For students interested in applying to residency at a VA medical center, what are some characteristics that make a high-quality candidate?
Dr. Kelleman: I am always proud to see optometry students applying for residency. Optometry is unique as a health profession, in that residency training is optional for graduates. I am a firm believer that completing a residency is always the right choice for a young optometrist, and for the profession as a whole. Optometry is now extremely medically oriented, and residency training will ensure that we continue to serve our patients in a manner that is commensurate with the expectations that come with our role within the health care team. This is especially true for graduates looking to find work in a disease-oriented practice setting.
When evaluating candidates, we of course review an applicant’s entire file, taking into account success in their coursework, National Board scores, etc. Though I find that you can truly learn a great deal about a candidate by their recommendations from previous preceptors and faculty as well as their extracurricular activities. Professional references that detail a strong work ethic, a desire to learn, and a true concern for patient care tell me that an applicant will make an excellent resident. Extracurricular activities, whether it be in research settings, clinical settings, or in organized optometry, help to demonstrate the dedication that is necessary to be successful during residency.
A big advantage to a residency at the VA is the complexity and volume of cases that a resident encounters, and we want to ensure that residents leave here with a great deal of clinical expertise and knowledge. Demonstrating this dedication to their practice shows that a candidate would utilize this opportunity to further their training and truly become the best clinician possible.
Dr. Mick: Like many VA hospitals with optometry residency programs, San Francisco VA (SFVA) is a tertiary referral center. Many patients have quite complex eye diseases and ocular manifestations of systemic disorders. Consequently, we want to recruit residents that are solid clinically and have a broad knowledge base. Because our residents care for patients with a wide variety of personalities, consult regularly with subspecialty ophthalmologists, and interact with members of our large multidisciplinary staff, strong communication skills are a must. Finally, the San Francisco VA has a proud history of our residents going on to make significant contributions in the areas of patient care, research, education, and professional service, so evidence of leadership is highly valued.
Dr. Denton: A few characteristics I look for include previous experience as an extern at one of the VAMC’s across the nation, CV with either sports and/or leadership included, passionate about some aspect in optometry, and a few factors that breaks the applicant away from the rest of the applicants. I would love to see a failure, and then how the applicant dusted themselves off and continued toward success. Although I have certain standards that should be met with GPA and board scores, those do not necessarily drive my ranking.
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. Kelleman: An admission that I will make is that I was likely a bit over-confident as a clinician on day one of my residency. What I quickly learned during my residency, and have continued to learn in my years since then, is that the practice of optometry, especially the treatment and management of ocular disease, is much more complex than what I had originally garnered from my textbooks. I am amazed at how often we encounter atypical presentations of disease, or how often we note subtle findings during an exam that may convolute or change our list of differentials.
The advantage to residency training, especially in our population, is the sheer volume of complex cases that a resident encounters. What our residents leave here with, is an ability to think critically, to appropriately question all differentials, and formulate a management strategy that ensures the patient will be appropriately cared for no matter how complicated the case. Once they leave here, this ability allows our residents to manage any case that they are presented with, regardless of familiarity.
Dr. Mick: Residencies at VA hospitals such as SFVA offer intensive year-long training experiences that combine a large number of patient encounters with supplemental educational curriculums. In addition to what is learned through seeing complex patients, one of the main goals of the SFVA program is to teach the residents effective clinical reasoning skills. These skills will benefit the resident regardless of their eventual practice modality and as our current understanding of ocular diseases and how we diagnose them change over time.
Dr. Denton: A residency provides a year of fine-tuning your clinical skills, incorporating these skills with the previous didactic knowledge, and allowing new grads to start making decisions as a doctor. The resident’s confidence should greatly improve throughout the year too.
Our program is very different than other residency programs. Why specialize in one aspect, when you can grow tremendously in many areas of optometry for one year. We have a title of "Ocular Disease with an emphasis in Primary Care." Sounds boring, but the emphasis, primary care, is doing what is right to take care of your patient. The patient may need low vision, or a medically necessary contact lens, or a neuro-rehab plan to assist in maximizing their quality of life. Ocular disease is a main staple but having the opportunity to add clinical tools to your toolbelt and start fixing patients is very rewarding. All aspects of optometry are on the table for our residents.
An additional goal would be to add significant meat to the skeleton of a CV. This is the key to obtaining a good job position afterwards.
It is interesting how each resident will do the necessary patient numbers for accreditation, then become surprised that they desire to keep going in aspects like contact lenses and low vision. It also is remarkable how having experience with these extra skills will be the deciding factor when applying for a job.
What is a typical “day in the life” of residents at your particular VA medical center? 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. Kelleman: Our residents spend most of their time in direct patient care, though we have a didactic curriculum and several scholarly requirements as well that help round out their experience. Most days, residents see patients between 8am to 4:30pm, with a break between morning and afternoon sessions. We have a great deal of geriatric patients, and the residents are commonly managing conditions that are more typical of this population, though there is still a great deal of variety in what they encounter.
Residents will also frequently examine urgencies and emergencies that present to the clinic. There is an urgent care on the floor below us in the hospital, so oftentimes they will ask for consults when patients walk in with ocular complaints or conditions. Some days we will have the residents supervise the interns during patient care, so that they gain experience with precepting as well. We also have several ophthalmology clinics which our residents rotate through, allowing them to work directly with a retina specialist and a glaucoma specialist.
