AAO 2017 Retina Subspecialty Day: Innovative Retinal Interventions Session


Christopher Aderman, MD Associate Retina Specialist, EyeHealth Northwest, Portland, OR (former retina fellow at Wills Eye Hospital, Philadelphia, PA)

Jaya B. Kumar, MD Associate, Florida Retina Institute, Orlando, FL (former retina fellow at Cole Eye Institute, Cleveland Clinic, Cleveland, OH) Dimosthenis Mantopoulos, MD, PhD Assistant Professor of Ophthalmology,  Diseases of the retina and vitreous,  Geisel School of Medicine at Dartmouth, Lebanon, NH (former retina fellow at New Jersey Retina - Rutgers  Robert Wood Johnson Medical School, Township, NJ) Patrick R. Oellers, MD Associate, Retina-Vitreous Surgeons of CNY, PC, Syracuse, NY; Assistant Professor, SUNY Upstate Medical University, Department of Ophthalmology, Syracuse, NY (former retina fellow at Massachusetts. Eye and Ear, Harvard Medical School, Boston, MA) [gallery ids="2878,2877,2873,2871" type="rectangular"]

Across the country second year fellows are nearing the end of their training. Many fellows have already signed a contract and are getting ready for their new job. Having the stress of finding a job and contract negotiations off one's back, yet being able to nurture skills and techniques to become a retina surgeon in the last months of fellowship is a most exciting time. Yet there are some important steps to take now and in the next months to make sure that the transition from fellowship to the first job becomes a success. In this article, four recent retina fellowship graduates with various backgrounds share their experiences of how they recently moved into their first job as an attending.

Panelists are Christopher Aderman, MD who graduated from Wills Eye and entered a multi-speciality practice, Jaya B. Kumar, MD who graduated from Cole Eye Institute and started her job in a retina-only group, Dimos Mantopoulos, MD, PhD who graduated from NJ Retina and started in academics and Patrick Oellers, MD who graduated from Mass. Eye and Ear and entered a position in a retina-only group with an academic affiliation. We hope that the interview below informs about best practices and provides valuable insights and lessons for all current fellows.

 After signing your contract, what were the most important next steps?

Christopher Aderman, MD: Given that you probably still have about six to eight months left of fellowship when you sign your contract, the most important thing to do is to continue learning to be a great retina doctor and surgeon.  With the pressure of finding a job no longer weighing on your shoulders, really take the time to learn and see as much as you possibly can in your remaining months.  Try to imagine what you would do in every situation in clinic or in surgery as if you do not have the backup of an attending.  This will allow you to focus on the areas where you lack confidence and help your transition to practice.  It’s critical to get in touch with the administrator in the practice who is responsible for credentialing and make sure this is squared away before starting. This includes medical license, DEA, hospital, and insurance credentialing, which can often take much longer than you would think.  If details about schedule, office locations, or surgery centers were not fleshed out before signing your contract, I would recommend keeping in contact with the practice to update you on things.  This will help you decide where exactly you want to live as you start looking for an apartment or house. If you’re unfamiliar with the practice landscape in your new location, I would dedicate some time to researching the retina docs in the area and get a sense of the referral patterns. Then, if you have extra time or days off as your clinic builds in the first few months, you can use that time to meet with possible referring docs.

Patrick Oellers, MD:  I agree, in my opinion, complete the due paperwork as soon as possible. Hopefully you have administrative help in your new practice, and you should contact that person and get to work right away. Some payers can be very slow in the accreditation process and you might not be able to see certain patients if you can’t accept their insurance, so it’s important to work this out as quickly as possible to have a smooth start.

Jaya B. Kumar, MD: I think it’s important that after you have signed your contract, to enjoy and really get the most out of your fellowship. Pay attention to how your attendings discuss preoperative expectations, review risks, benefits, and alternatives, etc. Think about how you want to run your clinic. What style of practice did you like from each attending? Learn as much as you can in the operating room. Take notes, even when you’re assisting. Ask questions from management, to billing, to theoretical situations in the operating room- your attendings, staff, managers, and co-fellows are great resources. Save a couple videos of you or your attendings performing complex or even simple procedures so you can have them later on in your practice to review. Save presentations and photos of interesting cases from fellowship as you may have to give lectures to students, residents, or optometrists in the community.

