Growing Pains in Retina

Tips for attending physicians entering their first ophthalmology practices from those who recently made the transition.

By Christopher M. Aderman, MD; Ferhina Ali, MD; and Katherine Talcott, MD
 

As the academic year draws to a close, a new crop of retina surgeons will be navigating their fledgling careers, an unfamiliar path for those accustomed to the structured training environments of residency and fellowship. This progression to the workforce can be challenging, so we reached out to a few recent graduates who have made the transition. In this article, they shed some light on their experiences.

What was the biggest challenge you encountered when transitioning to your first job?

Andre Witkin, MD:  The buck stops with you. Every decision in the clinic or OR is ultimately yours. This becomes particularly challenging when there is a poor outcome. Not only can these cases be difficult in the moment, but you also have to continue to follow and care for these patients afterward, and it is hard not to get overwhelmed with worry for them.

Michael A. Klufas, MD:  Dealing with the unknowns prior to starting in the new practice: Where exactly will my family and I live? What will my day-to-day schedule be? Where will I be operating? Depending on the position, many of these items cannot be sorted out by the physician and the practice until months or weeks before starting.

John D. Pitcher III, MD:  To be constantly aware, from start to finish, of all the people involved with caring for my patients. From front desk staff to photographers to technicians and writers, there are many issues that ultimately interrupt your flow. As my practice quickly picked up steam, I struggled to pinpoint the inefficiencies that had to be addressed.

M. Ali Khan, MD:  The initial drop-off in clinical volume from a busy fellowship to starting and establishing a new practice was difficult. As the senior doctors in my group noted, “Enjoy it while it lasts.” You can use the downtime to meet referring doctors, finish papers and publications from fellowship, or get acquainted with new OR facilities.

What tips can you offer on how to plan for running your own clinic?

Dr. Witkin:  Starting slow, as Dr. Khan mentioned, can be helpful because it allows you to figure out the computer system and how the clinic is managed. If your electronic health record system has certain shortcuts or templates, you should customize them early so you do not have to relearn them later when you are busier. If you like to have things run a certain way, make sure the technicians know your preferences.

Dr. Klufas:  Constantly reassess bottlenecks: patient wait times, prepping of injections, imaging delays, etc. The staff is there to help the physician, who must act as captain of the ship. Explaining why you want certain things done differently can involve staff members in the process and encourage them to adopt your practice patterns.

Dr. Pitcher:  Instead of just seeing yourself as the boss, try to view your role as that of a leader. Showing your team the level of performance you expect is much more effective than simply telling them. Keep your staff members engaged by connecting with them on a personal level. Challenge them by delegating responsibilities and taking advantage of their individual skill sets and strengths.

Dr. Khan:  Do not be afraid to (respectfully) voice your own preferences. Things may be slow at first, so you will have a good chance to get a sense of what works and what does not work in terms of patient flow. As always, being courteous to patients and staff members goes a long, long way.

Christopher J. Brady, MD:  If you are in academics, seek “the serenity to accept the things you cannot change, the courage to change the things you can, and the wisdom to know the difference.” This is really only partly in jest. There may be a desire to make a splash in your new setting and set things up just the way you like, but this effort might better be put toward making good relationships with patients and perfecting your surgical technique.

What OR starter tips can you offer for one’s first solo cases?

Dr. Witkin:  If you will be training fellows or residents, emphasize to them—and to yourself—that you will be performing the entirety of the cases for the first few weeks or months. Once you feel more comfortable yourself, you can start to get the trainees more involved. Having surgical equipment representatives assist you for your first OR block can be helpful to allow you to become familiar with new types of equipment and to make sure your preferred settings are programmed properly.

Dr. Klufas:  I would recommend starting with lower risk cases, such as chronic full thickness macular holes, nonclearing vitreous hemorrhage, and macula-off retinal detachments. Take your time. Even if you are in an ambulatory surgery center with cost constraints, the quality and outcome of your surgery is more important than being fast. Sometimes taking a moment to stop and think can pay large dividends.

Dr. Pitcher:  Copy and modify OR preference cards from your surgical mentors in fellowship. If you submit these to your new surgery center a few months in advance, they can order your equipment (machines, instruments, disposables, etc.) ahead of time, and it will be ready for you. It is much less stressful to operate when you are using familiar tools.

Dr. Khan:  Make sure you are comfortable with the patient flow and the equipment available at your surgery site. It is normal to be nervous for your first cases, so not having to worry about the pre- and postop workflow helps you focus on the case.

Dr. Brady:  It is important to be flexible when joining an established retina group. If slightly different forceps are commonly used for a minor task, I think it is better to roll with the established preference rather than requesting that your specific instrument be purchased; you might learn about a better instrument. If there is some instrument or suture that you use commonly and really prefer, however, I would consider requesting this. You do not want to be a prima donna, but you want to have the tools you need in order to perform procedures as safely and efficiently as possible.

What is your advice on developing and managing a referral base?

Dr. Witkin:  Be nice to everyone: staff members, assistants, patients, other doctors, etc. Anyone you meet can be a potential referral source. Send letters or make phone calls to referring doctors, especially if the patient is referred for an emergency.

Dr. Klufas:  If there is a marketing director in the practice, ask him or her to plan in-person visits for you to top referring providers in the area, as well as old referral sources who have not sent many patients to the practice in recent years. People who have not sent referrals in the past may be open to a new physician, and this can be a way to grow your practice quickly. Giving lectures to local optometry societies and at continuing medical education events can be a good way to introduce and establish yourself as a new specialist in the area.

