With the second year of vitreoretinal fellowship wrapping up, the path ahead remains exciting, nerve-wracking, challenging, and rewarding. Whether the practice setting is academics, private practice, or a hybrid model, many graduates—including myself—have some important questions about the months ahead. Here, I summarize some practice pearls from four of my mentors at Wills Eye Hospital/Mid-Atlantic Retina: Ajay Kuriyan, MD; Yoshihiro Yonekawa, MD; Sonia Mehta, MD; and Michael Cohen, MD.

SAAGAR PANDIT, MD, MPH: WHAT WERE THE GREATEST CHALLENGES THE FIRST YEAR AFTER FELLOWSHIP?

Dr. Kuriyan: The combination of taking some time off and slowly building up surgical volume felt strange after operating at a high volume during fellowship. It helped to go through the mental exercise of reviewing the steps of surgeries and thinking of potential common complications and ways to manage them for my early cases.

Dr. Yonekawa: Most retina fellowships in the United States provide the highest levels of medical training, and we don’t have many issues with patient management. Former fellows sometimes contact us about medical questions and mystery diagnoses, but for the most part, you’ll find yourself in cruise control quickly. However, an area where the learning curve is steep is the business and administrative side of medicine. Everyone asks about coding, but it’s much more than that. Your senior partners will be invaluable resources to teach you the aspects of medical practice that are not covered in depth during fellowship. Even if you are in a university practice, try to learn these aspects of health care, and you’ll be able to provide more seamless quality care.

Dr. Mehta: Managing patient expectations. You may encounter patients with significant retinal pathology who want to see 20/20 tomorrow. It’s helpful to set patient expectations in a compassionate way prior to treatment. Fellowship is a great opportunity to observe how your attendings navigate these difficult conversations.

DR. PANDIT: IN THE LAST MONTHS OF FELLOWSHIP, WHAT SHOULD FELLOWS FOCUS ON TO PREPARE?

Dr. Kuriyan: I would encourage fellows to self-reflect and identify areas of weakness in the OR or clinic and work on them with a mentor before the end of fellowship. Also, if an attending switches with you, pay attention to things they are doing better (eg, addressing issues with the view, hand position, etc.). You can learn different things from watching an experienced surgeon when starting versus ending fellowship.

Dr. Cohen: What helped solidify the type of retina specialist I wanted to be was gravitating toward specific attendings as mentors and role models. This helped, especially after I had already mastered much of my training. Acquiring this knowledge helped to frame my approach to different problems in a way that resonated with my thought processes. Gravitating toward someone you feel approaches and appreciates the world and retina like you do will help you set up your own framework to grow from.

Keep your medical retina knowledge sharp. Most fellowships are heavy on surgical experience in the second year, and your medical retina knowledge can falter. Take every opportunity to gain as much medical retina knowledge as you can. See as many patients as you can. Two years is a very short period for training, and it will go by quickly.

By your second year, your hands will be able to do all the required maneuvers. However, it remains important to think about surgical decision making and consider possible ways a case could unfold. Foresee complications and determine how you would deal with them. Even if you are not the one in the surgeon’s seat, this mental exercise is important. Get ahold of surgical planning beyond surgical maneuvers.

DR. PANDIT: IN WHAT WAYS DID YOU REMAIN INVOLVED IN ACADEMICS AFTER FELLOWSHIP, AND WHY?

Dr. Yonekawa: My mentors always used to say that being academic is a state of mind; you can be academic wherever you are. Retina specialists tend to have an academic mindset in general, and that fire continues to drive most of us to stay involved in advancing, educating, and protecting our field.

You can do clinical research in any practice setting. You’re always seeing interesting pathology, so keep that sharp analytical mindset when seeing patients and keep writing about new observations and hypotheses. Get involved with clinical trials. A good place to start is by talking with your medical science liaisons. Sign up with DRCR Retina Network. Stay in touch with your co-fellows and mentors, and contribute to projects. Reach out to local medical schools or residencies, and volunteer your time to conduct research.

