Mentoring Retina Fellows From All Walks of Life

The journey to becoming a retina specialist is one of the most rewarding career paths—but it’s not a cheap one. Many trainees struggle with medical school debt, low resident and fellowship salaries, application fees, and travel expenses, adding undue stress to an already challenging training experience. Mentors can play a crucial role in helping retina fellows navigate the clinic, OR, and the transition from trainee to attending.

Here, Katherine E. Talcott, MD, asks Yoshihiro Yonekawa, MD, and Adrienne W. Scott, MD, FASRS, to share their pearls for mentoring retina fellows who hail from diverse economic backgrounds.

DR. TALCOTT: WHAT ARE THE CHALLENGES SOME TRAINEES FACE DUE TO ECONOMIC CIRCUMSTANCES?

Dr. Scott: Trainees experience varying circumstances, and it’s important for us to understand that they have been training for some time. Even once trainees start a salaried position, they may have debt to repay, familial obligations such as childcare costs, and moving expenses. Even credentialing and board certification can be very costly.

As mentors, we must understand the context in which fellows and trainees come to us, as many already have quite a bit of debt or financial insecurity by the time they are in our training programs.

Dr. Talcott: As a fellow, you don’t have a salary that reflects all the training you have completed. I remember when many of my friends outside of medicine were all making real salaries and had been doing so for about 10 years, and I was still a fellow. That contrast was striking.

Dr. Yonekawa: Our trainees’ financial situations are quite diverse, and everything is more expensive these days, whether it's rent, groceries, transportation, eating out, or attending conferences.

DR. TALCOTT: WHY SHOULD MENTORS BE COGNIZANT OF A FELLOW'S ECONOMIC BACKGROUND?

Dr. Yonekawa: Although a fellow’s economic circumstances wouldn’t be the first conversation you have with them, extreme situations are sometimes expressed beforehand, usually in personal statements during the application process. It’s important for programs to know what obstacles an applicant faces in their journey to get where they are. In addition, economic capacity isn’t something we should assume based on where people grew up; just because a fellow grew up in an affluent area doesn’t mean they are financially stable now, and vice versa.

Managing Economic Concerns in Medical School and Residency

Jayanth Sridhar, MD, shares his pearls for mentoring trainees from the beginning.

---

RETINA TODAY (RT): WHAT ARE SOME OF THE CHALLENGES TRAINEES MIGHT FACE DUE TO ECONOMIC CIRCUMSTANCES?

Jayanth Sridhar, MD: Ophthalmology has several hidden costs that can disadvantage trainees without financial flexibility. Taking additional time during training (for example, a research year) can delay attending-level income and increase financial strain. Away rotations and research experiences, especially if unpaid, often require out-of-pocket travel and living expenses that exceed what typical student loans cover. Finally, the application process itself is expensive, and with competitive match dynamics, some applicants may need to apply more than once, compounding costs.

RT: HOW CAN PROGRAMS BE SENSITIVE TO ECONOMIC HARDSHIPS AND LEVEL THE PLAYING FIELD?

Dr. Sridhar: Medical schools and residency programs (and their affiliated institutions) should strongly consider offering subsidized housing for medical students on away rotations and building residency application fees into the tuition coverage. Unpaid research opportunities should be rare to avoid hurting economically disadvantaged applicants.

RT: HOW CAN MENTORS SUPPORT THESE TRAINEES?

Dr. Sridhar: Mentors can proactively steer trainees toward paid opportunities, grants, and travel funding and normalize asking for support early. We can also leverage our networks to reduce logistical costs (for example, connecting rotating students with affordable housing options through residents, alumni, or institutional resources).

RT: WHAT SYSTEMIC CHANGES NEED TO HAPPEN TO BETTER SUPPORT TRAINEES?

Dr. Sridhar: There are three important changes: 1) Reduce or eliminate application fees, or make fee waivers universal and automatic based on need; 2) Establish subsidized housing/support for away rotations; and 3) Severely limit unpaid research positions. If a program cannot fund a trainee’s work, it should not rely on their labor or benefit from their output.

---

Jayanth Sridhar, MD
Chief of Ophthalmology, Olive View-UCLA Medical Center, University of California Los Angeles, Los Angeles
jsridhar119@gmail.com
Financial disclosure: Consultant (4DMT, Alcon, Apellis, Eyepoint, Genentech/Roche, Regeneron, Samsara); Speaker (Regeneron)

The most important thing is to level the playing field for all trainees and support each fellow equally—and that means assuming that resources are limited for everyone. You don't want to force your trainee into a situation where they must pay for something unexpectedly.

