New attending advice thread

[Sweatshirt]

I've been on these forums since I was a junior in undergrad. Tomorrow I start my first day as an attending fresh out of residency and it's kinda surreal. I will be rural hospital employed, only podiatrist for about 60 miles or so in all directions. Any advice or words of wisdom are greatly appreciated. I know I am well trained, confident, and have a lot of tools in my toolbox to help my patients. However, I still can't help but feel nervous for this new start. Thank you all for your help and advice over the years. Despite the negativity on these forums they have has a positive impact on my podiatry journey

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[Shiyuan]

I've been on these forums since I was a junior in undergrad. Tomorrow I start my first day as an attending fresh out of residency and it's kinda surreal. I will be rural hospital employed, only podiatrist for about 60 miles or so in all directions. Any advice or words of wisdom are greatly appreciated. I know I am well trained, confident, and have a lot of tools in my toolbox to help my patients. However, I still can't help but feel nervous for this new start. Thank you all for your help and advice over the years. Despite the negativity on these forums they have has a positive impact on my podiatry journey

Congrats bro!!! Stay humble and care for your patients. Word travels fast. Always do the right thing. DO NOT get talked into doing cosmetic foot surgery.

 

[Adam Smasher]

Don't take the job too seriously. You'll be happier.

 

[Pronation]

Never ever close a wound primarily.

 

[Hybrocure]

It’s normal to feel nervous. I’m not a hot shot like some of these guys but I found that once I was an attending every surgery felt like I was doing it my first time even though I’ve done the same procedure many times over during residency.

Also - don’t underestimate conservative treatment. It might work better than you think it will and you’ll be surprised how many patients want to avoid surgery. In fact, it’ll often be the crazy ones who will actively seek surgery out. This is something you may not have been exposed to in residency given we as residents often had surgical patients funneled to us without much clinical background knowledge.

Many fractures my attendings would’ve taken to the OR I’ve been able to just CAM boot as an attending without a problem and everyone was happy.

I think most importantly as an attending - try to respect everyone. There were docs in residency I would joke about but now as an attending I completely understand why they did what they did. Don’t look down on your colleagues. Other podiatrists are valuable resources and friends ultimately. You’ll have patients who left other pods near you and see you for second opinions etc saying this and that. I’ve found more often than not their previous docs did good work and the patient was just crazy.

 

[heybrother]

1. You'll be even more confident-capable in a few years. You will grow. You will mature. But you'll have some stress and you aren't done learning. Keep reading. Keep watching videos. Keep prepping for your cases. If your residency had a process for doing a systemic work-up and plan for the post-op - keep doing it if it makes sense.

2. You are going to find out that not everything that worked in your residency works out of your residency or in your hands.

3. Don't drag things out if you know they'll work - tell people what they need. I had some patients with diabetic wounds that I slow played a little at first. I worried that in some way the patient would perceive me as being overly aggressive if I immediately suggested surgery. I don't drag those cases out anymore.

4. Listen to what the patient says - ask yourself, am I offering something new? So many doctors won't tell a patient what they are thinking. You really can set people's minds at ease / help encounters by asking questions - what did they come here to achieve or find out today. Am I offering you something you feel you can accomplish. Did you come here today hoping to be scheduled for surgery?

5. If you talk to other podiatrists you may repeatedly hear that old expression - it takes 3 years to learn how to cut but 10 years to learn who to cut on. No amount of telling people this seems to make any difference. My residency director always said "In general, you don't regret the cases you didn't do".

You will inevitably be in a room with a person who is hurting, who has pain out of proportion, who has combined neurologic and MSK pain. You will have a patient who you would like to perform conservative therapy on and they will be pushing for aggressive surgery. Cases where people are really hurting can obviously be the biggest most wonderful wins - you solve their problem, but they can also be the biggest disasters. The worst rehabs. You will be hungry for surgery, for the opportunity to prove yourself. The patients will tell you things like - I was already set to have this surgery with doctor so and so, but I didn't get around to it or I moved here and now I need it. We already did all those things etc. Be very careful.

If you want to tackle disasters because you think its the right thing - so be it. If you think you have to do them because you need to do cases to stay in business and you need the money - that is not the case. No amount of pay is worth a disaster.