Your state ophthalmology society is a great community to join. Advocacy makes more sense once you know the direct effect that legislation can have on your own practice and patients. Stay attuned with happenings on Capitol Hill and the business side of medicine, and attend meetings such as the ASRS Business Meeting and the AAO Mid-Year Forum.

As for continuing education, there are tons of educational resources now. Online learning through social media, podcasts—such as “Straight from the Cutter’s Mouth,” by Jay Sridhar, MD, and BMC’s “New Retina Radio”—journals, blogs like retinaroundup.com, and YouTube have exploded. Vit-Buckle Academy, EyeTube, and the ASRS website are resources I recommend to my trainees. Many organizations and residency/fellowship programs offer free webinars on their grand rounds, including the weekly Retina Imaging Conference and Chiefs Rounds at Wills and the Yannuzzi Rounds by Lawrence Yannuzzi, MD. Also, attend conferences, and stay active members of societies; many of them place an emphasis on young retina specialists. Volunteer to be on committees. For those with strong research interest, keep publishing, and mark your calendars for when you will be eligible to apply for Macula Society (2 years in practice) and Retina Society (3 years in practice).

Dr. Mehta: In residency and fellowship, I was grateful for the mentorship and teaching I received and wanted to pay it forward. My passion, and one of my greatest joys, is participating in the education of the next generation. I am actively involved in surgical education and the development of clinical skillsets of fellows, residents, and medical students. I also oversee the International Scholars program for the Retina Service at Wills Eye, in which we interact with faculty, fellows, residents, and students from around the world. It is a wonderful way to exchange information, advance the field, and enhance visual outcomes of patients with retinal conditions. I enjoy patient-centered research, and when we come across challenging blinding diseases, we look to science and research to advance the care of these patients.

DR. PANDIT: HOW DID YOU GROW YOUR SURGICAL SKILLS AFTER GRADUATING FROM FELLOWSHIP?

Dr. Yonekawa: The most important lessons you learn will be from patients. Make adjustments if your retinal reattachment or macular hole closure rates are slipping. Everyone thinks their single-surgery success rate is greater than 90%, but you must track every case to get a idea of where you fall.

Continue to learn from colleagues. The way you practice may change substantially depending on the practice setting and available equipment. Be flexible. The best surgeons can fix eyes with any instrument or vitrectomy machine.

DR. PANDIT: HOW OFTEN DID YOU REACH OUT TO MENTORS/COLLEAGUES FOR ADVICE?

Dr. Mehta: If you have a question and cannot find the answer in a trusted resource, reach out to a mentor. Often, the other person is happy to share their experience. If you are unsure what to do in a challenging situation, think about what is best for the patient, and use that as your guide.

One of the greatest things about the medical field is that the opportunity to learn is present throughout our entire career. As a medical student, I had an attending who only wore a short white coat, like the medical students did. His message: We are forever students in the medical field and constantly learning from our patients and colleagues.

DR. PANDIT: WHAT ARE THE UNIQUE CHALLENGES FELLOWS FACE WHEN STARTING THEIR FIRST JOB?

Dr. Cohen: When you are entering any job, it is important that your expectations match the reality of your experience. A relationship with a job is like any other relationship; there are essential tenants such as honesty, trust, and respect that must be present to make the relationship work.

DR. PANDIT: DID YOUR FELLOWSHIP PRACTICE PATTERNS CHANGE AS AN ATTENDING?

Dr. Cohen: If you ever get to a point where you can’t learn more, you need to reconsider what you are doing. We are constantly changing our approach, challenging our thought processes, and striving to be the best clinicians possible. My overall practice patterns have not changed, but I have tweaked minor things in the clinic and the OR to become more efficient. For example, you must explain the risks and benefits of procedures to your patients. I have become even more conservative as an attending, and this is coming from someone who was always very conservative to begin with.