The transition from trainee to independently practicing physician is one that we all look forward to with hope and anxiety. For my first job, I decided that I wanted to venture out of academia. There were several reasons behind this decision, however, the true driver was “to face the real world” or “find my own style.” The following reflections are a synthesis of the lessons learned during this year, which I hope can help you in your own medical journey.

1) You will likely work more than during residency or fellowship.

Without a doubt, the hours are better than during your intern year, however, now you are more efficient. In this lesser amount of time, you will see more patients than ever before. The expectations of your output as an attending will double or quadruple. If you felt that admissions and consults were endless during training, let me tell you, that was only the warmup session.

• If you are in an inpatient service, expect to see or follow up more patients than before. Often, trainees would be sheltered by attendings of “non-teaching cases” or “easy follow-ups.” During this new phase of your professional career, these follow-ups become your responsibility.
• If you are in an outpatient clinic, expect your show rates to be better than during training. 
• There might be no partner to sign off on some of our patient care duties. For example, just because you are on inpatient consults during this week doesn’t mean that your outpatients can’t get sick and won’t try to reach your office.

If you prove yourself useful to your patients and your organization, new consults and referrals will keep your telecommunications devices buzzing all day long. This can happen during spurts (in my case during respiratory viruses season) or as a continuous drip of patients.

2) Nonacademic practice can be as intellectually challenging as academic life.

A common misconception (and one that I shared myself until last year) is that if you leave academic life (working in a teaching environment) your thinking skills will rust. I want to challenge this belief with my own personal experience with a common disease in my field: asthma.

During my training, I saw hundreds of consults for acute asthma exacerbations, but as a member of a large inner-city academic institution, it was uncommon for me to follow all these patients longitudinally after discharge (some followed at other hospital systems, others were lost to follow-up, and others followed with other trainees). During this past year I’ve had the privilege of longitudinally following up my patients and have been able to do initial, secondary, and advanced testing for them, which has translated into improved quality of life and proper identification of their clinical subtype. As a physician, these cases helped me develop a more nuanced understanding of asthma.

3) You don’t know what you don’t know.

Following the above thought, in your first year out of training you will realize that you have yet to learn a lot about your own specialty. 

• Don’t fault your training: It might be that your attendings shared with you as much as they could from their clinical experience, but the patient population you now serve is completely different.
• Be humble and accept that medicine is a lifelong learning experience. It would be insane to presume that in three to five years of training you have mastered centuries of medical knowledge and deeply understand new discoveries.
• Embrace new trends with caution. We as humans are vulnerable to hype. Remain critical of new technologies and use them as evidence turns in their favor.

4) Each step forward poses new challenges.

During this first year of attending-hood, I was tasked with developing an outpatient pulmonary practice, an inpatient consultation service, and ICU staffing for a small community hospital in the city of Tucson, Arizona. Throughout this year I have seen firsthand the increasing complexity of ensuring that all the moving parts of health care communicate with each other.

We started our Pulmonary Function Lab with simple pulmonary function testing only ordered by me, and this has expanded to community providers using our services. This higher volume has afforded us to expand our line of service and add more advanced pulmonary testing.

In each step in this process, we’ve had to revisit our ordering system, processing mechanism, approval process, scheduling, and test performance. Building a practice or department is like a reverse game of Jenga in which every time you add a new piece you must ensure that the structure keeps standing.

5) Make time for administrative duties.

Nobody likes them and they won’t go away on their own. Separate a block of time in your schedule to take care of these affairs and make your life easier. Do not attempt to “fit in” administrative tasks between clinical duties. One will always trump the other and only two outcomes are possible: subpar patient care or delay in completing administrative tasks.

6) Enjoy the little victories!

Getting your first diagnosis right, having your first procedure go well, your first safe, and your first good review. You are becoming an accomplished physician. The years of sacrifice, dedication, and hard work are finally paying off!

What advice would you give your fellow physicians? Share in the comments.

Felix Reyes, MD, is a pulmonary and critical care physician in Tucson, Arizona. Aside from his clinical duties, he is developing a community respiratory program serving east Tucson. Follow his journey on Twitter at @felixmd10.

Image by Nuthawut Somsuk / Getty