There are several components to the didactic portion of our residency. We have monthly grand rounds meetings between both VA campuses in CT where residents will either present cases or a recent piece of literature for journal club. Residents also make presentations at a morning lecture series at the Newington campus – focusing on larger, landmark studies in optometry/ophthalmology.
We encourage our residents to attend the American Academy of Optometry meeting, with many residents submitting posters for resident’s day. Many residents will attend additional local Optometric meetings, or other larger conferences such as SECO or Optometry’s Meeting. Our residents are also required to complete a manuscript of publishable quality, so they also gain experience in researching, writing, and editing medical literature. So while we do focus heavily on the value of direct patient care, our residents remain very involved from an academic perspective as well.
Dr. Mick: The residents at SFVA spend approximately 80% of their 40-hour week providing direct eyecare to our veteran patients. The remaining 20% is filled with a didactic learning program that includes a journal club, a joint optometry/ophthalmology case conference, a clinical seminar, grand rounds at the UCSF Department of Ophthalmology, and a retinal conference led by a member of the UCSF retinal faculty.
Dr. Denton: The demographics for veterans are mainly males from 24 to 99 years of age with most being in their 60’s and 70’s. Tuesdays and Wednesdays start out with Grand Rounds for an hour (7am-8am) in a room that has a 50-inch TV for maximal viewing. The resident can choose to either learn or lecture. Each is given the opportunity and it is up to them how they proceed. Attendings, student externs and the resident are present. Patients start at 8am those days. These are also the two ocular disease clinic days. One of these days we have the resident attend with the student externs, while the other day the resident performs the exams on their own.
The Emergency Department (ED) has a direct line (think walkie-talkie/pager combo) and may call one-five times in a given day when the resident is present in clinic. This provides a great way to prepare their future for acute care walk-ins. After triage, the resident plans what needs to be done to assist the patient, meanwhile, balancing the rest of the day’s responsibilities.
Attendings are available for progressive guidance and any questions. We also have a very good relationship with our ophthalmology colleagues down the hallway, and a handful of neurologists around the corner. Each enjoys teaching and providing a team-approach to taking care of the patient.
We strive to allow for a realistic experience for our residents. The schedule of our clinic has a couple long (12-hour) days and some shorter (8-hour) days. By the time they are done, the resident will know what it is like to work both and have a preference.
Additional opportunities include shadowing various specialists in the VA or civilian sector. We have great access to the Medical University of South Carolina (MUSC) program as many of their doctors also work at the VA. We do have some flexibility with our residency. As long as each of the goals for accreditation are met, we do not mind fine-tuning the schedule for the resident’s benefit. For example, this could mean seeing more specialty patients, or more precepting time with student externs.
What is one of the biggest challenges residents may face during their time here?
Dr. Kelleman: Time management is probably the main challenge that residents face. Between clinic responsibilities, charting and administrative work, and didactic/scholarly activities, there is plenty to keep a resident busy during their time here. Though I find that once residents get settled and familiar with the system, they seem to budget their time appropriately, allowing them to find a good balance between their busy work lives and personal lives.
Dr. Mick: Early in the program, the complexity of the patients and the busy schedules are a challenge for the residents. But their confidence and skills grow with each week, and before they realize it, they are efficiently managing difficult patients and hectic clinic loads that were a struggle when they started. The SFVA program emphasizes a continuously increasing level of medical decision-making autonomy for the resident throughout the year so that when they begin their independent career, they are extremely self-reliant. During this maturation process, occasionally residents feel a level of expected discomfort, but they are necessary steps.
Dr. Denton: The biggest challenge is bouncing between many different types of patients and exam types throughout the week, while knowing the ED may call at any moment with something amazing to experience.
Dr. Kelleman: Since our residency is focused on the treatment and management of ocular disease, most residents pursue a practice setting that focuses on this modality. The most common would likely be ophthalmology practices, group OD/MD, or medically oriented OD groups. However, we do have former residents currently practicing in a wide variety of settings. Some have bought private practices or started their own practices, and enjoy the advantages of ownership. Others practice in community health centers. Some practice medical optometry within corporate practices as well.
I think one of the main advantages to gaining so much clinical experience and learning how to be a truly critical thinker is that it allows our residents to thrive no matter what practice setting they wind up in.
Dr. Mick: Because the SFVA program emphasizes developing clinical decision making that is applicable to any type of practice, our former residents have gone on to be successful in numerous career paths. Approximately 30% of our former residents are employed in optometry private practice, 30% in optometry/ophthalmology private practice, 20% within the Department of Veterans Affairs, 10% within Departments of Ophthalmology, 5% in industry roles, and 5% conduct full-time research. Regardless of work modality, over 40% of our former residents have devoted at least part of their careers to educating optometric trainees.
Dr. Denton: The greatest aspect of our residency is its versatility. We have had residents jump to an OD/MD practice, a VAMC, or private practice. We support all kinds of jobs. Each resident is different and has their own goals. We like to guide them to meet those goals.
Conclusion
More information on optometric residencies can also be found in the American Schools and Colleges of Optometry’s residency directory.
