1. What are the qualities of an ideal fellow in clinic?
Jeffrey Heier, MD: In my opinion, the ideal fellow is hard working, conscientious, motivated, and open to new ideas. Most busy retina fellowships offer unique opportunities to learn. Some of these are clearly defined, such as clinic and OR responsibilities. Others are not so obvious, such as individual discussions with different mentors regarding treatment decisions, approaches, or manner of handling various diseases or situations. Often, the most valuable experience can be derived from a quiet or after-hours informal discussion. The ideal fellow recognizes these opportunities and takes advantage of them. The ideal fellow treats every patient as if they were his or her own, with compassion and meticulous attention to detail. This results in their gaining the trust of their attendings and ultimately results in a better learning experience, not to mention better habits when they are on their own. Finally, the ideal fellow treats the nonphysician staff with the utmost respect—if they do everything and anything they can to help the staff, the staff will reciprocate. Staff support is invaluable.
Arunan Sivalingam, MD: An ideal clinic fellow shows up to clinic on time, sees patients in a timely manner, asks questions when there is uncertainty about the diagnosis or treatment. If the primary clinic fellow is delayed with hospital consults or other responsibilities, the remaining fellows should be aware and be available to pitch in. Lazy behavior or unwillingness to help out if there are patients to be seen breeds resentment and impedes the functioning of a busy clinic. The optimal working environment is when all the fellows consider themselves a unit, working together regardless of their primary responsibilities for the day.
2. What are the qualities of an ideal fellow in the OR?
Dr. Heier: The ideal fellow in the OR is calm, attentive and inquisitive. All fellows want to operate (as they should), but the ideal fellow learns as much from assisting and observing as from performing the surgery. Great surgeons gain tremendous insight from carefully watching their mentors, then applying these lessons to their own cases. On the opposite end of the spectrum, some fellows are intent only upon operating and often don't "master" the art of retina surgery. Struggling through a complicated diabetic tractional retinal detachment, then watching an experienced retina surgeon perform a similar case can be invaluable. Great OR assists often make great surgeons, and I often find the reverse to be true as well—if a fellow is a poor assist, he or she is often a poor surgeon. It goes without saying that the ideal fellow has outstanding hands.
Gaurav Shah, MD: Certainly there are no absolute ideal qualities for a fellow to possess in clinic or in the OR, but I look for somebody who works well with the staff in the office and in the operating room, someone who is a team player with regard to the working environment in both arenas, and someone who consistently does things in a correct and efficient manner. I would also add that punctuality is extremely important both in the operating room and the clinic in order for the system to work.
Dr. Sivalingam: One of the strengths of our programs is the diversity in the attending staff. Our attendings come from programs all over the country, and as a result our fellows are exposed to many different ways to approach the same problem. An ideal quality in a superior OR fellow is the ability to take instruction as well as criticism from the attending staff. The fellow should be on time, aware of the cases scheduled, acquainted with patients and their history, knowledgeable about the proposed surgical procedures, techniques, and equipment. The fellow should be able to efficiently prepare for the next case and complete all of the administrative duties in a timely fashion. In addition, surgeons and fellows rely on the efficiency and expertise of the support staff, anesthesia, and nursing. A good fellow is respectful and appreciative of the ancillary personal.
3. What impresses you most about your best fellows?
Dr. Heier: My best fellows have a true desire to learn to become the best vitreoretinal specialist possible. Their actions are guided by this desire, not to impress or wow anyone, but to truly learn. The best fellows are always questioning why something is done or not done, and wondering why it could not be done differently. When in the OR, they are always thinking about the next step, or a different approach to a complicated problem. They are also outstanding to patients and staff, understanding that a great physician is more than a great surgeon or diagnostician.
Dr. Shah: At the Barnes Retina Institute, we have been particularly blessed with fellows who perform extremely well. What sets them apart is their ability to manage their time and multitask, given the many responsibilities involved in a fellowship. It is not easy to please 12 different attendings while being pulled in 12 different directions, but our fellows certainly do that with a smile and do it correctly time and time again. When our fellows are given a task, we always expect it to be done correctly and on time, without any additional reminders or prompting.
Dr. Sivalingam: Our best fellows are enthusiastic 24/7. They are available, compassionate, helpful, well-read, organized, and true team players. Excellent fellows are unselfish with their time and knowledge both with one another and with residents. Our outstanding fellows have the insight that our fellowship is a limited opportunity to acquire every possible bit of knowledge from as many sources as possible, and that this task is achieved through hard work and dedication. They also recognize their limitations and are willing to ask for help when they are uncertain. Fundamentally, an outstanding fellow is also an outstanding individual in his or her personal life.
