Making the Transition from Fellowship to Practice
Highlights from a roundtable with retina fellows held at the VBS 2.0 meeting, Las Vegas, Nevada.
Anton Orlin, MD, is an assistant professor of ophthalmology at Weill Cornell Medical College where he also completed a vitreoretinal fellowship. During his residency at the Scheie Eye Institute in the department of ophthalmology at the University of Pennsylvania Perelman School of Medicine, he was 1 of 4 residents nationwide chosen to present his retinal research at the annual Association of University Professors of Ophthalmology (AUPO) meeting. While Dr. Orlin remains active in research and education, his primary focus is on clinical and surgical care.
Christopher Brady, MD,
Wills Eye Hospital, Philadelphia.
Peter Campbell, MD,
Casey Eye Institute, Portland, Oregon.
Jonathan Chang, MD,
Bascom Palmer Institute, Miami.
Luis Haddock, MD,
Massachusetts Eye and Ear Infirmary, Boston.
John Miller, MD,
Massachusetts Eye and Ear Infirmary, Boston.
Eric Nudleman, MD,
Associated Retinal Consultants/William Beaumont Hospital, Royal Oak, Michigan.
Mrinali Patel, MD,
Weill Cornell Medical College/New York-Presbyterian Hospital, New York.
Aleksandra Rachitskaya, MD,
Bascom Palmer Institute, Miami.
Jamison Ridgeley, MD,
Wake Forest Baptist Health, Winston-Salem, North Carolina.
Retina fellowships are designed for ophthalmology residency graduates seeking advanced subspecialty training in vitreoretinal diseases and surgery. The surgeons who participated in this roundtable are a reflection of the stellar fellowship opportunities that exist at the leading medical centers across the country today. Several are focused on academics and research, others are eager to bring a decade’s worth of education and training to the clinical and surgical setting. However, they all welcome the opportunity to transfer findings from their research initiatives into the clinic and to bring information from their patient encounters into the laboratory. While the changing face of health care is a concern—particularly for those entering private practice—all are eager to finally flex their independence and help move the specialty forward via a delicate balance of research, education, and patient care.
PLANS FOR THE FUTURE
Anton Orlin, MD: Tell us about your fellowship program.
John Miller, MD: At the Massachusetts Eye and Ear Infirmary, there is a strong emphasis on didactics and research, and we have research opportunities in basic science, retina, and glaucoma. We have a weekly macular conference where we are questioned on a series of 3 cases that the residents present and we talk through the management and workup of those patients. The emergency room at our facility keeps us very busy, and we get a lot of experience in primary evaluations and ocular trauma.
Jonathan Chang, MD: I am in a 2-year fellowship at Bascom Palmer Institute, a tertiary care research center. This program is heavily focused on academics. The first year was structured as a professional fellowship with a faculty mentor. During the second year, Dr. Aleksandra Rachitskaya and I acted as chief residents and directors of ocular trauma. We managed all of the administrative things for the residency, such as rotation schedules, cataract staffing, and vacation.
Luis Haddock, MD: I am a second year follow at Massachusetts Eye and Ear Infirmary and I mainly work in 1 of the facility’s satellite offices. I focus on clinical work, but I also do some clinical research. (Note: Dr. Haddock has since transitioned out of his residency and into a clinical research position at Bascom Palmer Eye Institute in Miami.)
Eric Nudleman, MD: I am a second year fellow with the Associated Retinal Consultants at William Beaumont Hospital in Royal Oak, Michigan. The practice is a large group of retina specialists, many of whom are active in basic and clinical research. There is a tremendous surgical volume, which provides the fellows with great training, as well as opportunities for original research. After my fellowship, I am joining an academic department at University of California San Diego.
Jamison Ridgeley, MD: I am a second year fellow at Wake Forest Baptist Health in Winston-Salem, North Carolina.
Mrinali Patel, MD: I am a first year fellow at Weill Cornell Medical College in New York.
Aleksandra Rachitskaya, MD: I am in my final year of a fellowship, and I am a chief resident at Bascom Palmer Institute in Miami.
Christopher Brady, MD: I am a second year fellow at Wills Eye Hospital in Philadelphia.
Peter Campbell, MD: I am a second year fellow at Casey Eye Institute in Portland, Oregon.
Dr. Orlin: What type of practice do you plan to join and what factors influenced your decision?
