The final year in optometry school
is an exciting time for students, as they transition into becoming independent Doctors of Optometry. It is also a time for students to contemplate career paths and consider residency training
as means of achieving their professional goals.
In this article series, we are interviewing residency directors from across the spectrum of optometric practice modalities
. We will shed additional insight for students contemplating whether or not residency training is right for them.
Today we are interviewing three residency directors from Indian Health Service Hospitals across the Southwest. Christopher Cordes, OD, FAAO, Breanne Flores, OD, FAAO, and Richard Hatch, OD.
Dr. Cordes is the IHS Residency program director and staff optometrist at Albuquerque Indian Health Center
. This program is affiliated with Southern California College of Optometry at Marshall B. Ketchum University.
Dr. Flores is the IHS Residency program director and staff optometrist at Tuba City Regional Health Care Corporation
. This program is also affiliated with Southern California College of Optometry at Marshall B. Ketchum University.
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.
For students that are interested in applying to residency with Indian Health Services, what are some characteristics that make a high quality candidate?
Dr. Cordes: The biggest advantage would be an IHS rotation site. You get exposure and know what the "system" is. Having previous IHS experience is a great thing. However, it is not the end all be all. Being outgoing and ready to learn is important. IHS will push you in many ways, professionally and personally. Having an open mind is also a desirable quality.
Dr. Flores: We value applicants who are highly motivated to step outside their comfort zone and work in a challenging rural setting. We look for applicants who are enthusiastic and good team players. It is important that they are open to self-improvement and mentorship. We also recommend that applicants come to interview in person.
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.
- 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.
- 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.
- 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.
- 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.
- 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.
What specific advantages will residents take away from their training? What clinical/professional expertise will they be able to carry forward into their careers?
Dr. Cordes: The greatest selling point of an IHS residency (any of them) is, on the whole, you will be prepared to deal with ANYTHING which shows up in your office/chair. IHS offers everything from kids to elders and everything in between. You will get a broad base to deal with any primary care/ocular disease setting for the rest of your career. My mentor used to say 1 year in IHS is worth 15 year's worth of private practice experience.
Dr. Flores: Our remote location provides a challenging clinical setting where we practice full scope optometry and practicing in Tuba City will give the resident a comprehensive clinical experience in just one year. Since we do not have local ophthalmology specialties we often follow more complex disease cases than you would see working in a larger city. Working in a hospital-based setting gives our resident the opportunity to work closely with other specialties to co-manage patients. These valuable communication skills will serve them well in any future mode of practice.
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.
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.
What is a typical “day in the life” of residents at an IHS hospital? This could include details on patient demographics, clinical hours, or after-hours call, etc. Also, are there additional opportunities to give CE lectures or participate in other extracurriculars such as journal clubs?
Dr. Cordes: The ABQ IHS residency is clinically dominant. So, hopefully, in a typical day you will be seeing patients. Diabetics, glaucoma, red eyes, kids, adults... it really is, in my opinion, the broadest base for patient age range experiences, despite being all Native patients. There are also quarterly journal clubs, weekly IHS resident case reports via Zoom, and always the required case reports (three here at ABQ) and the presentation in conjunction with an IHS meeting.
Dr. Flores: The residency program is heavily weighted towards direct patient care. We treat patients of all ages and manage a variety of anterior and posterior segment disease. TCRHCC is a 70-bed hospital which offers inpatient care, a variety of outpatient clinics, and many specialty services. Due to the multidisciplinary setting, the resident has the opportunity to consult, co-manage, and shadow other medical specialties and learn how to communicate and coordinate care in an effective way.
In addition to the clinical experience, our program also has a strong academic component. There are three lecture requirements, monthly grand rounds presentations, required reading and discussions, and the IHS resident’s journal club which is held quarterly. The journal club is a great experience which gives our resident the chance to meet up with the other IHS residents to discuss journals, share experiences, and explore the area. The resident also has the opportunity to set up shadowing of ophthalmologic specialties such as retina and oculoplastics.
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.
What is one of the biggest challenges residents may face during their time here?
Dr. Cordes: Having worked in both rural, semi-rural and urban IHS, I feel the biggest challenge at ABQ IHS is relating to the Native traditional lifestyle and customs. In the semi-rural and rural sites you are working/living in with the specific culture (reservation). In ABQ, it is a city, so you don't get that. However, you do get a lot of diversity in the tribal populations served here.
Dr. Flores: Tuba City is on the Navajo reservation and being one of the larger border towns we have many amenities that other sites do not, however, we are still in a remote location. Our closest city is Flagstaff which is about 75 miles away. Living and working on the reservation is an important learning experience and because it’s remote, a lot of our patients are going without basic utilities that you or I may not think twice about. This gives the resident a unique set of social challenges to learn from.
But just because our site is remote does not mean it’s lonely! There are lots of opportunities to get involved in the local community like coaching soccer or T-ball, participating in local races, or going on community sponsored hikes.
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.
Is there a specific practice setting/modality that residents commonly pursue after training?
Dr. Cordes: We have only had two residents so far. One is in an OD Medical Based OMD practice and the other is working for IHS. So, I know most IHS residents tend to lean more medical or stay with the IHS.
Dr. Flores: Many of our residents enjoy the challenging and rewarding experience of working in Indian Health Service and continue to practice in rural healthcare. Sixty seven percent of our residents went on to work for TCRHCC as staff providers, and 78% went to work in other IHS facilities. The others work in private practices which focus heavily on treating ocular disease.
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.
While residency training may not be necessary for achieving every new grad’s career goals
, it can certainly help facilitate personal and professional growth. Indian Health Service residency programs provide students with an opportunity to gain experience practicing in a multidisciplinary setting while also seeing a vast array of patient cases heavily geared towards ocular and systemic disease management. IHS residents are also able to have a unique and memorable cultural experience that they may not have otherwise had.
Students interested in a career path practicing in a challenging, multidisciplinary patient setting may find that an IHS residency is the perfect starting point into a successful and fulfilling career in optometry.