For nearly as long as medical school has been a requirement for ophthalmologists in training, so too has as internship year been required. This is true not only for ophthalmologists but for anesthesiologists, dermatologists, radiologists, radiation oncologists and more. While many students choose one year of internal medicine, a year of general surgery or a transitional year (combination of both medicine and surgery) can be chosen instead. Today’s medical school graduates all undergo this year of training, but the bigger question remains: should they?
As tuition for medical school increases and physician reimbursements decline (at the time of this article a 21% cut is still pending), the path to becoming an MD has become more challenging. Currently most graduating medical students have some degree of debt, and most residency/fellowship salaries do little to help impact these amounts. Certainly any amendments to the current method of training which reduce the time required to begin practice would help young physicians.
Though from a financial aspect it may make sense to remove the internship year, many have argued that the education received in this time is critical to becoming an ophthalmologist. For example, the ability to treat diabetic retinopathy is linked to being able to understand the pathophysiology of the disease, and how medically it is diagnosed and treated. Learning the fundamentals of the practice of medicine has allowed physicians to treat the entire patient and not the disease, which can sometimes be misdiagnosed when we look too closely.
I can remember in my training seeing a patient in the emergency room for complaints of acute loss of vision. On examination I could not find anything wrong. I called the neuro-ophthalmology fellow to evaluate the patient for giant cell arteritis, who astutely noted that the patient’s glasses were filthy and, upon cleaning them, recovered her vision. But perhaps a more relevant story pertains to a resident at Bascom Palmer - Dr. Chris Alabiad; Dr. Alabiad was called to Jackson Memorial Hospital for a consult to evaluate “Bradycardia - ? due to timolol?”. Dr. Alabiad evaluated the patient, not only with an eye examination but the entire chart. On review of patient’s EKG he diagnosed the patient with Mobitz second-degree AV block and ultimately had the patient’s heart paced (he had placed the leads and set up the pacer himself).
While this story at first champions the need for more training in internal medicine, there is more background I need to divulge. In fact, Dr. Alabiad, before beginning his ophthalmology residency, had completed an entire internal medicine residency at Massachusetts General Hospital and was board certified. Sadly, it would be very difficult, almost impossible, to find a practicing ophthalmologist who could diagnose Mobitz type II AV block on an EKG. While my ability to treat hypertension and diabetes was excellent in internship, as the years pass I have unfortunately forgotten some and the rest has been replaced with new breakthroughs in understandings of disease, as well as newer medications and medication classes that I never learned. More often than not, I had heard our residents and fellows (who are closer to their internship years than I) say to patients “You need to discuss that with your primary care doctors.” Are they wrong for saying that? I don’t believe so. The truth is that internship year training can vary so much that it is extremely difficult to develop a core set of education that will be utilized in ophthalmology. I thoroughly enjoyed my intern year, and I have felt that the training has helped me become the physician I am today. Nevertheless I think it is time we re-evaluate this requirement and allow those graduating medical students to advance directly to the field they truly wish to practice: Ophthalmology.