The field of retina is constantly changing. In the past 10 years, there has been an exponential increase in the number of practice-changing prospective, randomized trials published in the field of retina. Advancements in pharmacotherapy and laser technology are similarly occurring at an ever-increasing pace. As fellows, we have instant access to the newest research in the form of conferences, lectures, and direct discussion with our attendings, many of whom are involved in these studies. It is clearly important during fellowship to learn the latest evidence, but it is even more important to learn from experienced clinician scientists how to critically review published data and how to incorporate these data into our clinical practice.

Nowhere is experience more essential than in the OR. Thankfully, modern vitreoretinal surgical techniques have reduced overall complication rates, but when complications occur, they can have devastating visual results. Learning how to avoid complications and knowing what steps to take if they do occur takes years of practice. In many fellowship programs, a significant amount of autonomy exists in the OR, which to a degree is good because this mirrors what we will experience in our careers. Fellowship, however, offers the chance to sit next to an experienced surgeon, so we must take advantage of that knowledge as we learn to operate. Once in practice, we may miss having such a valuable reference.

As we are learning the different surgical approaches of our attendings, it is important to follow up on these patients to know their long-term outcomes. Something may seem to work well in the OR, but if it is not successful in the longer term, that is valuable information.

In part 1 of this 2-part column on getting the most out of your fellowship, we interviewed some of our senior attendings to get some words of advice. Here, in part 2, we interview some recent graduates of fellowship.

1. What part of your fellowship did you feel best trained you for your first year in practice?

Caesar K. Luo, MD: It's tough to pin down one part of my training that groomed the trail. There's a reason we say we practice medicine, because the more we do it, the less we have to think about the small stuff. At Associated Retina Consultants, we were exposed to the approaches of 9 different surgical attendings. Additionally, one of the most valuable aspects of my fellowship was practice management. Although seeing patients is paramount, I now find that the things that make my day-to-day more comfortable are the little things I picked up at my fellowship such as different ways to save time on injections, making a billing sheet, and patient flow for diagnostics. These are valuable processes, and I would encourage all fellows to look at logistical aspects of the practice in your fellowship to achieve a sense of the things you think work vs those that don't.

Melissa D. Neuwelt, MD: During fellowship, I was acutely aware of the tremendous opportunity I had to work with leaders in the field of retina. I was fortunate to be in a high-volume program. We saw a great breadth of pathology, from pediatric retina to oncology and uveitis, as well as plenty of age-related macular degeneration (AMD) and diabetes. Not only did I gain clinical knowledge from my attendings, but I also spent time in my fellowship getting to know them personally. I worked closely with the residents, fellows, and visiting doctors. I would encourage fellows in all programs to cultivate all of these relationships, as they will carry forward for the rest of your career.

Andre J. Witkin, MD: For me, it was helpful to try to determine what went into the decision-making for each patient and to watch how attendings interacted with patients, in particular for interventional or surgical counseling. Details that may seem minute are magnified once you are the one making the decisions. Specific examples of this in the clinic are deciding whether to perform combined cataract and macular surgery on the same day, what type of anti-VEGF medication to use in any particular patient and why, and how often to follow patients with AMD or retinal vein occlusions. In the OR, it was particularly helpful to observe or perform a variety of different techniques to manage the same problem. The most challenging cases, or the cases in which an unforseen event occurred, were often the most instructive, as these are the most frightening situations when you are performing the surgery as an attending.

2. Is there any situation in particular in your current practice for which you wish you still had an attending there with you?

Dr. Luo: Every day. At this point, I don't wake up in a cold sweat anymore, but every day there's at least 1 moment when I say “WWGWD?” (What would George Williams do?) Don't be afraid of that; it'll make you spend an extra minute with your patient and ultimately help you care for them more effectively. We are understandably most nervous in the OR when we start, and these are the times when you look back and think they cut the cord a little too soon. That gets better very quickly when your patients start coming back looking great. Short follow up = great results, right?

Dr. Neuwelt: I find myself missing their guidance every day, particularly in the OR. The office setting is more forgiving because you can send the patient for imaging and weigh the options in your mind. There's always the chance to discuss cases with colleagues or mentors from fellowship. In the OR, you don't have the luxury to stop and take your time with a decision. During my final months of fellowship, even when I was in the surgeon's chair for the entire case, I made a concerted effort to take advantage of the attendings' expertise to hone my surgical skills. I asked them a million questions, not just about what they would do next, but why. Now that I am operating on my own, not only do I miss having someone to perform scleral depression for me (seriously!), I also miss the chance to discuss the next step of the case out loud.

Dr. Witkin: As alluded to in the previous question, sometimes the most seemingly simple questions are magnified when you become an attending. It's very helpful to have partners who are eager to discuss cases. In retina, we are fortunate to have high-technology imaging, which makes the discussion of a case much simpler. Former co-fellows and mentors from fellowship continue to be sources of advice long after fellowship is over. Surgical cases require more expeditious decision-making, and whereas in fellowship you may have a more expert set of eyes giving helpful hints, you are often alone when you become an attending. This is particularly magnified in more complex cases or when surgical complications occur. As a young attending, it can be very helpful, therefore, to join a practice with more senior partners who are willing discuss surgical planning, or who might even join you in the OR during cases that you predict to be challenging.

