Upamanyu Nath

Ophthalmology is one of the most competitive specialties to enter with the latest figures for competition ratios showing 1,383 applications for 96 posts, in other words, 1 in 14 applicants are successful (1). This is a staggering increase from 1 in 3 in 2019. The main domains to prepare for is the MSRA (20% weightage), evidence folder (50% weightage) and interview (30% weightage). While it’s possible for IMGs to excel in the MSRA and interview with good preparation in the days leading up to the application, the evidence folder needs planning ahead, and this is where most IMGs lose out on.

This is evident if we are to compare the percent of IMGs in Ophthalmology training over the past 6 years-

2024- 9.45% IMGs

2023- 8.85% IMGs

2022- 8.10% IMGs

2021- 7.17% IMGs

2020- 6.41% IMGs

2019- 7.96% IMGs

Although slowly improving, the total number of IMGs in Ophthalmology training this year remained less than 10%. As per data from the General Medical Council (2).

International Medical Graduates (IMGs) often find themselves at a disadvantage when it comes to building a strong portfolio for several reasons:

1. Starting Late: Most IMGs begin their transition to the UK after finishing medical school, which means they miss out on valuable points that could have been accrued during their undergraduate studies.
2. Limited Access to Ophthalmology: SHO positions in Ophthalmology are exceedingly rare, making it challenging to access cases for reports, EyeSi simulator training, or even attending clinics and theatre sessions.
3. Financial Barriers: Many portfolio-building opportunities come with significant costs. For IMGs with limited financial resources, finding affordable options can be a considerable hurdle.
4. Insufficient IMG-Specific Guidance: Generic advice on building an ophthalmology portfolio often focuses on elements like undergraduate prizes, intercalated training, and the Duke Elder exam, which can feel exclusionary to IMGs. There is a lack of targeted resources for IMGs aspiring to enter this competitive specialty.
5. Uncertainty About Recognized Evidence: IMGs often lack clarity on which qualifications from their home countries are counted and how to strategically plan their portfolio-building efforts.

Starting in 2024, ST3 entry to Ophthalmology training has been discontinued. However, the maximum allowable clinical experience in Ophthalmology has been increased from 18 to 30 months.

It is essential to focus on achievable, high-yield elements to strengthen your portfolio within a limited timeframe. Let’s explore section-wise the key points that IMGs can work on:

1. Qualifications with Certificates or Letters of Proof

Qualifications with certificates or letter of proof

CUMULATIVE SCORING (Maximum 5 points) Please note that a cross-specialty requirement that intercalated one-year degrees taken during a primary medical degree are not scored has been imposed. Please state explicitly if any additional degrees to your primary degree are intercalated or not intercalated. Any degree designations not mentioned below must have supporting evidence signed by a senior administrator or supervisor stating that degree’s equivalence to one of the categories below. 1 point – per qualification taken as a separate course separate from the primary degree for at least 8 months full-time or equivalent- MSc, BSc, PG Cert (including Optometry degrees but NOT intercalated degrees). 3 points- for an MD or MPhil degree taken as a separate course before or after the primary degree. If you gained your medical qualification in a country where all students are automatically awarded an MD without additional study you cannot claim points for that MD. You may only claim points for an MD/ MPhil where you have undertaken a period of 2 years full time additional study and research and you must present a supervisor’s letter confirming this. 4 points – for a completed PhD or DPhil. You must have undertaken full-time research involving original work, usually of at least three years’ duration, and ideally resulting in one or more peer-reviewed publications. You must present a supervisor’s letter confirming this. MRCP and MRCS are not scored.

This section varies for each individual. For IMGs, obtaining a PGCert is usually the most attainable goal unless you have previous degrees. Various PGCerts are available, and to ensure credibility, check for accredited courses on the AoME website (3). On average, a PGCert costs between £3,000 and £6,000 and takes around one year to complete.

