After 4 years of medical school, 1 year of internship, 3 years of residency, and 2 years of fellowship, senior vitreoretinal surgery fellows can see light at the end of the tunnel. Nine and a half years later, we are embarking on our final 6 months of formal training. The thought of finishing vitreoretinal surgery fellowship evokes both excitement and fear as we move out from under the training umbrella. I sat down with several experienced vitreoretinal surgeons at Mid Atlantic Retina and Wills Eye Hospital in Philadelphia, Pennsylvania, to gather their practical pearls for maximizing the final 6 months of fellowship.

—S. K. Steven Houston III, MD

Allen Chiang, MD; Omesh P. Gupta, MD, MBA; and Sonia Mehta, MD, of Mid Atlantic Retina and Wills Eye Hospital had the following advice on how to smooth the transition from fellowship to practice.

SURGERY

When preparing to operate at a new hospital or ambulatory surgery center (ASC), what can you do in fellowship to make sure you have a smooth transition?

Allen Chiang, MD: During the 2nd year of retina fellowship, you are exerting so much energy and focus on acquiring and honing surgical skills that it can be easy to overlook some of the nuances that help ensure a smooth surgical case in the OR. It is important to realize this as you prepare to transition into clinical practice, even if you are going to remain in an academic setting. The devil is always in the details.

For example, I would recommend formulating your own preference cards now, which gives you ample time to fine tune them to your liking. The same goes for vitrectomy machine settings and even preoperative preparation. Chances are that you have, perhaps unknowingly, simply been using your institution's settings. Familiarize yourself with what works for you. In addition to this, take the time to make an inventory list and photographic catalog of the various pieces of equipment that you have used. This can come in very handy as you transition to your new surgery center or hospital, which may not have a particular item in stock. Having a quick reference guide to assist OR managers in seeking approval, placing orders, and securing the equipment for you will prove helpful.

Similarly, review and consolidate your surgical notes, which hopefully you have been taking throughout the year. Organizing these notes not only helps to solidify tips and tricks that you have learned, but also will provide a useful reference as you journey out into your first couple of years of practice in particular. The same holds true for surgical videos—reviewing and editing at least several of your best videos is prudent. This will come in handy when you are called upon to give talks, whether to residents or to community ophthalmologists as you build your practice.

Before you actually start operating at your new surgery center or hospital, be sure to get an orientation from the OR or ASC manager. Meet the staff, as well—the charge nurse, OR nurses, and OR managers. Ask to see and touch the OR equipment. Figure out how and where to dictate a report and how to review and sign it. This extra effort will go a long way to ensuring a smoother transition. There are enough variables in retina surgery as it is—the last thing you need is to be figuring out how to make adjustments on a different microscope, stool, or footpedal.

Be 100% sure that the indirect ophthalmoscope in the OR is functional before your primary scleral buckle. If it is a wireless model, that means making sure it is charged and that there is a fully charged backup battery. Regardless of wired or wireless, make sure the OR has a new bulb handy at a moment's notice. Perhaps this all sounds obvious, but remember that you are entering into a new OR environment. Being compulsive in this way can spare you a lot of chest pain.

Sonia Mehta, MD: Make your preference cards while in fellowship. Get a sense of what you like in terms of instruments, preoperative preparation, and vitrectomy machine settings. I would also make a list of instruments and equipment you like. This is very useful when you transition to a new surgery center or hospital when they do not have your preferred item in stock or if you are helping to build a new surgery center.

Omesh P. Gupta, MD, MBA: The transition from fellowship to practice is challenging for everyone. There are a lot of growing pains that occur over the first couple of years of practice. In terms of operating alone for the first time, preparation is the key. I would start by having your favorite vitrectomy settings copied over to your new machine. If you will be operating with an unfamiliar vitrectomy system, ideally it would be nice to have the machine brought into the OR prior to finishing your fellowship. In addition, I would arrange for the surgical representative to be present for your first couple of days in the OR. I would also make sure that your favorite laser, forceps, etc. are available.

During fellowship, we learn different techniques for everything we do. How did you determine which techniques you would use to approach a specific surgical problem?

Dr. Gupta: Most of the techniques that I used a lot during my first couple of years after fellowship were due to the fact that I did not have an experienced assistant with me. A lighted laser, perfluorocarbon, and scleral buckle often were handy. A good lighted laser allows me to scleral depress and laser peripheral pathology by myself. Perfluorocarbon was helpful especially for shaving peripheral vitreous gel in a rhegmatogenous retinal detachment. The perfluorocarbon displaced gel anteriorly. Then, placing the vitrector right on the meniscus of the perfluorocarbon allowed me to achieve a much better shave than trying to shave with mobile retina. A scleral buckle also provided scleral depression in difficult cases when I wanted vitreous base support for 360°.

