Inside the Optometry Residency: Indian Health Service

Dr. Hatch has devoted the majority of his decades-long optometric career to working with the Indian Health Service. He has helped start numerous optometry departments at various IHS hospitals throughout the Southwest. He was most recently stationed at Zuni Comprehensive Community Health Center and has been heavily involved with their residency program since its inception. This program is affiliated with Southern California College of Optometry at Marshall B. Ketchum University.

Dr. Hatch: You will be familiar with the following Zuni applicant scoring factors with which all staff members score each applicant. Those scores are totaled and put in rank order this thoroughly discussed in staff meetings where consensus is reached prior to submission to the ORMatch system.

1. Appearance, attitude, communication skills, professionalism, and professional involvement: Each applicant submits a curriculum vitae which provides a foundation to which additional information and impressions are added including from an applicant's site visit.
2. Academic and boards performance and licensure: Zuni requires a certified transcript to evaluate an applicant's academic performance and experience and to confirm their graduation from an accredited school of optometry. Also required is documentation showing that an applicant has passed all applicable boards and is licensed by the time they report to the residency program.
3. IHS career potential: The Indian Health Service invests significantly in its residency programs both financially as well as with staff time and clinic facilities for use by the resident. One reason, among others, for making this investment is to bolster the recruitment of exceptionally qualified new staff, already proven to be capable of handling and familiar with the scope and unique challenges of IHS practice. Such residents have so much advantage in being selected for a full-time IHS position with benefits such as the possibility of loan repayment. The success of this endeavor is reflected in the fact that the majority of IHS optometrists have come from experience as IHS residents.
4. Adaptability to Zuni Community & hospital environment: Few come to IHS residencies with the experience of living in a setting typical of most IHS hospital locations, that often being in a rural community with a population of a different culture. Some may find living removed from the convenience of city amenities unsettling, while others are excited about experiencing a new cultural and environmental experience.
5. Recommendations: Zuni requires each applicant to provide at least three formal letters of recommendation detailing the impressions of others with and under whom the applicant has worked. Needless to say, applicants with only positive recommendations are considered with the view that letting a position even go vacant is better than having a problematic person and a situation where both a resident and staff are unhappy.

"Between the lines" above are inferred a desire on the part of an applicant to learn both by study and by clinical experience. IHS staff anticipate having residents that will bring enthusiasm to see and learn new things at every turn. The staff are inspired by such an attitude and are motivated in their own work to constantly expand their knowledge, skills, and abilities, including those brought by a new resident fresh out of optometry school training. Residents are expected to be excited and willing to work with others both professionally and personally, as they interact with staff of other disciplines within the facility and with patients and their families.

Dr. Hatch: Perhaps there is no better setting than an IHS facility to experience working closely with other providers of most health care disciplines. At Zuni, for example, residents work literally only a few steps away from the ability to confer with staff in the out-patient clinic, urgent care, emergency room, pharmacy, in-patient rooms, dental clinic, radiology, audiometry, public health nursing, dialysis center, physical therapy, podiatry, diabetes program, women health services, and behavioral/mental health. Also, residents work closely with tertiary eye care providers to whom they frequently refer patients.

A resident leaves their experience taking with them the ability to feel at ease calling on any other specialty provider and collaborating with them in serving patients.

Also, residents will leave comfortable and experienced in dealing with practically any eye presentation, including those found in hospital in-patients as well as patients of all ages—from infants to the elderly of all genders, in taking after-hours call and in performing routine school screenings.

Through participation in "journal clubs" with other residents, they carry into their careers experience in critically researching the professional literature and studies as well as in preparing and presenting lectures at professional meetings, to the local medical staff, etc. that will keep their practice "state of the art". Residents will also leave IHS residency with most of the required points in hand to qualify for sitting to become a Fellow in the American Academy of Optometry.

An overarching benefit residents take with them of value wherever their career leads is being part of a network of colleagues that will bolster their professional and personal experience life-long.

Last, but perhaps not least, IHS residents take with them substantial financial compensation and benefits resulting from the completion of one year of federal Civil Service employment. Whether they add that year toward retirement eligibility by continuing in a permanent IHS position or by working in the VA or other federal setting immediately or later on in their careers, at the least their IHS residency will give them a great financial start.

Dr. Hatch: IHS residents find they will need to work hard. Many clinics offer them the usual five 8-hour days weekly schedule and most offer alternative options such as 9-hour days giving a day off every two weeks and 10-hour days with a day off weekly. As Civil Service GS-11 step 1 employees, residents receive a half-day of leave every two-week pay period. This is in addition to sick and other leave categories. Regular clinic workdays do not include weekends. However, most residents are involved in after-hours and weekend call schedules for which they receive overtime pay.