2. Prizes and Awards

Prizes/Awards with proof

CUMULATIVE SCORING (Maximum 5 points) 3 points – for Crombie Medal (1st place in FRCOphth part 1 exam) 2 points – 1st in final undergraduate degree or equivalent e.g. Honours or Distinction where < 15% of the year achieve this. Evidence explicitly demonstrating this must be presented. Achievement in intercalated degrees is not scored. Degrees preceding or following a primary medical degree can be scored on this basis where evidence explicitly demonstrates < 15% of the year achieve this. National Undergraduate prize through competitive examination (in any specialty), e.g. The Duke-Elder prize: 2 points for coming in top 10% of entrants, 0.5 points for being in the top 60% (40th centile or a pass in 2016 or earlier Duke-Elder sittings). For any other prize please indicate the number of entrants and your position. 1 point will be awarded for being in the top 20% of entrants. 1 point each- for each successful research grant application where the candidate was lead author and the application led to substantial peer-reviewed published research. Travel and other bursaries will not be scored unless there are exceptional circumstances/ achievement demonstrated. 0.5 points each- for Best presentation or poster at a national or international meeting (may also be used in evidence for Presentations section). Being highly commended or any other designation will not be scored. 0.5 points each (maximum 2 points within this section) for each prize / distinction/ merit related to substantial parts (i.e. more than 4 weeks full-time) of the medical or dental course or Foundation Programme awarded to no more than the top 20% of students and doctors. Evidence explicitly demonstrating these criteria must be presented. For any other prize please indicate the number of entrants (must be more than 400) and your position.

If you missed the opportunity to take the Duke Elder Examination during your undergraduate studies, don’t despair. Points are available for “National Undergraduate prizes through competitive examination (in any specialty),” meaning if you have evidence of being in the top 20% of any national undergraduate competitive examination, you will earn 1 point. Honours or distinctions in your MBBS also carry weight—2 points if awarded to less than 15% of your cohort. Be mindful that an “honours” in your home country may equate to a merit in the UK, in which case you’ll score 0.5 points if it was awarded to less than 20% of the year. Successful research grants or awards for best poster/presentation also qualify for points in this section.

3. Ophthalmology Specialty Links and Commitment to Date

Ophthalmology specialty links and commitment to date as a career

CUMULATIVE SCORING (Maximum 12 points) Refraction Certificate (or exemption as fully-qualified post-registration optometrist):   2 points   FRCOphth part 1:  3 points or 1 point for attempting the part 1 FRCOphth on at least one occasion. Non-peer reviewed publications (0.5 point each) & case reports in ophthalmology or other peer-reviewed (PubMed-cited) research publications in ophthalmology not included in other sections (1 point each): 2 points max. within this section (points only awarded if candidate is first author). Please indicate clearly impact of non peer-reviewed publications. Ophthalmic elective and/or separate undergraduate project:  2 points max., 1 point per achievement. Please provide evidence of reflection on achievements. If electives were cancelled due to COVID and evidence is provided that an elective was planned then this can be scored. Undergraduate projects must have supervisor support explicitly stating the project was equivalent to 2 weeks’ full-time work. Taster week: 1 point max. (or evidence presented of a Foundation year attachment in Ophthalmology). Attending ophthalmology clinics and theatre sessions outside of a formal taster week and spaced out over more than 3 months (minimum 10 sessions with dates & supervisor-signed evidence): 1 point max. Evidence of ophthalmology simulation training (including EyeSi experience): 1 point for each activity of at least 4 hours, max. 2 points Meetings attended: 3 points maximum, from which 3 points max for National / International Ophthalmology educational meetings attended (1 point per meeting) and 1 point max for Regional Ophthalmology meetings (including Royal Society of Medicine Ophthalmology Section) attended (0.5 points per meeting). Meetings included in this section must not be included in Presentations section. Evidence not included above- discretionary: 2 point max. (not including taking Duke-Elder, logbook of surgical cases or WBAs).

