Prashant D. Tailor MD, Brian Soetikno MD, PhD
Stein Eye Institute, UCLA, Los Angeles, CA
One of the most thoughtful sessions at VBS 2026 examined a question at the center of every teaching operating room: how to give fellows enough autonomy to grow while still protecting the patient, maintaining efficiency, and preserving the rhythm of a case. Moderated by Jordan Deaner, MD, with panelists Margaret Greven, MD, Michelle Liang, MD, and Brian Toy, MD, the discussion was practical, candid, and familiar to anyone who has trained or taught in vitreoretinal surgery. The panel focused on judgment, emphasizing that good surgical teaching depends on balancing the needs of the learner, the demands of the case, and the responsibility of the attending in real time.
A major theme was the nervous fellow. The panelists spoke openly about the many ways anxiety appears under the microscope, from hesitation and tremor to loss of flow or becoming overwhelmed in a high pressure moment. Importantly, this was not framed as a personal failing, but as a normal part of surgical development that requires thoughtful management. One effective strategy was breaking a case into smaller, clearly defined steps so the fellow can focus on the immediate task rather than the full weight of the operation. The conversation also touched on practical ways to reduce tremor outside the microscope, including avoiding excess caffeine and, in select circumstances, the use of beta blockers. Just as important was the tone set by the attending. A calm, steady voice can keep a fellow grounded, while visible frustration can quickly magnify tension in the room.
Communication, both before and during surgery, emerged as another essential element of teaching well. The panelists stressed the importance of being deliberate with language in the operating room, particularly when the patient may be awake and listening closely. Offhand remarks, visible alarm, or dramatic phrasing can heighten patient anxiety and unsettle the team. Dr. Deaner asked the panel specifically about preoperative conversations with patients, with general agreement among all members of the panel that fellows should be introduced clearly as active members of the surgical team, while reinforcing that the attending surgeon remains fully responsible for the procedure and every decision made during it.
The discussion around switching was especially nuanced. Taking over from a fellow is sometimes necessary, but the way it happens can shape how the learner processes the moment. Dr. Liang described situations in which it may be best to step in briefly, stabilize the case, and then hand control back so the fellow can regroup and continue. The panel made the point that switching is not always a response to poor performance. At times it is simply the best choice for visualization, efficiency, or execution of a demanding maneuver. Still, because fellows often experience being switched out as a personal blow, the attending’s judgment and demeanor matter enormously. Dr. Sharon Fekrat from the audience highlighted an anecdote where she left senior 2nd year fellow alone after he/she had been struggling starting a peel because she knew the fellow could do it and taking over would be devastating for confidence that late in training.
Complications were discussed with equal honesty. One example involved contact with the optic nerve resulting in a peripapillary hemorrhage, which led to a broader conversation about ownership. The consensus was straightforward: the attending owns the complication. Fellows and residents are extensions of the care being delivered under that attending’s supervision. At the same time, the fellow must be part of understanding what happened, learning from it, and following the patient afterward. In the end, the session was a reminder that teaching surgery is not simply about transferring technical skill. It is about cultivating judgment, resilience, accountability, and trust while balancing the competing demands of education and patient care.
