July marked the beginning of fellowship for rising vitreoretinal trainees across the country. I sat down with several colleagues to discuss the transition from residency to fellowship and offer advice for making the most of the first year of fellowship. 

– Anand D. Gopal, MD

DR. GOPAL: WHAT WAS THE TRANSITION LIKE FROM RESIDENT TO RETINA FELLOW?

Jordan D. Deaner, MD: This transition can be daunting. You are still a trainee but are frequently asked to act as an attending, which means staffing residents and treating non-surgical retinal disease independently. You can prepare for much of this. Spend as much time in the retina clinic and ORs as you can. Increase your confidence by performing as many lasers, injections, and procedures as possible before fellowship.

Louis Z. Cai, MD: As a retina fellow, there is a lot more pressure to know what is going on. Your retina knowledge is only as good as what you learned in residency. It's okay not to know, but it's important to know where to get information and to have a framework for approaching complex situations. For me, the hardest part of transitioning to retina fellowship was learning the logistics and expectations of a new institution (eg, where to get supplies, where to send clinic patients, and how to navigate OR scheduling). Leaning on the residents and other fellows was very helpful during this time.

Austen Knapp, MD: You end residency feeling pretty good about your skills and knowledge in cataract surgery and general ophthalmology. Then, once in fellowship, you must try something relatively new all over again with a higher level of responsibility. However, having a strong foundation in general ophthalmology and medical retina is tremendously helpful. It's a humbling experience but so worth it!

DR. GOPAL: HOW DID YOU PREPARE FOR THE RETINA OR?

Dr. Deaner: Know everything you can about the patient you are operating on. Know the indications and standard steps for the planned surgery. Nothing impresses me more than when my trainee can tell me the history of a complex patient and the steps of surgery. When you get the chance to operate, be confident but cautious. Slow, intentional movements show me that you are technically good but also thoughtful. These actions make me confident that you are ready to progress and do more advanced portions of the surgery.

Aditya S. Rali, MD: When I was a resident, a vitreoretinal fellow gave me a 25-gauge pars plana vitrectomy instrumentation set (that was opened for a case but unused) to play with to get a feel for the instruments. It may sound silly, but at the start of fellowship I would sit at my desk and mimic the movements I struggled with in the OR. Overall, most of the attendings understand that vitreoretinal surgery is hard. If you have done your homework for each case and show that you're thinking through the cases, you should be fine.

Dr. Knapp: Simulating vitreoretinal surgery in a wet lab environment is challenging. However, one of my mentors told me, “Suture, suture, suture.” This is extremely practical advice. As vitreoretinal surgeons, we do a great deal of work with the anterior segment, including suturing. Getting involved with retina cases during residency is also helpful in familiarizing yourself with the equipment and the steps of retina surgery. Simple things like knowing the microscope, how the foot pedals work, and the basic principles of each surgery you are doing go a long way early on.

DR. GOPAL: WHAT ARE YOUR TIPS FOR BALANCING LIFE OUTSIDE OF FELLOWSHIP?

Dr. Cai: You must think of time with friends and family as mandatory. So often as physicians we put aside our home life to focus on our careers, but the narrative should be reversed. Say yes to social engagements, even if all you want to do is finish up that paper at home. Schedule calls home just like you would schedule your patient follow-ups.

Dr. Deaner: Try your best to insulate your work and personal life from one another. When you are at work, try to be fully present. Dedicate your operating days and call days completely to work so that you aren’t worrying about trying to meet a personal deadline outside of work. Similarly, when you are off work, keep it that way. During fellowship, this doesn't mean you won't have work to do on evenings or weekends but try to schedule it for a block of time and stick to it.

Asad F. Durrani, MD: The key is to make efficient use of your time. On lighter days or calls, I would try to get research done in between seeing patients. It is important to carve out protected time for pursuing your hobbies, exercising, and relaxing with loved ones to prevent burnout.

DR. GOPAL: HOW DID YOU PREPARE FOR THE WRITTEN AND ORAL BOARDS?

Dr. Deaner: For written boards, repetition is key. The greatest piece of advice I can give is to be present and pay attention during your residency didactic lectures. Finally, I did OphthoQuestions (Edcetera) during my downtime and then crammed questions starting a couple of weeks before the examination. For oral boards, find a single, reliable study partner. Learn the format of the examination and what is expected of you. Schedule a couple of hours once a week to review cases with your study partner and ramp up the frequency of your sessions leading up to the board examination. Just before the examination, my co-resident and I reviewed cases for a couple of hours every night.

Dr. Durrani: For written boards, I also used the OphthoQuestions. I started at the end of July and worked mostly on the weekends to complete the questions before the written boards. For oral boards, I started preparing 3 months before the examination, used Ophthalmology Clinical Vignettes, and practiced going through the cases with my co-fellow. I also used Case Reviews in Ophthalmology and the Oral Boards videos.

DR. GOPAL: WHAT DO YOU WISH YOU KNEW BEFORE STARTING FELLOWSHIP?

Dr. Deaner: First, the Dunning-Kruger effect is very real. You won't learn everything in fellowship. If anything, you will mostly learn how much there is to learn and grow. Take it in stride and learn as much as you can every day. I still read nearly every night. Second, vitreoretinal surgery fellowship is hard. It will test your intelligence, stamina, and resolve. There are super high highs and pretty low lows. Stay close to your classmates and co-fellows. Celebrate each other's wins and commiserate when the going gets tough. Our field is the most rewarding in ophthalmology, but it takes grit to succeed.

Dr. Cai: You will have hard times, especially in the OR, where you will question your ability to do surgery. You will have times when residents know more than you do about certain topics even though they are the ones staffing you. Trust your training and trust yourself. It's hard for everyone, and it's okay to have a little imposter syndrome. Even the greatest retina specialists were fellows at one point.

Dr. Durrani:I would have started on research earlier in my fellowship, as the abstract deadlines for all the major conferences come up quickly. I also wish I had been more mindful of ergonomics at the start of fellowship. It is easy to be so focused on excelling clinically that we forget to maintain good posture during stressful times early in fellowship.

DR. GOPAL: ANY FINAL PEARLS OR TIPS?

Dr. Cai: Enjoy spending time with the friends you have made during residency. When you start fellowship, be vulnerable and learn from as many people as you can, not just your attendings. You're going to be sending patients to the wrong clinic or messing up the electronic consent documentation, and it will be okay.

Dr. Deaner: Keep in contact with your mentors from residency. The retina world is small, and they will be great resources when you are looking for a future job. Do some reading in advance (you will have more time as a senior resident than as a fellow). The Duke Manual of Vitreoretinal Surgery and Vitreoretinal Surgery Online (vrsurgeryonline.com) are great references. Michels Retinal Detachment and Ryan's Retina are the classics. Finally, enjoy your year as a senior resident!

Dr. Knapp: Take the trips, spend time with your people, read one new thing every day, ask for help when you need it (not after the fact), be open to feedback, learn new things in new ways, and invest in your relationships and yourself.

Dr. Rali: You want to come into fellowship with a solid foundation of surgical and medical retina knowledge. At the same time, it is also important to enjoy the end of residency. Residency and fellowship can both be a grind, so it's nice to be refreshed before starting fellowship. As for the first few months of fellowship, it can be a challenging time; vitreoretinal surgery is different from the surgeries we typically master in residency, but everyone goes through the same learning curve. No one is born knowing how to do vitreoretinal surgery, so stay patient and keep at it. It becomes a lot more fun once you start improving!