As rising second-year fellows, we often wonder how best to take advantage of this final year of training to prepare for life as an attending. These are some of our last opportunities to hone our skills under the guidance of mentors, and we want to absorb every last morsel of advice to make the transition to independent practice as smooth and stress-free as possible.

To answer some of these pressing questions, I asked several vitreoretinal surgeons at Wills Eye Hospital what advice they would give their younger selves as they transitioned from fellows to attendings.

LUIS ACABÁ-BERROCAL, MD: WHAT DO YOU WISH YOU KNEW SOONER AS A NEW ATTENDING RETINA SURGEON?

Jordan D. Deaner, MD: Being a vitreoretinal surgeon can be difficult, and that’s okay. We didn’t choose this path because it’s easy; we chose it because it’s challenging and demands the best of our skill, judgment, and resilience. Tough cases are inevitable, and how you prepare for and respond to them makes all the difference. Preparation begins well before you enter the OR. In about 90% of cases, I can predict exactly what I’ll do and what I’ll need preoperatively. Mentally rehearsing the case helps the procedure run smoothly. Anticipate what could go wrong, especially in complex surgeries, and plan how you’ll respond. This foresight can be the difference between staying calm under pressure or being caught off guard. 

When things go awry—and they will—act swiftly to stabilize the situation. Once you have things under control, take a moment to center yourself, assess the situation, and plan a new path forward. Following a tough case, don’t carry the weight alone. 

I encourage all my fellows to have a trusted peer confidant, someone they can call to talk through difficult cases in confidence. Sometimes, complications occur not because of any error, but because of the complexity of the disease itself. Having someone who understands this is invaluable. We must ensure our minds and our emotions are just as well tuned and taken care of as our hands to be the very best vitreoretinal surgeons.

Samir N. Patel, MD: As a new attending retina surgeon, you’ve been trained to intervene and fix problems. However, one of the most powerful skills you’ll develop is knowing when to not intervene but observe instead. This might seem counterintuitive after years of focused surgical training, but it’s a cornerstone of excellent patient care and long-term success.

Joshua H. Uhr, MD: I did not fully appreciate how much I still had to learn. I felt stressed early on that I did not know everything. I worried that, without an attending sitting next to me at the microscope, I might not be prepared to manage an intraoperative complication. To prepare, I read extensively and watched tons of surgical videos before my OR days, and I ran many cases by colleagues and mentors. I went over every conceivable “what if” scenario and challenged myself to hypothetically manage them. I realized that 2 years of retina fellowship, while sufficient to learn and master the fundamentals, is not enough to see every clinical scenario or encounter every complication. In the few years I’ve been in practice since completing fellowship, I feel like I’ve completed another fellowship.

DR. ACABÁ-BERROCAL: WHAT ADVICE WOULD YOU GIVE SOMEONE AS THEY FINISH FELLOWSHIP?

Dr. Deaner: Always rely on the fundamentals of vitreoretinal surgery. No matter how complex or overwhelming a case may seem, every surgery can be broken down into basic principles and approached one step at a time. This mindset has helped me navigate many cases that initially felt impossible. When you’re faced with a challenging scenario, pause for a moment. Assess the situation. Remember the goals of surgery and then move forward using the core foundation skills that you learned during your training.

Dr. Patel: It is important to predict and account for all requirements of the surgery. The OR in which you operate as an attending may be very different from that of your training institution. I would recommend getting into the OR ahead of time to get used to things so that you don’t have the weight of new adjustments added to your first case on your own. I would also recommend reaching out to local surgical reps to help ease the transition. Observing a colleague prior to your first case also gives you perspective on how things run. On your first day operating, schedule lightly. This will allow you plenty of time and eliminate at least one pressure for the day.

Dr. Uhr: Being a new attending is a big adjustment. For the first time, the full weight of responsibility for a patient’s care and outcome rests squarely on your shoulders. To add to the stress, you’ll see cases for which you don’t know the diagnosis or are unsure of the best management approach. You’ll encounter situations in surgery that you haven’t seen before. If you’re like me, you’ll second guess yourself. My advice to manage this is simple: Always ask for help. Having a good support system is immensely helpful as a new attending to learn more not only about your cases, but also about others’.

DR. ACABÁ-BERROCAL: IF YOU COULD GO BACK TO FELLOWSHIP, WHAT WOULD YOU FOCUS MORE ON OR TAKE ADVANTAGE OF?

Dr. Deaner: This is a bit of a double-edged sword. In fellowship, you want to operate as much as possible to gain technical skill and experience. However, some of my most valuable experiences as a fellow were at the end of my training. Observing how experienced attendings approach surgery—both technically and strategically—offered insights I couldn’t have appreciated earlier. Even when you’re not the one holding the instruments, stay engaged. There’s a tremendous amount to learn by watching experienced surgeons operate.

Dr. Patel: Most retina fellowships provide the highest levels of medical and surgical training. However, whether you join a university-based practice or a private practice, there is a steep learning curve in understanding the business and administrative side of medicine. Try to spend some dedicated time with your fellowship mentors to understand the nuances of CPT and ICD-10 codes, modifiers, payer-specific policies, and the documentation required to support them.

Dr. Uhr: During fellowship, I wish I focused less on absolute surgical numbers and more on getting as broad of a surgical experience as possible. I was fortunate to train at an institution with many attendings trained through diverse fellowship programs and brought a wide range of surgical techniques, preferences, and tips and tricks to the table. Take advantage of the breadth and diversity of your attendings’ skillsets. Try to use as many instruments, techniques, and surgical platforms as you can. If there’s a particular area that you want to work on, don’t be afraid to tell your attendings. The broader of an experience you have, the more prepared you’ll be after fellowship.