The transition from being a trainee to an attending heralds an exciting time for retina fellows across the country. Whether one is in a private or academic practice, this period may be accompanied with anticipated anxiety. We took this opportunity to ask recent graduates to share their experiences and challenges in their new roles as retina attendings. They offered some key pearls and advice for new retina surgeons.

— Alok S. Bansal, MD; Nik London, MD; and Andre Witkin, MD

What are some avenues to gain exposure in your new community and meet referring doctors?

David Barañano, MD, PhD: Giving lectures and going out to meet colleagues are both important ways for a new retina specialist to introduce him or herself to a community. What is more important is gaining the doctors' confidence and establishing trust. This takes time as it requires establishing a record of excellent care. Often the initial referrals one receives are either inconvenient or unexciting. These referrals are still opportunities to demonstrate the three A's: available, able, and affable. When presented with the opportunity to care for a colleague's patient, I try to communicate my findings, plans, and prognosis clearly and quickly. If I am referred a patient from a new doctor I have not met, I try to call the doctor to introduce myself and discuss the patient directly. Not only does this help coordinate the patient's care, but it gives me a sense of that specific doctor's practice patterns, his preferences in terms of follow-up, etc.

Rahul Khurana, MD: The best way to get exposure to referring doctors is meeting them in person. Having a personal connection and having them match your face with your name is invaluable in generating referrals. Most doctors these days are so busy that not everyone can go out for lunch or dinner, so going to their office and introducing yourself is a good way to start. I typically coordinate with their office manager because I don't want to visit on a busy clinic day. Giving lectures in the community and going to regional eye society meetings is also a good way to gain exposure, but ultimately meeting doctors face to face is probably the most effective way to generate referrals.

Leon Charkoudian, MD: Many new retina specialists have spare time, and I agree that it is important to use that time to go out and meet referring doctors. They are much more likely to refer to you once they've put a face to your name because you have made the effort to come to their office. Countless times I've gone to meet a referring doctor and then had several new patients referred to me from that doctor shortly thereafter.

Jeremy Wolfe, MD: Every physician has a different way of doing this, and I think the trick is to find what works best for you. Like the others, I chose to visit the offices of referring (or potential referring) doctors. When I was starting in my practice, I would finish my day and then go and visit the referring doctors in the area. I did not have scheduled appointments, but most referring physicians were happy to spend a couple of minutes chatting with me. My group has established referral networks, so I made sure to visit these offices to introduce myself. After that, I went to other practices in the area and discovered other physicians who now refer patients to me.

How do you like to communicate to keep the referring doctor informed?

Dr. Wolfe: There is no single method of communication that will be effective across the board. As electronic health records (EHRs) become more common, automatic letters may be sent at every visit. I dictate a personalized letter for every new patient, call in certain instances, and send updates with significant clinical changes. I do this periodically with all of my patients with age-related macular degeneration.

Dr. Khurana: Writing good letters is the best way to keep the referring doctors informed, particularly for new patients. It really depends on the individual doctor—some prefer letters while others are OK with a text message. For complicated cases such as a dropped lens or anterior segment complications, I like to call the referring doctor after the surgery. For routine or nonemergent cases, however, a letter is usually sufficient. You also don't want to be calling too much as the referring doctors are also busy.

There is an art to creating a concise yet meaningful letter. When I first started, I wrote very long and thorough letters, but I realized most doctors really don't want multipage letters. Another attending advised me to aim to have all the information on 1 page. I think it's okay to initially err on the side of writing more detailed letters because it also demonstrates to the referring doctors your knowledge base and skill set.

Dr. Barañano: Communication preferences seem to vary among referring physicians. I always send a prompt letter to the referring physician. Some appreciate a phone call, others would prefer not to interrupt their schedule for routine referrals. In general, the more complex or rare the case, the more likely I am to call the referring physician. For acute retinal detachments, endophthalmitis, and anterior segment surgical complications, I usually call or text the referring doctor immediately after the case is complete. Dr. Charkoudian: In the days of EHRs, it is easy to keep a referring doctor informed with a letter that requires minimal effort to create. I do, however, try to obtain as many cell phone numbers for referring doctors as possible, and text messages are a quick and personal way to communicate directly.

How do you best balance growing your practice while continuing to be involved in academic pursuits?

Dr. Khurana: Pursuing academic activities is important because it adds variety to your daily clinical practice. This is easier in a university setting as it tends to be intertwined with clinical work, but even in a private practice setting there are many great opportunities to get involved. First, you can volunteer as a clinical faculty member at your local university. Working with residents, even once per month, forces you to stay up to date on the literature and also exposes you to new things. Second, clinical trials in your private practice are a great opportunity to work with industry and clinical research. Working on advisory boards or consulting with companies developing new products is always exciting. Last, but maybe most important, is to be inquisitive regarding your own patients, always asking questions about how you can improve their care.

Dr. Barañano: I am still learning to do this. A lot seems to depend on the clarity of the initial plan to maintain academic involvement. I will say that as a young retina attending just out of fellowship, it is easy to focus too much on the growth of one's clinical practice. The rewards are more immediate and reliable than those of academic pursuits. I think it takes a certain discipline to set limits to clinical activity to protect academic time. This is one area where good mentorship is indispensible.

Dr. Charkoudian: Many of us still have unfinished projects from fellowship once we start our new positions. Working on those during the slow first few months in practice provides a nice segue toward staying in touch with academia. Continuing to go to meetings at academic institutions also helps.

Considering the potential for stress in a new surgical environment where you are operating by yourself for the first time, what is the best advice you can give?