Dimos Mantopoulos, MD, PhD: I would echo that. Sending your credentials to the state medical board and to the new employer’s human resources in a timely manner is critical. The good news is that retinal fellows have gone through the similar process before so this time should be easier. If you’re proactive anytime a new issue comes up everything will go smoothly and you will be able to enjoy your summer vacation.

 How did you get accustomed to the new practice?

Patrick Oellers, MD: I arrived about 2 weeks early to settle into the new house and got to visit the practice a couple times. Meeting with the lead scribe and getting acquainted with the new EMR was particularly helpful. I got to drive around town quite a bit and met with a lot of referrers before I started and it was very helpful to build personal relationships. Then, I made sure to have some face time with my new partners and get their take on various things in the clinic and the operating room.

Christopher Aderman, MD: Before starting in my first clinic, I had several days built into my schedule to shadow the other docs in clinic and the OR to get a sense of the flow, the medical records system, and billing. This is also a great time to get acquainted with staff and to better understand the culture of the practice.

Dimos Mantopoulos, MD, PhD: We had an new employee extensive orientation before I started seeing patients. Even though some parts of the new hire orientation did not directly apply to me, it was a great opportunity to learn more about the structure and history of the organization and network with staff from other departments. Prior to my first day, the department sent letters to the referring providers introducing me to the community. I did not have to go out and visit them myself but eventually met everyone at academic activities that our department organized. Finally, prior to my first day at the clinic, my colleagues and the supporting staff walked me through the protocols and the nuances of the EMR so I was prepared to start seeing patients. Working with an experienced scribe from the beginning can be valuable.

Jaya B. Kumar, MD: I agree, this is a great time to get to know your colleagues and staff. Fortunately, I have a great supportive staff that made this transition smooth. Talk to your scribes and technicians, let them know your preferences, and provide them with feedback either on a daily or weekly basis.

 How did you first day of clinic go?

Patrick Oellers, MD: I saw about 10 patients in a half day, mainly to get used to the environment in a low stress setting. Then, I slowly increased clinic numbers, making sure being very comfortable in the first couple of weeks. Having extra time paid off because I was able to spend more time with my new patients, which I think helped to build a good reputation from the start. I was pretty busy after about 1 month and it was great having those first couple of weeks to ease in.

Jaya B. Kumar, MD: I agree with Patrick and think it’s important to start off light. Take your time getting to know your patients. Even an established patient to the practice is a new patient for you. Also take time to figure out your flow and the electronic medical record. For the first several weeks I called the referring doctor for each new patient I saw to introduce myself, discuss the patient, and also thank them for the consult.

Christopher Aderman, MD: Like Patrick and Jaya, my first clinic days felt slow!  At first, I was worried about this, but quickly realized that having low patient volumes at the start is a good thing as it allows time to navigate unexpected issues that come up – and they definitely will. Since every single patient will be a new patient to you, the extra time allows you to build stronger relationships with these new patients.  Finally, the extra time allowed me to think about process improvements and efficiencies in clinic flow and how I might be able to incorporate some things I learned in fellowship into my new practice.

Dimos Mantopoulos, MD, PhD: For me, the first few weeks were a great opportunity to create “smartphrases” and shortcuts on the EMR. This is something that can save you a tremendous amount of time and boost your productivity on a daily basis. Being proactive, asking questions and taking good notes will make a great impression on your colleagues.

 And the operating room? It can be challenging to operate solo in a completely new environment with potentially new machines, instruments and personal.

Dimos Mantopoulos, MD, PhD: Do not take for granted that every OR has the equipment you’ve been using in fellowship. Even having the same vitrectomy machine or the same microscope doesn’t mean much necessarily. Ask the circulating nurses from both the “old” and the “new” OR to send you a list of the equipment and instruments they have. Spend time reviewing and comparing them. If there’s something major missing make sure you order it prior to starting your new job. In some instances it can take months until an instrument becomes available for you. Some of the intraocular dyes and viscoelastic gels are considered pharmacologic agents so getting them approved from a committee might take longer than you think. Finally, prior to doing a complex case, make sure you have a good surgical plan in mind and, if in doubt, do not hesitate to ask your mentors.