Dr. Pitcher:  Referral dinners are fine, but the way you really earn a consistent stream of patients is through each individual care experience. If patients go back and report an exceptional experience at your office, you will see more patients from that referring physician shortly thereafter.

Dr. Brady:  Availability and communication are key. This can be difficult to manage in an academic institution—especially if you also have research duties—but taking charge of a retinal detachment, a dropped lens, or a case of endophthalmitis is a great way to start a good relationship with your anterior segment colleagues. Having the patient make it through a terrible situation thinking you and the referring doctor are great physicians is wonderful advertising. Also, this is common sense, but remember: There is no reason to ever speak ill of a colleague with a patient.

What do you wish you had paid more attention to in fellowship?

Dr. Witkin:  It is important to see your preceptors as mentors not only at work but also in life. It can be just as helpful to seek advice from them about other aspects of life as a retina physician. These could include financial planning, family life, extracurricular interests and activities, and questions that are related to work life but not directly to patient care.

Dr. Klufas:  Often, fellows are concerned with operating as much as they can. I would argue that watching as much as you can is also valuable. Whether you join a large or small practice, it is unlikely you will spend significant time with your partners in the OR learning from them in the apprentice model used in fellowships. Take note of how the attending physicians interact with other faculty members and partners, referring providers, clinic staff, etc. Navigating these relationships in your career as an attending can be just as important as the quality of the work you perform.

Dr. Pitcher:  Thoroughly counseling a patient preoperatively can set you up for success and ultimately save time. Pay attention to how your mentors explain a patient’s condition to him or her and how they set that patient’s expectations for the surgical experience.

What do you like most about your current practice setting?

Dr. Witkin:  Location was a big deal. I love Boston, and it is close to my family. I also knew the doctors at Tufts University School of Medicine before I joined, and I already knew I would enjoy working there. I liked the idea of being in an academic setting, as it was an opportunity to pursue a variety of work interests aside from patient care, such as teaching, writing, performing research, and attending meetings.

Dr. Klufas:  Being busy clinically and having the opportunity to participate in fellowship education, clinical research, and academic conferences at Wills Eye Hospital is a unique and special opportunity. There are many changes happening in health care, and it is exciting to be part of the talented group of physicians at Mid Atlantic Retina who are constantly reassessing and evaluating the practice to adapt to the market.

Dr. Pitcher:  The people you interact with on a daily basis make all the difference. Region, resources, reimbursement, etc., all have much less impact on your happiness. I am fortunate to work with some of the best staff and partners anywhere, and, for me, going to work every day is a truly enjoyable experience.

Dr. Khan:  I have been lucky to transition to an academic practice with a long history of excellence in ophthalmology. Continuing to work with mentors who have already navigated successful careers (receiving grants, publishing in high-impact journals) has been a great experience. Exposure and access to ongoing surgical and medical clinical trials has also been a major plus. Similarly, helping to train and work with fellows is especially rewarding and keeps the job fresh.

What have we forgotten to ask?

Dr. Witkin:  Do not expect to know the answer to every question or how to manage every patient right out of fellowship. Do
not be afraid to get advice from your colleagues. Learn from every positive and negative patient experience. Learn from your peers and share your experiences with each other. Enjoy being a part of the retina community!

Dr. Klufas:  No job is perfect, and you are unlikely to get a perfect position, particularly one directly out of fellowship. Be a sponge at the end of your fellowship, continue to hone your surgical skills, and do not take any case for granted, even if it is “just” a macular pucker. That patient is going to be sitting across from you a few months after surgery, and the buck will stop with you.

Dr. Pitcher:  Growing pains are normal early in your career. It is easy to let a suboptimal outcome or unhappy patient get you down, but make an effort to focus on all the positive things that happen in a given day of clinic or surgery.

Section Editor Christopher M. Aderman, MD
• second year vitreoretinal surgery fellow, Wills Eye Hospital, Philadelphia, Pa.
caderman@midatlanticretina.com

Section Editor Ferhina S. Ali, MD, MPH
• second year vitreoretinal surgery fellow, Wills Eye Hospital, Philadelphia, Pa.
fali@midatlanticretina.com

Section Editor Katherine Talcott, MD
• second year vitreoretinal surgery fellow, Wills Eye Hospital, Philadelphia, Pa.
ktalcott@midatlanticretina.com

Christopher J. Brady, MD
• assistant professor of ophthalmology at the Wilmer Eye Institute at the Johns Hopkins School of Medicine, Baltimore, Md.
cbrady5@jhmi.edu

M. Ali Khan, MD
• assistant professor of ophthalmology at Doheny & Stein Eye Institutes at David Geffen School of Medicine at UCLA
ali.khan.05@gmail.com

Michael A. Klufas, MD
• vitreoretinal surgeon, Mid Atlantic Retina; assistant professor of ophthalmology, Thomas Jefferson University, both in Philadelphia, Pa.
• retina chief, Eyetube.net
• @NJRetinaDoc; mklufas@midatlanticretina.com

John D. Pitcher III, MD
• retina specialist and partner, Eye Associates of New Mexico; assistant clinical professor of ophthalmology at the University of New Mexico, both in Albuquerque, N.M.
jdpitcher@eyenm.com

Andre Witkin, MD
• assistant professor of ophthalmology, Tufts University School of Medicine, Boston, Mass.
ajwitkin@gmail.com

 

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About Retina Today

Retina Today is a publication that delivers the latest research and clinical developments from areas such as medical retina, retinal surgery, vitreous, diabetes, retinal imaging, posterior segment oncology and ocular trauma. Each issue provides insight from well-respected specialists on cutting-edge therapies and surgical techniques that are currently in use and on the horizon.