Transition To Fellowship & Faculty: Challenges & Solutions

It’s almost the end of this academic year and July 1st is just around the corner. Whether you are an internal medicine resident moving on to a nephrology fellowship or a senior nephrology fellow about to become an attending, the transition time can be nerve-racking and challenging. I have highlighted my experiences during the transition from residency to fellowship and then to private practice. This was inspired by a recent tweet from Diana Mahbod and the wonderful thread that followed with replies.

1. You may not always have the answers– As a new fellow or attending, I have often felt the pressure of giving the right diagnosis right away to the teams calling in consults.

Remember that it can take a couple of days for you to get to know a new patient and to figure out what’s really causing the AKI or a particular electrolyte abnormality. It’s ok to say the etiology is unclear, give a differential, and keep looking for answers over a couple of days. Like the Airway, Breathing Circulation are for a crashing patient, nephrology has its own ABCs in my opinion- electrolytes, hypertension, and volume status. It’s important to explain your thoughts and acutely address the ABCs.

2. The transition is hard for everyone– A famous Greek philosopher called Heraclitus said: “Nothing is permanent but change”. But embracing change can be often challenging. Moving from one city or job or institution to another is hard for everyone. Newness invites scrutiny. When you start a new position or a new job you are heavily judged. Do not be discouraged by this, because this is universal. The good news is that you are not alone, everyone goes through a similar phase and it is time limited. In the beginning, you will find yourself at the bottom of the proverbial food chain, and you will need to be there for a while but there is always light at the end of the tunnel. Keep your head down and focus well on your work. Try to give your best. It is also very important to remember that you cannot please everyone, so keep calm and just power through. Ask for feedback from time to time from your senior fellows or colleagues, this will send a message to your colleagues that you are striving to get better at your job. Never forget what you went through during your own transition time and extend that much-needed support to other people in the future.

3. Efficiency is not overrated– When I transitioned from being a resident to a nephrology fellow, I was not efficient. Fellowship was extremely busy and we as nephrologists take care of very complex patients.  I found it challenging initially to get my notes done in time. On several occasions, I stayed back at the hospital finishing work. My senior fellows and attendings always kept pushing me to get more efficient, and I will confess, I used to think that efficiency is overrated. Who cares if my notes get done late as long as I am doing everything right, correct? Wrong. It is in the best interest for you (for your own sanity and work-life balance) as well as the patients that not only you do the right thing in time but also document everything in time. You do not want to be in front of the computer for long hours writing notes, so learn to pace yourself from early on, it will go a long way. In order to be efficient, planning your day the night before is very helpful. Think about which patients need to be seen earlier or which ones will need more attention/time. This will change from day today. Multitasking is inherent in our specialty as we see patients in hospitals, clinics, and dialysis units. Hence, try to develop a system and a schedule which cuts your in-between travel time (windshield time). It is always best to finish your charting and patient calls on the same day rather than procrastinating. Look for other physicians in your hospital or practice who are efficient and ask for their advice.

4. There is no dearth of opportunities or mentors- I am very proud to be a part of the nephrology community. There are innumerable opportunities for broadening your network, getting involved in educational projects, learning from each other and just meeting and interacting with new ‘Nephrons’. The camaraderie is real. Mentorship is the key to success and in our specialty you will never find yourself away from a mentor, look for them- on Twitter, at your institution, at a different institution or even someone far away in another country.

5. Be a jack of all trades first, and then maybe a master of one– During fellowship, try to get your feet wet in everything you can- lines, ultrasound, interventional nephrology, glomerulonephritis, peritoneal dialysis, stone clinics, etc. Try to do it all. You never know what skills you will need once you are out of fellowship and practicing in real life. No experience or skill will ever go to waste. I believe that there is nothing wrong with not having a niche.

6. Second guessing yourself is normal and natural. This happens to everyone as you are transitioning from a fellow to a new attending. Have reasonable confidence in yourself and your training and do not hesitate to ask for advice or run things with your colleagues. If you are hesitating to ask advice from colleagues at your own institution or practice, take to Twitter or your friends at other programs, or form a messaging group of your former co-fellows.

7. Communicate. Always try your best to call the consulting team and hospitalists back with your recommendations, even if you wrote an excellent note. You can pull people towards you by being an excellent communicator and it is always appreciated. This is one of the best ways to get more people to know about you when you are new.

Manasi Bapat, MD
Nephrologist, CA, USA
NSMC intern 2018

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