Dear Senior Resident or Fellow, I’m guessing this feels like both an exciting and scary time. And bittersweet too because one life chapter closes as another opens. Allow me to share thoughts on your transition. I bring up, among other issues, some uncomfortable ones and do so to inoculate you against their possible downsides.

Greatest Challenges in Being a New Attending

On your new job, you will be surrounded by a few or many colleagues, or perhaps none at all. Even in the best scenario, it’s likely that you will feel some isolation because the time of greatest camaraderie occurs now during training. Sad to say: It may never reach this level again. This likelihood of your relative isolation is the most compelling reason I’m writing you today, while you still have months together in your training program. My advice is to prepare for this change in your day-to-day experience at work by strengthening the bonds with your colleagues now. Plan on keeping in touch and decide how and when this might occur. For the in-town group, you can decide to get together in person at some regular interval, perhaps once a month. If you’re moving away or most of you are dispersing, decide to do online meet-ups instead.

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Another change in becoming an attending is decreased opportunities for curbside consults. If you stay in touch with your colleagues, you can use each other for informal consults. Simply keep the patients’ identities confidential and agree that you’re sharing “general medical advice” and not acting as formal consultants.

Another potential challenge you’ll face is feeling like an imposter. When you transition from treating patients as a resident or fellow to treating them as an attending, you will be struck by the increase of responsibility you feel. This will become especially evident with your first self-pay patient. Suddenly, you will question whether the benefits you offer are worth, let’s say, $350-$500 an hour. Please regard this as a positive challenge. If you don’t believe your services are worth that much, then ask yourself what it would take to bring your skill set and the benefits you offer up to that price point. Sorry, unless your new practice has a sliding scale and your self-pay patient meets criteria, you can’t just decide to charge them half as much because you’re new and just getting into the swing of things.

Of course, my point here applies to your treatment of all patients, not just self-pay patients. It’s just that when you know a person is paying out of pocket that this realization of a possible gap in “cost to value” strikes more acutely. Every patient deserves your best, of course, irrespective of how much they pay or who pays for them. My advice is to always keep learning and improving. Pay attention with every patient to what interventions work and which don’t. Attend conferences. Force yourself to expand your treatment armamentarium. It’s easier than you think to become fixed in your approach over the years. Your challenge is to believe (on good evidence) that what you do is worth whatever the cost of your services is and, preferably, a lot more than that.

Financial, Time, and Focus Possibilities Related to Your New Job

As your income increases, consider increasing your standard of living (your annual spend) to somewhere in between your current and new incomes, that is, avoid increasing your spending all the way to match your new income. Even with this approach you will still experience a substantial increase in what you spend, while avoiding (or slowing) getting caught in the rat-race. Imagine the freedom and flexibility you will have by accumulating (saving or investing) your surplus money.

An alternative approach is to not maximize time spent working. Even if you take a part-time job you will still increase your income substantially. So, this and the previous point highlight that with your transition to taking the role of an attending, you can have some ratio of surplus money or time. What will you do with more money? Possibly with more time? What choices would most reflect and align with your long-term goals and life values? Good questions to ask anytime and especially apropos during a time of transition.

Also, consider specializing in a clinical niche of particular interest to you. This does not require completing sub-specialty training and applies equally to general psychiatrists and sub-specialty psychiatrists. The happiest psychiatrists I know are those who develop deep expertise in a particular area, such as in managing adults with ADHD, consulting with women who are pregnant (or considering pregnancy) or breast-feeding, treating the “doubly gifted,” that is, high performing kids with additional issues such as ADHD or ASD, or providing second opinions to patients with treatment-resistant conditions. I know psychiatrists with patients from all over the country and even the world who travel to see them for consultation (and often follow-up through tele-medicine). I like to point out to clinicians that your catchment area is now the globe.

Thoughts for Your Remaining Months in Training

One of my biggest personal accomplishments during my training – for which I thank my supervisors – was becoming able to tell the people that meant a lot to me that they meant a lot to me. Before then, I was too shy to tell anyone anything like that. So, this is the time to let your colleagues, supervisors, and staff know that you’ve cherished the experiences you’ve shared and are grateful for what you’ve learned from them.

Learn everything you can NOW while still in training. Prescribe (when clinically appropriate, of course) the medications you haven’t yet prescribed. I have found that it gets harder to incorporate new treatments into your armamentarium once you’re on your own. For new-career psychiatrists, the most challenging meds are the older ones. They remain phenomenally effective but carry a greater adverse effect burden. Before you leave, consider prescribing (as appropriate) a TCA, MAOI, and clozapine. Assist in sessions of ECT or TMS if available and, if not immediately available, confer with your training director on getting involved in outside clinics that provide these somatic treatments.

Thanks. My wish for you is that you will remain energized, challenged, and gratified by the career you have chosen.

All the best,

Dr. Jack


Today’s Quotes

“Forever friends are a treasure chest of understanding and compassion. Cherish them.”
Ann Leigh Mercree

“I’m owed nothing, but I’ve been gifted with everything. As such, I owe everything the commitment that I will never find myself treating ‘everything’ as ‘nothing’.”
Craig D. Lounsbrough

“Someday you will miss today.”