 

[wakaflocka88]

Know your limits, period. Zero shame in referring stuff out. Don’t be one of the instagram heroes, just go and enjoy life >>>>>>>>>> work any day.

 

[DYK343]

Dont be afraid to stand up to your employers BS. Youre new and want to make an impression. Have to be civil. But know what your contract states and dont go beyond it. If you continue to give they will continue to take.

Youre a human and need to have a home life. So many hospital DPMs get wrangled into a never ending cycle of work, work, go home - and then get called back in.

I know because ive been in this cycle and its not fun.

And what others said above

 

[Retrograde_Nail]

I've been on these forums since I was a junior in undergrad. Tomorrow I start my first day as an attending fresh out of residency and it's kinda surreal. I will be rural hospital employed, only podiatrist for about 60 miles or so in all directions. Any advice or words of wisdom are greatly appreciated. I know I am well trained, confident, and have a lot of tools in my toolbox to help my patients. However, I still can't help but feel nervous for this new start. Thank you all for your help and advice over the years. Despite the negativity on these forums they have has a positive impact on my podiatry journey

Despite your training you won’t get really good at surgery until about 3-5 years in. If you get a lot of surgical pathology you will be cruising sooner.

Start studying how to pass ABFAS now and chart your notes just like they want them.

Make smart phrases for everything.

Say no to revision cases your first couple of years out. A lot train wrecks are going to find you your first year out. Just say no until you get your bearings.

Embrace wounds and infections. This is profitable pathology.

Nothing beats experience. Your first few years out will be some serious growing pains.

 

[podiatryresident]

I've been on these forums since I was a junior in undergrad. Tomorrow I start my first day as an attending fresh out of residency and it's kinda surreal. I will be rural hospital employed, only podiatrist for about 60 miles or so in all directions. Any advice or words of wisdom are greatly appreciated. I know I am well trained, confident, and have a lot of tools in my toolbox to help my patients. However, I still can't help but feel nervous for this new start. Thank you all for your help and advice over the years. Despite the negativity on these forums they have has a positive impact on my podiatry journey

Congrats on your new journey! Can I ask how you found that job ? Thank you so much

 

[newfeet]

I've been on these forums since I was a junior in undergrad. Tomorrow I start my first day as an attending fresh out of residency and it's kinda surreal. I will be rural hospital employed, only podiatrist for about 60 miles or so in all directions. Any advice or words of wisdom are greatly appreciated. I know I am well trained, confident, and have a lot of tools in my toolbox to help my patients. However, I still can't help but feel nervous for this new start. Thank you all for your help and advice over the years. Despite the negativity on these forums they have has a positive impact on my podiatry journey

Congrats! Marry a local and stay at your rural job.

 

[Feli]

...Start studying how to pass ABFAS now and chart your notes just like they want them. ...

Good advice, but probably barking up the wrong tree...

Forum Members - ABFAS/ABPM

Hey guys While looking for jobs , I inquired with a few local hospitals about how to go about getting privileges. Several of them sent me info and I wanted to highlight a board concern. Not sure how to really take it, but here’s a excerpt from one of the docs re: board status. “Board...

forums.studentdoctor.net

 

[Sweatshirt]

Thanks all, loved reading the replies this morning before the new job. No patients today because it's all EMR training and HR stuff today

 

[Sweatshirt]

Congrats on your new journey! Can I ask how you found that job ? Thank you so much

PracticeLink however it was not advertised. I was reached out to by a recruiter

 

[Sweatshirt]

Congrats! Marry a local and stay at your rural job.

Already married thankfully with a very supportive spouse who wanted to try rural as well. Getting on the same page with your spouse is key or else you'll fall into the "MONTANA?!" meme. I probably wouldn't recommend rural if you are single unless you want to live an introverted life

 

[Pronation]

I probably wouldn't recommend rural if you are single unless you want to live an introverted life

Damn, rural is so crappy that I can’t even order a bride from a magazine to go over there??

