Drs. Priya Sharma, Edward Wood, and Rehan Hussain

Earlier this year, we invited Drs. Priya Sharma, Edward Wood, and Rehan Hussain to give us a little insight on the process of applying to retina fellowship. Thank you very much to @Michael Venincasa for providing our episode outline. 

 LISTEN TO THE EPISODE HERE

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[1:20] Introduction

[2:50] At what stage did you decide to apply for a retina fellowship?

[6:05] What was your timeframe for preparing and completing your applications?

[8:30] Did anyone present at/attend ASRS, Retina Society, or other meetings?

[11:45] Different programs require different specifics for applications (letter from program chair, letter from residency director, college transcripts, etc.). How did you keep track of what each specific program required?

[13:30] Jay suggests scanning important documents (transcripts and others) onto your computer early so you have it easily available when applying for fellowships, jobs, or licensures.

[15:00] Discussion about building relationships with mentors. There are not too many retina attendings in the country and most tend to know each other, so letters of recommendation go a long way in the application process.

[19:20] How did you decide on your list of programs to apply to? What factors did you look for in each program?

[22:58] Ten things to consider when weighing a program: program reputation, location, number of fellows, surgical volume, subspecialty exposure, didactics, call schedule, number of faculty, working with residents, research. (And #11: where prior fellows ended up after graduation.)

[24:26] Residency applications often offer flexibility with dates. How is the flexibility for fellowship applications?

[25:49] Did you have any pre-interview routine, or was there a certain way that you prepared?

[28:05] What were the most common questions you encountered most in your interviews?

[33:05] Jay suggests that fellowship interviews feel more colleague-to-colleague than residency interviews because attendings want to know if they can spend a large amount of time with you, and if they can provide for you the things that you need to succeed.

[33:55] What was the average number of primary/total surgeries quoted for you by programs while on the interview trail?

[39:02] With so many interviews, how do you not forget what each program brought to the table, or how did you prevent programs from “blending together?” Did you make a “running rank list?”

[44:14] What specific things did programs do that made the process more enjoyable?

[48:24] How did you ultimately choose your rank list?

Future superstar ophthalmologists: Chris, Hong-Uyen, and Patrick. 

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Are you applying to Ophthalmology this year? With the SFMatch deadline around the corner, ophthalmology hopefuls are making their final edits to their personal statements. Here are a few last minute tips, adapted from an earlier episode where we interviewed recently matched residents. 

Transcription credit goes to @Michael Venicasa, who is a third year medical student at Miami Med. Thank you very much!

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[3:10] Why was ophthalmology a good match for you? Hong-Uyen was attracted to the combination of clinic and micro-surgery. Patrick was interested in a number of specialties but found himself continuously returning to his interest in ophthalmology. Chris originally was planning on pursuing cardiology, but switched gears during his second year.

[6:52] How did you ultimately decide on ophthalmology? Hong-Uyen found herself excited to go to work every morning during her ophthalmology rotation at Bascom Palmer and decided that ophthalmology was something she could do for the rest of her life. Jay read about lots of specialties but found himself most interested in ophthalmology after his rotation.

[8:47] How many programs did you apply to? Patrick applied to 60-70 programs based on where he has lived or where his family lives. Chris also applied to 60+ programs and chose his programs after talking to mentors and seeing which were most attractive to him. When Jay applied the average applicant applied to approximately 50 programs.

[12:30] What is the timing for the process of applying? Hong-Uyen suggested applying as soon as possible, on August 15. Patrick waited until near the time of application to ask for letters from ophthalmology faculty, but for mentors from other specialties (with whom you may not have worked with after your clinical rotation ended) he suggested asking for letters early.

[13:43] What types of physicians wrote your letters? Chris suggested two ophthalmology letters + one non-ophthalmology letter. As a medical student it can be difficult to have the same impact on a patient in an ophthalmology clinic versus an internal medicine clinic, and a letter from a non-ophthalmology mentor allows you to show this other side of yourself.

[15:00] How did you manage your interview schedule? Hong-Uyen made a schedule to record her preferred dates for each program. She created a separate email account with its own ringtone on her phone, so that she would know which emails were important and which were not. Chris mentioned that SF Match commonly lists interview dates for different programs when you apply, and that replying to emails very quickly is extremely important. He used Student Doctor Network to keep track of when each program released their invites.

[19:10] Describe the logistics of your interviews (clothing, finances, etc.). Patrick suggested that you want them to remember you for the interview instead of for what you were wearing. He suggested Southwest Airlines since they were more lenient with changes. Chris suggested planning a break in the middle of your interview trail and to plan a “flexible” elective during this time. Hong-Uyen booked her flights 2-3 weeks before the interview to best account for possible changes.

