Sometimes the best advice may come from someone close in age to the mentee.
Sometimes our mentors have been practicing for 30 years; others may have practiced for only 3. Fellows and recent graduates navigating the waters of real-world retina sometimes find practice management pearls from the people who speak their language—that is, retina experts in their own peer group. Long-practicing mentors can provide sage advice that elevates a good retina surgeon to an excellent retina surgeon; young retina doctors managing day-to-day challenges can provide the practical advice one needs to develop a professional life.
We have invited four young retina doctors to offer answers to some of our readers’ penetrating questions. Our writers’ range of practice—academic and private, multispecialty and single specialty—ensures variety in their insights, and yet their common experience results in universal pearls of wisdom.
—Derek Kunimoto, MD, JD
Q1: WE ARE TRAINED IN FELLOWSHIP TO PROVIDE GOOD PATIENT CARE. WHAT WERE THE ONE OR TWO MOST UNEXPECTEDLY IMPORTANT THINGS THAT HELPED YOU BE SUCCESSFUL IN YOUR FIRST YEAR OUT OF FELLOWSHIP?
Bedside manner is everything. During your first year in practice, there are many obstacles to gaining the trust of patients: You look young, you are fresh out of training, you may not sound confident. Taking the extra time to sit with your patients and explain their medical condition or just listen to what they have to say goes a long way toward solidifying your relationship with them. This often means more to a patient than the number of years you have under your belt.
Being chief resident and director of ocular trauma at Bascom Palmer Eye Institute at the University of Miami prepared me well for my first year of practice. I had the knowledge and the surgical experience I needed to succeed as a junior attending physician. However, patient care is not just about the right diagnosis and appropriate treatment. My mentors at Bascom Palmer taught me not only how to take care of retinal diseases and sight-threatening injuries, but also how to take care of people. Their interactions with patients and their families built trust, created realistic expectations, and fostered the knowledge that these patients needed to comply with treatment. During my fellowship, I followed these patients and regularly saw how sincere and caring patient relationships could lead to better outcomes.
In fellowship, we learn the most appropriate medical treatment plan for a patient. Sometimes that’s the easiest part. Medicine isn’t practiced in a bubble. In the real world, patients’ expectations and vision needs sometimes supersede textbook recommendations. I’ve learned to ask every newly referred patient about their occupation and hobbies. This will help break the ice and, more important, give you an idea of the patient’s visual demands in everyday life.
Most residents and fellows do not have to worry about building a practice. Your individual reputation matters much less to your patients than the reputation of your attendings or your academic center. This changes significantly once you are out of fellowship. It is critical to recognize how important your reputation is to building a strong and growing practice.
Maintaining a positive, lifelong relationship with your mentors will prove invaluable. Whether it’s questions about coding or thoughts on a difficult case, don’t hesitate to ask for help and advice, especially early on.
Q2: WHAT DID YOU WISH YOU WERE TAUGHT OR SPENT MORE TIME ON IN FELLOWSHIP?
Something I took for granted during fellowship was our referral network. I never had to spend time speaking to referring doctors or sending letters. In practice, I quickly learned the importance of building and maintaining a strong referral network. Keeping in close contact with our referring doctors is important for obtaining new patients. It also creates teaching opportunities and a tightly knit eye care community.
My fellowship provided an excellent base in all aspects of taking care of vitreoretinal patients. However, the fellowship is just the beginning of learning. I appreciate being in an academic environment at Cole Eye Institute, which provides exposure to the most novel technologies in our field. Given the rapid development in the field of retina, I already do things slightly differently than in fellowship. For instance, during fellowship, I mostly used a 23-gauge vitrectomy system; now I use a 25-gauge system almost 100% of the time. As a fellow, I did not have access to intraoperative optical coherence tomography (OCT), OCT angiography, or a 3-D visualization system, all of which I now have. I think the most important part of fellowship is to learn how to continually learn for the rest of your career.
The first 30 seconds you spend with a patient are often the most important. You need to earn their trust and determine what they want to get from the encounter. A few key pieces of information are critical. Who sent the patient to you? What is the chief complaint? Are they symptomatic, and, if so, to what degree? If you know these answers before you enter the room, it helps guide the entire patient experience. Try to get a sense of how much knowledge the patient has about their condition and how much they actually want to know.
Starting off on your own is a lesson in humility. The stakes are raised, and the challenges are more numerous and more difficult. Immediately, whether in the clinic or the OR, you learn to fall back on the fundamentals you learned during training. Ensure that your fundamentals are rock solid. Review your cases with your attendings, talk about treatment algorithms, seek feedback, and never stop being self-critical.