This means that urgent and emergency departments may call them for a phone consultation or to come in to see a patient. Residents have the experience of seeing patients not only in the optometry clinic but in the emergency room, urgent care rooms, out-patient clinic rooms and in-patient rooms. They may also have the opportunity to go with public health nurses to see a patient in the patient's home.

Residents generally have the flexibility to set their own schedule including the time allotted for each appointment. Most start with perhaps a patient each hour and gradually work up to one every 20 or 30 minutes. They can designate time for special clinics such as post-op follow-ups, fields, routine exams, contact lens care, pediatric care, etc.

They participate with other staff members in going out to conduct screenings at Headstart programs, public schools, boarding schools, etc. They frequently fill-out driver’s license vision forms for patients and other work-related forms such as for firefighters, etc. Residents see a reasonable number of low vision patients and work with state services for the blind in securing resources to help them.

As members of the hospital Medical Staff they attend Medical Staff Meetings, giving continuing education presentations to the Medical Staff and other groups in the hospital once or twice during their residency year. This gives them valuable first-hand insight into how a hospital and its medical staff function. Residents participate in quality assurance and accreditation activities taking away first-hand experience in dealing with the JCAHO accreditation processes.

Residents also have valuable first-hand experience dealing with a hospital business office and coding departments, learning how to use an electronic medical record system and code their work appropriately for billing and other purposes. They have the opportunity to pursue research interests with EHR data available to them to study such things as the incidence and cause of vision loss, the prevalence of refractive conditions, treatment outcomes, etc.

Most IHS facilities close clinic a half-day each week where out-patient clinics are closed to regular patient care affording time for meetings, training, etc. In regards to training, most IHS facilities provide time and funding for travel and tuition for staff, including residents, to attend professional meetings and continuing education programs. Residents, at least at Zuni, also have a half-day every two weeks set aside for study, research, and other non-direct care endeavors. Also, they are encouraged to schedule time to visit and observe at other eyecare institutions (i.e. observing eye surgery, specialty care for glaucoma, retina, neuro-ophthalmology, etc.).

So, there are many activities that are woven into a resident's day-to-day experience, most under their control and direction to meet their interests and professional development goals.

Dr. Hatch: Perhaps the biggest challenge is adjusting their lifestyle to a different environment, often in a more rural environment, amid a different cultural setting. This may mean that it is a two hour drive to the nearest airport, golf course, Costco, or car repair service. Internet and cell phone services may be difficult or slow. Delivery services such as Amazon may be slower or less available.

One resident said the absence of public and commercial transportation as well as increased personal vehicle travel expenses are challenging. Another said weather conditions can be challenging. Although most applicants may see this as upsetting and a sacrifice, it does come with compensating advantages.

For example, there often is new and expanded access to many diverse outdoor activities and cultural experiences ranging from hiking in and visiting multiple National Parks and Monuments, popular ski venues, river and lake activities, including fishing, boating and water skiing and observing unique Native American traditions and ceremonies, that attract people from all over the world. Lastly, residents have the opportunity to learn of the historic and rich cultures of the western US.

One of the residents at last week's journal club meeting mentioned that for her, a big challenge is getting patients scheduled for needed eye surgery and other specialty care. This was somewhat unexpected as the IHS has traditionally had exceptional access to such services. However, the pandemic has had tremendous impact on such care. Normally, IHS facilities work closely with other institutions to which they refer patients to arrange funding, transportation, and whatever else may be needed to facilitate patients getting timely and appropriate care.

Of course, jumping from optometry school into a busy hospital clinic setting with high incidence of diverse eye conditions and ocular disease is usually challenging for any optometrist. Residents all agree that the amount and degree of complex cases is challenging. One resident at a recent journal club meeting said she was taken aback by seeing practically every day patients with high astigmatism, commonly exceeding six diopters.

Language can also be a barrier for some patients, but the residents said this is not a big problem as clinic interpreter staff is available and such patients often bring a family member that can interpret for them. Of course, IHS residents have ready access to their staff colleagues within and beyond the optometry clinic throughout the hospital. They will find that such back-up is constantly available, broadening their clinical skill and experience.

All in all, one can see that every day for an IHS resident can present a new experience that will afford them great satisfaction and memories that will last a life-time.

Dr. Hatch: The IHS residents at the recent journal club unanimously agreed that none would be pursuing opening their own practice after residency. Rather they first raised interest in the possibility of continuing in an IHS position. About 25% of IHS residents continue with permanent positions in IHS clinics. Additionally, the journal club residents talked of plans for some type of corporate practice. Another resident said that the VA is a possibility.