[22:05] How much did the various programs differ? Chris felt that most programs had a similar general format with a “Meet & Greet,” Grand Rounds, Lunch, Tour, Interview Session, and Conclusion. There generally was a social event the night before, which allowed him to see the residents outside of the school. Hong-Uyen felt that if she was unable to go to the social event, she did not want to go to the interview itself. Jay thinks that freeing up the residents during interview days shows that the program cares about their interviews. Likewise, Hong-Uyen felt that food choice was an important demonstration of effort.

[28:50] What were your interviews like? Patrick’s interviews were mostly conversational; the candidates are all excellent, and so the programs care about whether or not you will fit in there. Chris’ “curveball” questions included one program asking him to identify pathology on a scan, and a question about his favorite YouTube video. Patrick found himself very aware of the degree of autonomy at different programs, and Hong-Uyen suggested that it is just as important to look for a variety of surgical opportunities instead of simply surgical (cataract) volume.

[37:30] Many feel that applying to only one geographical area makes you look “uncommitted.” How did geography play a role in your application? Chris suggested not limiting yourself to one area of the country, and that broadening his horizons allowed for great experiences. Jay suggested that if you do have a legitimate geographical constraint, you should talk to your mentor and not let that scare you.

[39:10] How did you organize your rank list? Hong-Uyen used her “gut” and the suggestions of her mentors; she felt that she should have asked more residents about the strength of their fellowship programs. Patrick kept a list of programs on his phone, adding new programs above or below others after the conclusion of each interview. Jay suggested taking notes soon after each interview, on the flight back home.

[43:45] Did you send thank you letters or tell any programs that they were your #1 choice? Chris feels that, even if the school asks you not to send a note, it is important to send a thank you note with a few specifics that you appreciated most about their program; he sent emails. Hong-Uyen also sent emails. Jay felt it important to send a thank you note to anyone with which you connected and that, since programs cannot legally initiate the conversation but can respond once you initiate, these notes open the door for further communication.

[45:55] How did you find out where you matched? Patrick had a shelf exam the day before and went to sleep thinking that he would get an email at 7am and have to wait until 11am for the program to call. He went to sleep between 7am and 11am and missed the call! Chris was ironing a suit for his transition year interview. Hong-Uyen thought that USC had already called all of their matched applicants and was surprised to receive a call from a Baltimore number.

[50:25] What would you do differently to improve your application? Chris found research, academics, and extracurricular activities to be the three “pillars” of the application. He wished that he started research earlier so that more projects could be done instead of in-progress. Patrick suggested that it is important to have a mentor who will help you network and improve your application. Hong-Uyen said that it is okay if you are not AOA or publishing lots of research, and wishes that she realized this earlier.

Jennifer MacKinnon plays the harp while a patient undergoes a heart procedure. 

I remember a few times as a medical student, my surgical attending asked me to "put on some music." If you've ever had to DJ for a roadtrip or a small get-together, you know how difficult that kind of request might be. What kind of music does everyone like? How can I possibly please everyone? At least for friends, the music I play won't hurt anyone, but in the operating room, the stakes are higher; any possible distraction might lead to an adverse outcome. Despite the potential issues, it does seem that many surgeons, nurses, and anesthesiologists feel that music helps set a calmer mood and raise focus levels. I got a chance to ask Dr. Sridhar about his experiences (spoiler: he doesn't like certain types of music!!).

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LC: Hi Dr. Sridhar, I recently read this article suggesting that learning motor skills with music actually can make our brain form stronger white matter connections . I've noticed a lot of ophthalmologists listen to music while they operate. Do you usually listen to music in the OR, or is it something that you have no preference on? 

JS: Super interesting article Louie. I got used to listening to music in the operating room as a fellow, and there are several benefits; the white matter connections are just icing on the cake! First of all, many of our surgeries are done under monitored local anesthesia. The patient receives sedation for relaxation and local anesthesia to the operative eye  but is otherwise awake and listening. Most patients prefer to have some music to relax further during the surgery. Second, the room atmosphere is appreciably different with harmonies in the air instead of silence only broken by the ominous beeping of a heart rate monitor. The staff is more relaxed, and that allows everyone to do their job in a more efficient and patient-centered manner. Third, I think having that Pavlovian cue that when the music starts = it's time to operate helps a surgeon feel mentally ready to tackle whatever challenge the surgery presents.