Dr. Haddock: I debated the pluses and minuses of joining a private practice or a hospital and 1 of the reasons that I decided to move on to Bascom Palmer is because I did my residency there and it is a place that will give me the opportunity to do a variety of things— research as well as clinical work.
Dr. Brady: I am joining the faculty at the Wilmer Eye Institute at John Hopkins. I am very excited about working with residents and fellows and excited to be developing more of an independent research career, as well.
Dr Nudleman: I am going to The Shiley Eye Center at University of California San Diego. After careful consideration, I decided that teaching and research are important to me, and the best place to do that is in an academic setting. The department is a good fit for me because there are a lot of clinician-scientists there, and I am planning to have a laboratory. I like the fact that there will be mentors there who can help me navigate that path.
Dr. Ridgeley: I will join Cape Fear Retinal Associates as a third retinal surgeon. I considered both academic and private practice opportunities, but wanted to remain near family. When I got an offer from a practice in the right location, I was happy to accept.
Dr. Patel: I hope to ultimately teach and conduct research in my future career. I have always had an interest in basic science and advancing medical research. I like the idea of being able to take questions that are raised in the clinic to the laboratory or take the research findings that unfold in the laboratory to the clinic. I like the synergy associated with that dynamic. Of course, research takes time and energy away from seeing patients, so it will ultimately come down to finding the right balance. The other aspect about institutions that have rigorous research and teaching arms is that they tend to be academic institutions and, therefore, you are surrounded by others who are also excited about advancing the field. I see this as an intellectually engaging environment that I find that very appealing.
Dr. Rachitskaya: I have accepted a position at the Cleveland Clinic Cole Eye Institute in Cleveland, Ohio. I am looking forward to working in an academic environment. I have enjoyed it throughout my residency and my fellowship, and, as Dr. Patel mentioned, I think it is a great opportunity to take the ideas that you see in the clinic into the realm of research and help advance the field of retina.
Dr. Orlin: Staying involved with research is intellectually stimulating, but it is also a good way to keep up to date on the newest and best diagnostic and treatment modalities, which ultimately translates to better patient care—not only in one’s practice, but also for the field of retina. Dr. Ridgeley, given that you will join a private practice, will you have opportunities for research?
Dr. Ridgeley: I have discussed the possibility of instituting some basic clinical trials, including DRCR.net, which I think is not only a good way to keep myself motivated and learning about therapies and principles, but also a way to potentially enhance the reputation of the practice.
MAKING THE LEAP
Dr. Orlin: What are some challenges that you anticipate during the transition from fellowship to full-time practice?
Dr. Brady: During my fellowship, I had independence in the clinic and supervision in the OR. For me, the main difference between fellowship and practice will be the complete independence. I anticipate some surgical challenges, including knowing when I have peeled enough membrane or whether I have drained enough subretinal fluid without someone providing guidance. Other challenges that I anticipate include dealing with the changes that will come about because of ICD-10, which I think will be a game changer.
Dr. Campbell: One advantage of training in a place with several faculty members is that you observe a variety of ways of doing things. Transitioning next year will be about making those decisions on my own. Everyone runs their clinic differently and deciding how I want to do things may involve some trial and error, which will be both challenging and frustrating.
Dr. Orlin: What else would you have wanted to experience in your fellowship that would make the transition a little smoother?
Dr. Campbell: Because I trained in a university hospital environment, I was not really exposed to what a private practice looks like or what the pros and cons of practicing in a private practice are.
Dr. Orlin: What are you most looking forward to in terms of starting your practice?
Dr. Brady: After 10 years of medical training, it is exciting to think about being out on my own, making judgment calls, seeing my patients come back to me, and feeling that independence and growth. I am looking forward to embracing both the complications and the successes.
Dr. Haddock: I am looking forward to developing long-term relationships with patients. When you are in a fellowship, you are going from 1 rotation to another and sometimes it is hard to keep up with the long-term care of some of those patients. I think I will really like to follow my patients and get to know them a little better.
Dr. Campbell: I am looking forward to making my own decisions about how to care for patients and developing my own style after so many years of having someone overseeing me. It will also be nice to lay down roots. Many of us have been migratory for the past 10 years. This marks the first time when some of us will be in the same spot where we can forge relationships in the community. These are the things that our peers who are not in medicine did a decade ago. It is like finally growing up.
Dr. Orlin: I have been in practice a little over a year and a half. In terms of launching a successful practice, I think it is very important to establish a good reputation in the community, to treat patients with compassion and respect, to be available for emergencies, and to keep referring physicians up to date on how their patients are doing. What do you think are some important aspects of being successful in your future practice?