Patrick Oellers, MD: After I started, I also observed my partners in the operating room. Obviously, there are nuances to every operating room and seeing how these experienced retina surgeons operated in this specific setting helped tremendously. Before my first day in the OR, I made sure that I had my settings for the microscope and the vitrectomy machine set. The company reps were all interested and willing to be there the first day and that helped quite a bit. It was also possible to buy a few items such as sutures or instruments that I particularly liked from fellowship, but the new operating room didn’t have. For this, it helped that I collected preference cards of my attendings towards the end of fellowship. In terms of operating, I mostly tried to stick to the techniques the way I performed in fellowship, but adapted certain new things that work particularly well for my partners right away. Now I continue to find my own style which is a mix of what I learnt from my various fellowship mentors and some incorporation of techniques that work well for my partners.

Jaya B. Kumar, MD: The biggest challenge, I think, is getting used to be in the operating room without a second set of eyes or a reassuring voice in the background. It’s important to book your cases longer than you anticipate so you have plenty of time and don’t feel rushed. Before starting, it helped to get acquainted with the surgery center(s) and meet the staff.  I let them know your my preferences, glove size, food pedal settings, etc. I also made a list of instruments that I used in fellowship and found out what they had before asking them to order anything new. I also spoke to our local surgical representatives to help set up your vitrectomy machine ahead of time. If possible, during fellowship ask your local surgical rep save your settings, and bring them with you (on a flash drive or chip) to your new job.

[caption id="attachment_2872" align="aligncenter" width="2771"]chris aderman OR Christopher Aderman, MD, enjoying his new digs[/caption]

Christopher Aderman, MD: Thankfully, the transition to operating solo was not jarring as my new surgical centers have very experienced retina staff and they use the same equipment and scopes as I used in fellowship.  Like Patrick, I would absolutely recommend that you get in touch with your device reps to transfer vitrectomy settings to the new machines. Also, try to be as detailed as possible in discussing your instrumentation and preferences with the scrub techs and nurses. The more variables you can control, the more comfortable and confident you will be doing your first cases.

Any last words of wisdom?

Jaya B. Kumar, MD: Enjoy the process! Becoming a retina specialist took years of training, hard work, and dedication. We are finally here! It’s a privilege to practice this art and take care of patients. Stay in touch with your mentors and peers from training, and reach out to them with questions or interesting cases. Get to know your colleagues in your area and become a member of your state ophthalmic society. Meet your local drug/surgical representatives. And finally, I think it’s important to keep up your intellectual curiosity through reading, asking questions, and eventually pursuing research projects.

Dimos Mantopoulos, MD, PhD: Retina fellows are usually very motivated individuals who try hard to maximize the medical and surgical training they get. Nevertheless, one of the challenges they underestimate is coding and billing and this is something they should master by the end of their fellowship. One piece of advice I’d give is that you don’t want to risk your medical license by over-coding but, at the same time, you want to make sure that your clinic will get the appropriate credit for the services it provided. The AAO and the ASRS have some good online resources for this. Furthermore, paying attention to how your fellowship mentors bill and asking them questions before your graduation can make your life easier.

Patrick Oellers, MD: I strongly believe that we are all lifelong learners. Our practice patterns will be very different in 10 or 20 years from now. We have a solid foundation from fellowship, but  arguably the first 5 years out are the most important to build your practice and your own unique “physician persona”. Work hard, stay humble and keep taking advice from trusted mentors. Hopefully you keep in close touch with your fellowship mentors, and it pays dividends to listen to and learn from your new partners as well. Lastly, life after fellowship is great. You are finally a vitreo-retinal surgeon, enjoy it!

[caption id="attachment_2874" align="aligncenter" width="1200"]oellers w mentor eliott Patrick Oellers, MD with his mentor, Dean Eliott, MD[/caption]

Christopher Aderman, MD: The transition to practice is definitely an exciting and overwhelming time, but have confidence in the fact that you have been learning and training for this moment for decades.  This is your time to build your style of practice, borrowing from all of your mentors and making it your own.  Do not forget your mentors’ phone numbers!  They are more than happy to discuss complex or interesting cases and their insights are sometimes more valuable after you have started practicing on your own.  Never be afraid to admit when you don’t know the answer or to ask for assistance – never stop learning!  Remember that you have chosen an amazing specialty where you can provide a lot of benefit to patients who need you.