Things are different: Adapting to the first few months in practice

by John W. Kitchens, MD

Retina Associates of Kentucky
Lexington, Kentucky

At work…
In the OR…
At home…

There will never be a time in your life when things will change as dramatically as when you start your first job. During your training (e.g., medical school, residency, and fellowship) the chances are that you were not “the one” who was fully responsible for the outcomes of surgery or patient care. In addition, it is likely that you never made anywhere near the amount of money that you are about to start making. Finally, you are probably moving to a brand new city where you don’t know a lot of people. These are three very big changes in your life. Changes like these do not occur without a great deal of anxiety.

At work…
Everything at your new job will be different. The charts will be organized differently, the exam forms will be done differently, the technicians may work up patients differently, the OCTs may be printed in a different fashion, the lasers will function differently, etc. These things take some getting used to. Good partners will welcome you to follow them for a few days to see how things are done. It does not hurt to come an hour early to work with the equipment and learn how to turn things on and alter settings. Nothing is more embarrassing than not knowing how to turn on a slit lamp or work the laser (especially when you are the young, new doctor).
Often, you will bring a different perspective to a practice on how things are done. This can help to increase efficiency and may improve the practice as a whole. It is great to make suggestions if something can be done in a better fashion. Try to avoid recreating the way things were done in fellowship just because it will make it easier for you. I would also advise waiting at least one month prior to making any major suggestions. This allows you to see if something is done a certain way for a reason. Often, early on, you will see fewer patients and this will allow you the chance to become familiar with the charting system, the employees, and the billing system. Take advantage of this extra time as it will ease the transition greatly.
Billing is one area that is routinely neglected in training. Chances are good that you have seen three-fold more PVR cases than you saw billing sheets filled out. This is one area that you should spend time with early on. Talk to your partners about how they bill surgical procedures and clinic visits. Spend time with the billing department and ask them to audit your first 100 charts prior to posting the charges. The Academy has a lot of good information on billing and coding (http://www.aao.org/aaoesite/coding/index.cfm). The Academy also puts on a seminar called CodeQuest that is very informative. This is an area that you will catch onto quickly, but effort must be applied.

In the OR…
One of the biggest hurdles in an early career is that of the operating room. There are multiple changes that occur when you walk into an OR for the first time. First, you are the one responsible. There are no faculty members present to tell you what type of buckle to use, or whether to peel a certain membrane. No one else is responsible for the outcome of that patient but you. This can put a lot of pressure on a new surgeon. Just realize that you have been well trained. Before doing anything major, ask yourself “what would my mentor do in this situation?” That will help you think through your decisions and will guide you in tough spots.
Second, the setup in the OR will likely be different than what you trained with. You may not have the settings that are familiar to you. The scope, laser, and other peripherals may also be completely different. Spend time with the nurses and technicians to learn how the equipment works, the types of peripherals, and how things are done. Spend time with your partners in the OR to watch how they do things, what instruments they prefer, and what their settings are for various things. Also, take time during your fellowship to learn the settings that you use. It is also a very good idea to learn how to setup and “trouble-shoot” the vitrectomy machine during your fellowship. It is a good idea to have the vitrectomy machine representative come in for your first few days in the OR. They will be make sure that everything goes well from an instrumentation standpoint.

The final recommendation is to not lose confidence early on. Most vitreoretinal specialists start out slowly. It is tough to get really confident in your new set up when you are doing a handful of cases early on. Realize that everyone has cases that don’t go well and don’t lose faith if you have a complication early on. Your partners have been through the same process before and should be very supportive. Talk to them about tough cases. Don’t be afraid to ask them to sit in or help out with cases. There is a tremendous amount that you can learn from your partners. Asking their advice on a tough case will show them that you are humble and respect their skills and opinions.

At home…
One important area that often gets neglected during the first few months of practice is your home life. If you are married, please remember that all of this is new to your spouse. Spend extra time with your significant other early on. A new city can be very exciting, but it also can be a very lonely place. Your happiness will depend more on how happy your spouse is than how successful your first 10 macular hole surgeries.