Scared to be an attending

[chillaxbro]

Graduating soon. Pretty scared, not gonna lie. Especially since I trained in an academic setting and was sort of spoiled. I'm worried about working in a community job, standalone ER, etc where there are basically no to minimal consulting or back up services.

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[Porfirio]

You will do fine. Be prepared to learn more your first year out than the past 2.5 years (or 3.5 years). Call your old residency attendings for advice if you need it, and use WikEM.

Work as much as you can, save as much as you can, live like a resident for 2-3 years, pay off debt, and have some fun.

 

[Apollyon]

Honestly, if your first job is at an uncovered, single coverage place, that might be difficult.

However, as above, rely on your training, and you will survive. I did SO much more Ortho in my first year out than I EVER did in residency.

 

[Rekt]

Hopefully you're moonlighting. I thankfully didn't pick an academic center and have had more autonomy, volume, and procedures than I could imagine, but I've been moonlighting at several places that are solo coverage with literally zero consultants but surprising volume, and I still learn/solidify a ton.

So, if you aren't, I'd spend the next six months moonlighting as much as possible. I still have some fear of when I start my job, mainly of getting a disaster case or missing something silly on day one but I feel like that's normal.

 

[Mr. Vandemar]

Started at a fairly high acuity, high volume single coverage ED for my first job (couldn’t find anything else…) and while it’s still sometimes scary, I’ve adjusted and am surviving. And learning. So will you.

 

[dadaddadaBATMAN]

Graduating soon. Pretty scared, not gonna lie. Especially since I trained in an academic setting and was sort of spoiled. I'm worried about working in a community job, standalone ER, etc where there are basically no to minimal consulting or back up services.

Congratulations, you’ve self identified as the less lethal variant of new attending.

It’s a lot like what you see in the r2s. The arrogant ones will f everything up and not realize it till a case goes to Qi or they get sued three years later.

I’m not sure how much moonlighting adds. Personally didn’t moonlight. I think the advantage is $ and it will change how you view the last few months, disadvantage is liability, free time. Do what feels right

 

[TheComebacKid]

I don't think it's possible to take away the sick to your stomach feeling before your first shift as an attending. I nearly threw up in the parking lot. My first patient ever as an attending was an unstable hypoxic lady in persistent VT storm that got lit up a bunch of times. About a month in I had saddle PE that arrested in from of my eyes that I had to lyse with TPA without any CT imaging, just US findings.

I'm still here. Tons of people have gone through this before you. Tons will go through it after you. It's rough for everyone. But it gets better for everyone, much faster than you'd think.

Residency does not prepare you to know everything when you come out as a new attending. But it prepares you for sick from not sick. Trust that even though you don't know all the answers, you will have the ability to navigate through some treacherous waters and figure stuff out. Residency teaches you that. Residency does always tell you how to do X Y or Z, but it does teach you about how to determine what the patient NEEDS. You can figure out how to get there once you know what they need.

The vast majority of bad outcomes that will happen will happen irrespective of any of your interventions or decision making.

Ask people for help. I still send EKGs to my attendings from residency when it's a real head scratcher. Develop good relationships with consultants. Run stuff by them. If you are in a real bind and not sure, transfer to a higher level of care. Much of the time people will accept your transfers without much question. If you are in the community, consultants can be helpful. You are not expected to know everything.

Make decisions that help you sleep at night. Not 100% sure about some young gals abdominal pain? Just CT them. In the first few months I had an astronomical CT rate. It's already going down just a little over a year into this. These patterns will not last your entire career.

You'll do great.

 

[bravotwozero]

I would avoid single coverage shops *if possible*.

At night, you may be the only doc in the entire hospital at these places, covering floor codes, icu train wrecks, difficult airways, and whatever crashing patient that comes into the ED. You try calling the ICU doc and get told to eff off because they want to sleep.

 

[HemorrhagicShock]

At the same time my single coverage experience in a fairly low resourced hospital (very soon after I graduated) definitely put hair on my chest, allowed my balls to fully drop, and gave me serious real-life skill when it came to moving a department when you're the only captain of the ship. .

 

[Angry Birds]

Graduating soon. Pretty scared, not gonna lie. Especially since I trained in an academic setting and was sort of spoiled. I'm worried about working in a community job, standalone ER, etc where there are basically no to minimal consulting or back up services.

Chillax, bro... you'll be fine

 

[Angry Birds]

That joke out of the way, I'll just say: I also went from a Level 1 Trauma center to single coverage situation with no consultants. It was scary but I feel that I would never have leveled up if I knew there were back-up people I could rely on. There is an advantage of doing it this way though the start can indeed be scary. The truth is that you are probably better trained and capable than many of the people who have been working at your shop. I certainly found this to be the case for me.