 

[newfeet]

Already married thankfully with a very supportive spouse who wanted to try rural as well. Getting on the same page with your spouse is key or else you'll fall into the "MONTANA?!" meme. I probably wouldn't recommend rural if you are single unless you want to live an introverted life

I thought my wife was on the same page. Stuff changes once you are there. I would have kept my last job if I wasn't married with kids. The money was good and the cost of living wasn't bad. I would have married a local or a Canadian across the border.

 

[Boba Foot]

Stay on good terms with your residency attendings, and hopefully they're cool with you shooting ideas past them. It's one thing to be in residency where you're doing everything because you're told to and that's "the way to do it", but its a different ballgame when you're the pitch caller. Making your own decisions will feel strange at first and you'll need the reassurance of docs with experience until the training wheels really fully come off. Working under or with another pod who isn't a jerk is a huge plus too. Clinically, you'll start to feel much more comfortable after the first 6 months or so.

 

[msion]

Agree with a previous comment about not taking the job too seriously.
All patients are crazy. If they are not then look into their med lists. Risk management is key.
If you care too much you will feel so defeated when that one patient decides to sue you.

Your mental health is very important. I used to feel nervous about all the procedures I performed. I worry when patients complain or they didn't return to their follow-ups. I lost sleep over the Charcot recons.

Then I read this book...

Life is good.

 

[newfeet]

Agree with a previous comment about not taking the job too seriously.
All patients are crazy. If they are not then look into their med lists. Risk management is key.
If you care too much you will feel so defeated when that one patient decides to sue you.

Your mental health is very important. I used to feel nervous about all the procedures I performed. I worry when patients complain or they didn't return to their follow-ups. I lost sleep over the Charcot recons.

Then I read this book...

Life is good.

That is a really good book. I have it in my office.

 

[Weirdy]

Also read it. Good book.

 

[josebiwasabi]

1) Think of your first couple years as an attending as additional PGY training. I learned more from my failures than my successes and was humbled numerous times.

2) Do not care more about whatever pathology than the patient. You can only do so much. You will burn out so quickly if you care more about saving the patient's foot than the patient does.

3) Create a new set of professional goals. My short term goals include getting on the lecture circuit, becoming an industry consultant, and becoming involved with a residency program. My long term goals involve slowing down clinical practice by age 50-55 or so, but continue to be invited to lecture internationally as an excuse to travel. Your list may look completely different from mine.

4) Create non-pod-related goals and pick up a hobby. Your career is only a part of you, do not let it define you completely.

 

[billBOB213]

#2 on that list is something that every new attending needs to learn

 

[Weirdy]

#2 on that list is something that every new attending needs to learn

Most of us learn that in residency if you've seen enough volume.

Might be more personality based.

 

[Pronation]

Oh no, another one of my Charcot recons ended up in a bucket!

 

[billBOB213]

Most of us learn that in residency if you've seen enough volume.

Might be more personality based.

Well said, something you def learn in residency but I had to relearn when I was the attending and all on my shoulders.
But learned quickly lol

 

[Weirdy]

Well said, something you def learn in residency but I had to relearn when I was the attending and all on my shoulders.
But learned quickly lol

Makes sense. Not out yet so appreciate the insight everyone sharing on here.

 

[air bud]

Oh no, another one of my Charcot recons ended up in a bucket!

Oh no another one of my Charcot recons printed on payday

 

[Redsting]

Lots of good advice.

A couple things to add

1) Don't bad mouth another doctor. I've had less than ideal results (usually due to compliance) and if they weren't somewhere else and got another opinion and they talked bad or I got sued cause of what they said, I would be less than happy. I am sure the doc did what they thought best at the time. There are a lot of other reasons, just don't do it.

2) Don't be afraid to say you don't do X.

3) Just treat patients as people. Not a number.

 

[Hybrocure]

Lots of good advice.

A couple things to add

1) Don't bad mouth another doctor. I've had less than ideal results (usually due to compliance) and if they weren't somewhere else and got another opinion and they talked bad or I got sued cause of what they said, I would be less than happy. I am sure the doc did what they thought best at the time. There are a lot of other reasons, just don't do it.

2) Don't be afraid to say you don't do X.

3) Just treat patients as people. Not a number.

