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  • So you want to be an ophthalmologist.

  • You like the idea of exploring a fascinating organ and helping patients save their vision.

  • Let's debunk the public perception myths of what it means to be an ophthalmologist,

  • and give it to you straight.

  • This is the reality of ophthalmology.

  • Dr. Jubbal, MedSchoolInsiders.com.

  • Welcome to our next installment in So You Want to Be.

  • In this series, we highlight a specific specialty within medicine, such as ophthalmology, and

  • help you decide if it's a good fit for you.

  • You can find the other specialties on our So You Want to Be playlist.

  • A lot of you asked for ophthalmology, so that's what we're covering here.

  • If you want to vote in upcoming polls to decide what future specialties we cover, make sure

  • you're subscribed.

  • If you'd like to see what being an ophthalmologist looks like, check out my second channel, Kevin

  • Jubbal, M.D., where I do a second series in parallel called a Day in the Life.

  • Once the world is back to a more normal baseline, we'll be doing a Day in the Life of an Ophthalmologist.

  • Ophthalmology is the medical and surgical specialty dealing with ocular and orbital

  • diseases - pretty much anything relating to the eyes and immediate surrounding structures.

  • Ophtho is unique in that it isn't a strictly medical or surgical field, but rather a blend.

  • The practice of ophthalmology can be categorized into three main areas: medical, procedural,

  • and surgical.

  • There are many diseases that are unique to the eye, but also several systemic diseases

  • that have manifestations in the eye.

  • Within the medical focus of ophthalmology, there are 5 main categories:

  • First, infectious.

  • Infectious diseases of the eye can be viral, bacterial, fungal, or parasitic in nature.

  • These include STI's like syphilis, chlamydia, and gonorrhea, to fungi like candida, to parasites

  • like toxoplasmosis or the worm causing river blindness, Onchocerca volvulus.

  • These infections may be confined to the eye, but may also be systemic yet manifest in the

  • eye.

  • For example, with syphilis, a patient may only recognize the ocular symptoms, such that

  • the ophthalmologist is the first person to diagnose the patient with a systemic infection.

  • Next, systemic inflammatory diseases can cause uveitis, or inflammation in the eye.

  • These diseases are wide and varied, from rheumatoid arthritis and lupus to inflammatory bowel

  • disease and sarcoidosis.

  • Diabetic retinopathy occurs in patients with poorly controlled diabetes.

  • In short, the small vessels get damaged, which we call microvascular damage, resulting in

  • scarring, bleeding, retinal detachments, and can even cause blindness.

  • This is the leading cause of vision loss worldwide.

  • Malignancy Believe it or not, you can get tumors in your

  • eye.

  • This can be retinoblastoma, which is screened for in newborns, choroidal melanoma, which

  • is actually not directly related to skin cancer, or primary intraocular lymphoma.

  • The eye and orbit are a common site of metastases for other cancers, meaning a primary cancer

  • releases cells in the bloodstream that take hold in the eye.

  • It makes sense, as the eye has the highest rate of blood flow per weight compared to

  • any tissue in the body.

  • Prescription and recreational drugs can both cause long term damage to the eyes.

  • For example, chronic alcoholism may result in vitamin deficiency leading to vision issues.

  • Alternatively, methanol should never be ingested, as it causes optic nerve delamination which

  • can result in blindness.

  • Glaucoma has two main types, acute angle closure and primary open angle.

  • Both can lead to damage to the optic nerve and irreversible vision loss.

  • Open angle glaucoma is the leading cause of irreversible blindness worldwide, and is called

  • thesilent thiefas it slowly causes vision loss overtime without patients being

  • aware.

  • Ophthalmology has a variety of procedures, which one wouldn't necessarily consider

  • surgical, as these are performed in the office, not the operating room.

  • The way lasers are used in the field is almost science fiction.

  • A laser retinopexy is essentially spot welding to prevent retinal detachment.

  • This is used to treat retinal tears.

  • For acute angle closure glaucoma, which is highly urgent as it can cause rapid vision

  • loss, a laser peripheral iridotomy is used to create a hole in the iris and reduce pressure.

