On being a New Attending

By Lindsay Melvin  (@LMelvinMD)

< Editors note: This piece is a great and honest reflection about an important topic for junior attendings: developing our supervisory styles. The articles highlighted by Lindsay are important reads for anyone who is still in the liminal space between residency/fellowship and early career faculty appointment. I hope you enjoy this piece as much as I did! – @TChanMD>

I often wonder if Resident Lindsay would have liked to work with Attending Lindsay. As I’ve transitioned into the new role of attending physician this last year, there have been more than a few times I have doubted this would be the case.

As a new July approaches, I have been reflecting on the milestone of completing my first year as a fully independent academic clinician. When you’re in training, it seems like the attendings have it all figured out. Intelligent, confident, organized: the attendings I worked with were fantastic role models. When it was my turn, I certainly didn’t feel that way. As a newly minted attending, at times it is tough to shake the intense imposter syndrome.

insomnia.jpgSleep did not come easily to me in my first month on service. What was it about my new role as attending that differed so greatly from the years of senior-ing I have done to prepare? Finally able to sleep in my own bed every night, why now was I lying awake for hours? Or worse, falling into a fitful, nightmare-plagued sleep filled with incoherent worries about my patients?

In part, I felt distant. Being one step removed: from the on-call environment, from the bedside in the moment, from the immediate decisions- I missed these pieces greatly, and they served as a source of some of my initial anxiety. More pressing than immediacy was the issue of control. How do you remain in control of a team of patients and learners, even when you’re not in the hospital? How do you be the best doctor you can be and give each learner the best experience you can?

It took time, reflection and many chats with wise colleagues to begin understanding the transitional challenges I was facing. In the hopes of helping the next cohort of new graduates sleep better, here are some thoughts on the core issues I have grappled with in this transition:

1) Trust – In the era of competency-based medical education, we hear a lot about trust, and entrustment specifically. As a new supervisor, I had to learn to build trust with learners and share (what is ultimately my own) responsibility for a patient’s care. This felt different from my days as a senior resident, where I could be as involved as I needed to be with patients I worried about. Forming trust once is challenging enough, never mind repeatedly with many learners over the course of several rotations! The building of trust, and subsequent entrustment, is often subtle – based just as much on the intangible than the tangible (1). Recent work by Sheu and colleagues helped me to understand that trusting myself was an important part of the formation process (2). Understanding what trust means to me as an Internist is something I still spend lots of time pondering.

2) Resident Autonomy – Clinical supervision in medical education is a paradox. It is wholly necessary, and yet, our residents strive for the utmost autonomy possible. The concepts of trust and resident autonomy are not always inversely correlated. My ‘supervisory style’ (3) varies day to day, but I know that I’m considered ‘hands on’ – my residents tell me so. Where is the line between being involved in patients’ care, as any attending needs to be, and being ‘hands on’ in a negative way? This struggle makes me feel as though at times I am encroaching on my residents’ autonomy. I explain myself to my teams, as if somehow involvement in my own patients’ care requires excusing. I make explicit my thoughts, questions and concerns, sharing my cognitive processes and preferences. I hope they see my involvement as supportive, not suffocating. Luckily, my residents often forgive me for being ‘hands-on’ because I’m a new attending– will this always be the case?Picture1

3) Teaching – alongside caring for our patients comes the added pressures to provide high-quality, relevant teaching and clinical pearls. My teaching style is evolving over this new phase in my career. Right now, I find my teaching revolves around our team of patients, embedded as much as possible into our daily work. It involves a lot of questions. I ask for details. I ask a lot of ‘Why?’. I reflect on how this is something that might have irked Resident Lindsay. I can just imagine her complaining to her colleagues about her super-hands-on staff, who instead of giving answers, just asks more questions.

I realized something midway through this academic year: the most adept attendings I look to as my role models were intelligent, confident, organized- and skilled illusionists. The illusion of control is a powerful thing. Some more ‘hands on’ than others, I relished working with those attendings who trusted me, let me flex my own decision-making-muscles and grow. Yet they never failed to know each detail I didn’t, supporting and gently guiding when I needed it. They kept complete control over the team – yet allowed me to learn and grow safely. I strive to achieve this fine equilibrium that master clinician teachers strike.

If there is one certainty in medicine, it is that we are all forever learners in some form. Evolving from resident to a new attending has been full of lessons. Balancing providing excellent care to my patients with trust, resident autonomy and teaching continue to be at the forefront of my mind. Hopefully, Resident Lindsay wouldn’t find Attending Lindsay so bad after all.

 

References
1. Hauer KE, Oza SK, Kogan JR, Stankiewicz CA, Stenfors-Hayes T, Cate OT, et al. How clinical supervisors develop trust in their trainees: a qualitative study. Medical education. 2015;49(8):783-95.
2. Sheu L, Kogan JR, Hauer KE. How Supervisor Experience Influences Trust, Supervision, and Trainee Learning: A Qualitative Study. Academic medicine : journal of the Association of American Medical Colleges. 2017.
3. Goldszmidt M, Faden L, Dornan T, van Merrienboer J, Bordage G, Lingard L. Attending physician variability: a model of four supervisory styles. Academic medicine : journal of the Association of American Medical Colleges. 2015;90(11):1541-6.

Black and white image via Kevin Chodzinski on Flickr

All other images are property of the Royal College