The FRCOphth Part 1 and Refraction Certificate exams are accessible globally for IMGs. As of 2024, the cost for the FRCOphth Part 1 is £650, while the Refraction Certificate costs vary (e.g., £830 in the UK, £1385 in Singapore and Malaysia, and £1040 in India, Egypt, and Pakistan). The scoring criteria for the 2025 application cycle mean that just appearing for the FRCOphth Part 1 will score you 1 point, while passing it earns you 3 points.

Engaging with your local Ophthalmology department is essential. Email consultants to arrange a taster week (1 point), attend at least 10 clinic/theatre sessions over three months (1 point), and practice on an EyeSi simulator for a minimum of 4 hours (1 point). Look for additional local simulation training opportunities (up to 2 points) and inquire about potential case report topics (up to 2 points). By connecting with your local department, you can earn a maximum of 7 points.

If your local department lacks an EyeSi simulator, you can find locations and contact information on the RCOphth website (4). Attending the RCOphth Introduction to Ophthalmic Surgery course guarantees 1 point and provides an introduction to using EyeSi. Costs vary by membership status: £498 for members and trainees, and £595 for non-members (5).

Local and regional meetings offer an opportunity for easy points (0.5 points per meeting, up to 1 point total), while international or national conferences can provide up to 3 points. Writing articles or letters to the editor for non-peer-reviewed publications can earn you 0.5 points each.

4. Multi-Source Feedback (MSF)

Multi-Source Feedback (MSF)

(Maximum 3 points) The MSF must have been taken place within 18 months of the interview date if the candidate has been in clinical posts for this period. Candidates not currently within a clinical post who do not have an MSF within the timeframe (e.g. undertaking a longer period of research or an extended period of leave) should include the MSF from their most recent clinical post. The MSF should include feedback from a minimum of 5 respondents if in a general practice post or 7 respondents if in a hospital post.  Your educational supervisor or equivalent supervisor should collate this information and summarise it in a report. The report should include the period the MSF covered.   The report must be signed by the educational supervisor or department lead and stamped with a departmental stamp unless including a standard Team Assessment Behaviour Form (TAB) printed from E-portfolio which does not require a signature or departmental stamp. For candidates without access to an on-line portfolio or unfamiliar with the MSF process information can be accessed from the link below. Click for:  Multi Source Feedback Guidance Points will be awarded as follows: 0 points – for significant negative comments 1 point – minor negative comments or non-satisfactory scores 2 points – satisfactory scores with appropriate good comments 3 points – satisfactory scores with a large number of superlative positive comments, e.g. “best trainee I have ever worked with”.

Collect an MSF from colleagues in your most recent position. If you lack access to Horus for this, your Educational Supervisor can compile the feedback into a document for signature. An MSF format is also available on the Severn Deanery website (6).

5. Publications

Publications

(Maximum score 6 points) Candidates cannot place the same work in both presentations and publications domains. Please choose which domain to include the work in. Duplicate work in different publications will not be scored. List peer-reviewed original research publications or high-quality systematic review articles (not letters to a journal) with the pro forma information detailed below and then after each pro forma information in turn, upload a photocopy of the first page of each paper. No marks will be given without a copy of the first page of either a published or “in press” paper and in the latter case evidence of final acceptance for publication must be presented. On the pro forma list each piece of evidence including the citation of the journal (author’s name(s), article title, journal name/title, volume of journal, issue number of journal, page or range of pages, year of publication and DOI or URL) and indicate whether you were 1st, 2nd, 3rd or 4th author. 3 points for each publication where you are 1st author or joint first author and 1 point for any other publications up to 4th author (unless > 8 authors in total for article when 1st author only counted). If you are one of three or more joint first authors then you will be scored as a second author. If there are more than 6 joint first authors then no score will be given. No points will be awarded in this section if you are 5th author or lower in the citation. No points will be awarded in this section for case reports. This evidence can be included in “Ophthalmology specialty links and commitment to date as a career” if the work is in Ophthalmology. Quality of the work presented and impact of the journal may be taken into account when scoring. Click to download: Publication Pro forma

While original research can be challenging, reach out to your department to connect with consultants who are actively engaged in research. Getting involved early is key, as research often requires significant time. Systematic reviews are a more accessible entry point; your institution’s library typically has resources and librarians who can guide you through the process.