  • Eye injections are also performed, such as anti-VEGF for treatment of diabetic retinopathy

  • and macular degeneration.

  • In a similar vein, a diagnostic tap and inject is where the ophthalmologist gets fluid from

  • the eye and then injects antibiotics or antivirals through the same needle.

  • Lastly ophthalmologists sometimes perform lesion removal and excision, like when I got

  • my chalazion drained.

  • When it comes to surgical procedures in the operating room, ophthalmologists can perform

  • either extraocular or periocular cases, meaning those that are outside and around the eye,

  • or intraocular surgeries, meaning within the eye.

  • Orbital surgery includes excision, debulking, or taking biopsies of masses and lesions in

  • the orbit.

  • Reconstructive surgery around the eye can be done after trauma, like a baseball to the

  • orbit, or after extensive surgery, such as after a cancer resection.

  • Restorative or cosmetic surgeries include eyelid surgery for ptosis, meaning droopy

  • eyelids, or having excess skin over the eye.

  • Strabismus surgery is concerned with the actual eye muscles to help bring the eyes into proper

  • alignment.

  • In terms of intraocular surgery, there are four main ones.

  • First, cataract surgery is the bread and butter for general ophthalmologists, and is the most

  • common outpatient surgery, with 3 million surgeries performed every year in the U.S.

  • It makes sense, since cataracts is the leading cause of vision loss in the world and everyone

  • gets it, assuming they live long enough.

  • Phacoemulsification is the technique used, whereby ultrasound technology breaks up the

  • cataracts and a vacuum sucks it out.

  • An artificial lens is placed in the eye with specifications unique to that individual's

  • refractive error.

  • Second, cornea surgery, including corneal transplants.

  • Corneal surgery also includes LASIK or PRK, another form of laser eye surgery that isn't

  • as well known as LASIK.

  • Third, glaucoma surgery, which includes placing tiny tube shunts or performing trabeculectomies

  • to redirect flow of the fluid in the eye.

  • And lastly, retinal surgery, which includes repairing retinal detachments, macular hole

  • repairs, removing foreign bodies within the eyeball, and even lens removal following a

  • complicated cataract surgery.

  • After completing medical school, ophthalmology residency is 4 years, with the first year

  • historically being a transitional or preliminary year, meaning you wouldn't actually start

  • ophthalmology training until your second year.

  • However, more residency programs are integrating the first year so that you will get some ophthalmology

  • exposure even as an intern.

  • In terms of competitiveness, ophthalmology is misunderstood as being far more competitive

  • than it really is, in part because it participates in the SF Match rather than the traditional

  • NRMP.

  • In terms of match rate, in the last few years official data range from 86-89 percent for

  • US graduates.

  • The higher than usual number of international applicants deflates the overall match rate,

  • making it seem more daunting than it truly is.

  • USMLE data is not reported by Step 1 and Step 2, but rather as a combination of both scores.

  • Parsing this data, Step 1 averages are likely around 240 and Step 2 averages are likely

  • around 250.

  • If you're considering ophthalmology, this is great news, as the data shows it's far

  • more attainable than the popular narrative would have you think.

  • That isn't to say it's easy to get into.

  • You'll still need to be an above average student.

  • As with any other specialty, having publications, strong letters of recommendation, and good

  • Step scores go a long way in helping your chances.

  • Going to a US allopathic, meaning MD school, is much more advantageous compared to attending

  • an osteopathic, meaning DO, or international medical school.

  • If you graduate from an osteopathic or international medical school, expect an uphill battle, with

  • official match rate data around 20-40% for these students rather than high 80's for

  • your US allopathic counterparts.

  • Medical students that end up applying to ophthalmology are usually those who understand the importance

  • of a good lifestyle.

  • Outside of ophthalmology, the stereotype is that they're myopic nerds who are fascinated

  • by a small organ, or that they're huge introverts or cannot handle real surgery.

  • Obviously, stereotypes aren't quite true.