Dr. Mehta: It is important to understand the rationale for a technique. In the final 6 months of fellowship, I would recommend having a preoperative plan for every case and then understanding the rationale for a different approach. In the beginning, it is good to use techniques that you feel most comfortable with and that will ensure a good surgical outcome.

What is one piece of surgical advice you wish you knew before starting in your practice?

Dr. Gupta: One piece of advice that I wish I appreciated more was the mental and physical preparation needed prior to long days in the OR. The physical preparation is more often overlooked than the mental. This is particularly true for those of us recently out of fellowship. Whether relocating, moving into a new house, or having young children, your exercise regimen usually suffers. I also make it a habit to review all the cases before the day I operate. I try to write special notes and reminders to myself on the chart the day I sign the patient up for surgery. Then, when I review the patient's chart the day before surgery, I remind myself of these nuances before each case. I also make sure my difficult cases are scheduled earlier in the day. From a physical standpoint, I am more alert, and I find myself thinking about a difficult case throughout the day if it is scheduled near the end of the day.

Dr. Mehta: This was actually told to me when I was in fellowship training but it is a valuable pearl I would like to share with all graduating fellows: At some point in your fellowship training or practice, you may feel very smooth, comfortable, and confident with your surgical abilities. Do not lose your vigilance or become careless, because that is when complications can develop.

RESEARCH

As you are building your practice volume, how can you stay involved in clinical research?

Dr. Gupta: If you want to stay involved with clinical research after fellowship, then you must make it a priority. You will be stretched in more ways than you could ever imagine after graduating fellowship. It is okay for research to take a back seat to other priorities in the short term. However, if you stay away from it for too long, then other priorities will consume your life, making it more difficult to get restarted.

Dr. Mehta: In the beginning as you are building your practice, clinic schedules may be light. Take advantage of this time to finish projects you have been working on during fellowship. Also, keep a list of project ideas or interesting cases that come up along the way to share at academic conferences.

Dr. Chiang: As you first start out in practice, your focus will naturally be on how you can get busier. It is easy to overlook the fact that once you are actually busy, you will not be able to go back to being less than busy. Take advantage of the lighter clinic volume while you can. For example, finish up and submit those research projects and papers that were carried over from fellowship. To stay up to date on current research, skim the table of contents of the various journals for articles of interest, then selectively review them. Serving as a reviewer for select journals is also helpful for staying up to date on current research.

The first 5 years of practice can be very busy clinically as you are building your practice. How would you recommend staying up to date on current clinical research and surgical techniques? Do you recommend any specific meetings or conferences?

Dr. Gupta: Obviously, ophthalmic journals are helpful with staying up to date. I have found some of the non–peer-reviewed journals that we commonly get in the mail also have some very good articles. In terms of meetings, the one that is designed specifically for our age group is the Vit-Buckle Society. They have a great program intended for the graduating fellow and early associate.

Dr. Chiang: With regard to attending meetings, I enjoy the Vit-Buckle Society meetings in particular because of how they encourage lively and open discussion, particularly about topics in retina surgery. Most members and attendees are generally younger retina specialists, which engenders this approach. However, the American Society of Retina Specialists (ASRS) and American Academy of Ophthalmology (AAO) retina subspecialty annual meetings are well organized and generally high-yield. Finally, the ASRS surgical video series and Eyetube are nice resources for surgical techniques.

Dr. Mehta: I would recommend getting access to major journals such as Retina and Ophthalmology. I typically skim the table of contents for the retina topics and then review the articles. The journals will publish new surgical techniques, and EyeTube may also be a good source for emerging surgical techniques. As for specific meetings, I would recommend AAO subspecialty day and ASRS. I also enjoy the Vit-Buckle Society meetings—it is a younger crowd and more surgically oriented.

TRANSITION TO PRACTICE

Do you have any advice on managing a busy clinic? Advice on streamlining the clinic flow?

Dr. Gupta: Being able to manage a busy clinic takes practice. Give yourself some time to get adjusted to your new practice. Also, give yourself some time to talk to patients and communicate with referring doctors. As time goes on, then it would be worthwhile to improve your efficiency and suggest changes around the office.

Dr. Mehta: Make a clinic template for your schedulers to follow. Scribes can be very helpful once they get to know your style. Make preference cards for your injection setups and laser settings so technicians can have these ready to go. Also, when clinic is not moving as you want, make a list of bottlenecks or problems you identified as the day progressed and share this with your practice manager. Also, have your clinic manager observe your clinic to help identify these bottlenecks and address clinic flow issues.

We all will have patients with difficult diseases. When you have a difficult medical or surgical case, whom do you approach for advice, management questions, etc.?