LC: How do you decide what kind of music gets played? What do you usually end up listening to? 

JS: I think that if the patient is awake for the case their taste takes precedence so they are most comfortable. Otherwise I defer to the rest of the operating room and only exercise veto power for country and rap.

An example of Dr. Sridhar's favorite genre of music. 

LC: Could you see music having any positive or negative impacts for you when you’re actually performing surgical techniques? I’m imagining that certain types of music could put you into the zone, others might relax you, others might hype you up… etc.. What do you think? 

JS: Another great question. There has to be a lot of variability surgeon to surgeon. I do not think certain types of music are better at different points of the surgery, but then again I would have never expected the research findings in the article that inspired this back-and-forth. I think for me personally the slower more relaxed Muzak type fare can dull the energy in the room. During more intricate or higher-risk maneuvers I prefer to have the volume and overall noise in the room down to a background level. Otherwise, I am fairly low maintenance.

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Here's what other Retina Surgeons had to say!! 

Question: Do you listen to music while operating? If so, what kind, and do you operate better with it?

1. Gangster Rap. 
2. Hahaha Yes Music. Pop if MAC, late 90's early 2000s hip hop if general. I do operate better with it. 
3. Yessir. Hip hop, Top 40s, old school R&B. Better. If the case isn't going well then I turn it down. 
4. Yes. Usually whatever the nurse puts on but thinking now to create my own lists with pop/acoustic. 
5. Yes. Michael Jackson if MAC, hip hop BBQ on pandora. Better with music. 
6. Yes. Pearl Jam, Outkast, anything the tech/nurse wants. Better with music. 

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Louie

We're starting Prof & Pupil, a miniseries of posts, where Dr. Sridhar and I talk about different aspects of ophthalmology, retina surgery, and more! These are presented in conversation format (much like classic Greek philosophical texts), and we hope they'll be both enjoyable and quick to read! 

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Jay: Louie, you got the opportunity to observe some retinal surgery with me this past week. What was your first impression of what we do compared to other surgeries in medical school you have observed this past year?

Louie: Retina surgery is completely different from the surgeries I saw in trauma, colorectal, and OB GYN. I felt like from beginning to end, you knew exactly what you were dealing with based off the scans and photos. I felt that in other surgeries there is a lot of uncertainty about what you might encounter and what techniques you might have to employ. There's a lot of chaos- random bleeding, adhesions you weren't expecting, etc.. For retina surgery, at least from my perspective, it seemed like you had complete control from start to finish. The procedures were clean, systematic, and very precise. Maybe that's not how you actually felt while you were operating... haha. Also I notice you were using one sterile glove instead of two?

Jay: Yes, we rarely double glove although perhaps we should. Thankfully our needle exposure is not the same as other fields! That's flattering that you say that. Definitely the imaging technology has made our lives a lot easier. Still, what I love about retina surgery is no matter how much we try to control every detail, things can be unpredictable and you have to rely on good habits to approach unusual situations. What maneuvers appeared most challenging from the student perspective?

Louie: I think for me, the hardest part is definitely seeing how deep you are in the vitreous when you're doing a vitrectomy. You have to have very good stereopsis to perceive the depth correctly. I don't know if you've seen the movie Prometheus, but there's this scene where a drone goes into a cave and scans it with lasers. I always wonder how helpful it might be if your instruments could emit a grid of light around it, and you could judge exactly how far you are away from the borders. 

This is an image of what I'm talking about..  

Jay: that's a great point Louie. One of my mentors Dr. Allen Ho used to talk about a vision for the future of visualization during surgery. We already have products on the market such as the ngenuity from Alcon that allow for heads-up 3D display for surgery using a large TV monitor and 3D glasses. We also have OCT Technology built into our microscopes that allows us to see the retina in higher detail and with a greater perspective of depth and the retinal layers than ever before. People have discussed in the future having motion tracking or indicators to guide a surgeon much the way modern cars do with collision warnings.

Did you observe anything done in other fields that you think we should adopt in our surgical practice?

Louie: I think all those ideas are awesome. One of my favorite aspects about ophthalmology is that everybody in the field seems to embrace and actively seek ways to improve the status quo. The heads up display will literally turn the operating room into a video game! How quickly do you see people adopting new technology, from proof of concept to actual use? For example how long did it take for the vitrector to be put in every operating room?

I think the other surgeries have a lot more to learn from retina surgery actually! Haha but if there was one thing, I noticed that because of the scopes and positioning of the bed, it's easy to feel kind of cramped when you're sitting there (especially if you're tall). This isn't really a problem with other surgeries since you can stand and stretch and move around. I'm not sure how you could change that.