  • After completing residency, you can choose to subspecialize further with a fellowship,

  • most of which last 1 year, except for surgical retinal and oculoplastics which are two years.

  • Cornea deals with surgical and medical management of corneal eye diseases, and includes refractive

  • procedures like LASIK, PRK, and SMILE, which is essentially an even less invasive option

  • than LASIK.

  • Surgical retina is a 2 year fellowship, primarily focused on retinal diseases from diabetic

  • retinopathy and retinal detachments.

  • Compared to other subspecialties, the lifestyle is not as optimal, as there are occasional

  • emergent add-on cases, like retinal detachments, but even these can generally wait until the

  • next morning.

  • Medical retina is a 1 year fellowship dealing with medical management of similar retinal

  • diseases.

  • You'll be performing lasers and injections, but no retinal surgeries.

  • Glaucoma fellowship will have you trained in medication, lasers, and surgery to decrease

  • intraocular pressure.

  • Oculoplastics is a 2 year fellowship dealing with orbital diseases and adnexal structures

  • such as the eyelids, tear drainage system, and the face.

  • It includes both aesthetic and reconstructive surgeries.

  • With a pediatric fellowship, you'll deal with all ocular issues that children have,

  • ranging from glaucoma to retinopathy of prematurity, meaning abnormal blood vessel development

  • in the retina in premature babies.

  • However, your bread and butter will primarily be refractive errors, amblyopia, and strabismus,

  • meaning misalignment of the eyes.

  • Amblyopia is when the visual pathways in the brain are not developed properly due to poor

  • visual input, such from strabismus or refractive error, and this can result in permanent vision

  • issues in children if not properly corrected before age 7.

  • Neuro-ophthalmology is concerned with how the nervous system relates to the eye and

  • vision, meaning you'll be dealing with optic neuritis, optic neuropathy, double vision,

  • and paralysis or spasms around the eye.

  • Ocular oncology is an evolving field dealing with primary and metastatic tumors of the

  • eye and orbit.

  • You'll be working closely with oncologists, radiation oncologists, and dermatologists.

  • Completing a uveitis fellowship makes you the specialist for infectious and inflammatory

  • disease in the eye, particularly those of the uvea, which is at the front of the eye,

  • more specifically the iris, choroid, and ciliary body.

  • Ophthalmology is unique in that it combines medicine, office procedures, and surgery into

  • one practice.

  • It's also a highly innovative field with cutting edge technology.

  • For example, Ocular Coherence Tomography, or OCT, uses near-infrared technology to produce

  • cross-sectional pictures of a patient's retina, visualizing each layer independently

  • and measuring their thickness.

  • In terms of lifestyle, it's hard to beat.

  • You won't have to come in on weekends, and if you're on call, it's generally light.

  • For the most part, you're working a regular 8 to 5 job.

  • Compensation amongst physicians is in the upper third, with an average salary of $366,000

  • per year.

  • As a procedural specialty, compensation is largely a function of how many procedures

  • you perform.

  • If you can increase efficiency and do an extra few cataract surgeries in a given morning,

  • your compensation will reflect that.

  • The lifestyle is phenomenal as an attending, and compared to other residencies, particularly

  • surgical, ophthalmology is far more laid back.

  • Ophthalmology is also unique in that it's a highly visual field - no pun intended.

  • A great deal of your diagnosis will depend on your exam.

  • It's one of the few fields remaining where the physical exam is vital, and being able

  • to diagnose a patient from a physical can be gratifying.

  • Lastly, you'll be highly specialized in a very specific area.

  • Many systemic health issues manifest in the eye, so there will be times that you're

  • the first physician to catch an infectious disease or even cancer.

  • Because of your high degree of specialization, you may even catch important findings on imaging

  • that even radiologists may miss.

  • One example that comes to mind is a teenager with trauma to the eye during a sporting event

  • resulting in a fracture to his orbital floor.

  • The inferior rectus muscle of his eye was entrapped by the fracture, so that when he

  • tried to look up, not only was he restricted, but he has a drop in heart rate, known as

  • the oculocardiac reflex.

