Roundtable: Challenging the Dogma of Fellowship Training

Robert J. Weinstock, MD: Traditionally, ophthalmology residents who are interested in becoming specialists have abundant opportunities to seek fellowships in cornea/external disease, glaucoma, neuro-ophthalmology, ophthalmic pathology, oculoplastics, pediatric ophthalmology, vitreoretinal disease, and uveitis/immunology. Refractive cataract surgery and complex anterior segment surgery, however, are not a traditional fellowship. Upon completion of an ophthalmology training program, clinicians who do not seek a fellowship opportunity often head straight into either private or academic practice to become cataract surgeons.

The field of ophthalmology is changing tremendously, and clinicians require more training than ever to meet the growing demands of our patients. All of us participating in this roundtable discussion believe that now is the time to challenge the dogma of fellowship training. Some of us are forging a path for this change, and a growing number of private sector fellowships focus specifically on cataract and refractive surgery. (Editor's note: YoungMD Connect, a platform designed to connect aspiring and young ophthalmologists with their peers and mentors, features a fellowship finder. Learn more about YoungMD Connect and the fellowship finder in the accompanying sidebar on pg 80.)

I have offered a refractive cataract surgery fellowship at my practice for 6 or 7 years. Dr. Wiley, how long have you been doing it in your practice?

William F. Wiley, MD: I’ve also been offering one for the past 6 or 7 years.

Dr. Weinstock: It’s a real win-win for both the fellows and the experienced surgeons. Dr. Hura, what made you pursue extra training versus going right into private practice?

Arjan Hura, MD: When I interviewed and applied for fellowships, I looked at traditional academic cornea fellowships, private practice refractive fellowships, and anterior segment fellowships. I assessed how much cornea, cataract, and refractive exposure each type of fellowship afforded. In the traditional academic cornea fellowships, understandably, the focus was on penetrating and endothelial keratoplasty and the treatment of corneal pathology. The cataract volume on average was usually only 20 to 40 cases in total, and the cases were typically complex and not spaced consistently through the year. Likewise, in cornea fellowships, you might perform only 10 to 20 refractive cases, and you probably would not be the primary surgeon taking ownership for a lot of those cases.

In stark contrast, the volume of cataract surgery expected in a private refractive cataract surgery practice fellowship was closer to 1,000 procedures in a year. Another upside was that fellows get to utilize the latest premium technology and IOLs and become involved in clinical research studies. Such advantages were mirrored on the refractive surgery side, where fellows would use the latest technologies for SMILE, LASIK, and PRK.

For what I wanted to do—deliver exquisite premium cataract and refractive outcomes to patients and the highest possible quality of care—a private practice cataract and refractive fellowship was the best fit for me.

Caroline Watson, MD: I agree with Dr. Hura. I had a friend do a private practice fellowship several years before me, and it shifted my perspective. As a result, I applied only to private practice fellowships. My residency took place in the midst of the COVID-19 pandemic, and my surgical numbers—although good for my program—were diminished. I didn’t feel like I could safely go into practice and be a really strong surgeon without fellowship training. I felt like it was the best opportunity for me to polish my skillset and get exposed to private practice.

Dr. Weinstock: Dr. Moarefi, you did a fellowship under Dr. Wiley several years ago. What kind of value-add was your fellowship versus if you had gone directly into private practice?

M. Amir Moarefi, MD: During my fellowship, Dr. Wiley stressed to me that it’s easy to be a good surgeon but that great surgeons are molded by how they deal with challenges. That comes with experience. A high-volume cataract and refractive fellowship provides you with 5 to 10 years of experience in a single year.

When I was applying for jobs after my fellowship, I kept hearing how overqualified I was at that level, and that’s a nice thing to hear. I’ve been in practice for 3 years now, and I can look back and say that, in addition to the surgical experience I gained through my fellowship, it gave me the opportunity to align with someone who shared my ideals, not only in the clinical aspect but also in the business and personal aspects. That’s really the most important thing about mentorship, finding somebody who lets you have a vision of what you want to create for yourself. That helped me to set a trajectory for what I should expect from my career.

Dr. Weinstock: Great perspectives from all of you. Dr. Wiley, what do you see in the future for cataract and refractive surgery? How important is it for leaders in ophthalmology to urge younger surgeons to pursue something like this? How important is it to patient care in the long term?

Dr. Wiley: To become a next-level cataract surgeon takes volume and experience. It takes a good teacher to walk you through the entire process. Residents are armed with a lot of skillsets but not necessarily the skillset to do high-quality, high-volume cataract surgery. If you look at the volume of cases that is coming based on the aging population, we’re going to be doubling or tripling the current volume that we’re doing today. As a result, every surgeon who is operating today needs to be able to do better and more surgery. Someone coming out of traditional training might not be as equipped as someone coming out of a refractive cataract surgery fellowship.