It’s really just too small of a profession to bother stirring up bad blood. I have colleagues I’ll consult with on occasion who are big names both in my state and nationally and they couldn’t be nicer or more understanding of my missteps as part of the learning process when I talk to them about cases or refer stuff out of my hands to them. I do think as a whole we as a profession are strong in that regard. On the flip side I’ve also had patients come to me from big names and very good surgeons for second opinions saying this or that about the doctor not knowing that I personally know them or have scrubbed with them and know that they’re a good doctor who knows what they’re doing. It really puts in perspective how one sided some of that criticism can be.


The only times I’ve ever witnessed shade being thrown is workers comp docs who will review your notes with a fine toothed comb to find any reason why the employer is not liable for this or that and write an essay about it, yet their own clinic notes for their personal non workers comp cases are typical copy and paste templates lol.

 

[califoot23]

I'm in a dilemma and would love some help. I'm working with residents and am trying to figure out how to handle working with residents and teaching them while also making sure things get done the best they can and efficiently.

The residents at my program seem super competent and always come prepared. So far I have done a bunch of dirty cases which I let the residents do 100% of. I have had a handful of electives and have also let the residents do 95-100% of these cases so far.

I am trying to find my role here and am used to doing skin-to-skin as a resident with probably 85% of the attending I worked with. My personality is very relaxed and I love to teach, so letting the residents do stuff is what I wanted. I am not a very assertive person. That being said, my volume is picking up with difficult cases and I want to be the one doing them for right now because of ABFAS case review, OR times, and being new to the area and building a reputation with the OR staff and other physicians. I did a difficult trauma yesterday and it turned out fine but some moments were a little frustrating for me and I didn't know how to assert myself.

How do I go about explaining to the residents that while the first few electives cases they did with me were skin-to-skin, I am going to take over for the time being? I know it's my patients, my cases, and my responsibility/license on the line but I want to do so in a way that lets them know I am more than willing to teach and hand over the knife when I'm comfortable but right now I'm trying to figure my sh** out. I know in residency when we had attending who let us do absolutely nothing a lot of residents would get upset with that or check out of the case and just be hands in the way. It seems like the culture here is that residents do most of the cases with all of the attendings. Anyone else been in a similar situation?

 

[Hybrocure]

I'm in a dilemma and would love some help. I'm working with residents and am trying to figure out how to handle working with residents and teaching them while also making sure things get done the best they can and efficiently.

The residents at my program seem super competent and always come prepared. So far I have done a bunch of dirty cases which I let the residents do 100% of. I have had a handful of electives and have also let the residents do 95-100% of these cases so far.

I am trying to find my role here and am used to doing skin-to-skin as a resident with probably 85% of the attending I worked with. My personality is very relaxed and I love to teach, so letting the residents do stuff is what I wanted. I am not a very assertive person. That being said, my volume is picking up with difficult cases and I want to be the one doing them for right now because of ABFAS case review, OR times, and being new to the area and building a reputation with the OR staff and other physicians. I did a difficult trauma yesterday and it turned out fine but some moments were a little frustrating for me and I didn't know how to assert myself.

How do I go about explaining to the residents that while the first few electives cases they did with me were skin-to-skin, I am going to take over for the time being? I know it's my patients, my cases, and my responsibility/license on the line but I want to do so in a way that lets them know I am more than willing to teach and hand over the knife when I'm comfortable but right now I'm trying to figure my sh** out. I know in residency when we had attending who let us do absolutely nothing a lot of residents would get upset with that or check out of the case and just be hands in the way. It seems like the culture here is that residents do most of the cases with all of the attendings. Anyone else been in a similar situation?

I don’t work with residents as an attending, but when I was in residency if an attending told me honestly “hey I’m sorry but I want to do this case for boards” or because it’s a VIP patients or whatever; that was completely fine with me especially if they usually let me do stuff in their cases.

I wouldn’t sweat it. I’m sure it’ll go over a lot better than you imagine

 

[Shiyuan]

I'm in a dilemma and would love some help. I'm working with residents and am trying to figure out how to handle working with residents and teaching them while also making sure things get done the best they can and efficiently.

The residents at my program seem super competent and always come prepared. So far I have done a bunch of dirty cases which I let the residents do 100% of. I have had a handful of electives and have also let the residents do 95-100% of these cases so far.

