Transitioning from Fellow to Attending: 7 Things I Wish I'd Known

Hindsight is 20/20. Inevitably, everyone feels this at some point in their lives wondering, “If I knew then, what I know now, I would have…” Those experiences and challenges shape who we are today, but maybe anticipating such challenges would have made a task or a transition period that much easier to endure. As a new-in-practice pathologist, you try to be as prepared as you can be for your first attending role, but you would be hard pressed to find an attending several years into practice for which this statement does not resonate.

In the hospital where I practice, we are in a unique situation where there are more than a handful of junior faculty, many with less than five years of practice post training. Below I have summarized a few insights into the things we junior faculty wished we would have known before starting our new job and how this potentially would have helped make the transition from trainee to attending easier.

Knowledge gaps of other clinicians

As a resident and especially as a breast fellow, I understood that communication is a large part of the breast department and the interdisciplinary approach to patients. However, as a fellow, most of my communications with clinicians were either to relay if a report would be delayed or diverting a specific question to the attending about a particular diagnosis. In contrast, as an attending, not only are you communicating to relay anticipated sign out delays, you are also communicating thoughts on the diagnosis, if that diagnosis is concordant, and how this will affect the patient’s follow up. Some cases that require a phone call are obvious, such as not finding an explanation for a mass. However, other cases may seem straightforward to pathologists, such as a rare entity like osseous metaplasia being the cause for calcifications, but not so much so to a clinician. This is an instance for which a conversation should take place before a report is signed out and is automatically visible to the patient. I wish I knew then that more communication is always better than less. This would have saved me several conversations with a confused, disgruntled clinician who felt they were left in the dark about a particular diagnosis and would have allowed me to attain that clinician’s trust in me and my diagnoses much sooner.

Unclear professional development requirements

As a trainee, you often hear about continuing medical education (CME) but are not quite certain about what it entails, how to earn CME, and how much is needed to maintain licensure. Even in your first time certifying as a new-in-practice pathologist, the full scope of CME is not truly understood since proof of fellowship completion counts toward your CME. Additionally, if working at a private practice, attaining CME may be difficult due to lack of opportunities, monetary funds, and time off service to attend national meetings. Even when opportunities are plentiful, it can be difficult to organize CME documentation. I wish I knew the ins and outs of CME before starting as an attending. This would have made it less stressful when it came time to re-certify.

Difficulties in executing and completing research

If hired at an academic institution, know that research is an expectation of your role as a pathologist. As a resident or fellow, you likely participated in research projects and may even have presented them at national meetings. However, as an attending, you realize all the work that needs to be performed before you can even collect data. An Institutional Review Board (IRB) needs to be written and potentially modified multiple times to get approved. Writing an IRB is an art form that takes time, which is likely lacking in a new pathologist’s schedule. Additionally, patient confidentiality may present another roadblock and require you to hire a third party to acquire data needed for the project at hand. Finally, being that all pathologists at an academic institution need to perform research and publish, there are many individuals utilizing these resources. This may, in turn, cause the approval and data collection to take much more time than anticipated, causing you to potentially miss meeting submission deadlines. I wish I knew the extent of the expectations of research projects before starting as an attending, which would have allowed me to start performing research sooner in my career.

Pressure to prove yourself

When you start your new role as an attending, you often feel pressure to say yes to every project or opportunity that comes your way. Even though promotion is still years down the line, the need to say yes comes from wanting to grow and develop your CV. Aside from promotion, new-in-practice pathologists may feel a sense of urgency to produce something to show their worth to others in the department. This can lead to being involved in projects or serving on committees that you are far from passionate about. In hindsight, I wish I knew that saying yes is warranted when projects interest you or help further your career. Otherwise, it is okay to say no. Saying no, however, is often easier when you are already participating in several other projects or committees, so I would suggest seeking out passion projects early.

Emotional impact from making a mistake

During training, you hear from attendings that mistakes are inevitable because you cannot be correct 100% of the time. This is likely why some new-in-practice pathologists obsess over cases to try and delay when that first mistake will occur. With years of training under your belt, you are meticulous with cases and think that you will be prepared to deal with the mistake that will eventually occur. However, you realize that you often are not prepared for how hard the mistakes that you make can affect you emotionally, much less how to handle all the complexities of dealing with the mistake itself. I wish I was better prepared for dealing with that emotional roller coaster, including how it can affect you outside of work.

Cases with no definitive diagnosis

As a trainee, you sign out with an attending at the microscope, and they relay what they think about the entity on the slide. In your mind, you believe that if the other pathologists within the department looked at this slide, they would come to the same conclusion. You may or may not be present when they discuss an uncertain diagnosis with another pathologist. That pathologist may agree or disagree, suggest additional work up, or a different verbiage for the report to relay the findings. However, as time passed during my first years as an attending, I realized that showing a case for consensus—even to multiple pathologists—does not ensure an accurate and definitive diagnosis, only defensibility. I know that as a newer pathologist, I should show cases as often as I can, but I wish I knew that doing so doesn’t necessarily guarantee a correct, definitive diagnosis.

Value of supportive colleagues

When accepting a job, priorities vary. Different individuals may prioritize having a large breadth of cases in private practice versus looking at one system all day in academics. Others may value having professional development opportunities. Finally, location is an aspect that many individuals regard highly. Perhaps, it is a location that is your home that you want to return to, the place where your significant other resides, or even a place you always wanted to live in. However, the significance of future colleagues or workplace culture may not always be apparent as something you should prioritize. I wish I knew that good colleagues are a very important component of the happiness that you feel at work and should be considered one of, if not the, most important aspect to consider when taking a job.

In the end, looking back to move forward will always be something we must do in our lives to arrive at the answers we seek. However, since someone starting a new role has so many questions already, any passed down wisdom can be seen as beneficial. Therefore, by sharing the wisdom gained from our past experiences, we hope to help ease the transition period of future new-in-practice pathologists.

Carissa LaBoy, MD, FCAP, is an assistant professor of pathology with a subspecialty in breast pathology at Northwestern University Feinberg School of Medicine. Dr. LaBoy completed her residency training at McGaw Medical Center of Northwestern University and is board certified in anatomic and clinical pathology.