of uveitis at the Casey Eye Institute, Portland, USA)
Medical ophthalmology is a unique specialty where the doctor approaches the examination of ophthalmic conditions with a physician’s regard and an ophthalmologist’s eye. It encompasses a truly diverse range of fields where conditions may be isolated to the eye but very often evaluation of the patient will involve detailed understanding of systemic conditions and their management. As a physician by training there is intellectual satisfaction in this approach, and as an ophthalmologist, I feel that I am cherry picking the most interesting cases within ophthalmology. There are many opportunities to be involved in research, and part of the excitement is in bringing newer therapies to ophthalmic practice.
John Olson, consultant ophthalmic physician, Aberdeen Royal Infirmary
Before entering medical ophthalmology I was a typical medical registrar doing an MD thesis before competing for a senior registrar post in general medicine, diabetes, and endocrinology. My experience as a clinical research fellow in diabetic retinopathy led me to realise that there were many unexplored and unmet medical needs within ophthalmology. The choice I had to make was either to follow the conventional training route or to take a chance entering a new specialty. I have never regretted my decision; my clinical work is extremely varied, patients are invariably interesting, and therapeutic options are excellent. Uniqueness within medicine has its own demands, but also its compensations, such as the opportunity to lead the creation of Scotland’s national diabetic retinopathy screening programme, and more recently Scotland’s new managed clinical network for uveitis, a first for a sadly neglected tribe of patients within the United Kingdom.
Pros and cons of a career in medical ophthalmology
Interesting and varied work
Opportunities for research
Long term follow up of patients
Subspecialisation is possible
Minimal ward work
Small specialty so doctors may feel professionally isolated
Few training posts
Currently limited to teaching hospitals