It’s July, You’re an Attending

For doctors, there is something magical about the end of June. It marks the start of our academic year. You go to bed a questioning resident and hope to wake the next day as a confident, freshly minted attending. While I was preparing for my own metamorphosis, I asked a colleague about life post-residency. Her reply: “It’s glorious, like residency was a bad dream that never happened.”

Supercharged with this information, I met my attending life at full speed, signing up to run my first marathon and take both of my boards my first year in practice. And why not have a third baby, because, of course, I would have so much time on my hands.

The tricky thing, though, with metamorphosis is that all of the physical transformation occurs sight unseen. A caterpillar takes refuge inside a cocoon while it changes into a beautiful butterfly, the painful and ugly parts veiled from view. Trainees transform into attendings, however, under a watchful public eye. For me, that first year in independent practice was anything but glorious. Here are some of the things I learned during that formative year.

Hone Your Multitasking Skills

In most practice settings, your day will consist of seeing patients every 15–30 minutes. You will also do a bunch of things before and between patient encounters. Lunch breaks are just patient-free zones, great for catching up on phone calls and documentation. These will be things like checking all the documents in your inbox (images, consults, etc). Some consults will say things like “I”ve asked Mr. S. to discuss his chest pain with his primary,” or you’ll notice their blood pressure is sky high and want to bring them in to see you. So, you send a note to your nurse to schedule the patient.

Checking and responding to labs is another commonplace task. If you have a patient portal, sign up as many patients as you can. This decreases all the back and forth phone calls and messages. And please do yourself a favor and document after each patient. Seriously, take a couple minutes to just get your note closed. A short and done note is much better than the detailed note that is still unfinished.

The Cheapest and Most Valuable Test is the RECHECK

Yes, our job as primary care physicians never ends. But sometimes that is the beauty of it. If you are concerned about a patient, bring them back. Starting a patient on insulin? Give them some parameters and have them come back with a glucose log in a week or two. Bad COPD exacerbation? Steroids, nebulizers, antibiotics, and bring them back in the morning. If you need eyes in the home, set up home nursing. If you feel uneasy in any way, you can always have your nurses call in the morning to check on the patient.

Although our main goal is to keep our patients out of the hospital, this is not always possible. If their condition requires evaluation later that day, it may be prudent to send to the ER for consideration of admission (and please try to call ahead).

Get Comfortable With Uncertainty

Medical literature is increasing at a rapid pace. It is okay to say “I don’t know.” Follow this up with “But I will look that up for you.” If it is something small, double check Up to Date while the patient is changing into a gown. If it’s a big topic, look for a NEJM review over the weekend.

Many practice guidelines are available without a subscription on the web. Text pressing questions to your subspecialist friends. Also, make sure you are actively expanding your medical knowledge on a regular basis. Easy ways to do this are signing up for emails, following other physicians and leaders in your field on twitter, listening to medical podcasts (if you have not checked out The Curbsiders Internal Medicine Podcast, this is a must) and attending local and national primary care update conferences.

Reassurance Goes a Long Way

Sometimes, reassurance is needed and appropriate. Reassurance that, although you have seen this particular symptom repeatedly over the years, not much usually comes out of a work up. Or, simply saying, “The good news is that there is not any big horrible diagnosis I know of that causes these symptoms, but let me know in the future if anything new develops.” My patients have heard me say quite a few times that my favorite medical problem is the one that goes away, even if we weren’t sure what was causing the symptoms. Of course, always advise patients to call back with worsening or persistence or the development of new symptoms.

A few months into that overwhelming first year as an attending in outpatient primary care, an incredibly sage mentor told me, “You will feel like a completely different doctor at the end of the first year.” And she was spot on. Unlike the beautiful butterfly, I felt more akin to unformed clay being molded — and ultimately baked — in a kiln at a temp of more than 1,000 degrees. But, at the end of that incredible year, I felt fireproof.

I hope that, armed with these tips, you can walk into clinic that first day as an attending with your eyes wide open, prepared to embark on the steepest learning curve in medicine.

Lauren Kuwik, MD, is a medicine/pediatrics physician and a 2018–19 Doximity Author.

Image: bennphoto/shuttestock.com

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