Dr. Charkoudian: When I started operating on my own, I was surprised at the learning curve. I knew that I wouldn't have an attending sitting next to me, but the fact that everything was so different—the scope, vitrector, chair, equipment, bed, and many other things were different from what I used in fellowship—added up to a major adjustment. My advice is to try to get in the OR ahead of time to get used to things so that you don't have the weight of numerous new adjustments added on to that already stressful first case on your own. Observing a colleague who has already been working in that OR prior to your first case also gives you perspective on how things run.

Jorge Fortun, MD: I think the first step is to go in early and familiarize yourself with the OR staff and equipment. You can educate them as to how you like to perform certain steps of a procedure that may differ from other surgeons who operate at that facility. Also, it's important to take inventory of what equipment and instruments are available to you. In the beginning, it's good to rely on your fellowship training, but as your career advances, even early on, don't be afraid to try new techniques that may allow you to become a better and more efficient surgeon.

Dr. Barañano: Just as in fellowship, the key to good surgery is confidence, focus, and judgment. Each of these traits can be compromised by the distractions of operating in a new environment with an unfamiliar team. Do everything you can to make the day easy and to ensure that you are over-prepared. Over-post your cases so that you do not feel rushed. Arrive early. Preview each step of the surgery with the surgical nursing staff ahead of time. If possible, operate with an experienced fellow who can help you troubleshoot the inevitable challenges you can't anticipate. If a fellow is not available, consider scheduling at a time when another retina surgeon is operating so that help is available.

Dr. Khurana: Being by yourself in the OR will be a very different environment from what you had as a fellow. One of my former attendings gave me a great piece of advice, which was to choose your first 50 cases very wisely— that is, don't be too aggressive in signing up cases. Initially, I would assist my senior partners in the OR to become accustomed to and comfortable with the equipment and staff. Another key point is realizing when you may have a case that is beyond your capabilities early in your career. I would often run routine and complex cases by my senior partners and ask their advice. There is a tendency to want to be able to handle everything on your own, which for the most part you will be able to do; but surgical retina is a humbling field, and it never hurts to consult with someone with more experience.

Dr. Wolfe: As a new retina surgeon in the OR it is important to predict and account for all requirements of the surgery. It is appropriate to shadow one of your partners in the OR prior to your first day so that you can learn the lay of the land and meet the staff. On your first day operating, it would be wise to schedule lightly. This will allow you plenty of time and eliminate at least 1 pressure for the day.

It is also important to remember that, the first few times you are in the OR, you are also being evaluated! Make sure that you are friendly to the staff and clear with your instructions as you may follow a different pattern than that to which they are accustomed.

How do you handle difficult cases where you may not know the solution?

Dr. Barañano: I have always been quick to ask a colleague his or her thoughts on an interesting or challenging case. The ready access to enthusiastic, skilled, and more experienced colleagues is part of what makes academic medicine such fun. Joining a new department is a perfect opportunity for this as you can learn from new colleagues, some of whom trained differently and practice differently from your fellowship teachers. You may be surprised at some of the tricks you pick up after your fellowship is over!

Dr. Charkoudian: Hopefully you work with a colleague with whom you can discuss tough cases. Even if they are more senior, they often benefit from hearing the perspective of someone closer to training, so don't feel intimidated in asking. More often, though, my former cofellow and I text pictures and clinical questions back and forth a couple times a week.

Dr. Khurana: In the beginning, I would ask my senior partners about more challenging cases. But sometimes even more helpful was when I talked to my co-fellows or other friends also starting out in practice. In the beginning, I would talk to my friends just about every week about upcoming surgeries or interesting medical retina cases.

Dr. Fortun: As you finish fellowship, it's easy to think that you've seen and treated almost every clinical scenario. Even early on in your practice, however, you will be faced with unique clinical challenges. In these cases, don't be afraid to seek the opinions of more seasoned clinicians including more senior partners in your practice or even your former fellowship mentors.

What are some key tips you can offer for how to best manage your time between work and family?

Dr. Barañano: Schedule family time into your calendar and mark it as a priority. Do not just assume that whatever time is left at the end of the day is free for your family. If you have already put “family dinner” into your calendar at 6 pm, it is easier to weight its importance more heavily against a meeting of the Subcommittee to Improve Compliance with Clinical Documentation at the same time.

Dr. Charkoudian: As challenging and rewarding as retinal surgery is, I have found that fatherhood is much more challenging and far more rewarding. Even a retina surgeon who is not crazy busy makes plenty of money. I have purposely tried not to make decisions to increase the bottom line at the cost of time with my family. I don't want to look back 20 years from now and have regrets.

Dr. Khurana: Often when fellows first come into practice they are very concerned about being busy immediately. This is important, and you should make every effort to meet referring doctors, but once you become busy it's very difficult to become un-busy. Everyone becomes busy with time. In the first year of practice, there is a lot of free time to become acquainted with your new environment, office staff, and OR, while finishing projects that you had from fellowship. Being able to balance work and family will be critical to your ultimate happiness, and you should definitely carve out time for your family.

David Barañano, MD, PhD, is an Assistant Professor of Ophthalmology at the Wilmer Eye Institute at the Johns Hopkins School of Medicine. He can be reached via email at david.baranano@gmail.com.

Leon Charkoudian, MD, is an Associate at Cape Fear Retinal Associates in North Carolina. He can be reached via email at leonc@jhu.edu.

Jorge Fortun, MD, is an Assistant Professor of Clinical Ophthalmology at the Bascom Palmer Eye Institute. He can be reached via email at jfortun@med.miami.edu.

Rahul Khurana, MD, is an Associate at Northern California Retina Vitreous Associates. He is a Clinical Assistant Professor of Ophthalmology at the University of California, San Francisco. He can be reached via email at rnkhurana@gmail.com.

Jeremy Wolfe, MD, is an Associate at the Associated Retinal Consultants in Michigan. He can be reached via email at jeremydwolfe@gmail.com.