Author: Justin Bright, MD (Henry Ford Hospital, Detroit, @JBright2021) // Editor: Alex Koyfman, MD (@EMHighAK)

To the Class of 2015 – Congratulations!! You’ve made it. After at least 11 years of post-high school education, you have finally reached that proverbial finish line and are ready to transition from resident to attending. What I would like to share with you is some advice about what life is like on the other side. Now that you have finished residency, it’s safe to say that you know the medicine really well. But, I have come to find that your learning about life as a professional is just beginning.

First piece of advice – and I realize it’s as cliché as it comes – you never get a second chance to make a first impression. You’re walking into a new place and a new culture. You will know all the newest technologies and latest research fads. But, you won’t know simple things like, where can I go to the bathroom? How do I literally get someone admitted? What service takes care of particular problems at your institution? I can say with absolute certainty that your stress level will be higher than baseline just by walking in on your first day. Higher stress correlates with less patience and poorer communication. Snap at one nurse on your first day and it will take over a year to recover. That piece of advice is from firsthand experience. You really need to focus on situational self-awareness. You need to recognize when you’re running a little hot, and be able to harness it. Be cordial, grateful, and vulnerable. Don’t hesitate to ask for help. People like feeling needed. Your clerk is going to be your best friend. Introduce yourself right away and tell him/her, I’m going to need your help getting through the day. Getting help with the logistics in the beginning won’t undermine anyone’s view of your clinical competence.

This leads me to my second piece of advice – on one of your first shifts, buy pizza for the entire ED staff. Depending on the size of your shop, it may cost a few hundred bucks. The investment will be worth 10x that in good will. The staff will talk about it for months. You will be the doc that values his staff and wants to show how appreciative you are.

Try your best to learn everyone’s names. It’s hard – there’s one of you and tons of them. And our pesky name tag lanyards always seem to turn so the ID is not facing outwards. I try to memorize one person’s name per week. The most important names to remember: your security guards and housekeepers. Be the one doc who values everyone’s role in the department. I assure you most doctors walk by the housekeepers like they don’t exist. They keep your department clean and mop up things you definitely wouldn’t want to. Security guards keep you safe so you can go home to your loved ones. They deserve to know that you value their role.

After a month or two of work, you’re going to have a moment walking into the hospital where you realize, “this is my life now.” You will be able to imagine parking in the same spot and walking into the same ED for the next 20 years. It’s going to be a mixed emotion. In residency, you had different rotations to break up your ED months, and you were continually being exposed to something new. Now you’re an attending, and there are no rotations. There is no finish line you are trying to reach. There’s just you and your colleagues working a shift and going home. To make it through residency, you probably kept telling yourself how great attending life was going to be. You were going to be making a lot more money and it wasn’t going to be nearly as grueling. While the money part is definitely true, attending life can be every bit as grueling. It can be hard when your expectation of what the future would be like doesn’t meet your reality. It’s a totally normal feeling to have. You are not alone, and it doesn’t mean you chose the wrong specialty, wrong job, or city. It’s all part of the transition, and it almost always passes.

One of the best pieces of advice one of my attendings gave me was: whenever possible, go to the physician lounge. Introduce yourself to whoever is there. Serve on a committee. Get to know the physicians by their first names. Take an active stake in the future of the hospital. Your phone calls will go infinitely better when your colleague has a face to put with a name. The more involved you become within your department or hospital, the more indispensable you make yourself, and the more job security you will have.

If you want to have a great reputation with your consultants, be cordial with them, be grateful for their ED referrals, and never oversell an admission. They will know very quickly if you are someone who is clinically competent, or if you are a liar. I have gotten incredibly soft admits taken care of by saying from the outset, “This is a soft admission, but the patient can’t go home because… here’s what needs to be done on the inpatient side, and I’d be happy to take care of X, Y, Z for you while the patient is in the department.” They will also appreciate the times you take care of their patient at 2am, get them squared away, and don’t call until 6am to inform them of what you did and that they will be calling the office that morning. They value their sleep, and they value that you’re awake to take care of their patients. After a while, they will know that when you’re waking them up in the middle of the night, you genuinely mean it and you need their help just as they have needed yours at other times.

Do whatever you can to resist the urge to pick up more shifts. In the early years, you will be shocked by the number of zeros you can put in your paychecks. You will start thinking to yourself, if I work “X” shifts I can pay for “Y.” You will rationalize it as, I worked this hard as a resident, and I can still do it as an attending. In the short term, this may be true, but over the long haul, it’s the best way to insure you burn out well before you intended to stop practicing medicine. Use allotted vacation time. Give yourself adequate sleep and turnaround time on shifts. Don’t outspend your means. Don’t buy a massive house when one half the size would be more than sufficient. Treat yourself from time to time, but don’t buy every last thing you’ve ever wanted. The more you spend, the more you become a slave to the shifts, and the cycle is hard to break.

Don’t freak out about your student loans. Most of us got into this career by going more than $250,000 into debt pursuing our education. It was an investment in your brain and livelihood. There is a difference between being in debt and having no means to pay it off versus being in debt and making a 6 figure salary. You will pay it off. Just as I stated before, resist the urge to moonlight like crazy to pay off your debt in 3 years. Do not make yourself cash poor by paying off more than you should in a given month.

You may find yourself working in a department that places a significantly larger emphasis on metrics and patient experience than where you trained. This will be a tough transition for many. I have worked for groups that had total transparency with metrics – each month we got data on every member of the group and where we fell on the bell curve. It felt very threatening at first. I felt like the group didn’t care about patient care, only numbers. In truth, they cared very much about patient care. But they also cared about throughput, efficiency, and how the patient felt about their experience in the department. While we have altruistic feelings about helping others, we also like being compensated for what we do. The money comes from patients choosing your department over the one down the street. Be very aware of this. The stability of your job and the group’s contract may rely heavily on it. Be a proactive member and work to improve the experience of your patients; don’t ever publicly complain about it to the very people who have set up that culture of service.

In closing, as I walk into my shifts I find myself striving to live up to what I heard Amal Mattu say once: “Be the Tigger of your department, not the Eeyore.” When you are on shift, you set the tone. If you are happy to be at work, promote teamwork, and make sure those that do a great job are recognized, others will follow suit. If you are slow, negative, and stressed out, the same holds true. Be the doc that shows up and the nurses go, “Yes!” not the doc that causes nurses to say, “This is going to be a long day.”

We have chosen to work in an incredible specialty. We get to help people who have nowhere else to turn. People in their most vulnerable and scared state. Every once and a while, we even literally bring someone back to life. We are a specialty trained to run towards problems when everyone else’s instincts tell them to run away. It is an amazing feeling. There will be hard days, and no doubt days where you question why you ever chose to become a physician. Those days are likely to be few and far between. What you are more likely to feel is elation with the knowledge that you chose the best specialty in the best profession there is. Good luck to you as you move on with your career. It is such an exciting time! Your teachers are very proud of you, and excited to see the physicians you will become.