Within a short period of time, members of this year's graduating class of vitreoretinal surgeons will be entering their first jobs. We all have honed our clinical and surgical skills over many years in preparation for our new role as attendings. Nevertheless, there are many practical, real world skills that are not so evident during our training as residents and fellows. We thank Greg Fenton, MD, and Chirag Shah, MD, MPH, two attendings who recently completed their fellowships, for sharing their insights into the early years of practice.
Becoming a new attending will undoubtedly be filled with countless new experiences and excitement. We look forward to this transition and wish all of the other second year fellows best of luck in the next phase of their careers.
–Paul S. Baker, MD; Allen Chiang, MD; and Eugene A. Milder, MD
What were you most and least prepared for after finishing fellowship?
Greg Fenton, MD: I felt well prepared from the standpoint of medical and surgical training entering practice. I was certainly nervous taking those first steps independently, and almost immediately I encountered certain patient scenarios that were not identical to any that I had encountered previously. However, I found that my fellowship provided me with the tools to be able to make good decisions in new situations. I think that gaining good clinical and surgical judgment and establishing a discipline of continually learning are probably the most important things you can take away from fellowship training.
In general, I would say that my understanding of the business side of running a practice was pretty weak after fellowship, and I am now just beginning to scratch the surface of understanding it. I am beginning to see that it is very complicated and challenging to run a practice efficiently and successfully. We have a practice administrator who carries a significant amount of the burden in this regard. Many physicians, however, spend a lot of time doing important administrative work for the practice outside of their busy clinical and surgical schedules. Fortunately, no one expects a new graduate to have a good grasp of these things, and there is opportunity to learn from those who are senior to you as you move forward.
Chirag P. Shah, MD: I am fortunate to have received outstanding medical and surgical training during my fellowship, preparing me well for both the common and uncommon cases I have encountered in the office and the OR. After a busy fellowship, it is a hard to imagine a day without operating. I think it is common to feel a sense of withdrawal as you are building a practice one patient at a time. Use this transition period to spend more time with your patients and establish new research projects, as things will get busy quickly.
One challenge, despite my training, is the lack of grey hair on my head (I will read this in a few years and wish I still had hair). To most of our patients, young attendings look like teenagers. It is important to find a balance between confidence and humility to win over most patients. Keep in mind that despite your best intentions, some patients will prefer a more seasoned doctor; I offer these patients appointments with my senior partners.
What are some of the challenges you faced in entering the culture of a different practice? What adjustments did you make?
Dr. Fenton: Thankfully I have not encountered any significant challenges adjusting to the overall culture of the physicians in my practice. When I was looking at potential job opportunities I considered it a high priority to try to understand what the culture was like of a given practice and whether I would be a good fit for that culture. However, there were a number of ways of doing things to which I had become accustomed in fellowship that were different in my practice. Some differences included what data are usually collected and documented by technicians, how patient phone calls are handled, how tests are ordered and reviewed, what paperwork is involved in patient visits, and how patients are billed. I was used to one electronic medical record in fellowship, but my practice has a different system. All these changes meant that I was inefficient at the beginning as I became accustomed to a new environment. I learned that it is better not to assume that a clinic will automatically run the way with which one is familiar. Communication of expectations with the technicians and other members of the staff has been critical in helping to make the transition.
Dr. Shah: The most stimulating aspect of our field is that we are constantly learning and growing. The transition from one institution to another is no exception. During fellowship, for example, one becomes a surgical athlete, operating in a familiar setting with familiar equipment and staff. Be prepared to relearn surgery, at least parts of it, at your new institution, particularly if there is different equipment. You will have to modify your surgical techniques depending on what is available. Further, you will learn some pretty cool things that you might have never seen before.
William Blake captured the paradox of innocence and experience, which you will face as you enter a new practice. As the new person, you bring a fresh, innocent perspective with an inherent creativity that becomes dampened with experience. I think it is important to take note of your observations and thoughts as you start a new job. Some of your ideas could make your new institution better, and much of what you learn will make you better.
In regard to taking care of patients in the office setting, what changes have you made during your transition from fellow to attending?
Dr. Fenton: I think that my approach to patients in the office is very similar to how it was during fellowship. One adaptation I made was creating a procedure session once a week for injections and nonurgent lasers. In fellowship, we always performed procedures on the same day. I have found that in our busiest office, it is far more efficient to split the procedures from clinic. Also, I have gone through a few different ways of administering intravitreal injections, and have now settled on a way that works best for me. Finally, we always used postinjection antibiotic drops in fellowship, and I am starting to move away from this.
Dr. Shah: As an attending, the buck stops with you. I aim to do everything possible for a patient during their visit to ensure an accurate diagnosis and appropriate treatment plan. I am more inclined to check a fluorescein, indocyanine green, visual field, or other test to definitively rule in or rule out a diagnosis. If a patient needs to see one of my anterior segment colleagues for an urgent issue, I will walk him or her over to see one of my partners. I am also inclined to refer challenging cases to my senior retina partners for a second opinion.
One of the most gratifying aspects of my job is training fellows. I prefer teaching at the bedside (or, in our subspecialty, at the chairside) to point out interesting findings and share my approach with both the patient and the fellow. If things get busy, I make note of my interesting patients to review with fellows at the end of the day.
