Young Physicians Section: Understanding the Transition from Resident to Attending Practice

Jessica Fujimoto, MD FAAEM

As new attending physicians, we are still developing our professional identity and we still have unmet learning needs.”

The transition from resident to attending physician is a time of many challenges and immense growth. As new attending physicians, we are still developing our professional identity and we still have unmet learning needs. Yet, paradoxically, this comes a time when we are removed from all of the structure and guidance that has supported us thus far in our medical training.

Framing the Problem. Clearly, this is a critical time in a physician’s development, yet, its challenges are poorly understood, which in turn makes it a difficult process to improve. Fortunately, Westerman et al. introduced a framework for conceptualizing this transition from resident to attending practice, with influence from research in medical education and transition psychology.

In this framework, the authors propose that novel disruptions arise in this transition, which leads to coping, subsequently fostering personal development. Issues that fall under each of these themes can be further categorized into issues arising from novel tasks, roles, and contexts. 1

Disruptive Novel Elements. These deal with differences between practicing medicine as a resident in training as opposed to practicing as an attending. They are subcategorized into novel tasks, novel roles, and novel contexts, and they apply to both clinical and nonclinical work. 1 Some disruptive novel elements in Emergency Medicine include:

• Novel Tasks: billing and coding, navigating the logistics of patient care, ensuring patient satisfaction, becoming board certified, managing personal finances

• Novel Role: being a team leader, having the final say in medical decision making

• Novel Context: working in a new system, working at a faster pace, working with new nurses and staff, working with consultants who are not in house, achieving work-life balance 1,2,3,4,5,6,7,8

Perception and Coping. New attendings have varying reactions to the changes that come with this transition. Interestingly, surveyed new attending felt well prepared in medical knowledge and clinical skills, but felt poorly prepared for nonclinical aspects of work such as supervision of residents. 1 Some perceptions and coping in Emergency Medicine include:

• Novel Tasks: feelings of failure or incompetence, not knowing how to supervise NPs and PAs, feeling uncertain about EKG interpretation skills, learning how to avoid burnout

• Novel Role: uncertainty about others’ expectations, lack of conflict resolution skills, learning how to be the face of the hospital, learning how to be a good employee, being a good role model for learners

• Novel Context: needing colleague support in a safe space, continued engagement with professional development 1,2,3,4,5,6,7,8 Personal Development and Outcome. The process of perceiving and coping in response to disruptive novel elements leads to personal development and growth. New attendings came to realize that this transition and growth was a more gradual process, and their fear of failure faded as they developed task mastery. 1

Solutions. Using this framework, we can identify some strategies to ease this transition. We should minimize disruptive novel elements. Specifically, we should aim to reduce undesirable difficulties, while still allowing new attendings to experience disruptive novel elements that will lead to growth. We should also provide resources, space, and time to promote coping and reflection.

• Minimizing Disruptive Novel Elements: Residency programs should teach nonclinical skills (e.g. supervising residents, PAs, NPs) so that program graduates are better prepared to perform these tasks in their new attending roles. In addition, employers should develop social programs to help introduce new hires to their group’s culture and expectations. 1

• Providing Resources to Promote Coping: This is traditionally achieved via one-on-one mentorship that pairs a senior and junior attending. However, new attendings should also engage in peer group mentorship. A successful example was published by MacMillan et al., in which a group of new attendings started a journal club, meeting regularly to share practice-changing articles and ‘transition to practice’ topics amongst peers. 9

The transition from resident to attending physician is complex and poorly understood. Through the framework presented by Westerman et al., we can begin to understand the challenges that arise, and how we can help ease this transition for future generations.

References

1. Westerman M, Teunissen PW, van der Vleuten CPM, et al. Understanding the Transition From Resident to Attending Physician: A Transdisciplinary, Qualitative Study: Acad Med. 2010;85(12):1914-1919. doi:10.1097/ ACM.0b013e3181fa2913

2. Lin M. Doing well as a new EM attending physician. ALiEM. Published July 14, 2011. Accessed June 15, 2021. https://www.aliem.com/doingwell-as-new-em-attending/

3. Cosgrove A. Here Goes Nothing: Confessions of a New Attending. EPIC - The Official Newsletter of MOCEP. https://mocep.org/2019/03/heregoes-nothing-confessions-of-a-new-attending/. Published February 2019. Accessed June 15, 2021.

4. Thomas B. Lessons Learned During My First Year as an Attending Physician. ACEP Now. https://www.acepnow.com/article/lessons-learnedduring-my-first-year-as-an-attending-physician/. Published November 24, 2019. Accessed June 15, 2021.

5. Roberts JR. How to Survive as a New Attending. Emerg Med News. 2001;23(8):4.

6. Garmel G. Letter to Graduating EM Residents. EMRA. Accessed June 15, 2021. http://www.emra.org/residents-fellows/career-planning/letter-tograduating-em-residents/

7. Vega D, Scaletta T. Rules of the Road for Young Emergency Physicians.; 2009.

8. Rules of the Road: Tips for the New Class. Emergency Physicians Monthly. Accessed June 15, 2021. https://epmonthly.com/article/rules-ofthe-road-tips-for-the-new-class/

9. MacMillan TE, Rawal S, Cram P, Liu J. A journal club for peer mentorship: helping to navigate the transition to independent practice. Perspect Med Educ. 2016;5(5):312-315. doi:10.1007/s40037-016-0292-2