You’ve made it! You’ve slogged through the internship, residency and maybe even a fellowship to be the top dog. Numero uno. The alpha and omega.

You are now an attending.

The buck stops with you. All responsibility lies with you. Everyone comes to you for answers. You make all the big decisions.

Are you ready?

Of course not. Just a few days or weeks ago you were finishing your training, still leaning on your own attendings. You were pretty confident of yourself… you and your attending(s) agreed most of the time. You are not any different from a few days ago or a few weeks ago. Your strengths and weaknesses are still the same as they were. The only real difference is that you are trading on your own name now. There is no more ” Assessment and plan discussed with attending. Dr. Smith, my attending agrees.” You are Dr. Smith. Your resident now discusses the A/P with you and writes in their note that they discussed it with you. Your malpractice insurance no longer is some all-encompassing resident GME insurance. You have your own malpractice insurance now. (Occurrence or claims made, the differences of which I will discuss in a future post).

Being an attending is scary.

It doesn’t matter how confident you were in your last year as a chief resident or fellow or the best damn resident your program ever had or viewed as a “junior attending” for most of your last year. Your confidence will be different, you will second-guess yourself on things that you were 100% sure of before.

Awareness is the key.

This will seem weird, but being an attending a lot like being an intern again. You are the most dangerous person with power in the hospital. You must remember this, there are few, if any that can “catch your mistakes” for you anymore. In fact, because of second-guessing yourself you will look up information a lot during the first few months. This is a good thing. You will learn a lot more about your own weaknesses and you may even catch a mistake or two. As such, you should spend at least the first 3 months bringing your confidence back to acceptable levels.

And then…?

Once your confidence returns, and you are more comfortable with your own judgement, you will want to work on teaching your residents and starting your research. Try to remember what you did as a “good resident”. Remember all those golden nuggets that were given to you as you made your way through residency. I think one of the most important parts of teaching residents is understanding their current level of expertise. You can not expect to talk to an intern in the same way as your fellow or chief resident. The jumps in knowledge are enormous.

Teaching residents is hard.

I think the most basic advice is to treat every resident as an individual. Notice I did not say “differently” as that has a different connotation. Residents learn at different speeds and have different strengths and weaknesses. Ask for feedback from your residents, what about your lectures do they like or dislike. What else would like to see you do?

Don’t be that attending.

Attendings forget very quickly how it was to be residents. I’ve seen this happen myself when a friend of mine became my attending and just completely forgot how it was to be a resident. He complained that the residents are so slow and cause him extra work. I was like… “Dude, you were slow as a resident too.” After I said that he got very defensive. Don’t be that attending. After we talked he chilled out a bunch and was much more forgiving to his residents. But this just serves to prove a point:

How quickly we forget..

Residents aren’t attendings. It is near impossible for them to be as efficient as attendings because they simply don’t have the experience to make the judgement calls. If you want them to be more efficient, then you need to teach them to do so. Where are they spending too much time? Let them know what is important. Residents can and should try to emulate the attendings they want to be like. Be that attending.

Start early.

As an academic attending, you will be shaping the young minds of your specialty. If you want to shape minds, start early. Devote some of your time to the interns to teach them the ropes early on. Cultivate a culture of learning with a mentorship/protegé model. As an intern, having a senior resident to mentor you is huge. A senior resident or chief resident may look to you to mentor them if you have a particular expertise they are looking for. Having your own protegé(s) will keep your mind young so that you won’t become set in your ways.

This goes for you too. As a young attending, you should be seeking out advice from full professors on how to move forward with research… if you haven’t already. You need to learn the ropes of which courses you need to finish and which people you need to talk to for IRB approval, who your in house statisticians are and know them by name, and which journal(s) are easier to get an early submission/approval into. These things are all experience based which you must learn from someone who has already gone through all this, ie. a full professor, someone who is willing to mentor you, hopefully with similar interests to yours.

It’s ok to disagree.

You will probably disagree with your colleagues sometimes and that is ok. The key is to be both respectful and tactful about it. Remember that everyone in the hospital has the same goal of helping the patient in the best way they know. These “best ways” will be different for different people and different specialties.

Yelling at each other helps no one.

Documenting your disagreement with another attending in the patient’s chart is both unprofessional and ridiculous.

TL;DR

Being an attending is scary.

You are the most dangerous person with power in the hospital now.

Don’t forget how it was to be a resident. Don’t be that attending.

Teach your residents how to be like you, start with the youngest (the interns) first.

Cultivate a culture of mentorship and find a protegé to keep your mind young.

Find your own mentor to start upon your academic endeavors.

-Sensei

Agree? Disagree? Questions, Comments and Suggestions are welcome.

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Disclaimer: I am not an academic attending. I went into private practice after fellowship and then moved on to work with Veterans Affairs.

This post is based on: 1) My own opinions of what I would want in an attending when I was a resident/fellow and 2) my wife’s experiences as an academic attending. Perhaps she is better qualified to write this post than me, but that will be an update for another day if she wants to add her own commentary.