What adaptations have you made in the OR during your transition from fellow to attending?
Dr. Fenton: When I first arrived, I made an effort to try some of the buckling elements and forceps that were already stocked for the other surgeons, and I have mostly switched to these because I feel that they were equivalent to what I had in fellowship. I had experience with both the contact lens and binocular indirect ophthalmomicroscope (BIOM) viewing systems in fellowship, and the practice I have joined uses the BIOM exclusively. I have adapted by using the BIOM exclusively. In general, my approach to selecting surgical patients is probably a little more conservative than it would have been in fellowship now that I bear the sole responsibility for my patients.
Dr. Shah: I trained using a noncontact viewing system for vitrectomy. I now have the option of using the handheld wide-angle lens, which I never used during fellowship. I have come to realize that both the contact and noncontact viewing systems have their own separate advantages and disadvantages, and I now choose depending on the case.
Thanks to my fellows and partners, I have learned how to perform endoscopic vitrectomy as an attending. I thought I had seen it all in fellowship, but I now realize that I will never have to perform vitrectomy with a temporary keratoprosthesis again because of endoscopy. There is a relatively steep learning curve, but I am fortunate to have access to this technology.
Having just trained as a fellow, I value the opportunity to foster the surgical development of my fellows. After a 6-month adjustment to my new OR, I found it easier to allow my fellows to sit in the surgeon's chair. Of course, it is important to weigh the patient's needs as well as the fact that you are establishing yourself as a surgeon in your community. For appropriate cases, I first review the surgical plan with my fellow while we are scrubbing, to detail how I would like him or her to approach the case, and then guide him or her from the assistant's chair. I must admit that operating is one of my favorite activities in life, and I often wish I could be a second-year fellow forever. It is gratifying to help train fellows and watch them flourish into skilled surgeons.
Can you offer any advice for building a practice in your first year after fellowship?
Dr. Fenton: My practice sent out announcement cards to referral sources and advertised my arrival in local papers. I visited many potential referral sources over the course of several months. When you are just starting out, the chances are that you will not be extremely busy. Having this free time is a good opportunity to visit optometrists and ophthalmologists as well as endocrinologists and primary care doctors depending on your specific practice situation. My practice has a main office and three satellite offices. I started relatively busy in two of the offices and not as busy in the other two. Therefore, I focused my efforts on reaching out to potential referral sources within a 20 mile or so radius of these two less busy offices. My practice had a long list of all optometrists and physicians who had ever referred patients to the practice, so I was able to use this list when planning my visits. I also searched online and added others to the list. This is a very humbling process. Some people will be very friendly and welcoming, and others may show no interest or, in rare cases, can even be rude. Referral patterns for certain providers can be well established, and there may be politics involved about which you may know nothing. It is important to approach the process with humility, friendliness, and openness, regardless of what you encounter when you enter an office.
How have you built relationships with referring doctors?
Dr. Fenton: When I receive a patient referral, I make sure to send a detailed letter promptly. I also send update letters as the patient returns for future visits. I will sometimes call the referring doctor that day with an update, depending on the acuity of the problem. I have also given referral sources my cell phone number, which helps to reassure them of my availability to them. It is very important that you respect the referral source and encourage the patient to return to him or her for their nonretina eye care (eg, cataract surgery, glasses prescription) even if you have individuals in your practice who could fill that role.
Dr. Shah: It is most important to do a good job taking care of their patients. If their patients can see again, and if they had a good experience with you, they will sing your praises to the referring doctor. It is important to be diligent about dictating letters to keep referring doctors updated. I think it is helpful to meet doctors who refer patients to your practice; nothing beats a personal connection. Depending on your practice, you might go doortodoor, or it might be better to give lectures to the general ophthalmology and optometry community.
Most new attendings have extra free time while their practice is in the building phase. How do you recommend spending this time most productively?
Dr. Fenton: As discussed above, using your free time to build your practice is important. Visiting potential referral sources is crucial. The extra free time also makes it easier to catch up on journals, work on your own research, go to national meetings, or do some networking by getting involved in local ophthalmology or retina groups/societies. The advice I received from my partners was to enjoy time with my family and to try not to worry about not always being busy. I was told that I will get busier and busier and should enjoy the free time while it lasted. I took that advice and have not regretted it. And they were right: I continue to get busier.
Dr. Shah: This honeymoon period is the ideal time to accomplish a lot; it does not last long. I recommend finishing any outstanding research projects from fellowship and establishing new research projects at your new institution. Also, spend this time reaching out to the community with lectures on general retina topics and personal introductions to referring doctors.
Chirag P. Shah, MD, MPH, joined Ophthalmic Consultants of Boston in 2010. He can be reached at cshah@post.harvard.edu.
Greg Fenton, MD, joined the Wheaton Eye Clinic in Illinois in 2010. He can be reached at gfenton@wheatoneye.com.
Allen Chiang, MD; Paul S. Baker, MD; and Eugene A. Milder, MD, are second year vitreoretinal fellows at Wills Eye Institute, Thomas Jefferson University, and members of the Retina Today Editorial Board. Dr. Chiang may be reached at allen_chiang@alumni.brown.edu; Dr. Baker may be reached at pbakerny@yahoo.com; and Dr. Milder may be reached at genemilder@gmail.com.
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