SENIOR RESIDENCY or CLINICAL FELLOWSHIP?

-Dr. SAMENDRA KARKHUR

Ophthalmology is one of those branches in Medicine which until now did not have a super-specialty degree like DM or MCh. Now PGIMER, Chandigarh is the only institute in India which offers MCh in Vitreo-retina Surgery. However, this does not meet the requirement of several hundred diploma and degree holding ophthalmologists passing out each year in India. These young ophthalmologists seek sub-specialty training in various fields like Vitreo-Retina, Uveitis, Glaucoma, Oculoplasty, Ocular Oncology, Cornea and Refractive, Neuro-Ophthalmology, Pediatric Ophthalmology and Squint.

The reasons are firstly the lack of adequate sub-specialty rotation, limited availability of equipment/training in majority of government or private medical colleges in the country that offer post-graduate courses in ophthalmology. Secondly, increasing awareness and rising demand among patients who seek specialty care in ophthalmic problems similar to other fields in medicine.

Currently, after post-graduation or diploma in ophthalmology a candidate takes two routes to achieve the sub-specialty training in various fields. These are senior residency (henceforth called ‘SRship’) and clinical fellowships (henceforth called ‘fellowship’). I will discuss these two paths in detail and the advantages/ disadvantages of each; this may help many of my colleague standing at crossroads, in making an informed decision.

SRship is termed as the gateway to academic medicine in India. The duration may vary from one to three years and needs to be completed before one can apply for teaching or faculty position in a state or central government institution. In general, state medical colleges accept a candidate for the post of lecturer or assistant professor with one year of SRship from an MCI recognized institution. In central government institutions like AIIMS (New Delhi & all the other AIIMS), PGI Chandigarh, JIPMER Pondicherry, SGPGI Lucknow etc.; three years SRship is usually required before one can be considered for the post of assistant

professor. This period is counted as a teaching experience and need not necessarily be consecutive i.e. a cumulative period of three years in different institutions is sufficient. Also, three years of research experience in a recognized institution or a combination of both teaching and research is equally valid to begin your journey towards becoming a professor.

Now, what I have elaborated above is – what you get at the ‘completion’ of your SRship; which of course is equally important to what you get ‘during’ SRship! So, the experience you receive during your SRship fully depends on the institution that you are associated with. If the institution has sub-specialty fragmentation in the department (which unfortunately very few eye departments in the government institutions, have in our country) then you may have the option of attaching yourself to a particular sub-specialty of your liking. If this is not the case, then you will end up gaining teaching experience but not necessarily the specialization. However, keep in mind that most places do perform basic cataract/refractive, oculoplasty and glaucoma to say the least and you possess a choice to either embark upon an academic career with a satisfying institutional life or a good comprehensive ophthalmologist with thriving private practice. Public sector in India has its challenges; but if you want to have a broader impact on society, bring about a change in the public health sector or want ‘professor’ prefixed to your name, then this option may be well worth it!

When we look at fellowships vis-a-vis an SRship, the most obvious difference is the lack of teaching experience at the end of a fellowship program. Very rarely are the fellowship programs counted as teaching experience and one must enquire about the same from MCI. Another difference that stands out is the great variety and flexibility in pursuing a fellowship of your choice. For example, there are well structured programs across country in private and charitable institutes of great repute like LVPEI Hyderabad, SN Chennai, NN Bangalore to name a few prominent ones. These institutions provide fellowships for a period of 1.5 – 3 years in subspecialties like Cataract, Refractive, Vitreo-Retina, Glaucoma, Oculoplasty, Ocular Oncology, Pediatric ophthalmology and Neuro-ophthalmology. A vast majority of ophthalmologists in the country today are trained at these institutes and have established great careers. At the completion of fellowship program, one has the option of working in similar academic institution for a great academic and research career. On the other hand, a private practice is an equally good option.

One important thing to be noted here is that over the past few years, there has been an increasing trend towards diminishing number of surgeries and hands on

experience, in several reputed institutions in our country. This makes it difficult for a fellow to establish a private practice at the end of two years fellowship, which may be owing to lack of confidence in managing an independent surgical case. This situation is worsened by a signed ‘service bond’ after fellowship on meagre salaries. On an average with or without post-fellowship bond, the time spent by a fellow at an institution can range from 3 to 5 years before one is confident of starting an independent private practice. This model of retaining a trained hand by institutions does not bode well for several fellows who might want to move back to their home town at the completion of fellowship. They may be unwilling to stay away from families and spouse due to inability to pay off hefty amounts, which makes the signed bond a compulsion rather than an option. YOSI is making efforts in this direction which should help bring about a change, to this unhealthy bond culture, raising its head in the ophthalmology training in India.

In the end, choosing a fellowship or SRship depends on an individual’s postgraduate training, sub-specialty of interest, future career choice – private/ institutional practice and the city or town one would like to settle in. The most important factor is discussing with your mentors, seniors and colleagues; who will be able to guide you in taking a decision which is very crucial at this juncture. All things considered, an individual makes his or her own destiny; where institutions and programs can only assist you in achieving your goal in life.

Dr. SAMENDRA KARKHUR MS, DNB, FICO, FAICO (UVEA), MNAMS, is presently appointed as an Assistant Professor in Ophthalmology, AIIMS Bhopal, Madhya Pradesh. He has completed his training in Vitreo-Retina, ROP & Uvea from PGI, Chandigarh. He is a visiting instructor at Byers Eye Institute, Stanfor University School of Medicine, Palo, Alto, CA, USA. Stanford

He can be reached at karkhurs@gmail.com