4. What are some things you have seen fellows do that you wish they did not?
Dr. Heier: Unfortunately, I have seen fellows treat patients as if they were objects or problems rather than human beings. It can become easy to forget that these patients are no different from their spouse, parent, or child, and should be treated as such, with the degree of care and compassion that they would hope their family would receive. Patients may not be "theirs," but they should treat them as if they are.
Additionally, when I see fellows not paying attention in the OR when they are not the primary surgeon, I take this is a sign that they are not benefiting appropriately from their surgical training.
Dr. Shah: The major thing the fellows should not do, which I think they realize in retrospect, is become frustrated when they face a system such as Veterans Affairs Administration or another such bureaucratic clinic and try to change the system themselves rather than going through the proper channels to improve the process or effect change. It is sometimes difficult to implement changes in these systems, and I always encourage our fellows to look for necessary changes in terms of patient care and efficiency. We stress, however, that changes must be processed through the appropriate channels. Following this route is beneficial not only for training; as a fellow proceeds to practice, he or she will have gained experience in dealing with frustrating circumstances.
Dr. Sivalingam: Undesirable behavior I have seen and dealt with includes being unsupportive. Basic lack of consideration and respect for peers, support staff, and patients is tantamount to unacceptable conduct. We have had fellows who did not pull their weight in clinic and the OR and did not understand the team concept. Dishonest, condescending, and selfish behaviors are unacceptable.
5. What advice would you share with a new first-year fellow?
Dr. Heier: Work hard to get as much out of your fellowship as is possible. It is a unique opportunity to experience a variety of approaches to the handling of patients, management of common and complicated diseases, and observation of different approaches to the practice of being a retina specialist. It sounds clichŽd, but this time will help guide them for the rest of their professional lives. Do not be afraid to ask questions—they will come up when you are on your own, and you will be grateful the time was taken to understand the issue.
Dr. Shah: My advice to a first-year fellow is to work as hard as you have ever done in your life and try to learn as much as you can in your 2 years of fellowship. Our fellows learn the language and intricacies of retina, and it is important to know how to apply these intricacies to clinical practice. All of the fellows want to be in the OR, but I tell them it is important to spend enough time in the office in order to learn to function efficiently in the office environment and take care of patients.
Dr. Sivalingam: My advice to a first-year fellow is to come ready to work and learn. You will have an amazing learning experience if you come understanding the following ideas: you and your classmates are teammates; everyone deserves to be treated with equal respect; and everyone will work 100% plus 10%. Lastly, this is not a competition, but an opportunity to work with colleagues working to achieve the same goal: to become world-class retina surgeons. If a fellow proceeds with these ideas in mind, he or she will take away everything our fellowship has to offer.
6. If you were to do fellowship again, what would you do differently?
Dr. Heier: Happily and fortunately, I regret no aspect of my fellowship. It was a hard but extremely rewarding time. Much of the advice provided here was similar to if not the same as what was shared with me by several of my mentors from residency.
Dr. Shah: The only thing I would add to my fellowship experience would be more business acumen. Clinically and surgically, I would not change anything about my training at Wills because it was the most important part of my retina training and remains so. I value the colleagues and friends I met while doing my fellowship in Philadelphia.
Dr. Sivalingam: If I were to do my fellowship again, I would do everything the same. I benefited from the strong, clinically diverse program Wills had to offer. I have no regrets. This fellowship has only gotten better with 19 retina specialists working as a team. We are training our fellows to become world-class retina specialists. We have matched our top three in our rank list for the past 3 years. My only worry is that if I were to apply today, I might not be accepted to Wills.Ên
Jeffrey S. Heier, MD, is a Clinical Ophthalmologist specializing in diseases of the retina and vitreous at Ophthalmic Consultants of Boston. Dr. Heier is a member of the Retina Today Editorial Board. He can be reached at jsheier@eyeboston.com.
Arunan Sivalingam, MD, is the Co-director of the Retina Service and the Director of Retina Fellowship at Wills Eye institute. He is a Clinical Associate Professor at Jefferson Medical College of Thomas Jefferson University Hospital in Philadelphia. He can be reached at +1 800 331 6634.
Gaurav Shah, MD, is the Co-Director of the Retina Fellowship and is an Assistant Professor at Barnes Retina Institute in St. Louis, MO. He can be reached at +1 314 367 1181.
Darrell E. Baskin, MD; Jeremy D. Wolfe, MD; and Chirag P. Shah, MD, are second-year vitreoretinal fellows at Wills Eye Institute in Philadelphia, PA. Dr. Baskin may be reached at darrellbaskin@gmail.com; Dr Wolfe may be reached at jeremydwolfe@gmail.com; and Dr. Shah may be reached at cshah@post.harvard.edu.
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