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Young Ophthalmologists
Big Decisions, Part 1: Is a Fellowship for You?

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Editor's note: This month we kick off a new series looking at the big decisions faced by many YOs. The first question: Whether or not to get a fellowship. While this story focuses mainly on the decision as faced by U.S.-based ophthalmologists, we plan to do a future story on U.S. fellowship opportunities for internationals. Let us know what you think of the series or would like to see us cover in the future by emailing cfoist@aao.org.

The question of getting a fellowship can be a tricky one. Do you need the additional training within the area of ophthalmology you want to practice? Will it give you an edge in a competitive market? Can you command a higher salary with a fellowship? For most people, the two immediate issues are cost and time.

Weighing the Pros and Cons
As a rule, most fellowship programs are either one or two years. Some fellowship stipends are funded by the program itself or a research grant, while others are not. In these latter cases, you need to provide your own living expenses.

But if you ask YO Info editor Aaron Miller, MD, neither of these issues should be at the top of your list when deciding on a fellowship. According to Dr. Miller, you should instead ask yourself three very important questions: What is my passion? Where do I want to live and practice? Will a fellowship help me fulfill my needs?

Finding Your Passion
“Passion for your profession is the key,” Dr. Miller says. “Never, ever allow money to be the deciding factor. You have to love what you are doing to make this a lifelong career. If you truly love doing cataract surgery or a little aspect of all subspecialties, then you likely don’t need a fellowship. If your heart is in an area that is more focused or specialized, then you will likely want to pursue the fellowship route.”

Assessing the Need
Once you identify your passion, you can determine if a fellowship is needed to practice your area of interest. According to Dr. Miller, “In most hospitals or surgery centers, you can only be credentialed for certain procedures based on whether or not you’ve completed a subspecialty fellowship. For example, a general ophthalmologist can perform horizontal eye-muscle surgery, but in many hospitals, you must have completed a pediatric ophthalmology fellowship to be allowed to perform vertical eye-muscle surgery in that facility.”

Considering the Geography
Your next big question should be where you want to set up shop. If you are going to be in a rural area, for instance, Dr. Miller says it might be more difficult to be subspecialized and use your training. In this case, a fellowship may not be necessary. Conversely, if you are in a more densely populated, competitive market, a fellowship may help you stand out, even if you aren’t fully using your subspecialty.

Another factor to consider is the demand for what you do in your area. What is the patient-to-doctor ratio? Will a subspecialty help you stand out or is the patient population such that your presence alone will bring in referrals and patients?

Pursuing a Fellowship
Natasha Herz, MD, a member of the YO Info editorial board, found the fellowship question to be a tricky one. While many residents feel they don’t get enough surgical experience during their residency and therefore pursue a fellowship, Dr. Herz said that she received wonderful surgical experience at the Baylor College of Medicine in Texas, and felt that what she learned would be more than enough for her to practice general ophthalmology. Also, since she was not trying to secure a position in academics, which would necessitate a fellowship with a strong research focus, she knew that a fellowship was not critical given her career path.

However, the one factor that did push her to choose to do a fellowship was the fact that she knew she was going to be practicing in an urban, highly populated, highly competitive location (the Washington, D.C., metro area). “Not only are there a lot of ophthalmologists in my area,” Dr. Herz explains, “but there are also many optometrists, and I felt I needed the extra edge of a fellowship.”

She also considered the fact that doing a fellowship would only be one extra year of schooling, and that if she didn’t do it immediately following her residency, she would not do it in the future. “My plans included starting a practice, buying a house, and starting a family,” Dr. Herz said. “And once I started down that path, the idea of going back for my fellowship was not realistic, as I would likely have to quit my practice, relocate, and so on.“Therefore, for me, when I considered the fact that I would only need a one-year fellowship and that the extra year would provide me with additional expertise to offer my patients, as well as allow me to demand a better salary, I felt the investment was well worth it.”

Forgoing a Fellowship
Carl Haley, MD, had a very different experience. For Dr. Haley, one of his goals as an ophthalmologist was to live and practice in Dallas. During his final year of residency, he weighed his options, which included either going into academics or entering private practice (and there seemed to be no imminent job openings in Dallas at the time). For various reasons, he had always been interested in academics and he was leaning in that direction early in the year.

