Finished medical school? Now you’re a doctor. Done with residency? Now you’re really a doctor. Earned your fellowship certificate? Yikes. It’s the end of the line. Really. And now all of the highs and lows are yours and yours alone.
Dr. James Lubowitz, founder of the Taos Orthopaedic Institute in New Mexico, and fellowship director at that institution, has observed many newly minted surgeons go through the anxiety of taking on full responsibility for the welfare of patients. He explains, “The main issue is that someone is going from a situation where they are being supervised to a situation where they have complete autonomy. Such responsibility is enormous, especially when you’re talking about an invasive interventional procedure that patients are relying on to improve their lives.”
And while it may seem like the young are being hurled from the nest, in fact, says Dr. Lubowitz, there is time to adjust. “Throughout the process of becoming an orthopedist there are increasing amounts of autonomy conferred upon trainees, such that there is a gradual exposure to more and more responsibility. On the other hand, the stress is still very high, probably because no amount of gradual exposure and increased autonomy can prepare surgeons for the total responsibility that awaits them. In the end, there is no gray area. All throughout training 100% of the responsibility ultimately falls to the attending; there is always a teacher to answer questions and/or assist you. When the fellowship ends, however, the trainees go from having someone there to no one at all.”
The Reality of Responsibility
When reality sinks in, the fellows move in a little closer to soak up as much knowledge as possible. “Toward the end of the year in particular I may say, ‘Do you want to watch me do it one more time? Because as of August 1st you’re never going to have anyone to watch you ever again.’”
“I don’t get many ‘no’ responses. It’s funny because for their entire training orthopedists clamor for more and more hands on experience like 16 year olds yearning to get their drivers licenses and to get their hands on the wheel. Then all of a sudden they realize, ‘Hey, this is real. I’m going to be completely on my own.’”
This is not to say, however, that Dr. Lubowitz won’t answer their phone calls. “Sometimes for months, and even years my former fellows contact me for advice. We have established a mentoring relationship, and they sometimes look to me for emotional support and a sympathetic ear. The problems they’re facing can be related to problems we all face, so I just commiserate with them and validate their experiences.”
But in the heat of fellowship, don’t wait until someone starts missing rounds or says the patients are annoying. Dr. Lubowitz: “It is important to monitor fellows for high levels of anxiety, something made easier because we have guidance from the Accreditation Council for Graduate Medical Education. This includes quarterly evaluations in which we ‘screen’ for any signs of burnout or extreme fatigue. Program directors should be proactive and raise those or other issues with fellows. In our program we discuss the stress of transitioning out of fellowship from the initial interview until they walk out the door.”
A significant part of handling anxiety is feeling like you have some control over a situation. To this end, says Dr. Lubowitz, fellows can ease their transition by retaining their dedication to learning. “We teach fellows to develop the tools to continue their medical education. This includes courses, literature, and new techniques…all things which help them be prepared, and thus less anxious.”
In addition to continued education, confidence and humility are important to this transition. Dr. Lubowitz explains, “Fellows who transition with fewer difficulties are those who have confidence in their surgical skills and have a realistic ability to provide an accurate self assessment. Some orthopedists have limitations, especially when they are in training. If a surgeon can say, ‘This is good, but I can be better’ then that shows a certain appropriate level of humility. It is human nature for even the most confident surgeon to express the occasional self doubt and humility. Part of this gets to maturity. I don’t know of any other apprenticeships where you start on your own so late in life. Sometimes in surgical training there is a real discrepancy between age and level of maturity in terms of what you know about being a professional in the real world.”
WWMMD? (What would my mentor do?) That, says Dr. Benjamin Domb, a specialist in sports medicine and hip injuries at Hinsdale Orthopaedic and Loyola University in Chicago, is what flows through one’s mind during this period of transition. Dr. Domb, who completed a sports medicine fellowship followed by a fellowship in hip arthroscopy and joint preservation, entered practice two years ago. “You start to imagine every situation you encounter as how it might play out if you were alone and would be the one making the final decision…and of course you think, ‘What would Dr. XYZ do?’”