I am trying to find my role here and am used to doing skin-to-skin as a resident with probably 85% of the attending I worked with. My personality is very relaxed and I love to teach, so letting the residents do stuff is what I wanted. I am not a very assertive person. That being said, my volume is picking up with difficult cases and I want to be the one doing them for right now because of ABFAS case review, OR times, and being new to the area and building a reputation with the OR staff and other physicians. I did a difficult trauma yesterday and it turned out fine but some moments were a little frustrating for me and I didn't know how to assert myself.

How do I go about explaining to the residents that while the first few electives cases they did with me were skin-to-skin, I am going to take over for the time being? I know it's my patients, my cases, and my responsibility/license on the line but I want to do so in a way that lets them know I am more than willing to teach and hand over the knife when I'm comfortable but right now I'm trying to figure my sh** out. I know in residency when we had attending who let us do absolutely nothing a lot of residents would get upset with that or check out of the case and just be hands in the way. It seems like the culture here is that residents do most of the cases with all of the attendings. Anyone else been in a similar situation?

Sounds like you’re a good doctor and care about your patients. Just be patient with the residents and assertive as needed.

 

[Scrantonicity]

I'm in a dilemma and would love some help. I'm working with residents and am trying to figure out how to handle working with residents and teaching them while also making sure things get done the best they can and efficiently.

The residents at my program seem super competent and always come prepared. So far I have done a bunch of dirty cases which I let the residents do 100% of. I have had a handful of electives and have also let the residents do 95-100% of these cases so far.

I am trying to find my role here and am used to doing skin-to-skin as a resident with probably 85% of the attending I worked with. My personality is very relaxed and I love to teach, so letting the residents do stuff is what I wanted. I am not a very assertive person. That being said, my volume is picking up with difficult cases and I want to be the one doing them for right now because of ABFAS case review, OR times, and being new to the area and building a reputation with the OR staff and other physicians. I did a difficult trauma yesterday and it turned out fine but some moments were a little frustrating for me and I didn't know how to assert myself.

How do I go about explaining to the residents that while the first few electives cases they did with me were skin-to-skin, I am going to take over for the time being? I know it's my patients, my cases, and my responsibility/license on the line but I want to do so in a way that lets them know I am more than willing to teach and hand over the knife when I'm comfortable but right now I'm trying to figure my sh** out. I know in residency when we had attending who let us do absolutely nothing a lot of residents would get upset with that or check out of the case and just be hands in the way. It seems like the culture here is that residents do most of the cases with all of the attendings. Anyone else been in a similar situation?

For sure, I wouldn't sweat it at all. Maybe let them do some of the dissection, or a bone cut here and there, and of course closing--as long as you're communicating with them why you want to be more hands on yourself, they should really understand. Tell them you want them to be involved, but as a new attending you need your own experience doing some of these difficult cases without someone over you...it makes perfect sense.

 

[Feli]

I'm in a dilemma and would love some help. I'm working with residents and am trying to figure out how to handle working with residents and teaching them while also making sure things get done the best they can and efficiently.

The residents at my program seem super competent and always come prepared. So far I have done a bunch of dirty cases which I let the residents do 100% of. I have had a handful of electives and have also let the residents do 95-100% of these cases so far.

I am trying to find my role here and am used to doing skin-to-skin as a resident with probably 85% of the attending I worked with. My personality is very relaxed and I love to teach, so letting the residents do stuff is what I wanted. I am not a very assertive person. That being said, my volume is picking up with difficult cases and I want to be the one doing them for right now because of ABFAS case review, OR times, and being new to the area and building a reputation with the OR staff and other physicians. I did a difficult trauma yesterday and it turned out fine but some moments were a little frustrating for me and I didn't know how to assert myself.

How do I go about explaining to the residents that while the first few electives cases they did with me were skin-to-skin, I am going to take over for the time being? I know it's my patients, my cases, and my responsibility/license on the line but I want to do so in a way that lets them know I am more than willing to teach and hand over the knife when I'm comfortable but right now I'm trying to figure my sh** out. I know in residency when we had attending who let us do absolutely nothing a lot of residents would get upset with that or check out of the case and just be hands in the way. It seems like the culture here is that residents do most of the cases with all of the attendings. Anyone else been in a similar situation?