  • This happens because the eye muscle contains sensory nerves from the ophthalmic division

  • of the trigeminal nerve.

  • When the entrapped muscle tries to move, these nerves can become activated, which then synapse

  • on the vagus nerve, resulting in bradycardia, or a slower heart rate.

  • The flip side of being so highly specialized and independent is that you may feel more

  • isolated compared to other specialtists.

  • Whereas most of medicine is moving towards incorporating teams, you won't be as deeply

  • involved in coordinated care as an ophthalmologist, apart from the occasional consult to rheumatology,

  • neurology, endocrine, and of course the patient's PCP.

  • There's also a steeper learning curve in residency, as much of ophtho is not emphasized

  • in medical school.

  • You'll be doing new imaging, a new, more detailed physical exam, and learning about

  • pathologies that weren't highlighted in medical school.

  • Depending on your personality, you may not like the rapid change in the field - you must

  • be willing to adapt.

  • For example, up until the 1980's, extracapsular cataract surgery was the most common type

  • of cataract surgery performed.

  • However, in the late 80's and 90's, phacoemulsification, whereby ultrasound is used to break up the

  • lens, took over for a variety of reasons.

  • Some ophthalmologists, particularly the older ones, were unable to adapt to the new standard

  • and simply stopped performing the procedures.

  • Additionally, if you want to work in more desirable locations, such as a larger city,

  • you will probably need to specialize, as it's more difficult to be a general ophthalmologist

  • in dense metropolitan areas.

  • Lastly, ophthalmologists feel that there is increasing encroachment from optometrists.

  • This isn't an uncommon theme in medicine, which we'll discuss further on this channel.

  • Optometrists are essential providers in eye care and are at the front lines for a great

  • majority of eye diseases, and do plenty to earn their OD.

  • However, in many states, optometry organizations are pushing to increase scope of practice

  • to include laser procedures, small surgeries, injections, and medications which are typically

  • safer in the hands of more extensively trained ophthalmologists.

  • It's not a “us versus themmentality, but rather we must think of what is best and

  • safest for the patient.

  • How can you decide if ophthalmology is the right field for you?

  • The stereotype is that if you're an introverted nerd that prefers geeking out alone over working

  • in teams, ophtho may be a good fit.

  • But in actuality, anyone can be an ophthalmologist and there's a wide variety of personalities.

  • You should, however, be detail oriented and comfortable working with your hands, which

  • means not being a massive klutz.

  • Ophthalmology is a nuanced and delicate field, and those who appreciate the importance of

  • precision are more likely to succeed.

  • Given the rapid rate of technological development in the field, you should also be willing to

  • and hopefully even excited to use new technologies.

  • And finally, ophthalmology is more competitive than average, so you'll need to be willing

  • to work intelligently to position yourself favorably.

  • That translates to more than just high board scores, but also playing the research game,

  • being a leader, and crushing your clinical rotations beyond just surgery.

  • And who better to learn from and be mentored by than ophthalmologists themselves.

  • Big shout out to Dr. Mundae and the other ophthalmologists from Med School Insiders

  • that helped me in the creation of this video.

  • If you need help acing your MCAT, USMLE, or other exams, our tutors can maximize your

  • test day performance.

  • If you're applying to medical school or ophthalmology residency, our ophthalmologists

  • can share the ins and outs of what it takes and how to navigate the process most effectively.

  • We've become the fastest growing company in the industry, and it's no surprise.

  • Our customers love us because we're committed to delivering results, period.

  • Learn more at MedSchoolInsiders.com.

  • Thank you all so much for watching!

  • What specialty do you want me to cover next?

  • Leave a comment down below, and make sure you're subscribed to vote in the upcoming

  • polls.

  • If you enjoyed the video, hit that thumbs up button to keep the YouTube gods happy.

  • Much love to you all, and I will see you guys in that next one.

So you want to be an ophthalmologist.

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所以,你想成為一名眼科醫生[Ep. 10] 。 (So You Want to Be an OPHTHALMOLOGIST [Ep. 10])

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