“At the time, given my goals in the academic sphere and affinity toward anterior segment surgery, I felt that it would be important to pursue a cornea fellowship to keep more options open and gain further academic, surgical and clinical training,” Dr. Haley said. The way he saw it, a fellowship could only help with job opportunities in the private practice world and expand the scope of clinical and surgical treatments that he would be able to offer patients.

However, within weeks of the match, a job he had known about became available years sooner than expected. “It was everything I wanted in the private practice sphere,” Dr. Haley said. “It was a busy surgical and clinical practice in the Dallas area. If I did not take the job at the end of the academic year, someone else would have been offered the job.”

In his case, pursuing a fellowship would have meant losing the job in his hometown. After much thought, he decided to drop of out the match and forgo a fellowship in favor of accepting the job opportunity in Dallas.

Clearly, Dr. Haley’s situation is unique. An important reason that many people do a fellowship is to expand their job opportunities. However, in his case, he would have lost a great job if he had pursued a fellowship.

Changing Your Mind
Of course, there are occasions when the answer isn’t so straightforward. When Lance Kugler, MD, was at the end of his residency, he considered pursuing a fellowship in cornea and refractive surgery. He had registered for the match and was deep into the process, having even gone on several interviews.

“I found the interview process to be very educational,” says Dr. Kugler, also a member of the YO Info editorial board. “And through the process of evaluating my opportunities, I got the impression that I didn’t actually need a fellowship for what I wanted to do. I wanted to have a practice that focused on cataract surgery without giving up other aspects of general ophthalmology, such as medical retina, lid surgery and refractive surgery.”

During the fellowship interview process, he received three very strong job offers in markets he wanted to live in — none of which required a fellowship. Nor did any of the practices think a fellowship would enhance his marketability in their market. Dr. Kugler decided to withdraw from the match and accepted a position with a practice that was looking for a cataract surgeon with an interest in refractive surgery.

It proved to be a very good decision for him. The community had an open-access laser center, which meant that there was no need for the upfront overhead of starting a refractive surgery practice. Shortly after starting, he was seeing a steady stream of cataract patients and several refractive patients, and after one year, he accepted partnership.

However, over the course of the four years Dr. Kugler has been with the practice, it has become clearer to him that his passion and interest in cataract and refractive surgery has grown exponentially. And although he has been able to do some refractive surgery, he doesn’t feel he would be able to reach his potential without subspecialty training. Therefore, he recently decided that a year of subspecialty training in cornea and refractive surgery would be valuable for the rest of his career.

“This was a huge decision for me as well as my family,” Dr. Kugler said. “Obviously, this decision involves a significant pay cut. Plus, I have to move my family from Omaha, Neb., to Nashville, which carries with it its own set of expenses.”

While it certainly would have been less disruptive to enter a fellowship immediately after residency, Dr. Kugler sees advantages to doing it later. “First of all, I have been able to pay off my school loans by working for the past four years, therefore my financial situation is much better now,” he says. “Plus, I have become active in the Academy and have gained valuable perspective on the national level.

“Most importantly, the learning curve for the first four years of practice has been very steep and I am entering fellowship with a stronger skill set and more experience. I now know what my weaknesses are and know specifically what I need to learn during fellowship.”

Interestingly, the criteria Dr. Kugler used to choose a fellowship program this time is completely different than it was after residency. This time around, he placed an emphasis on fellowships that provide strong refractive surgery experience but, just as importantly, provide education in the business and marketing of a medical practice, including financing, patient relationships and ethical marketing strategies — in other words, the “real world” of ophthalmology.

“By postponing my fellowship, I have learned to look at the entirety of ophthalmology and everything you have to experience, understand and navigate above and beyond the science,” Dr. Kugler says.

In Summary
There is no question that the decision to pursue a fellowship is a very important one, with many factors that must be weighed. But, at the end of the day, Dr. Miller’s advice rings loud and clear: “What you really need to decide is, do you truly need specialty training to practice your heart’s passion, and would that subspecialty help you in the market you are looking to practice?”

The answer to those two questions should let you know if a fellowship is in your future.

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About the author: Kimberly Day is a freelance health writer and medical editor and a frequent contributor to YO Info. She is the co-author of Hormone Revolution and ghost writer of Eat Papayas Naked.