Ensure that any publications are in PubMed-indexed journals to earn points in this category.

6. Quality Improvement (QI) / Audit Projects

Quality improvement / Audit projects

(Maximum score 5 points) A copy of your best QI project or audit, performed within the last 3 years of the interview date, must be uploaded with either presentation slides or a text document showing standards, methods, outcomes and recommendations.  An additional covering letter signed by the supervising consultant explicitly confirming your specific role in the project / audit must be uploaded. This is especially important to confirm the points to be awarded as below. Points will be awarded as follows: 0 points – if no evidence of QI / audit work in portfolio.                               1 point – for participation but no specific roles documented or specific format followed. 2 points – for initiation and design of the QIP / audit and some evidence of specific format. 3 points – for initiation, design and writing up the QIP / audit and specific format followed. 4 points – as above and was personally involved in implementing the QI strategy / completing the audit loop and implementing change 5 points – for published audit (not to be added to Publications section) or QI guidelines implemented supra-regionally. Note: Some modification of these marks may be made dependent on quality of project and impact of the work. If you are not clearly lead on the project then the maximum score is 1 point.

QI projects are generally more accessible than original research. Reach out to your departmental clinical audit team for ongoing audits that can be repeated. Joining an existing audit is a good way to gain experience, but leading one can earn you 3 points, making it the most rewarding option.

7. Presentations

Presentations

CUMULATIVE SCORING (Maximum score 6 Points) List of presentations and copies of abstracts or posters, stating whether it is a poster presentation or oral presentation.  Proof must be uploaded through an abstract book or signed letter from supervisor. Presentations must be of original work and not didactic lectures. Presentations duplicating work will not be scored. Explicit evidence detailing that all the preparatory work was completed for presentations cancelled due to COVID will be accepted. 1 Point – Regional presentations (For example regional ophthalmology society meetings or other specialty equivalents in the UK or regional ophthalmology meetings of other countries or equivalent non-ophthalmology meetings. Regional designation includes specifically English, Scottish, Welsh meetings). Local hospital or university-specific meetings are not scored. 2 Points – National presentations (For example, RCOphth Congress, British Oculoplastic Surgery Society, or other specialty equivalents in the UK or national ophthalmology meetings of other countries or equivalent non-ophthalmology meetings)  3 Points – International meetings – (For example Association for Research in Vision and Ophthalmology, American Academy of Ophthalmology, etc or equivalent international non-ophthalmology meetings.) Meetings in non-UK countries where explicit evidence is not presented as to the international nature of the meeting are scored as national or regional meetings. NB: The same paper presented at different meetings will only be counted once e.g. the highest-ranking meeting. Also: Accepted presentations, but not yet presented, will be awarded points. Oral presentations score points as shown above, e.g. 2 points at national meeting. Poster or video presentations score half points shown above, e.g. 1 point at national meeting. Second author or lower scores a half of the oral presentation or poster points, e.g. 0.5 points for a poster at national meeting. Candidates cannot place the same work in both the presentations and publications domains. Meetings included in this section must not be included in Ophthalmology Specialty Links section. Please choose which domain to include the work in.

Presentations stem from original research, systematic reviews, and case reports. If you have completed any of these, submit them to conferences for points. Regional presentations may have higher acceptance rates, so consider targeting those. Various apps like MedAll and Eventbrite, websites like Eye News and online searches can help you find relevant conferences (7-9).

