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Residents & Fellows Corner | July/Aug '20

Assessing the Value of Intern Year

How do traditional, transitional, and integrated internships compare, especially in the time of COVID-19?

The path to becoming a fully licensed, board-certified physician is long, arduous, and not without great personal sacrifice. After 4 years of medical school, newly minted physicians must complete a clinical residency in a medical or surgical subspecialty of their choice during an additional training period ranging from 3 to 7 years. After residency, some physicians choose to further subspecialize in their field by completing a fellowship, which can be yet another 1 to 3 years of training.

Traditionally, the first year of residency is referred to as an internship. Although distinguished by name, most primary care specialties have an integrated internship that naturally flows into the remainder of the residency program. However, certain specialties, such as ophthalmology, dermatology, radiation oncology, radiology, anesthesiology, and physical medicine and rehabilitation, do not start specialty training until the second year of residency and instead have a unique internship in the form of a preliminary or transitional year that is distinct from the rest of residency training.1 These preliminary and transitional programs serve to establish a foundation in internal medicine, general surgery, or even pediatrics, and they often vary drastically in structure and clinical experience.2

Preliminary year programs traditionally encompass more primary care months than their transitional year counterparts, which are often more flexible and allow for 1 to 6 months of non-primary care specialty electives, rotations at other hospitals or institutions, and dedicated time for research.3 These preliminary and transitional years are sometimes done at the same location as the specialty residency program, but many are uncoupled and can be completed anywhere in the country. Due to such a wide variety of internship experiences, ophthalmology residents who match at the same program may start their first year of specialty training with very different clinical backgrounds.

TRADITIONAL VERSUS TRANSITIONAL INTERNSHIPS

In my conversations with ophthalmology residents, fellows, and attendings, I have noticed that there appears to be a difference of opinion on the long-term value of completing a traditional internship with a focus on almost a full year of primary care versus a transitional year that may allow for many months of exposure to ophthalmology or other areas of medicine that are beneficial for ophthalmology training.

Proponents of a more traditional internship year espouse the perspective that we are physicians first, ophthalmologists second, and subspecialists third. Understanding the basics of how to clinically manage common pathology such as hypertension, diabetes, or kidney disease is crucial, as many ophthalmic patients have these comorbidities (often with ocular manifestations) and are on medications that can affect the eye and even ophthalmic surgical planning. Having the skill set to triage or respond to common medical emergencies is intrinsic to the identity and role of a physician, and the exposure to several months of internal medicine training during intern year is essential for this formation to take place.

On the other hand, there are those who feel that there is little practical carryover from a traditional internship to ophthalmology training or practice and that the majority of knowledge or skills geared toward primary care are often forgotten or could be replaced with clinical experiences that are more relevant to recognizing and treating ocular pathology. Ophthalmology has evolved drastically over the past several decades, as we are constantly learning and making discoveries about the eye that lead to new imaging modalities and medical and surgical interventions. As ophthalmology has grown as a field, so has the amount of material that ophthalmology residents must learn and understand. Some believe that 3 years of ophthalmology residency is not enough time to master the numerous subspecialties, and not all programs can offer the same surgical volume.

Time dedicated to ophthalmology in intern year may be a supplement to ophthalmic clinical training and may lead to earlier acquisition and development of fine technical skills, such as applanation tonometry, slit-lamp biomicroscopy, indirect ophthalmoscopy, and gonioscopy, which are not traditionally taught in medical school. Extra time in ophthalmology also allows for attending didactics, imaging conferences, wet labs, and meetings—all of which facilitate understanding the language of ophthalmology and ease the learning curve of a subject that is traditionally not well covered in medical school. Finally, earlier exposure to one’s ophthalmology department and faculty may kindle earlier research opportunities or mentorship experiences, allowing more time to conduct clinical studies or ignite lifelong professional relationships.

A SHIFT TOWARD INTEGRATED INTERNSHIPS

Over the past several years, there has been a growing movement to integrate internship into the rest of ophthalmology residency to allow residents more time to study ophthalmology during intern year.4 More residency programs are adopting the integrated approach, with some offering an integrated internship at the same institution as the ophthalmology program and others working with local hospitals to arrange for several months of intern year to be spent with the ophthalmology department. Many programs have seen great success with this, and my personal experience training at an integrated program and working with the first two generations of residents to experience the integrated internship corroborates observations by those at similar programs.5

THE EFFECTS OF COVID-19

In the setting of COVID-19, many colleagues in ophthalmology and other non–primary care subspecialties have been summoned to help care for afflicted patients in emergency departments, on medicine floors, and in intensive care units. In certain COVID-19 hotspots, ophthalmology residents and fellows and even attendings were suddenly thrust back into an environment where they were once again using their stethoscopes, assisting codes, interpreting systemic lab and imaging results, placing lines, and having difficult life-and-death conversations with patients and their loved ones.

It has been amazing to see physicians from all areas of medicine and surgery come together for the greater good, to help treat those directly affected by this unprecedented global pandemic. It is selflessness and collaboration on this scale that reminds me why I decided to become a physician, and it is wonderful to see so many ophthalmologists continue to inspire and lead the way in medicine at large. To everyone who has helped take care of COVID-19 patients, thank you for your courage and compassion and for representing the best of our profession!

CONCLUSION

At a time when patients and the US health care system needed additional physician support from non-primary care specialists, physicians in ophthalmology were prepared to help. In this era when many residency programs are adopting integrated internship programs, we must consider whether certain specialists’ sudden transition back to internal medicine would have been possible without the months of exposure to primary care they received during a traditional intern year.

1. ACGME Specialties Requiring a Preliminary Year. ACGME. July 1, 2017. www.acgme.org/Portals/0/PFAssets/ProgramResources/PGY1Requirements.pdf?ver=2017-09-08-114529-173. Accessed August 14, 2020.

2. Requirements for Certification. American Board of Ophthalmology. abop.org/become-certified/requirements/. Accessed August 14, 2020.

3. ACGME Program Requirements for Graduate Medical Education in the Transitional Year. Accreditation Council for Graduate Medical Education. July 1, 2020. www.acgme.org/Portals/0/PFAssets/ProgramRequirements/999_TransitionalYear_2020.pdf?ver=2020-06-29-164050-813. Accessed August 14, 2020.

4. Oetting TA, Alfonso EC, Arnold A, et al. Integrating the internship into ophthalmology residency programs: Association of University Professors of Ophthalmology American Academy of Ophthalmology white paper. Ophthalmology. 2016;123(9):2037-2041.

5. Christiansen SM. Integrating the internship into ophthalmology residency – the new standard. EyeSteve.com. August 3, 2016. eyesteve.com/ophthalmology-integrated-internship/. Accessed August 14, 2020.

author
Arjan Hura, MD
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July/Aug '20