Integrating the internship into ophthalmology residency – the new standard

Future ophthalmologists have several options for completion of their post-graduate year one (PGY-1) internship prior to beginning ophthalmology residency. The American Board of Ophthalmology requires only that these newly minted doctors complete an internship in any field, including internal medicine, surgery, pediatrics, obstetrics, or a transitional year.

A new internship option, the integrated internship, is the best thing to happen to ophthalmology education in a long time, and in the coming years, will produce the most qualified, experienced residency graduates our field has ever seen. Let me tell you about the concept of this integrated internship, as I both wish I had this as an option for my own internship and am currently witnessing its overwhelming success as I work with these integrated interns on a daily basis.

Prelim medicine vs transitional internships

When deciding what type of internship to complete, I quickly learned that the two main options were the preliminary (prelim) medicine internship or the transitional internship. Prelim medicine interns spend essentially the entire year on inpatient internal medicine rotations, with just a few months available for elective rotations in internal medicine subspecialties. These programs typically allow little, if any, exposure to ophthalmology, as their focus and funding is aimed at training internal medicine physicians. The more popular option, however, is the transitional internship, where interns complete seven of months on core internal medicine rotations, including the ICU, emergency department, inpatient medicine, and outpatient clinics, but with the option for electives in a variety of subspecialties, including ophthalmology, radiology, family medicine, anesthesiology, and others. For me personally, my main goals in deciding what type of internship to complete were two-fold: 1) to gain fundamental knowledge of medicine in both the inpatient and outpatient settings and 2) to maximize early exposure to ophthalmology. At that time, I felt, and still feel, that ophthalmologists are physicians first and ophthalmologists second, and that a strong foundation of internal medicine is key to our profession, but that of similarly high priority is our need to learn as much about our subspecialty as possible in order to provide the best care for our patients.

With these two goals in mind, I applied to both transitional year and prelim medicine internship programs. I interviewed at seven prelim medicine programs, only one of which offered an elective month in ophthalmology. The program at which I ended up completing my internship, Methodist Hospital, in Indianapolis, Indiana, touted a two week orbital dissection course taught by an oculoplastics fellow, a two week microsurgery course where I learned skills that have helped ease my transition to ophthalmic microsurgery, and two elective rotations in ophthalmology. This internship program also offered, among others, electives in neuroradiology, anesthesiology, family medicine, and rheumatology. At that time, this transitional internship was a perfect match for my internship goals, and I would still today highly recommend it to anyone.

The integrated internship

The integrated internship, in my opinion, is a sort of hybrid between preliminary medicine and transitional internships. Interns essentially complete the required months in internal medicine rotations, and then complete the remaining 5-6 months in ophthalmology. When I applied to ophthalmology residency, only a handful of these internships existed, one of which being the Moran Eye Center at the University of Utah, where I attended medical school and whose residents spoke highly of their internship experience. The University of Iowa was just about to start their version of the integrated internship when I applied for internship and residency positions, but this new internship would not become available until the following year. I matched at the University of Iowa for residency, but prior to beginning residency I completed my transitional internship in Indiana, as mentioned above; therefore, my class is the final residency class to have had the option of completing the internship somewhere else before starting residency. I have since learned that other integrated internships exist, at least to some degree, at MUSC, Rush, Univ of Mississippi, and UCSF.

Integrating the internship into residency

In a few months a “white paper” describing this concept of “integrating the internship into residency” will be published in the journal Ophthalmology (it has been e-published online and is awaiting print publication). Here are a few quotable highlights in the article, along with my parenthetical editorial commentary:

“The acquisition of an additional 6 months by integrating ophthalmology-specific training into the intern year would effectively extend our residency to 42 months in length. These additional 6 months could be used to enhance leadership, teamwork, research, or quality improvement skills or be used for “mini-fellowships”devoted to acquisition of additional competencies.” (six more months of ophthalmology training without actually extending the overall duration of training? yes, please!)

“Unfortunately, the experience of the ophthalmology intern is variable, and their service on some rotations can have little relevance to the ultimate practice of ophthalmology. The intern year often does not include acquisition of ophthalmic knowledge and skills.” (This is absolutely true! So much of what interns do is irrelevant to the practice of ophthalmology).

“The transition to an integrated internship will be difficult…Even if enough positions exist, ophthalmology residencies will need to demonstrate that the caliber of their applicants justify taking slots currently reserved for open competition in the match.” (In my experience observing pre-ophthalmology interns as a med student, being one myself, and talking with my resident colleagues, pre-ophthalmology interns are among the best interns on any inpatient medicine service – I don’t think justifying the caliber of ophthalmology interns will be very difficult, as they are already very highly regarded among interns everywhere).

“The 4 PGYs are not efficiently used to train future ophthalmologists. The current PGY-1 requirement is highly variable, not linked to ophthalmology objectives, and usually not coordinated with the PGY 2-4.” (This statement is dead-on accurate. No commentary needed).

My experience with the integrated interns

Let me add some additional observations about my current co-resident colleagues who completed the integrated internship here at the University of Iowa, and, who interestingly arrived at the same time to begin their internship that I arrived to begin residency.

• These residents understand the hospital system far better than do I. While we completed the same number of required inpatient core rotations, they were here, whereas I was learning the system elsewhere.
• They know the other hospital residents far better than do I, making middle-of-the-night questions or curbside easier easier to both accept and request.
• They know the EHR. As an intern I used Cerner, and struggled to learn Epic when starting residency. They started their residency having a year of Epic already under their belt.
• The attendings know them, and trust them, a whole year sooner. In residency, how much you get to do surgically is related to how much the attending physician can trust you. One more year of developing rapport and trust is a huge benefit when it comes time to operate.
• Their early surgical exposure is amazing. On July 4th I was on back-up call with a new first year resident that had just completed the integrated internship all of four days prior. She flawlessly repaired a simple eyelid laceration (with my supervision), a task I would have definitely waited another two, three, or even six months to feel comfortable doing on my own.
• They’re just good, really good. I have now watched as two post-integrated internship classes have begun residency here at the University of Iowa. By the end of their internship, they are functioning, in my opinion, at least six months, and in some cases eight or nine months ahead of schedule.

The future…

I believe that gradually, and with the help of the article coming out in a few months, ophthalmology residencies nationwide will begin integrating the internship into the ophthalmology residency. As word gets out about this new opportunity to gain ophthalmology skills during internship, residency applicants will begin asking more about this new option, which will increase its demand, and in both an effort to satisfy demand amidst competition for the best residents, and with a renewed excitement for this improvement in ophthalmology education, the number of integrated internships will continue to increase. Soon enough, the integrated internship will surpass both the prelim medicine internship and the transitional internship as the new standard in ophthalmology.