On the refractive surgery side, residents can’t be expected to know seven or eight different types of refractive surgery and be good at them all right out of training. The intensive learning experience offered by a refractive cataract fellowship, in my opinion, is critical if you want to be able to provide that type of care to patients.

Dr. Weinstock: Many ophthalmologists jump right from the academic mentality of medical school and residency to the private sector without any bridge. Having a bridge year between academics and the private world can help them learn other aspects of medicine, including the business. Has that been a big area of education for you in the past year, Dr. Hura?

Dr. Hura: That’s a great point. In the private practice setting, you’re trying to deliver a premium experience. A patient walks through the door, and they’re made to feel welcome. Every part of the patient experience is exquisite, from the time patients walk through the door to the time they’re being seen for their postoperative examination. This is not a level of medicine that you’re taught in the traditional academic setting.

Dr. Watson: I enjoyed learning about the back part of the office and really getting into the billing. People who work in the billing and coding office have allowed me to spend time with them before our clinic starts to teach me one on one. That’s a huge gap in our knowledge as well.

Dr. Moarefi: I learned that perception is reality and that patients’ perceptions of how they’re being treated and how they feel can change their whole experience. Dr. Wiley taught me that it’s advantageous to put people in place to handle the things that I’m not good at so that I have more time to focus on what I am good at. Creating a positive patient experience brings you joy because you’ve created happiness beyond yourself. There are so many layers to this that you don’t see in an academic fellowship or if you strike out on your own right after residency.

Dr. Weinstock: There’s a tremendous benefit from our side as well. I hope that other private practice cataract and refractive surgeons start fellowships. It’s not hard, and it’s a huge win for the practice. It brings another qualified, high-level surgeon into the practice, and it adds tremendously to the efficiency and the throughput of our practice.

Dr. Wiley: I totally agree. Initially, I wasn’t sure how it would impact patient care. Was it going to be lateral or a step backward? I found, however, that it’s actually a step forward. Two highly skilled individuals can provide better care than just one.

The other thing is I’ve become a better surgeon because of my fellowship experience. I look at things differently when I am teaching. I am constantly being challenged and asked questions, and this raises your game.

Dr. Weinstock: I find myself paying a lot more attention to the details of the case, every step, because I’m fixated on training the fellows to master every single movement of the hands. It’s made me more efficient and made everything more polished. I would like to see our entire industry promote the maximum amount of education and mentorship for all surgeons, no matter what their specialty, to make surgery safer for patients.

There’s only so much you can do with your own two hands. When you train other surgeons, the care they provide is an extension of yourself, and more patients are in safe hands. That’s a big-picture look at the importance of training in general.

Dr. Wiley, how do we expose residents to different fellowship opportunities?

Dr. Wiley: When a resident is torn between an academic and a private practice path, I tell them to picture themselves in 5 or 10 years. What is their ideal situation? For those who know they want to be in private practice doing high-volume cataract and refractive surgery, a private practice fellowship is the best stepping-stone to achieve that goal. Additionally, I think residents should have a chance to rotate in a private practice to see what else is available outside academics. That helps them make a good decision on their next stepping-stone.

Dr. Moarefi: When I first came into residency, I thought I wanted to specialize in oculoplastics. Then I shadowed Dr. Wiley as he performed refractive surgery for one Saturday, and that changed my perspective. Before that time, I didn’t know too much about refractive surgery. As a resident, it’s your duty to learn and put yourself in situations that help you to see what’s best for you.

I also would argue that I wrote more papers and did more academic work with Dr. Wiley in my fellowship year than I did as a resident. Even for those who enjoy the academic aspect of patient care, there’s still quite a bit of opportunity in a private practice fellowship.

Dr. Hura: I really like what Dr. Moarefi said. Ophthalmology is a unique field, and a lot of innovation and research takes place in the private sector. Industry also likes collaborating and working with private practice centers that have a lot of data. For those who are interested in engaging with industry, there’s a lot of opportunity for that in a private practice.

The final thing I wanted to touch on is this: If you have the spirit of innovation, it’s often a lot easier to have access to the latest technology in the private practice sector, as decisions to acquire equipment can be made faster. This is a huge benefit of refractive cataract surgery fellowships.

Dr. Weinstock: Probably one of the most profound educational processes in the fellowship year is learning how to communicate with patients. When I came out of training, I thought I had to explain every detail to patients. I learned from my mentor—my father—how to be in and out of the room in 3 to 5 minutes but deliver to the patient feelings of security, comfort, positivity, and trust in that time. It’s a very hard thing to do.

Dr. Watson: In my residency experience, my attendings didn’t help us hone that skill—and it is a skill to learn how to ask the right questions, how to sit, and what to say to patients. Watching Dr. Weinstock demonstrate these things is such an important component of being in a private practice setting and delivering great patient care.

Dr. Weinstock: We could talk for hours about the importance of refractive cataract surgery fellowships. Quite honestly, I have found great reward in building relationships and lifelong friendships with our fellows and colleagues.