The only thing more intimidating than your first day as an intern is your first day as an attending. There is the inherent realization that you no longer have the safety net of practicing under someone else’s medical license. But even more than that, if you take a job at a different institution than where you did your residency training, you are forced to relive the same anxiety-provoking sensation you experienced as both a medical student at the start of a new rotation, and as a resident starting residency or off-service months.
When you graduate from residency, you feel comfortable practicing emergency medicine within the context in which you trained. Yet, more likely than not, your future place of employment will differ significantly — in a multitude of respects. Moving to a different region of a country exposes you to a different patient population with a different set of disease processes, some of which you may have never seen. Individual institutions will vary in everything from their charting and ordering systems, to their recommended pharmacotherapies based on local antibiograms and departmental policies. Even the support and ancillary services will differ from where you trained. Will your future employer have an observation unit or a separate psychiatric ED? Will you have 24-hour in-house consultants? What about 24-hour radiology techs or social workers? The list of variables is endless, and we often go through residency oblivious to the different approaches to patient management that we will be forced to adopt.
While your first few shifts as a newly minted attending physician may cause some undue anxiety, learning to adjust your practice style during residency can relieve future apprehension. Whether you’ve already landed a post-residency fellowship position, or are just starting to consider going into community practice, use the patients that present to you during residency to start mentally training yourself for this transition. Is that STEMI patient a good candidate for TPA if your future employer doesn’t have a cath lab? What type of antibiotics would you use for the patient with pyelonephritis if local resistance patterns were different? How about an alternative pharmacotherapy for chemically sedating agitated patients if your future emergency department doesn’t stock your preferred antipsychotic or benzo? Performing these mini mental exercises on shift will not only help strengthen your clinical knowledge, but they will ease the angst associated with post-residency transition.
Additionally, you should take advantage of the interactions with faculty members who have worked at other institutions. Inquire about their prior experience and practice patterns. Many junior faculty will have recently gone through this transition and can offer valuable advice. Regardless of where we end up, it is in our nature as emergency physicians to be versatile and skilled at adapting to new circumstances. Embrace the cultural change as you switch institutions. Don’t fall into the trap of “Well, at my home institution we did it this way…” Take the opportunity to continue to learn medicine in a different light. It is amazing to witness the true breadth of our specialty. I recently transitioned to a new position, and have seen the differences in medical practice first-hand. I left my inner-city residency behind — with its underinsured patients, HIV, and sickle cell disease — and moved into a tertiary-care referral center, where seemingly every patient has been an organ recipient. It’s a very different feel from where I trained. But it’s all emergency medicine.
Leaving the comfort and familiarity of your residency program is an inevitable part of your professional pathway as you segue to the next phase in your career. Like medicine itself, adaptation is an art. Start preparing for this change during residency to help ease your transition – your future self will thank you.