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"Now that you’re an attending, are you respected as one?"

October 2014

Published in the October 2014 issue of Today’s Hospitalist

AS THE MEDICAL DIRECTOR of a hospitalist program between 2005 and 2010, I was responsible for hiring and mentoring physicians. Given the attraction of hospital medicine to new graduates, most of our doctors were “rookie” attendings.

Before long, most were discouraged about the lack of respect they felt from other physicians, nurses and hospital administrators. But it soon became apparent that the level of respect these new attendings received correlated with their understanding and willingness to embrace the following principles. I’d like to share those principles with young attendings to help make their transition from residency more successful and satisfying.

Principle #1: The attending is always “on stage.”
During training, the resident is rarely “on stage.” That time is limited to the few minutes they spend at patients’ bedside being evaluated by their attending and the other team members.

After a few weeks, the resident shifts to a new service with different attendings and nurses and starts the process over again. This paradigm barely gives others an opportunity to form an opinion of the resident as a person and physician. It also creates an environment in which residents don’t experience any lasting rewards for or consequences of their behavior.

Attendings, on the other hand, are evaluated in more than just clinical situations, which already range from conducting a family meeting to directing a cardiopulmonary resuscitation effort. Attendings are also “on stage” when discussing a case with a consultant in a charting area, responding to a nurse who just admitted to a medication error or being questioned by an administrator about their higher-than-average length of stay.

Attendings are even “on” when they decide to pick up “or walk past “a piece of litter on the hospital floor. People use these seemingly inconsequential behaviors, which have no direct bearing on patient care, to form impressions. Those in turn determine the respect new physicians receive.

New doctors may be uncomfortable with this fishbowl environment. But this same environment also yields many opportunities to build a positive reputation.

Principle #2: There are no “off-the-record” comments.
Residents accept the fact that they lack clinical experience. They also know, however, that they are at that point in their career when they may be the most knowledgeable about the latest evidence-based medicine, which they rely on to guide their clinical care while they gain more experience. They also need their colleagues to have confidence in their competence, and they are eager to reassure colleagues that they possess the necessary clinical knowledge.

In practice, it may not be long before the young attending finds that the care rendered by another doctor is inconsistent with current standards. In an attempt to display their knowledge to new associates, it may be tempting to air the other physician’s poor clinical judgment.

But doing so will not make a positive impression. The doctor being criticized may have a good reputation and be well-liked “and that physician will receive the benefit of the doubt regarding a difference of opinion in patient care, whether warranted or not.

New attendings should also assume that any critical comments they make will eventually get back to the doctor in question, and they may not be able to repair the resulting damage. The bottom line: Never make critical remarks about a colleague publicly. Instead, discuss differing opinions of clinical care in a private, one-on-one conversation. The result will be increased trust and respect between these two individuals, regardless of whether they ultimately agree on the clinical issue at hand.

Principle #3: To be respected as an attending, act like one …
When it comes to accepting new admissions or consults, residents master the art of “blocking” admissions, and they have no problem explaining why a consultation they are asked to perform doesn’t require a bedside evaluation. In the real world, however, a respected attending will have multiple reasons why he or she is the best doctor available to admit or consult on that patient. Other physicians easily recognize the failure to make this attitude adjustment, and they don’t appreciate it.

Principle #4: … speak like one …
Certain language often accepted among residents may offend patients’ families, nurses, administrators and other physicians. Charting areas, nurses’ stations, the cafeteria and even the hospital parking lot are not safe zones where what you say isn’t heard by others. Remember principle No. 1: The attending is always “on stage.” You never know who may be listening and taking note.

Principle #5: … and look like an attending.
What you choose to wear has an impact on how much respect you’re given, a fact proven repeatedly in psychological studies. New attendings who continue to look like residents, perhaps by wearing scrubs every day, can expect to be treated like residents. We can all agree that appearance has nothing to do with quality of care and that dress should not influence how one is accepted as a person or a professional. But the reality is that it does, so just accept it.

Principle #6: The respect you get won’t be more than what you give to others.
Everyone wants to be valued and respected. Attendings who ask team members for their opinions or suggestions regarding a patient’s care plan understand this concept, and they show the same respect to a nurses’ aide as they do the VPMA. It is easier for staff to respect that kind of attending than one who treats people differently based on their title.

Embracing these concepts and incorporating them into daily practice is easier said than done. But the damage done to one’s reputation by a seemingly benign comment early in a career can be difficult to repair. The sooner a foundation for a respectful practice is laid, the faster and easier it will be to reap the rewards of being respected as an attending.

Douglas W. Bowerman, MD, is a hospitalist with Delphi Hospitalist Services LLC, which is based in Rochester, N.Y. A hospitalist since 2001, Dr. Bowerman currently practices at Clifton Springs Hospital in Clifton Springs, N.Y.