Jay: that's a great question about technology adoption. I think given globalization of information, sharing technologies and techniques are adapted faster and faster. The heads up display is already used as the sole visualization tool in a couple of practices and institutions nationally. Much like a viral video I believe it will spread more as more and more prominent surgeons go to meetings or webinairs and show cases using heads up viewing.

Definitely ergonomics is a challenge in our field. As a student I remember loving that the cases were mainly performed sitting down. However sitting puts your body in a fixed position which can result in stress on the head and neck. Developing good habits early in training at the slit lamp will help, but every person is a little different in terms of how their body fits with the foot pedals, the microscope, and the patients head position. There has been some debate whether robotic surgery similar to the Da Vinci used in other fields such as urology could eventually replace our current method of operating, but the jury is still out given a lack of evidence thus far.

Louie: That's really interesting and I look forward to trying those new tools! How many retina surgeries did you do throughout residency and fellowship, and how soon were you comfortable to handle cases on your own? In other words, how many cases do you have to do before you feel comfortable handling most complications?

Jay: I think the number of surgeries varies from fellowship to fellowship. Few residencies include much hands-on retina exposure although if you are able to obtain it, it’s an added bonus. The most important thing besides seeing lots of patients and scrubbing in lots of surgeries is learning strong principles from solid mentors. Every case is different; a retinal detachment and macular pucker, for example, are entirely different beasts in the way you approach them mentally in your pre-operative gameplan. So the number of cases to get comfortable really will depend on the pathology at hand.

 To be continued... 

Bascom Palmer Residents, 1967

This past weekend we had our annual graduation dinner for the departing residents and fellows. While it is always sad to see great physicians leave, it inspired me to hear the stories of our superlative graduates and the impact they had on the people around them. One graduating fellow in particular received a standing ovation for his performance both as a resident and fellow at our hospital. The entire evening got me thinking: "what qualities make the best residents?" Using  examples from the dinner and our guests on the podcast , I compiled a list of six attributes of top-notch ophthalmology residents:

1. They care. First and foremost, the best residents are dedicated doctors. Even before they build their full ophthalmology knowledge base, they are always working towards the best possible outcome for every patient. As one of our residents so aptly states: “Treat every patient as you would want your mother treated”.

2. They read. Years ago when I started training, I looked up articles on how to do well in ophthalmology residency. Dr. John Kitchens once described that Dr. Ed Norton, father of the Bascom Palmer Eye Institute, used to read at least one ophthalmology related item every day. As a beginning ophthalmology resident, there is so much to learn and it can be overwhelming to know where to start. Every little bit counts, and reading about your patients will not only enhance your ability to handle that specific situation, but also build the base upon which your career will stand. The best residents read early and often to construct a solid foundation that they continue to cultivate their entire lives. 

3. They respect. Here is a not-so-hidden little secret: the best residents are loved not only by their patients, but also by their colleagues and support staff members. Our superlative standing ovation graduate was described as knowing and being friendly with every single person in the hospital, from the maintenance staff to the custodians to the chairman. While that is a high standard to live up to, great trainees treat every team member with respect. Remember, everyone is on the same team to deliver the best patient care. Everyone includes everyone from the moment a patient walks through the door of the building to the minute they drive their car away from the parking garage. Every single team member is equally important in the process. 

4. They communicate. Being an honest, accurate, and timely communicator goes a long way in life and in medicine. Good communication means responding to emails from your co-residents and attendings, sending letters to referring physicians, and returning patient phone messages. It also entails telling your patients when things do not go as planned in an honest but measured fashion. You learn more about a physician’s character from complications than from successes.

5. They go the extra mile. When he came on the podcast (link), Dr. Kitchens described that once, as chief fellow at Bascom Palmer, he was taking a patient to the OR towards the later part of the day and passed by a first-year resident on his way home. The resident inquired about the case and decided to stay and observe the surgery. Years later that memory still resonates with Dr. Kitchens as an example of how motivated the best residents are. Going the extra mile means treating patients as a whole, not just their eyes. It means dealing with the tough social situations, like calling insurance companies to get approval for necessary medications. 

 6. They have balance. After reading the above, you may feel that being a great resident means sacrificing the rest of your life. While residency certainly requires a great degree of work-life unbalancing, the best residents still find time to eat as well as possible, sleep, exercise, and most importantly, cultivate their relationships. As many guests have stated on the show, you can't care for others if you don't care for yourself. 

-Jay Sridhar