Q3: WHAT DO YOU SEE AS THE KEYS TO BEING A SUCCESSFUL PHYSICIAN IN YOUR PRACTICE OR YOUR DEPARTMENT?
It is all about attitude and communication skills. We are all well trained and book smart, but the key to success is how you approach each patient encounter, each phone call from a referring doctor, and each request from partners or staff. Taking every opportunity to build relationships is paramount. Also, there is no substitute for hard work. Always be available to see the add-on patient at the end of the day or take the 5:00 pm retinal detachment to the OR.
At the Cole Eye Institute, I work with an outstanding group of dedicated and enthusiastic retina specialists. It is a very collegial and collaborative environment. Being a successful physician means working hard, taking great care of patients, being a team player, and contributing to the reputation of the department through various research interests and trainee education.
Each day, I encounter social, financial, regulatory, and practice pressures that may influence decision-making. I am a member of a large multispecialty group. There are several advantages to this environment. For example, as part of a large group I am less dependent on outside referral sources, and together we have a strong position in the greater health care landscape when it comes to negotiating contracts. Maintaining a shared vision and team-first attitude is key. When short-term goals don’t align among providers, it is important to remember that optimizing patient care for long-term benefit of the population is important, and compromise may be necessary.
There is no secret formula to success after fellowship. Work hard. Be a team player. Take excellent care of your patients. Don’t bring problems to your partners; bring solutions. Understand your business and the issues that are important to the practice. Keep learning. Find ways to challenge yourself and grow. Improve your staff. Be dependable. Be consistent. Be empathetic and kind. Repeat.
Q4: WHAT TIPS CAN YOU GIVE YOUR COLLEAGUES OR CURRENT FELLOWS ABOUT EXCEEDING EXPECTATIONS IN YOUR FIRST YEAR OR TWO OUT OF FELLOWSHIP?
Don’t treat yourself just as an employee of the practice. You are not here only to fill a spot. Set out to try to make yourself an integral part of the practice. Go above and beyond your clinical responsibility to enhance the practice. This could mean getting involved in clinical research, giving talks at national meetings or within your community, or simply finding ways to make the practice run more efficiently.
As one starts in a new academic practice, it is easy to be overwhelmed with multiple responsibilities: providing excellent clinical care, maintaining surgical volume and outcomes, finding a research niche, and contributing to trainee mentoring and education. Several principles have helped me in the past 2 years. The first is that patients come first. If you care about your patients, most other things have a way of taking care of themselves. The second is that, even though you must remain critical of yourself, you must also remember that the only surgeon never to have a retinal redetachment is a surgeon who never operates in the first place. The third is that you need to surround yourself with people whom you admire and who share your work ethic and your vision. Be a leader and always recognize those who help you along the way, be it your mentors or your secretary.
You only get one chance to develop your reputation. Volunteer to do an extra after-hours case on your partner’s patient. Bring a thank-you card to the staff member in charge of the arduous task of ensuring your credentialing with hospitals and insurance companies. Give your surgery scheduler or lead technician a gift card after a long week. Take advantage of a slow clinical start to call an optometrist who sends you a patient who was particularly interesting. Little things can go a long way toward proving that you are a hard-working team player.
In order to exceed your partners’ expectations, you must know what those expectations are. This starts during the interview process, continues when you become an associate, and should never stop. Embrace continual improvement. Talk openly and candidly with your colleagues about their expectations, and set your own expectations as well.
Exceeding patient expectations and exceeding partner expectations go hand in hand. Many patients are used to seeing busy doctors with packed schedules. Maximize chair time with your patients. Explain their diseases to them. Show them their imaging. Teach them. Time spent upfront pays off later.
Section Editor Derek Kunimoto, MD, JD
• managing partner, Retinal Consultants of Arizona, Phoenix; director, Scottsdale Eye Surgery Center, Scottsdale, Ariz.
Neal Palejwala, MD
• vitreoretinal surgeon, Retinal Consultants of Arizona, Phoenix
John D. Pitcher III, MD
• vitreoretinal surgeon, Eye Associates of New Mexico, Albuquerque, N.M.
Aleksandra Rachitskaya, MD
• vitreoretinal surgeon, Cole Eye Institute, Cleveland Clinic
Adi Smith, MD
• vitreoretinal surgeon, Delray Eye Associates, Delray Beach, Fla.