July is quickly approaching. Around the country, second-year fellows face the exciting yet daunting prospect of graduation and initiation into the retina world as new attendings. To prepare fellows for this transition, the Retina Today Fellows' Focus editors pooled opinions from retina surgeons with recent experience managing the leap in expectations and responsibilities that comes with moving up the ladder.

What was the biggest unexpected challenge you encountered when transitioning from being a fellow with attending supervision to serving as an attending with teaching responsibility?

Chirag Shah, MD, MPH: As a new attending, you are still learning. I learned as much my first 2 years as an attending as I did during my 2-year fellowship.

Andre Witkin, MD: For me, since leaving fellowship, the most difficult challenges have been in two areas of patient care: deciding when to operate and how to continue to manage patients after a poor outcome has occurred.

Allen Chiang, MD: I think sometimes fellows can fall into the trap of thinking that the fellowship diploma means they have learned all that they need to learn and that it is simply time to get to work. A good fellowship will equip you with the fundamentals, but the reality is that the learning continues and is lifelong.

Dr. Witkin: In terms of teaching, I think one of the greatest challenges is to figure out how to optimize a trainee's learning experience while still keeping the patient's best interests in mind.

Dr. Chiang: The best practical advice I received was to spend the majority of the time in the primary surgeon's chair for the first couple of years. Not unlike fellowship, there is a steep learning curve as you begin practice, both in the clinic and the OR, and I think it is a critical part of a surgeon's ongoing development that should not be delegated.

Dr. Shah: The challenge while teaching trainees is trying to figure how to find your style as you grow your practice. How much surgery do you pass to your fellow while you are still learning how to use new equipment and work with a new OR team? How do you integrate a fellow into your clinic when you are still trying to figure out how to manage patient flow, and while patients think both you and your trainee are still in high school? With experience, you become more confident and polished as an attending, and subsequently a better teacher to your trainees.

How do you balance letting fellows gain surgical experience and knowing when to take over a case?

Dr. Chiang: Although education and training of future vitreoretinal surgeons is an important and noble task, taking great care of the patient must always come first. Maintaining this priority provides clarity in these situations. Knowing when to take over requires keen observation of a fellow's innate and acquired skill level along with an understanding of what can go wrong with any given action during each step of the case. Similar to a driver's education teacher always having a foot hovering over the emergency brake pedal, careful attention and anticipation are essential.

Dr. Witkin: This is still something that I am learning, and I believe that this tradeoff comes with experience. I probably tend to take over cases more quickly than a more experienced attending surgeon, and I think one of the most important reasons for this is that it takes time to figure out how to clearly verbalize how certain techniques or surgical maneuvers should best be performed. I have found that one of the greatest challenges is to put into words what I have incorporated into muscle memory after performing the same surgical maneuvers hundreds or thousands of times.

Dr. Shah: The ability to anticipate complications is a skill that continues to evolve throughout one's teaching career and allows one to become a better surgical mentor. When I graduated from my fellowship I was told not to pass cases to fellows for the first year as an attending so that I could establish a reputation in my community. As the year progressed, I would pass more and more to my fellows, and in so doing I learned how to better anticipate rookie errors.

Dr. Chiang: Becoming a competent vitreoretinal surgeon is a long and graduated process. I place emphasis on perfecting simpler skills first, such as inserting trocars or performing a core vitrectomy efficiently, before proceeding to more advanced maneuvers. For me, breaking things down into steps or stages simplifies knowing when to take over a case—it clarifies the learning objective and pairs it with the fellow's current level of development.

Dr. Shah: I find it helpful to discuss the important and subtle surgical steps with the fellow before the case so he or she understands how to accomplish the goals of surgery without getting into trouble. If I notice that he or she is struggling and I feel we are risking harm to the patient and to the surgical outcome, I will take over for that step and then try to have the fellow finish the subsequent steps.

Dr. Witkin: Of course, if a fellow is struggling with a certain part of the surgery, or if the patient's safety is at risk, it is important for the attending to take over. Also, as fellows become more experienced, it is also important to switch back and forth from time to time even in simpler surgical cases to demonstrate subtle or nuanced techniques that might help fellows in their transition to becoming independent retina surgeons.

How does one evolve from a mentee into a capable research or surgical mentor for residents and fellows?

Dr. Shah: I do not think there is a single moment when you stop being a mentee and start being a mentor. We have been both throughout our training, and after completing fellowship the balance continues to shift more towards mentor than mentee. You very much will have many old and new mentors in your life.

Dr. Witkin: This also is something I am still learning. Perhaps one of the most important aspects of being a teacher is to also learn from residents and fellows. Again, this learning as a teacher comes with more and more experiences, as each new trainee comes with his or her own personality and background, different techniques or ways that he or she was trained, and different ways that he or she learns. As I continue to work with more trainees, my understanding of how to become a better teacher evolves.

Dr. Chiang: It is important to work hard and be at the top of your game. For me, emulation is a guiding principle; I try to emulate former mentors whom I deeply respect and benefited from. In many ways this will likely occur organically, but it does require intentional effort and reflection to understand how you have been influenced and, in turn, how you would like to influence your trainees.

Dr. Shah: As you mentor more and more trainees, think of your best mentors and emulate them. Trainees are much like your children. They may not be perfect in every way, but you love them regardless and will find great satisfaction by helping them grow from novice physicians to skilled surgeons who may one day care for you.

As an attending building a practice, what do you tell patients who ask about the role of a fellow in your surgeries?

Dr. Witkin: I tell patients that the fellow is there to assist me and that we both perform parts of the surgery. I also reassure patients that the fellow is supervised 100% of the time. If patients specifically request that I perform the surgery, I will oblige their request; however, I find that this occurs in the vast minority of cases.

Dr. Shah: Some patients request that I do the case, and I respect this request. For others who ask if I work with a fellow, I tell them surgery requires two people and I always work with a fellow. I reassure them that I am always the captain of the ship, but that I do depend on all the team members in the OR, including my fellow. Patients trust that I always have their best interests at heart and know that I will do my best to ensure a good outcome.

Dr. Chiang: I tell them that our institution has an outstanding reputation in part because it is a teaching hospital and that, as an attending surgeon, I am involved with training future retina surgeons. I explain to patients that fellows may participate in their surgery to the extent that I deem suitable and only with my supervision. Most patients are fine with this.


Retina fellowship may have provided an educational base, but the consensus seems to be that new retina attendings learn the most after the protective mantle of training has been shed. Emulate your mentors and be generous as a teacher, but always keep your patients' best interests in mind and take over surgical cases when necessary. n

Section Editor Bryan Kun Hong, MD
• second-year retina fellow at Wills Eye Hospital in Philadelphia, Pa.

Section Editor M. Ali Khan, MD
• second-year retina fellow at Wills Eye Hospital in Philadelphia, Pa.

Section Editor Jayanth Sridhar, MD
• second-year retina fellow at Wills Eye Hospital in Philadelphia, Pa.

Allen Chiang, MD
• attending surgeon, Wills Eye Hospital retina service; physician, Mid Atlantic Retina; assistant clinical professor of ophthalmology, Thomas Jefferson University, all in Philadelphia, Pa.

Chirag Shah, MD, MPH
• vitreoretinal surgeon, Ophthalmic Consultants of Boston, in Boston, Mass.

Andre Witkin, MD
• assistant professor of ophthalmology, Tufts University School of Medicine, in Boston, Mass.