As long as you can intubate and put in central lines, you're good. The rest you can stop and think about, look up in your resources, and even call a friend.
I confess that when I first started I even lacked confidence in intubation and central lines, and it was a quick master-or-die situation in the first year out. It was precisely the fact that I knew I had back-up options during residency (i.e. an attending, consultant, etc.) that prevented me from putting my game face on and saying, "I WILL GET THIS TUBE/LINE OR DIE TRYING"
So maybe you need the fear and lack of support, I don't know. But, just don't kill anyone.

 

[Groove]

You'll be fine. Remember, you can bounce a case off just about anyone. Any consultants at your hospital and even consultants on call at your nearest tertiary care center. You may be physically alone in the ED but you're really only as alone as you make yourself. When I was moonlighting as a resident in a single coverage ED out in the middle of nowhere, I'd call up a consultant at the tertiary care center on occasion to run something by them and they were always happy to talk to me about the case. (As well as avoid a transfer!)

If you weren't ready to be on your own...you wouldn't be graduating so just remember that. Relax. The first 1-3 years is a great time for professional growth.

 

[TrailRun]

Am in my first year as attending at single coverage community shop. Was the only job I could get given last years job market. It’s not ideal. Especially not having OB or some other services, and especially given how hard it is to transfer people lately. You do learn by being autonomous, but also miss out on learning by not having another doc to bounce things off of. You’ll probably be fine but it’s a lot more stress than being a resident for sure.

 

[bravotwozero]

Am in my first year as attending at single coverage community shop. Was the only job I could get given last years job market. It’s not ideal. Especially not having OB or some other services, and especially given how hard it is to transfer people lately. You do learn by being autonomous, but also miss out on learning by not having another doc to bounce things off of. You’ll probably be fine but it’s a lot more stress than being a resident for sure.

Did you end up having to catch any babies?

 

[Rekt]

Congratulations, you’ve self identified as the less lethal variant of new attending.

It’s a lot like what you see in the r2s. The arrogant ones will f everything up and not realize it till a case goes to Qi or they get sued three years later.

I’m not sure how much moonlighting adds. Personally didn’t moonlight. I think the advantage is $ and it will change how you view the last few months, disadvantage is liability, free time. Do what feels right

Not sure how you can knock it when you didn't even do it. By far the biggest growth I've had as a resident. I'll have year of essentially part time work before starting my real job. Almost all the places I interviewed said theres a massive difference between residents who moonlit and those who didn't when they started.

 

[dadaddadaBATMAN]

Not sure how you can knock it when you didn't even do it. By far the biggest growth I've had as a resident. I'll have year of essentially part time work before starting my real job. Almost all the places I interviewed said theres a massive difference between residents who moonlit and those who didn't when they started.

To be clear, I’m not knocking it.

However, on the face of it how many shifts are you going to be moonlighting when you’re working 20/28 with a set of nights? Let’s be generous and say you work 4 moonlighting shifts a month the last six months. That’s 1.5 months of attending shifts. Even if you could do 3 month worth it wouldn’t really matter much.

Most of the effect those people are seeing is probably that they are choosing people who are confident enough as an r3 to go be an attending, which is a different subset of residents.

It will probably make the attending jitters less but it just doesn’t matter that much.

The main thing I could see it doing is changing your approach to learning from your Attendings last six months. It probably would have for me.

So do whatever works for you.

Edit: just noticed you claim you’ll have a “year of part time work.” I have no idea how that can be true unless you’re working less as a resident than I do as an attending. That would not have been even close to possible where I went, but if it’s true, good for you. An extra years worth of shifts will make a difference in anyone, and has probably been great for the bank account.

I do question the wisdom of working a years worth a shift when you know the least you can in your entire career with probably the highest likelihood of committing a mind numbing malpractice error, but to each their own.

 

[RustedFox]

In some places, the nearest moonlighting opportunity is quite a drive away, in winter weather, over dangerous roads.
That's pretty much why I didn't want to.

 

[rokshana]

Not sure how you can knock it when you didn't even do it. By far the biggest growth I've had as a resident. I'll have year of essentially part time work before starting my real job. Almost all the places I interviewed said theres a massive difference between residents who moonlit and those who didn't when they started.

It’s moonlighted…

 

[Rekt]

To be clear, I’m not knocking it.

However, on the face of it how many shifts are you going to be moonlighting when you’re working 20/28 with a set of nights? Let’s be generous and say you work 4 moonlighting shifts a month the last six months. That’s 1.5 months of attending shifts. Even if you could do 3 month worth it wouldn’t really matter much.

Most of the effect those people are seeing is probably that they are choosing people who are confident enough as an r3 to go be an attending, which is a different subset of residents.

It will probably make the attending jitters less but it just doesn’t matter that much.

