The transition from chief resident to attending

During my year as a chief resident, I have the privilege to attend on the general medicine service for 8 weeks. I recently completed 4 weeks and, as expected, found myself in an entirely new realm of patient care and accountability. I would be remiss without recalling a few of the pivotal lessons and poignant moments that stand out.

Transitioning from resident to attending inevitably results in greater scrutiny. Despite my best efforts to prevent readmissions (especially within 30 days), I had several during my first month. A cirrhotic patient with a recurrent variceal bleed, a patient with sickle cell disease readmitted for a vaso-occlusive crisis after a sharp overnight temperature drop, and an older nursing home resident treated for a UTI who came back for seizures. Given the mounting pressure to prevent readmissions, I spent numerous hours dissecting the chart for each patient attempting to understand what went wrong and what I could have done differently. I discussed the cases with my co-chiefs and several senior attendings. The consensus was that, in many cases, readmissions will happen. This was obvious to me as a resident but now, as an attending (especially an attending on service for the first time), I felt I had done something wrong. The increased scrutiny, coupled with a heightened sense of self-reflection, led me to forget what I learned over my years of residency — sick patients tend to get readmitted.

The ideal teaching service affords everyone the opportunity to teach. At the helm of a large team (one resident, two interns, two students, and a pharmacist), I did my best to demonstrate ultrasound IVC measurements in a hypotensive patient with heart failure before giving fluids, pointing out Quincke’s sign in aortic regurgitation, and reviewing sodium homeostasis in a patient with hypernatremia.

For the first few weeks I was so concerned about being a good teacher that I neglected to be a student. Our team had admitted a patient who was struggling to breath and with newly diagnosed interstitial lung disease (ILD) when my student gave a brilliant, unprompted presentation on the etiologies of ILD on rounds. Only then did I remember that my students, interns, and residents all know things I don’t. Giving them the opportunity to teach me is vital and surely won’t be forgotten.

As a resident, I took pride in efficiency. Suspicious lung mass in a smoker’s chest x-ray? No problem — I could coordinate the CT scan, bronchoscopy, and pulmonary function tests the same day. My seniors hammered into me that disposition is the goal. The longer the work-up takes, the longer the patient stays in the hospital. When fixating on the total patient census, it’s easy to neglect practicing good internal medicine. As an attending, while I respect the differences between work-ups of inpatient and outpatient problems, I also realize it’s ok to adjust asthma medications, initiate treatment for GERD, or talk about depression in a patient awaiting placement for hip fracture.

Attending on the general medicine wards has been one of the most rewarding, fun, and challenging experiences of my short academic medical career. I’ve learned too many lessons to enumerate, but perhaps the most important of all is to not lose focus on the foundation I built during residency.

Akhil Narang is an internal medicine physician who blogs at Insights on Residency Training, a part of NEJM Journal Watch.

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