8. Education and Teaching

Education and Teaching

CUMULATIVE SCORING (Maximum Score 5 Points) Scores will be awarded as follows. 0.5 points each – for helping with an educational course (more than one session), designing an e-learning tool, writing an e-book, completing a “teaching the teachers” course and/or undertaking a formal role in examining undergraduates. 1 point – for contributing to at least three teaching sessions on different subject areas over a period of at least 3 months with formal feedback uploaded. 2 points – for a Higher teaching qualification e.g. a Diploma, Certificate in Medical education. 2 points – for writing a chapter in a postgraduate-level academic book (not an e-book or self-published book). Specific evidence of the publisher and impact of the book must be shown. 3 points – for writing a postgraduate-level academic book (not an e-book or self-published book). Specific evidence of the publisher and impact of the book must be shown. All evidence must come with either photocopies of a chapter index, attendance certificate or a signed letter from a supervisory Consultant/ Educator etc. as supporting evidence. Specific evidence demonstrating impact of e-learning projects or other teaching achievements must be presented. Specific evidence of impact of e-books in numbers downloaded or otherwise accessed must be presented. No points will be awarded solely for being a teaching fellow or anatomy demonstrator. Any educational activities as above undertaken in those roles will be scored.

Look for low-hanging fruits in this section. You can assist with educational courses or weekly/monthly departmental teaching sessions, earning 0.5 points for teaching in one session. If you can arrange an educational course and conduct more than three sessions on different topics in it, you’ll score 1 point. Completing a ‘Teach the Teachers’ course will add another 0.5 points. Consider reaching out to the undergraduate department at your local medical school or undergraduate department to explore roles in examining undergraduates, usually open to those at FY2 and above after completing a one-day training course. A PGCert in Medical Education can also earn you 2 points here.

9. Overall Portfolio Layout & Quality

Overall portfolio layout & quality

(Maximum Score 3 Points) Layout, organisation and quality of how the portfolio is presented will be assessed.

Finally, ensure your portfolio is well-organized and adheres to the required format. Numerous resources, including YouTube videos, can provide examples of successful portfolio layouts.

By focusing on these achievable components, IMGs can enhance their portfolios within the limited time available and improve their chances of success in attaining a training number in the competitive field of Ophthalmology.

References

1. Health Education England. 2024 competition ratios [Internet]. Available from: https://medical.hee.nhs.uk/medical-training-recruitment/medical-specialty-training/competition-ratios/2024-competition-ratios. Accessed 21st October 2024.
2. General Medical Council. Postgraduate trainees summary data [Internet]. Available from: https://gde.gmc-uk.org/postgraduate-training/postgraduate-trainees/postgraduate-trainees-summary-data . Accessed 21st October 2024.
3. Academy of Medical Educators. Our accredited courses [Internet]. Available from: https://www.medicaleducators.org/Our-Accredited-Courses . Accessed 21st October 2024.
4. Royal College of Ophthalmologists. EyeSi ophthalmic surgical simulators [Internet]. Available from: https://www.rcophth.ac.uk/training/simulation/eyesi-ophthalmic-surgical-simulators/ . Accessed 21st October 2024.
5. Royal College of Ophthalmologists. Skills courses [Internet]. Available from: https://www.rcophth.ac.uk/training/simulation/skills-courses/ . Accessed 21st October 2024.
6. Severn Deanery. Evidence folder library [Internet]. Available from: https://severndeanery.nhs.uk/recruitment/vacancies/show/oph-st1-25/evidence-folder-lib . Accessed 21st October 2024.
7. Medical Education Development and Learning [Internet]. Available from: https://medall.org/ . Accessed 21st October 2024.
8. Eventbrite [Internet]. Available from: https://www.eventbrite.co.uk/ . Accessed 21st October 2024.
9. Eye News. Events [Internet]. Available from: https://www.eyenews.uk.com/events/ . Accessed 21st October 2024.