They are your cases, your patients. You are the attending now. It is their privilege to scrub in. You can refuse them or let them do everything.

So, do whatever you want.

...personally, I based it totally on resident competence. If I teach well, they should be better than me when finished (but most won't). I have worked with good/great programs and poor quality ones also. I would treat them all the same, though; there is the occasional good resident at bad program. If I asked them a few pre-op questions and they had clearly prepped, I'd let them start. If they struggled at any point, they were done, they'd switch to be my assist and I'd explain key steps (exception of back to resident for skin closure sometimes). They could potentially finish the whole case, do fixation, etc sometimes if they were flowing well. I would half expect the pgy2 and pgy3 from the good programs to do just that. For other cases, they wouldn't even make it to the joint or tendon or whatever. I don't like the start-stop-start-switch-start approach; I feel that really kills efficiency.

On the trash cases (wound, amp, I&D, DPC), I would barely scrub in unless it was early in first year. It is just highly dependent on the residency quality and the ppl they match. I also would often leave during closure to talk to the family and pre-op the next one... then return to make sure all was good. Although that's perfectly fine to have residents work indirect supervision, be careful with that with mediocre/bad programs and letting residents be in the OR alone... it will freak some of them out, they are accustomed to being triple and quad scrubbed even for easy cases. Because podiatry.

 

[DYK343]

Im 7 years out. Im just now considering the possibility of residents. Still probably not ready.

It takes time to hand over the knife and teach with experience

I did a good residency but that doesnt mean I was ready to hand it over directly out of residency.

I thought I was ready to go but quickly learned without Dr X standing over my shoulder I had more to figure out.

You have to develop your own skills before you can properly teach.

Its not your time to pass the torch. Get some experience and slowly increase involving residents.

 

[diabeticfootdr]

You have to develop your own skills before you can properly teach.

Its not your time to pass the torch. Get some experience and slowly increase involving residents.

Agree 100%

That’s why I don’t hire people just out of residency to be professors.

 

[Hybrocure]

Honestly when I was out of residency as an attending it felt like I was new to surgery all over again. I knew how to do the cases sure, I’ve done them ad nauseum as a resident skin to skin but nothing compares you for that stress that every move you make is you doing it with full consequences and liability which isn’t really there as a resident. And of course the wtf moments when something goes wrong that you never encountered when you did those cases in residency.

That’s why I don’t work with residents. Handing over the blade just shields you from that feeling you will inevitably need to overcome which is you doing the surgery on your own, actually doing it well, and taking responsibility for every step. Plus, it helps to know how to do your cases alone and use the wheaty so you don’t look like a fish out of water when that resident doesn’t show for your case to retract, or you have a scrub tech who doesn’t want or doesn’t know how to do it right.

 

[Scrantonicity]

Flip side of the coin is if you're teaching residents, you are that much more involved in the case (meaning your head is 150% in the game) because not only are you trying to do the best for your patient, you're also trying to teach the best way you know how to someone else.

Nothing makes you better at something faster than teaching someone else how to do it. While it may be different for each person, I don't think there's ever a "too soon" to start working with residents--In my opinion, go for it unless you're either A) just not confident in your own skills, B) you're a horrible teacher and you know it, or C) you've just had bad experiences working with residents/students.

Edit: D) you're fast in the OR and you place a high value on low tourniquet time. Having residents can definitely make cases go slower--maybe having them do the closure, apply the dressing, and dictate makes up for it though...

 

[icebreaker32]

I talked with other surgical residents while I was in residency and some of their attending surgeons let them do most of the case and others did not let them do much at all during cases…..just like podiatry. What was different is that for routine cases it was much less common in other specialties to have multiple residents scrubbed in. They also usually had rotations at charity hospitals or VAs where the liability to the attending was limited and so the residents usually did those those cases skin to skin. Podiatry does not use the VA at most residencies to supplement the training……the VA usually is the residency for podiatry and they send the residents to a surgical center rotation to help get their numbers.

If we are being honest many of our residencies just like our job market are saturated. If most programs would cut the number of residents they took in half it would be a good thing as far as training.