Six Months to Go

Part one of a two-part series on navigating challenges in the final months of fellowship.

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

Second-year retina fellows across the country are entering their final 6 months of training. After years of medical school, internships, residencies, and fellowships, the end is near. As we finalize contracts for new positions and plan the next stages of our careers, we paused to check in with our mentors about how best to appreciate and get the most out of the final leg of this journey.

What tips can you offer for honing our clinical and surgical skills in the final 6 months of training? What can we do to prepare for operating solo?

Nikolas J. London, MD: By the final 6 months of fellowship, you likely know what works best for you, but this should give you the confidence to be open to other ways of doing things. You probably know the routine surgeries well, so pay close attention to less common procedures. Write down the steps. Your memory will fade, and, by the time you have joined a practice, it may have been a year since you last performed an unfamiliar procedure.

Rahul N. Khurana, MD: Practice envisioning complications, and ask your mentors how to navigate them. When you finish with training, you will be on your own in the OR. It is important that you are comfortable in this setting. Learn as much as you can from your mentors regarding all facets of medicine, from the OR and the clinic to running a practice and managing difficult patients or families.

Chirag P. Shah, MD, MPH: The reality is that you will learn as much, if not more, in your first 1 to 2 years in practice as you have in fellowship. As you enter the final stretch, make sure you understand how to troubleshoot the vitrectomy machine and any other equipment you will use as an attending (noncontact viewing systems, endoscopes, etc.).

James F. Vander, MD: You will become comfortable and familiar with most of the technical skills within the first 6 months of surgery. The last 6 months are when you begin to develop surgical judgment. I say begin because this process continues long after fellowship ends. Knowing when to peel aggressively, when to stop, what traps await you, and a myriad of other challenges are all critical milestones in becoming a mature, capable vitreoretinal surgeon.

Jason Hsu, MD: Do not get stuck on the idea that there is only one right way to do things. You may like the way one attending peels a membrane, while another’s approach to cannula insertion seems more likely to self-seal. Absorb all you have seen from your different attendings, picking and choosing what works best for you.

Getting exposure to as many cases as possible certainly helps, but it’s not the routine stuff that is challenging. It’s when the routine becomes not-so-routine, and, suddenly, a simple case can become much more complicated. The hardest thing to learn is surgical decision making. Taking the time to understand what is being done and why will go a long way when you are on your own. Learning to control your emotions and fears during a difficult case is essential, especially in the beginning.

Michael A. Klufas, MD: Equally important to honing your technical skills is learning how to conduct preoperative conversations with surgical patients and how to manage postoperative care, including complications. Although many of us love the OR, most of your time will be spent in the clinic once you have joined a practice.

Omesh P. Gupta, MD, MBA: Dr. Klufas makes a good point. Pay attention to how your attendings introduce themselves, obtain patient histories, go through relevant imaging studies, and discuss diagnosis and management. These subtleties are important. Fellows can pick and choose what they like and don’t like in patient interactions.

The most important aspect of managing surgical patients is the consent process. I cannot stress this enough. What surgeons tell patients and how they describe intraoperative and postoperative expectations is critical.

What opportunities should fellows take advantage of in transitioning from fellowship to being an attending?

Dr. Shah: Learn how to code during your fellowship—both medical and surgical codes.

Dr. Hsu: Don’t be in too much of a rush to be on your own; you’ll have the rest of your career to do that. But don’t rely on your mentor to hold your hand through every step either. Try to think, or even say aloud, what the next step should be. It helps to generate discussion, and it may help you understand the different preferences.

Sunir J. Garg, MD: It takes 3 to 4 years to become comfortable as an attending. I did not appreciate how much mine helped me with a number of small things until they were no longer around. In my first 1 or 2 years of practice, I knew how to take care of most clinical problems. But learning how to present issues to patients in a language they can understand without scaring them is an art—as is learning to spend time with them without running behind (I am still working on that issue).

What do you do to optimize well-being in your daily life?

Dr. Khurana: The most successful doctors at work are those who are happy at home. Invest in your health with exercise and diet. One change I have made in my life has been to focus on sleep. I have been able to get away with 6 hours in the past, but it catches up with me. So I have made sleep a priority. It is also important to maintain the hobbies that bring you happiness.