Dr. Domb: “Most fellows feel like calling their mentors often in the first couple of months. This is especially true of those stressful moments when you’ll be doing a given procedure for the first time in practice and you’re up the night before thinking through the steps of the case…and you know that there will be no one there to lead you through them. These are all-consuming moments when you’re thinking of the variety of things that could go wrong. Especially for cases that are unusual, it is invaluable to be able to call one’s mentor and talk things over.”
And then, you can always talk to yourself.
“Mental rehearsal is an essential part of surgical preparation, ” suggests Dr. Domb. “Much of the stress we experience is because we are doing things for the first time all alone. It is helpful to visualize each step of the surgery in great detail. Review each juncture where something could go wrong and decide—ahead of time—how you would deal with it. That way these things are ‘off the table’ as issues to be concerned about.”
Proving that nothing can replace experience, Dr. Domb says, “When you’re starting out you haven’t seen the followups and outcomes of the procedures you’re doing. Your mentors have told you that xyz procedure works and you’ve read that the procedure works, but you haven’t seen it for yourself. Getting further along in your practice, however, will gradually engender confidence and reduce stress. Some of my anxiety emanated from the fact that a significant area of my work, hip arthroscopy, is rather new and doesn’t have a long history of literature on the outcomes. After I achieved positive outcomes, however, my stress was allayed.”
Some of Dr. Domb’s wisdom comes from having trained at the esteemed Kerlan-Jobe Orthopaedic Clinic. “My program was dedicated to teaching us to prepare for our own cases, including the thought processes that would stick with us through the ‘heat’ of the moment in the OR. Such preparation instilled us with a sense of confidence that we were doing the right thing. Because we spent a lot of time reviewing the literature and evidence for cases, we came out of the fellowship not only knowing how to do surgery but with evidence indicating that we were doing it the right way.”
Advice for Newly-Minted Surgeons
Addressing the sometimes forgotten non-orthopedic areas of a fellow’s life, Dr. Domb states, “In many cases fellows have just moved to the area, often with a family in tow. There is a new job, new people, and a new locale. To reduce any of this peripheral stress, I would strongly recommend giving yourself some time and moving a little bit prior to starting your new job.”
The business side of the medical world can also raise the blood pressure. Dr. Brian Wolf, the Director of the Sports Medicine Fellowship at the University of Iowa, says, “Those fellows headed for private practice often get a rude awakening when they step into the wider world and find out how important a business background is in today’s world of medicine. Unfortunately, this type of information is not part of one’s training. Coding, along with other things that make a private practice viable, must be learned. There are such courses sponsored by the American Academy of Orthopaedic Surgeons, as well as the subspecialty societies, that can help make the transition out of fellowship less stressful.”
Drawing a line in the sand with regard to training makes for a quick change of hats. Dr. Wolf: “As many fellows do, I went straight from fellowship to an academic setting where I was teaching fellows and residents. In a situation like this, the important thing is not to take on things that you don’t feel ready to handle. You must be open to asking for advice, whether from a partner, previous mentor or colleague; people get into trouble when they are afraid to say, ‘I need help.’ You should also be extremely comfortable with xyz procedure, so that usually means you’ve done it several times. Just keep practicing the skills and get yourself to the point where you are comfortable walking someone through a case. And be patient with yourself. It is obviously a huge endeavor to take on this new role at the same time you are opening your own practice.”
And if there’s someone at home who can be patient with you, that’s helpful too. Dr. Wolf explains, “In so many cases fellows have moved to a new town to start a practice. If your spouse and/or kids are having difficulty settling into the area then not only will they be unhappy, but so will you. You will find it hard to fully concentrate at work if your loved ones are in the doldrums. Try to get them connected with friends and colleagues’ spouse. If that means you have a slower start to your practice then that’s just fine. It’s better than the alternative.”