The main thing I could see it doing is changing your approach to learning from your Attendings last six months. It probably would have for me.

So do whatever works for you.

Edit: just noticed you claim you’ll have a “year of part time work.” I have no idea how that can be true unless you’re working less as a resident than I do as an attending. That would not have been even close to possible where I went, but if it’s true, good for you. An extra years worth of shifts will make a difference in anyone, and has probably been great for the bank account.

I do question the wisdom of working a years worth a shift when you know the least you can in your entire career with probably the highest likelihood of committing a mind numbing malpractice error, but to each their own.

Maybe you were just an extremely weak resident. I question the wisdom of any resident that chooses not to.

 

[Apollyon]

Maybe you were just an extremely weak resident. I question the wisdom of any resident that chooses not to.

Dude, get some perspective before throwing invective. In my program, my PD forbade it, full stop. So, by your calculus, I didn't even get my "bite at the apple" to have my wisdom challenged.

You're one single guy versus literal thousands. Be the better man, and not insult people just because they disagree with you.

 

[dadaddadaBATMAN]

Maybe you were just an extremely weak resident. I question the wisdom of any resident that chooses not to.

Ha that’s adorable.

I’ve walked the walk, I’m good. I get that you think you have. But coming from you that doesn’t really mean a whole lot.

Good luck, you’ll clearly need it.

 

[betamale]

Just do the best thing for the patient (tests, treatments, consult, transfers, admits...). Dont ever think you're inconveniencing anyone or going to bankrupt a patient. If it's indicated...do it. Be aware of your biases, we all have it. This way, your conscience is clear and you can defend your medical decision making against any criticism. This will also sleep better at night.

 

[TrailRun]

Did you end up having to catch any babies?

Haha not yet! Don’t jinx me. Had a 39 wk contracting every 3min that I checked and thought was 6cm dilated, so had the local fire department rush her 40 mins to the nearest OB place. They checked her, called it 4cm, contractions had stopped, and sent her home. Oh well, such is life in the community

 

[Arcan57]

Being an attending is a solo sport, almost regardless of where you're working. Most places are going to have shift times and coverage carefully calculated to just cover the expected patient arrivals by time of day. The consequence of this is that, even in double/triple coverage, you spend your shift dealing with your own mess and they spend their shift dealing with their mess. You're not going to miss true emergencies. EKG looks iffy and patient looks great - repeat EKG. EKG looks iffy and patient looks horrific - activate. You're worried about dissection/tamponade/meningitis/etc? Do the testing to exclude it. New attendings making mistakes usually come in 3 flavors, and being double/triple covered doesn't solve any of the 3.

Flavor 1: Ignoring your gut - you've spent 3-4 years differentiating sick from not sick. If everything inside is screaming that something's wrong, it probably is. Letting someone that hasn't done an H&P on the patient try to talk you out of that feeling leads to a dark path.

Flavor 2: You don't recognize the disease and patient looks good - guy that doesn't normally come to your system that you admit for CAP that boards in the ED and has adrenal insufficiency as #11 on their problem list and crumps 5 hours later because they didn't get stress dose steroids. We don't ask for help when we're comfortable.

Flavor 3: You don't play nice in the sandbox - residency tends to encourage dealing with consultants in a heavy handed fashion. The narrative of the virtuous and courageous ED doc forcing the wicked and lazy consultant to do the right thing for the patient is prevalent. Wicked and lazy consultants exist, but they're not the norm. It's important to find the middle ground where you hold your consultants accountable without being dismissive or contemptuous of their expertise. Obviously, you're not going to have another EM attending on the line when you call a consultant unless things are completely FUBAR'd at your shop.

The corollary to dealing with consultants is that in many shops, the nurses are as or more valued than you are by admin. Most EDs are chronically short nurses and the cost of tolerating an EM doc that the nurses hate is too high for most shops. Be professional and kind to the nurses, even the awful ones.

 

[Birdstrike]

Graduating soon. Pretty scared, not gonna lie. Especially since I trained in an academic setting and was sort of spoiled. I'm worried about working in a community job, standalone ER, etc where there are basically no to minimal consulting or back up services.

This is normal. The worst it's going to feel is in the days and hours leading up to your first shift. After you get through that, the tension will deflate noticeably. Then, every shift for the first six months, it'll decrease a little bit more.

I remember a day about 6 months after my first shift as an attending. I had a really brutal, high acuity, insanely busy shift. At the end of it, I realized that despite how "brutal" it felt, I actually got through it pretty smoothly.

Like with most things, the fear is worse than the reality. Keep reminding yourself that you did the training. You passed. Your training will carry you through. Because it will. Plus, 98% of what you see when you're first out, will be easy. And remember that for the hard stuff, you can still curbside consult your more experienced partners. They're likely to be helpful. They'll want you to succeed nearly as much as you do.