Allen Chiang, MD: It is essential to stay committed to optimizing your well-being, particularly to develop the stamina needed for the pace and stresses of a busy retina practice. For me, the regular practice of yoga has introduced mindful awareness and a relaxing synergy of flexibility and strength to help ward off repetitive musculoskeletal injuries. Carving out quality time for family and engaging in hobbies such as painting also keeps me grounded.

Dr. Vander: Find time to eat during the workday. It won’t be an hour lunch, but take a few minutes. Snack on something healthy and drink plenty of fluids. Make time to work out at least 3 days a week. Make date nights and keep them, even if you are exhausted.

Dr. Hsu: Work-life balance is a constant struggle. We all lose perspective, but it’s essential to foster relationships and experiences outside of work to keep yourself balanced. Carve out time to do the things that are most meaningful to you. For me, spending time with my family is a top priority.

Dr. Klufas: Maintaining core strength and exercise are important to keep up with the physical demands of being a retina specialist. Pilates and yoga can be great. Make sure you are constantly reassessing the ergonomic situations in your new practice.

How should we make the most of our experience in the final 6 months?

Dr. Shah: Savor this time. Never again will you operate this much. As an attending, you bear the responsibility of your successes and, unfortunately, your failures. Spend time honing your judgment and observing attendings as they discuss bad outcomes.

Dr. Garg: Finishing fellowship was bittersweet for me. I was looking forward to some independence after being in school for 27 years. But the amount of time in the OR, the number of surgeries, and the camaraderie of the other fellows, residents, and attendings is hard to find in practice. Continuing to challenge yourself with tough cases under supervision from an attending is a great way to develop your technical skills and judgment.

Dr. Gupta: The most important thing to realize is that this is your time to learn. You will never have a bunch of expert mentors around you who are committed to your professional development and evaluating your clinical and surgical skills again.

Don’t shy away from negative feedback; become a better physician because of it.

 

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

Allen Chiang, MD
• faculty member of the retina service, Wills Eye Hospital; partner, Mid Atlantic Retina; assistant professor of ophthalmology, Thomas Jefferson University, all in Philadelphia, Pa.
@achiangMD; achiang@midatlanticretina.com

Sunir J. Garg, MD
• professor of ophthalmology, Thomas Jefferson University and the Wills Eye Retina Service; co-director of retina research and partner, Mid Atlantic Retina, all in Philadelphia, Pa.
sunirgarg@yahoo.com

Omesh P. Gupta, MD, MBA
• assistant professor of ophthalmology, Thomas Jefferson University Hospital; attending surgeon, Wills Eye Hospital; and partner, Mid Atlantic Retina, all in Philadelphia, Pa.
ogupta@midatlanticretina.com

Jason Hsu, MD
• co-director of retina research and faculty member of the retina service, Wills Eye Hospital; partner, Mid Atlantic Retina; and associate professor of ophthalmology, Thomas Jefferson University, all in Philadelphia, Pa.
jhsu@midatlanticretina.com

Rahul N. Khurana, MD
• vitreoretinal surgeon at Northern California Retina Vitreous Associates in Mountain View, Calif.; clinical professor of ophthalmology at the University of California, San Francisco.
rnkhurana@gmail.com

Michael A. Klufas, MD
• faculty member of the retina service, Wills Eye Hospital; vitreoretinal surgeon, Mid Atlantic Retina; retina chief, Eyetube.net; and assistant professor of ophthalmology, Thomas Jefferson University, all in Philadelphia, Pa.
@NJRetinaDoc; mklufas@midatlanticretina.com

Nikolas J. London, MD, FACS
• vitreoretinal surgeon, Retina Consultants San Diego; chief of ophthalmology, Scripps Memorial Hospital in La Jolla, Calif.
nik.london@gmail.com; 858-451-1911

Chirag P. Shah, MD, MPH
• vitreoretinal surgeon, Ophthalmic Consultants of Boston; assistant professor of ophthalmology, Tufts University School of Medicine, both in Boston, Mass.
cshah@post.harvard.edu

James F. Vander, MD
• president, Mid Atlantic Retina; clinical professor of ophthalmology, Thomas Jefferson University, both in Philadelphia, Pa.
jvander@midatlanticretina.com

No conflicting relationship exists for any author or contributor.

 

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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.