Medicolegal Issues

Transition Time


The light at the end of the tunnel has arrived—finally. The long hours, scut work, and call nights have paid off; you’re an attending. The transition to the “real world” can be intimidating, especially when you’ve been in training for so long. Here are some tips to ease the transition.

1. Cultivate relationships. Your interactions with nurses, house staff, case managers, social workers, and your colleagues are even more important as an attending and will serve as the building blocks of your reputation. Diplomacy during times of conflict is invaluable. Your approach to resolving situations can further your career—or be a barrier to success.

In the beginning, you might be misidentified as a resident, so it’s important to introduce yourself and have regular conversations with colleagues and consultants until you are recognized and are on a first-name basis with them. Effective communication will go a long way with your patients, their families, and primary-care physicians (PCPs). The benefits of good communication include good Press Ganey patient satisfaction scores, less liability from lawsuits, safer hospital transitions and discharges, and a successful HM practice.

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2. Learn the business of practice. The first year of practice will feature a steep learning curve in the areas of billing and documentation. Effective and appropriate billing is essential to maintaining the financial viability of a hospitalist group. Most HM groups provide formal training in billing and documentation as well as chart audits by billing experts. You may find it helpful to review “Billing and Coding” articles in The Hospitalist (also available at

Take time to learn business goals and areas in need of improvement, as this will allow you to improve individual and group performance. This may include maximizing pay for performance, improving hospital throughput by prioritizing discharges early in the morning, and reducing length of stay and readmission rates.

3. Seek work-life balance. Expect to be presented with multiple opportunities to get involved outside of your clinical duties. You could have the chance to participate in quality-improvement (QI) projects, teaching, hospital committees, and research. These activities will add to the depth of your curriculum vitae and give you a voice in hospital operations.

It’s important, however, to remember to pace yourself when you add duties outside the realm of your primary job responsibilities. Avoid spreading yourself too thin. As an attending, your work hours will be fewer and your salary will be better, but your responsibility will be greater. Be sure to set aside personal time and make job satisfaction a priority. More information is available in “A Challenge for a New Specialty: A White Paper on Hospitalist Career Satisfaction” (, which outlines the pillars of career satisfaction: autonomy/workflow, workload/schedule, reward/recognition, and community/ environment.

4. Stay current. In addition to reading prominent journals, such as the New England Journal of Medicine and the Journal of Hospital Medicine, look to newer resources that screen up-to-date literature for articles most relevant to hospitalists. American College of Physicians (ACP) members can sign up for ACP Journal Club Plus (, which provides periodic e-mail alerts when new articles meet customized quality and relevance filters. The Hospitalist has a monthly column, “In the Literature,” (see p. 9) that summarizes recent medical research. It also is important to understand how to find evidence-based information quickly. Familiarize yourself with Medline searches and pre-appraised literature resources, such as the Cochrane database, the print version of ACP Journal Club, and

5. Be efficient and thorough. Time-management skills are critical as an attending, especially when you’re being pulled in multiple directions. Develop a “to do” list to stay organized. When you are working with nurse practitioners, physician assistants, and residents, delegate certain duties to maximize your own efficiency. Their notes often can be used to assist with documentation, but remember to properly chart the clinical rationale for critical decisions and document medical stability on the day of patient discharge. Be sure you regularly review primary data, such as imaging, culture results, and consultant recommendations. Routinely communicate with PCPs—a prompt, real-time discharge summary is easiest when the information is fresh in your mind, and it ensures proper follow-up care.

6. Know help is available. Just because you’re not a trainee anymore doesn’t mean help isn’t available. Medicine is a constantly evolving field, and you will encounter novel disease states as well as changing diagnostics and therapeutics throughout your career. When you encounter a challenging case, use your colleagues as a sounding board for ideas. When you’re not sure what to do, consultants can be called to assist. Remember, you’re not there to impress others but to provide the best possible care for your patients. Sometimes that means obtaining the advice of a specialist.

If you practice with physician extenders or house staff, you’ll find it helpful to occasionally speak directly to the attending consultant. This helps promote collegial relationships, gives consultants a better understanding of your concerns, and improves your own base of knowledge.

7. Use supervisory skills. If you are practicing in an academic setting or one with physician extenders, you will want to be readily accessible to house staff, physician assistants, and nurse practitioners under your supervision. When you first greet a patient, be sure to clearly identify yourself as the attending physician. At the same time, afford trainees the opportunity to experience being the physician—allow them to actively participate in decision-making, reinforcing best-practice and evidence-based principles as you teach.

8. Understand licensing and certification. Understand your state’s policies and start the licensing process right away, especially if your first job is in a state other than where you completed residency. For most hospitalists, this means taking the medicine boards, then a recertification exam every 10 years, as well as regularly completing continuing medical education (CME). For those looking for a promotion down the line, familiarize yourself with the culture and selection criteria of your individual hospital or group. TH

Dr. Huang is assistant clinical professor in the department of hospital medicine at the University of California San Diego Department of Medicine. Dr. Patel is associate director of hospitalist services at Staten Island University Hospital and assistant clinical professor of medicine at SUNY-Brooklyn. Dr. Chacko is a member of SHM’s Young Physician Committee and medical director of the hospitalist program at Preferred Health Partners in New York City.

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