My Anniversary

September 29, 2014

Having just completed my first year as an attending physician, I realize that there is simply nothing that prepares you to be an attending-except being an attending.

I have no doubt that I learned from world-class supervisors during my residency and fellowship. From advanced psychopharmacology or the psychotherapeutic technique of Sullivan, my supervisors prepared me as well as they could for treating patients by allowing me to acquire a well-stocked toolbox of skills. Despite this, having just completed my first year as an attending physician, I realize that unfortunately there is simply nothing that prepares you to be an attending except being an attending.

One of my first consults as an attending was a man with decompensated congestive heart failure requesting to sign out against medical advice (AMA) because he claimed he could get better care at a nearby hospital. Having trained during medical school at that nearby hospital, I knew that he was demonstrating poor judgment. Of course the question at hand was not the quality of his judgment, but whether he had the capacity to exercise his poor judgment. Given that his urine toxicology was positive for opiates, benzodiazepines, and cocaine (none prescribed), I believed he may have been leaving because some of his preferred medications were not on our hospital’s formulary. Regardless of my suspicions, after going through the standard battery of questions, I concluded that in fact he did have capacity. As he signed the AMA form, he stated in a loud voice so all at the nurse’s station could here, “I am getting the (expletive) out of here.” As I was writing my consult and considering my constant subjective sense of being overwhelmed, I had the strong impulse to say the same thing and walk out with him.

Being an attending means making lots of decisions every day, for which you have full responsibility, and sweating those decisions out on rounds with medical students, residents, and fellows bearing full witness. If a schizophrenic patient has a QTc of 500 milliseconds, should I discontinue his lurasidone? When is the right time to discontinue a patient’s constant observation? How do you explain to someone that you were consulted because of concerns about the seeming psychosomatic origins of his inability to walk, only to return the next day because the patient has now learned he has ALS? How do I teach when I am uncertain?

All my attending supervisors had years of experience, and I never had the pleasure (more specifically the schadenfreude) of seeing someone go through the transition that I was undergoing. The more my senior attendings told me they remembered being “just like this” during their first year, the less I believed them.

On reflection, I am convinced that there simply is no replacement for experience. One cannot obtain some important lessons even from the most masterful teachers and one can only learn them by periods of self-doubt, self-questioning, trepidation, and ultimately realizing that despite your best efforts, the treatment sometimes fails the patient. Ultimately, I hope each anniversary as an attending does not feel like as much of a step up as the first, but I also hope that each future anniversary allows me to look back at the year before and feel that I have experienced something to make myself-and my patients-better.

Disclosures:

Dr Forman is an Attending Psychiatrist in the division of psychosomatic medicine at Montefiore Medicine Center and Assistant Professor of Psychiatry at the Albert Einstein College of Medicine in New York. He reports no conflicts of interest concerning the subject matter of this article.