For example, if you encourage a fellow to present at a multi-day meeting that requires air travel, they must figure out how to pay for their flights, hotel, and meeting registration, which routinely will cost $2,000-$3,000 these days. Programs should make sure that everything is paid for when encouraging fellows to attend academic and/or social events as part of their fellowship training.

You also need to let your fellows know ahead of time which meetings they are expected to attend and what expenses the program is covering.

Dr. Scott: Finances can be an awkward conversation, and even if the program pays for the expenses surrounding a conference, fellows may not get reimbursed for a month or two. It’s easy to assume they have enough resources to cover the bill, but some fellows may not be able to afford the lag in reimbursement.

This conversation reminds me of the virtual fellowship interviews during the COVID-19 pandemic, and how much the fellows appreciated it because, although they couldn't see programs in person, they could participate in many different interviews without picking and choosing which interviews they could afford.

Now that we're back to in-person interviews, fellows now must handle the economic burden associated with it—and mentors should be sensitive to that.

DR. TALCOTT: HOW CAN MENTORS BE SUPPORTIVE IF A TRAINEE IS DEALING WITH ECONOMIC HARDSHIP?

Dr. Scott: We don't necessarily talk about economics, but we need to be cognizant of its effect. For example, if I invite a fellow out for coffee, I cover the cost, especially if it was my invitation, and I know that some may not have the financial resources for something like that.

Dr. Yonekawa: The most important thing is to keep an open line of communication. Having economic challenges is nothing to be ashamed of. If a program can make changes to ensure these challenges are addressed and every trainee has an equal chance of success, not only does that help the fellow, but it also makes the program better.

DR. TALCOTT: HOW MIGHT ECONOMIC SITUATIONS HINDER TRAINEES’ GROWTH IN THE FIELD OF RETINA?

Dr. Yonekawa: In addition to the need for support for conferences and other educational activities, another significant challenge is often where the trainee lives. If a program is in an area with a high cost of living, such as New York City, and subsidized housing is not available, many fellows have to live further away, especially if they have children and need more space.

Fellows work long hours and are on call, and there’s a definite advantage to living close to the hospital. Trainees who live 30 minutes away have a 60-minute commute per consult, in the middle of the night. They won’t be as rested for clinic or OR the next day, and that can affect their performance. Most importantly, it may also affect their safety.

Fellows should discuss these concerns with their mentors and program directors beforehand so that they can communicate appropriately with other faculty. Program directors and mentors can often step in and help fellows find more affordable housing options close to the clinic, because in terms of housing and real estate, nothing beats local connections. Regarding safety, programs should help trainees get home safely, even if that requires reimbursing for safer transportation, such as a taxi rather than public buses.

For many fellows, another financial strain is childcare and family costs. Many fellows postpone kids until after training, but some decide to start families earlier, and that quickly drains your bank account. This means a fellow may be relying on a spouse with a “real job” to pay the bills or extended family from whom they can borrow money from time to time, or even taking out personal loans. If a fellow needs family support, that may dictate their program selection process to ensure they can live closer to family.

When your finances are tough, it can affect your overall wellbeing and, thus, performance. There is always some level anxiety, and it helps if fellows have good support networks that can provide support, whether financial or emotional, to mitigate the stress as much as possible.

Dr. Talcott: I remember when I matched for fellowship, I was overwhelmed by the cost of the next 2 years. The stress can get to you over the course of training, and you may have to make different decisions, such as taking out personal loans, than colleagues who don't face those same pressures. It can limit your ability to focus on learning and take advantage of all the opportunities.

Dr. Scott: Programs should try to ensure fellows don’t need to self-identify as someone with economic constraints. For example, programs can designate affordable housing or on-call housing to ensure all fellows have available housing in close proximity to the hospital. If a fellow is struggling with a longer commute, they don't have to necessarily admit to it; they can take advantage of the option available to all trainees, which removes the stigma from the decision.

Systemically, programs can consider making fellow salaries and fringe benefits equivalent with the standard compensation for the trainee’s post graduate year of training after medical school. It’s a basic step, but some programs unfortunately don't necessarily run on this type of compensation model. But it’s very much appreciated, especially by those who have had 10+ years of training and can finally enjoy a reasonable salary for their level of training. It’s the least we can do for trainees who work so many hours for the good of our practices, our hospitals, and our patients.

Dr. Talcott: Thank you both for your insightful comments. It’s important that we take the time to think about our trainees and their education experience.

Editor's note: This manuscript has been edited from the original transcript for clarity and space purposes.