Dr. Patel: I think the most important aspect of being successful in the first few years of practice is to continue developing clinical and surgical skills and building upon the ones that we learned in fellowship It is just a matter of striving to be the best doctor you can be, clinically and surgically, and success will follow after.
Dr. Nudleman: I think success comes down to doing the best you can at everything you do—taking care of your patients and treating them respectfully and ethically, and applying those same standards to colleagues, trainees, and referring doctors. One of my mentors told me it that for clinical care it really does not matter whether you are in private practice or an academic environment, or whether you are solo or in a big group—you are a physician and it is all about taking care of individuals. If you make that your priority, then everything will fall into place. I hope that is true.
Dr. Orlin: Has anyone thought about the dynamic of being trained as a fellow and eventually training a retinal fellow?
Dr. Chang: It is difficult to watch someone do something knowing that you will be more efficient. You have to be patient and give clear instructions. For me, I think of the great teachers I have had and focus on what made them great. In my experience, the best teachers have patience, give clear instructions, and do not get upset by unintended results. It is not easy, but sometimes you just have to take a deep breath and then decide whether you can keep going with instructions or whether you have to switch and do it yourself. The thing that keeps me going is remembering that not too long ago, I was in the same position as the doctor in training.
Dr. Rachitskaya: It is important to debrief and discuss if something does not go as anticipated so everyone involved can learn. All of us have been blessed with great mentors. It is helpful to reflect on what made them so good and incorporate those behaviors into our routine as we go forward with new trainees.
Dr. Chang: You have to find a balance between affording the fellows sufficient experience and also keeping patient safety and outcomes in mind. When you are first starting out, you want to establish yourself and you want to have good outcomes, so you may not want to hand over too much responsibility.
Dr. Rachitskaya: Ultimately the patient comes first whenever you do anything.
WORKING WITH INDUSTRY
Dr. Orlin: What have you learned during your fellowship regarding collaboration with industry?
Dr. Miller: A large part of clinical research trials is about establishing what the best standard of care is for given diseases. I think collaboration with industry is an important part of identifying new therapeutics and safety outcomes for new therapeutics.
Dr. Orlin: I agree with that. Clinicians and industry want what is best for the patient, and that takes collaboration to discover newer and better diagnostics and treatments.
Dr. Brady: As a clinician, I am grateful that when 1 drug is not working for a patient I have another to try. The more options I have, the better that is for my patients. But, if clinicians want new products on the market, then we have to collaborate with industry. We have to learn how to communicate our needs in a way that is meaningful to our industry partners. At the same time, we also have to be meticulous about reading the literature with a critical eye and not just focusing on the information that we hear directly from industry. We have to be cognizant about the distinctions between scientific results and marketing materials.
Dr. Nudleman: Beaumont has a lot of connections with industry, and 1 thing I have learned is that the industry representatives are very receptive to our experience— both positive and negative. They want to improve their products, instruments, and drugs, and they are looking to us for postmarket experience. As the users of these products, I think it is really our responsibility to interact with them and report successes or failures with the products we use. Physicians can also be the driving force for the development of new products. It can be a synergistic relationship between industry and the physician community, with the aim to improve the quality of patient care.
Dr. Campbell: The other aspect to the relationship between industry and clinicians is the patient perspective. The complexities of the relationship between clinicians and industry are not always transparent and can be confusing to the general public. I think clinicians as a whole need to be diligent about monitoring our behavior so that we do not face increasing governmental scrutiny and regulation. We all need to make sure that we always have patients’ best interest at heart and then figure out what we are comfortable with as far as our relationship with industry.
Dr. Orlin: The end of fellowship is an anxious time. On the 1 hand, it marks the final chapter in a long and sometimes arduous journey through medical school and postgraduate professional training. Thus, it is a relief to finally complete the academic requirements of becoming a retina specialist and to gain independence to make decision on one’s own. Yet, this freedom is also potentially daunting. When we embark on our chosen career paths after fellowship, it will be the first time many of us will be practicing medicine without supervision. However, we must remember that this is what we ultimately wanted when we decided to become doctors: The privilege of caring for patients and the responsibility that entails. It is an honor to practice medicine, and we as retina specialists are entering the field at an exciting time. The future is bright for the profession, and because of the superior training we have all received during fellowship, we are ready to help the field advance into the future.