On Becoming an Attending

Alison C. Shmerling, MD, MPH

Fam Med. 2018;50(6):472-473.

DOI: 10.22454/FamMed.2018.736442

Seven years ago was my white coat ceremony, during my first month of medical school. I remember the anticipation and nervous energy that filled the room, as distinguished physicians initiated my classmates and me into the medical tribe under the proud gaze of our closest family members. A wave of emotion washed over me as I repeated and internalized the powerful sentiments of the Hippocratic oath. The afternoon ended quickly, spitting us out into the next 2 years of long hours, dense textbooks, and standardized tests.

After memorizing countless slides, algorithms, and anatomical anomalies, I was ready to interact with real patients. Each month, for the next 5 years, I essentially started a new job. First, in the clinical years of medical school, I learned the nuances of pathophysiology in practice and the unwritten curriculum of the medical profession. I learned when to speak up, and when not to; when to expect a food or bathroom break, and when to expect to be busy for hours. And just when I started to feel part of the team, it was time for a new rotation, in a new part of town, with an entirely new team of physicians and nurses. Despite the uncertainty of each transition, someone always told me where to be, when to be there, and which patients to see. Soon, I found a certain comfort in this routine.

On Match Day, the same anticipation and nervous energy returned. Moving west across the country, now with new letters after my name, I suddenly had more independence, and more responsibility. Yet in training for broad-spectrum primary care, I again found myself with a new team, a new specialty, and a new part of the hospital every month. Every fourth week was spent learning a different vocabulary, hierarchy, and culture, in addition to unfamiliar clinical understandings and procedural skills. Again, I relied on the comfort of knowing where to be, when to be there, and which patients to see.

At residency graduation, only the nervous energy returned. While excited to start the next phase of my career, I realized that I would no longer be starting a new job every month. There would no longer be someone—an attending, a senior resident, or sometimes a nurse—looking over my shoulder. No one would be ready to assuage my imposter syndrome. Despite the challenges that came with the monthly transitions of medical school and residency, the transition from trainee to attending has, in many ways, been more difficult. As much as I had looked forward to completing my training, my entry into the less structured real world brought a wave of uncertainty.

This time around, the medicine is actually what feels the most comfortable. I don’t panic before signing an order, and I know where to look if I can’t remember the dose. I know when I don’t know, when to gather more information, and when it’s time to call for help. I generally know now where to be, when to be there, and which patients to see.

But as an attending, there is yet another fund of knowledge to learn. This time it’s about myself. It’s about who I am, and who I want to be. It’s about working within the semistructured framework of an academic promotional track, while finding my own path to fulfillment and success both at work and at home. For the last 7 years, when I wasn’t sure what I should be doing, I would ask someone. I’d be handed a blood gas to interpret, a patient to assess, or an article to read. Upon arriving home, the precious time was spent cooking, eating or sleeping, leaving little time for hobbies, friendships, and self-care.

I am now faced with the luxury of more time and control over my next steps. But, I also face the challenge of having little guidance about how to navigate the way forward. It’s learning when to be where, and which of these roles I should be when I arrive. I could continue to fill my week with upwards of 80 hours of clinical work, reading journals, meticulously scrubbing the chart for a long-lost detail of a patient’s history, seeing one more patient. Or I could read about recently passed legislation affecting the lives of my patients, sign up to mentor a student preparing for his or her own Match Day; read a book, run, or spend time with new friends. As rejuvenating as this time should be, I find myself struggling to enjoy it. I feel guilty for the minutes not spent in clinical care. I feel uncertain about how to use my newfound flexibility to its highest potential. While bargaining with myself and my mentors to fill my time to the brim, I know I should be cautious and selective in my commitments. I mourn the loss of a life that was intrinsically unbalanced.

And so, I again find myself starting a new job. This time the job is not only learning how to be a great clinician. It’s also learning how to be a great researcher, teacher, mentor, friend, daughter, and wife. I’m not yet sure how I will prioritize and balance these roles. But, I remind myself that each is one I have embraced before, with its own team, its own location, and its own culture. I remind myself that others before me have had similar struggles, and that without some discomfort one cannot grow. And as each of these new roles brings the same anticipation and nervous energy I’ve felt with each new beginning, I remember I can always approach them one month at a time. After all, that’s what I’ve been trained to do.


Conflict of Interest Disclosure: The author participated in a Policy Day event on mental health on November 2, 2017. The event was sponsored by Takeda Pharmaceuticals. None of their products or treatment for mental health are discussed in this essay.

Lead Author

Alison C. Shmerling, MD, MPH

Affiliations: Department of Family Medicine, University of Colorado

Corresponding Author

Alison C. Shmerling, MD, MPH

Correspondence: University of Colorado, Department of Family Medicine, 12631 E. 17th Avenue, MS: F496, AO1, Aurora, CO 80045


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