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Topic: Training

March/April 2020 | Features

Ten Tips for Graduating Glaucoma Fellows

Glaucoma attendings in their first year of practice offer advice to fellows nearing the end of their formal training.

Michael Lin, MD; Ayan Chatterjee, MD, MSEd; Jonathan Chou, MD; Haben Kefella, MD; Stephen Moster, MD; Mary Qiu, MD; Aakriti Garg Shukla, MD; David Smits, MD; Swarup Swaminathan, MD; Astrid Werner, MD; and Cindy Zheng, MD

Every summer, glaucoma fellows across the country finish their last year of formal training and prepare to launch careers as fully independent ophthalmologists. I spoke with 10 of my colleagues, all newly minted attendings who started practice this past year, and asked for their top tips for fellows as they wrap up their training and prepare to transition to attending life. Here is their advice, edited for clarity. MICHAEL LIN, MD | WILLS EYE HOSPITAL GLAUCOMA FELLOW 2019 No. 1: ALWAYS SEND NOTES BACK TO REFERRING PROVIDERS Ayan Chatterjee, MD, MSEd Duke Glaucoma Fellow 2019 It can take a while to build your practice from scratch. Sending notes back to your referring providers is important for continuity of care, and it is a great way to develop a rapport with optometrists and ophthalmologists in your community. By building these relationships, you can begin to get your name out there and let your referring doctors know that you are available and interested in helping take care of their patients. No. 2: BE PREPARED TO SPEND MORE CHAIR TIME WITH PATIENTS THAN YOU DID IN FELLOWSHIP Jonathan Chou, MD Stanford Byers Eye Institute Glaucoma Fellow 2019 During fellowship, you’re likely to see more than 60 patients every day in your attending’s clinic, but this is only possible because many patients have been seeing the same physician for years. When you first start your practice, every single one of your patients will be new to you and may have previously entrusted his or her sight to another doctor. Often, I make a small note in the chart about something personal that patients share so that I can remember it for future visits. Developing this rapport is especially important for glaucoma patients, who could be seeing you for decades. Build this trust early so that, when the time comes for surgery, they know that they are in good hands. No. 3: BE PREPARED FOR PATIENTS WHO PRESENT TO YOUR CLINIC WITH URGENT ISSUES Haben Kefella, MD Boston University Glaucoma Fellow 2019 Make sure your clinic has medications and equipment available and ready to use for patients who require urgent intervention for situations such as acutely elevated IOP, bleb leaks, and flat anterior chambers. You don’t want to be frantically searching around for acetazolamide tablets, bandage contact lenses, and OVDs in the middle of a busy clinic. This is especially true if you’re starting a new position as the only glaucoma specialist in an office that may not be used to dealing with these situations. No. 4: USE THE EXTRA TIME IN YOUR FIRST YEAR TO HONE CLINICAL SKILLS Stephen Moster, MD Wills Eye Hospital Glaucoma Fellow 2019 Your clinic volume will grow gradually, and you may have more time per patient than you are used to from busy fellowship clinics. Take full advantage of this by examining optic nerves and performing gonioscopy at a level of detail that you might not previously have had time for while trying to get through a packed clinic. A lighter patient load will also allow you time to discuss tough cases with your former co-fellows and mentors. Learning doesn’t stop just because you’ve finished your formal training. No. 5: CONSIDER TAKING AN EXTENDED BREAK AFTER FELLOWSHIP TRAINING Mary Qiu, MD Cleveland Clinic Cole Eye Institute Glaucoma Fellow 2019 My husband and I had the opportunity to spend 3 months traveling around the world together before starting our jobs in October 2019. It was a once-in-a-lifetime experience that allowed us to unplug, recharge, and hit the ground running when we started our new jobs. It will be rare to be able to take a long, continuous break from work in the future, so take a break if you can. No. 6: WRITE DOWN GOALS FOR YOUR FIRST YEAR IN PRACTICE Aakriti Garg Shukla, MD Johns Hopkins Wilmer Eye Institute Glaucoma Fellow 2019 Graduating to an attending position is the end of an era of formal education and the start of your career. Keep things exciting by setting goals for your first year. These can include completing board certification, applying for a research grant, learning a new procedure you were not exposed to in fellowship, creating a glaucoma surgical curriculum for residents and fellows, growing your referral base, becoming involved with an American Glaucoma Society committee, etc. Periodically check to see if you’re on track to achieve your goals by year’s end and set targets for the next 3 and 5 years. It’s easy to become immersed in routine clinical demands, but you’ll ultimately want to build upon the diverse skill set you cultivated in fellowship. No. 7: VISUALIZE STEPS TO MENTALLY PREPARE FOR YOUR OPERATIVE DAYS David Smits, MD Massachusetts Eye and Ear Glaucoma Fellow 2019 Advice I received from an attending during my fellowship was to visualize and rehearse the steps of a surgery before entering the OR, just as a musician rehearses a piece before a recital. Now in private practice, I perform fewer trabeculectomies and tube shunt procedures than I would at a tertiary care center, and there are no other ophthalmologists at my ambulatory surgery center. I am therefore under great pressure to be prepared. I have found it particularly helpful to rehearse all the steps of surgery prior to my operating day, particularly for procedures that I do not perform weekly. Refamiliarizing yourself with procedures and knowing the instrumentation will prepare you for the OR and any unexpected events. No. 8: TAKE PHOTOGRAPHS OF YOUR ATTENDINGS’ SURGICAL PREFERENCE CARDS AND SUTURES Swarup Swaminathan, MD Duke Glaucoma Fellow 2019 You’re already a bit anxious about operating on your own. No one will be sitting at the side scope giving you feedback anymore. The OR staff is going to ask what you want for your cases. This shouldn’t be a stressful question. The key is to prepare yourself during fellowship. Ask the staff at your fellowship institution for a copy of your attendings’ surgical preference cards. This information will be essential to creating the list of blades, sutures, and other surgical equipment that you like to use. If you are able to get these preference cards early enough and share them with your future institution or ambulatory surgery center, it will give the staff ample time to order any items they do not have prior to your arrival. No. 9: PLAN HOW YOU WANT TO PERFORM SURGERY WHEN YOU’RE AN ATTENDING Astrid Werner, MD Massachusetts Eye and Ear Glaucoma Fellow 2019 One of my attendings encouraged fellows to write out detailed surgical plans before each OR day. These plans included simple things such as anesthesia and postoperative drops as well as more complicated issues such as anticipated intraoperative complications. I found this exercise extremely helpful. It got me into the mindset of a surgical decision-maker who really owns the cases. I also started to collect video recordings of each of my attendings’ techniques. By the end of fellowship, I had a clear idea of which techniques I planned to use, and before my first cases as an attending I rewatched the relevant videos a few times. No. 10: BUY DISABILITY INSURANCE AS SOON AS POSSIBLE—AND UPGRADE THE POLICY ONCE YOU BECOME AN ATTENDING Cindy Zheng, MD Wills Eye Hospital Glaucoma Fellow 2019 After medical school, residency, and fellowship, your biggest asset is your ability to care for patients. Now that you will finally start earning an attending’s salary, you need to protect your future income in case you cannot work. Unless you’re lucky enough to be independently wealthy and just practicing ophthalmology for the pure joy it brings, strongly consider buying “own-occupation, specialty-specific” disability insurance for ophthalmologists. This covers you if you cannot perform any part of your job. Do your research, talk with other attendings, and discuss your options with experienced insurance agents.