Dr. Mehta: When managing patients with difficult diseases, senior partners in your practice and mentors from fellowship are great resources. Also, if your practice or institution has a retina conference, this may be a great forum for discussing complex cases.

Dr. Chiang: Senior partners in your practice are easily accessible resource. Mentors and colleagues from fellowship can also be helpful resources as you venture out. 

How did you develop relationships with referring doctors?

Dr. Chiang: I made the effort to meet with pretty much all of the referring doctors (ophthalmologists optometrists) in the geographic areas of my practice. I cannot stress how important this is to do, preferably either before you start or during the early phase of practice. In some cases I went off and did this on my own. In other instances, I simply tagged along with our marketing liaison as she made her rounds with referring doctors. 

There really is no magic formula. Some physicians enjoy meeting over lunch. Others may prefer a simple meet-and-greet in the office for a few minutes due to the demands of their clinic schedules. Still others may be more interested in attending a sporting event with you. Whatever it takes, do not underestimate the power of a face-to-face interaction when it comes to building relationships and expanding your referral network. 

Dr. Gupta: Constant communication with referring doctors is important not only for better patient care, but also for establishing a rapport with referring doctors. If you have some time to meet with doctors prior to starting your job, during a light office day, during lunch, or at dinner, it can be very helpful in promoting your practice.

Dr. Mehta: In the beginning as you are building your practice, clinic schedules may be light. I would recommend going out into your community and meeting your referring doctors. Nothing beats a personal connection. Also, you can give lectures to the general ophthalmologists and optometrists in your community. When building a relationship with your referring doctors, 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. When receiving a patient referral, it is important to send a detailed letter promptly and send update letters as the patient returns for future visits. It is very important that you respect the referral source and encourage the patient to return to him or her for nonretina eye care. 

Do you have any advice regarding finances?

Dr. Chiang: From a financial standpoint, resist the urge to overspend when annual income suddenly increases five- to sixfold. It is important to sit down and rework or actually make a budget. Make sure to account for all your monthly expenses, including educational debt payments. A starting number to save is around 20% of your income.

Dr. Mehta: I would recommend buying disability insurance while in fellowship because you can get lower rates as a resident or fellow. Make sure you get “own occupation” disability insurance. This covers your salary if you become incapacitated to perform your own specialty. Other types of disability insurance cover you only if you cannot perform any medical specialty, and others only if you cannot perform any occupation. After paying off debts, I would recommend putting aside an emergency fund of 3 to 6 months' salary. Typically, rent a home in the beginning; that way you can get to know your practice and your environment. About 50% of new physicians end up in a different job than the one they started immediately after training. Typically, it is difficult to make a real estate investment profitable unless you are planning on keeping the house for more than 5 years. I recommend that real estate should not be purchased until you are certain that you want to stay in the same location for a long period of time. 

Dr. Gupta: Obviously saving money and wise financial planning are good practices. For all of those items that were mentioned, I would recommend speaking to someone in your practice who can lead you in the right direction. Often an older partner, office manager, or mentor can offer great advice through previous successes and failures. Having that said, we have all exercised the highest form of delayed gratification. You are finally making some money. While I would advise you not to break the bank or substantially increase your debt, spend some money on something you will enjoy. Go on a nice vacation, buy a new car, or buy something nice for your home—life is too short.

FINAL THOUGHTS

As the 2nd year vitreoretinal surgery fellows venture into practice in the coming months, heed the advice from Drs. Mehta, Gupta, and Chiang to ease your transition. Stay humble in the OR, and always do what is best for the patient. Enjoy your careers in retina—the best* field in medicine. n

*May be subject to personal bias

Allen Chiang, MD, is an attending surgeon on the Wills Eye Retina Hospital Service, a physician with Mid Atlantic Retina, and on the clinical faculty at Thomas Jefferson University in Philadelphia, Pennsylvania. Dr. Chiang may be reached at +1-800-331-6634 or achiang@midatlanticretina.com

Sonia Mehta, MD, is a clinical instructor of ophthalmology at Thomas Jefferson University and Wills Eye Hospital in Philadelphia. She is in practice at Mid Atlantic Retina. Dr. Mehta may be reached at smehta@midatlanticretina.com.

Omesh P. Gupta, MD, MBA, is an associate with Mid Atlantic Retina. He may be reached at ogupta1@gmail.com.

S. K. Steven Houston III, MD; Ehsan Rahimy, MD; and David C. Reed, MD, are second-year vitreoretinal fellows at Wills Eye Hospital in Philadelphia, Pennsylvania, and are members of the Retina Today Editorial Board. Dr. Houston may be reached at shouston3@gmail.com. Dr. Rahimy may be reached at erahimy@gmail.com. Dr. Reed may be reached at davidreed43@gmail.com.