Nikolas J.S. London, MD: Honestly, I wish I had an attending with me all the time. It's like when I went off to college: I knew that I could make my own dinner and wash my own clothes, but not as well as my parents did. The same goes for all parts of my current practice, from the OR, to decisions in the clinic, to filling out a billing form. It is a necessary adjustment period, and I am in the midst of a mild adjustment disorder. More than anything, however, I loved having 2 to 3 attendings in clinic with me. Even for cases in which I was confident of the correct diagnosis and appropriate management, it was a wonderful learning experience to run the case by an attending. They would almost always drop a pearl.

3. What opportunities would you advise current or future fellows to take advantage of to help in the transition from fellowship to being an attending?

Dr. Luo: There are so many little things that go into making your transition easier that may not be outwardly apparent. Of course, learning retinal pathology and surgical techniques is the reason we train, but I would encourage all fellows to look at the other stuff. See what machines you like, meet the industry representatives who come through the office (they can help ease your transition in myriad ways), obtain a list of all the surgical tools you want for your tray, and take as many clinical photos and videos as you possibly can. You may never again have the opportunity to surround yourself with these great clinical minds in this kind of setting, so ask as many questions as you can. Note that your questions do not all have to be medical. Time management, for example, is critical to a surgeon's well-being, and all of your attendings have worked through this issue.

Dr. Neuwelt: As much as you try to make the most of every day and every case, you'll always look back and think you could have learned more. The biggest challenge in practice after fellowship is becoming familiar with new staff, ORs, and equipment. Knowing that I wouldn't always be operating with the Constellation (Alcon Laboratories, Inc.) after fellowship, I convinced one of our attendings to let me do a couple of cases with the spare Accurus (Alcon Laboratories, Inc.). I spent time with the photographers running the optical coherence tomography and fluorescein angiography equipment. I highly recommend becoming familiar with a diversity of vitrectomy machines, instruments, and imaging equipment. If anything, I could have spent even more time working with the photographers and OR techs. Fortunately, they are just a phonecall away, and I have called them already several times for tips and suggestions.

Dr. Witkin: It is helpful to discuss complex medical and surgical cases with a variety of attendings to gain a variety of options for management and thought processes when it comes to the ultimate decision-making for each patient. Review of the literature on unusual diseases that are encountered and the current recommendations for more straightforward retinal problems is helpful. Case presentations and conferences can also be helpful in formulating discussions. In the OR, although you may become comfortable with a particular technique for fixing a certain vitreoretinal disease, it is good to become familiar with alternative techniques to fix the same problem, and fellowship is a great time to do so. It is also helpful to watch how different attendings interact with their patients, and how patients are counseled.

Dr. London: The business side of running a retina practice is something a lot of fellows do not learn during fellowship. I was fortunate to train at Mid Atlantic Retina, one of the largest retina practices in the country, with an enormous staff, a team of billers, multiple office managers, a chief executive officer, and an entire research staff—not to mention the attendings who took a lead in running the business side of the practice such as James Vander, MD; and Mitchell Fineman, MD. All of them were more than happy to teach me about their roles in the practice. This part of training is not typically spoon-fed to fellows but requires some initiative on the part of fellows, and this is something I would encourage all fellows to seek out during their training.

Caesar K. Luo, MD, is in his first year of practice at Progressive Vision Institute in Pottsville, PA, after graduating from a vitreoretinal fellowship at Associated Retinal Consultants at William Beaumont Hospital in Royal Oak, MI. He may be reached at caesarluo@pvi-vision.com.

Melissa D. Neuwelt, MD, is in her first year of practice at Progressive Vision Institute in Pottsville, PA, after graduating from a vitreoretinal fellowship at Associated Retinal Consultants at William Beaumont Hospital. She may be reached at melissaneuwelt@pvi-vision.com.

Andre J. Witkin, MD, is in his first year of practice at New England Eye Center and is an Assistant Professor of Ophthalmology at Tufts Medical Center in Boston after graduating from a vitreoretinal fellowship at Mid Atlantic Retina at Wills Eye Institute in Philadelphia. He may be reached at ajwitkin@gmail.com.

Nikolas J.S. London, MD, is in his first year of practice with Retina Consultants of San Diego after graduating from a vitreoretinal fellowship at Mid Atlantic Retina at Wills Eye Institute. He may be reached at nik.london@gmail.com.

Francis Char DeCroos, MD; Adam Gerstenblith, MD; and Rajiv Shah, MD, are second-year vitreoretinal fellows at Wills Eye Institute in Philadelphia, PA, and members of the Retina Today Editorial Board. Dr. DeCroos may be reached at cdecroos@gmail.com; Dr. Gerstenblith may be reached at adamgerstenblith@ gmail.com; and Dr. Shah may be reached at rshah1878@gmail.com.