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Residents & Fellows Corner | Nov/Dec '15

Transitioning from Training

Graduating from residency or fellowship and assuming your first attending position is an interesting and challenging phase of life. On-call shifts should go down, while your salary goes up.

Graduating from residency or fellowship and assuming your first attending position is an interesting and challenging phase of life. On-call shifts should go down, while your salary goes up. The beauty and Achilles’ heel of training is that each service and each experience is time limited. If something is not going well, a particular rotation will be over within a few weeks. Yet, at the same time, training does not permit residents an appreciation of the long-term history of any particular patient or the opportunity to feel the consequences, good or bad, of their actions. Moreover, post training, no longer is there someone looking over your shoulder, whispering in your ear what to do. The psychological stress reaches unprecedented levels, as you now take your patients home with you in a way you never have before.

To psychologically become ready for this transition from training and to get off on the right foot, there are a few recommended rules to follow.

RULE 1: Slow down.

As an attending, you will need to speak about diagnosis, prognosis, and management with patients in a way that you did not have to in training. Set aside time to consult with your mentors and colleagues and to study up on your patients. Starting out, you neither need to nor can see patients as quickly as you did in your final months of residency or fellowship. In this day, when both doctors and patients complain about the time spent with patients, this is a chance to gain the trust of your new patients. The time you spend with them will pay dividends. You will likely have more than one patient who will come to you because he or she did not appreciate the “assembly-line medicine” received from a more experienced colleague down the street. You will also find that many patients put more trust in the doctor who has a good bedside manner. If you are in private practice and perhaps not the “end-of-the-road expert consultant,” word of mouth by loyal patients will be your major source of referrals.

RULE 2: Defer complex cases for a while.

As a new doctor, you will naturally be tempted to test your skills, and others will be happy to have a new physician to refer challenging cases to. In general, however, there is no need to jump right into doing high-risk cases your first week of a new job. Get used to things, let others become comfortable with and confident in you, and then start tackling tough cases.

RULE 3: Be available to your patients.

Give patients the ability to contact you via email, text, or online portals. Avoiding phone tag is an important way to build relationships with your patients and address problems early on. In my 13 years of practice, not a single patient has abused his or her access to me via email or cell phone.


Another key element of the transition to attendingship is practice building, which is too often not taught and easily overlooked in residency and/or fellowship. In addition to becoming familiar with the ICD-10 eye or specialty-related codes and the relevant CPT codes (cheat-sheets are very helpful here, as is time with coding consultants), here are some practical tips.

TIP 1: Pound the pavement.

Build a referral network personally. No one owes you patients or volume. Go out into your community and meet ophthalmologists as well as optometrists if that is compatible with you and your practice’s philosophy. Give noon conferences to internists, emergency room doctors, family physicians, etc.

TIP 2: Work hard and add to your practice.

Before you take the job, ask those in the practice what they need or would like to add to the group. Focus on growing the pie with new skill sets and techniques, optimizing or enhancing surgical or clinical flow and practices, adding geographic opportunities, etc., rather than taking your slice of the pie at someone else’s expense.

TIP 3: Be available to your colleagues.

When a referral call comes in at 4 PM on a Friday, accept it happily. Make sure your colleagues and referring sources know you are there for them, will take care of their patient(s), keep them appraised of developments, and send the patient back if they so wish.

TIP 4: Set financial expectations up front.

Monetary disputes are an underlying cause of dissatisfaction and departures by new associates. Strive to set financial expectations going in. Understand what is entailed in track to partnership, buy-in/buy-out terms, and practice valuation and, most importantly, know that everyone has to justify his or her own existence; if you don’t bring in substantially more revenue than your salary, benefits, and overhead costs constitute, then there is no point to you being there. For these issues, some business training in finance, accounting, and negotiations would be invaluable. A business consultant can also be quite useful.

TIP 5: Learn to negotiate.

Negotiating is a skill that too many physicians and trainees lack, as it is not really taught in medical school or residency. Too often in challenging situations physicians resort to ignoring problems, acquiescing, passive-aggressive sulking, split-the-difference compromises, or anger and intimidation in the service of a winner-takes-all strategy. None of these are productive in the long run. The technique of integrative negotiation, where each party lays out and draws out the other’s core motives, desires, and goals—fleshing out context and adding to the pool of meaning—is a very helpful skill set that can be practiced and learned. This often leads to long-term near-optimal outcomes, where all parties see where the other is coming from and can generally figure out a path to helping each other’s core goals along for win-wins.

TIP 6: Be grateful.

You are in a field that is important, dynamic, and valued. You were able to finish residency in 3 years—in Australia, residency is 5 years, and, in Britain, it is 8; further, in much of continental Europe and India, phaco is not taught in residency, and, in Indonesia, residents pay tuition!

TIP 7: Be mindful of your loved ones.

Last but certainly not least, take care of your spouse and/or family. If your spouse is unhappy with a location going in, chances are that you will leave. So why waste everyone’s time?


Being an attending is an exciting and rewarding role to fill. Preparing for this new phase by following a few key rules and tips will help to ease the transition process and boost your success in the early days of attendingship and beyond.