Preparation is Key to Tackle the Transition from Fellow to Attending Physician

Taking the proper preparatory steps throughout a hematology/oncology fellowship can help smooth the transition from fellow to attending physician, according to David Russler-Germain, MD, PhD.

“I’m a lymphoma attending physician-scientist, so my fellowship training was on the unique side because I did what’s called the Physician-Scientist Training Pathway. However, most of the lessons I try to share with [trainees] are universally applicable to anyone doing traditional clinical training,” Russler-Germain said.

In an interview with Oncology Fellows, Russler-Germain discussed his experience transitioning from a fellow to an attending physician following the completion of his hematology/oncology fellowship program at Washington University School of Medicine in St Louis, Missouri, in 2023. He highlighted the areas of his training that he found useful during his transition and the biggest adjustments during this time, and he shared advice for fellows preparing to make the jump to becoming attending physicians. Russler-Germain is an instructor of medicine in the Division of Oncology at Washington University School of Medicine.

Oncology Fellows: What could make or break a fellow’s program experience?

Russler-Germain: For most fellows around the country—and my experience was like this—the front end [of training is] loaded with inpatient consult rotations plus a smattering of outpatient clinical rotations. As you transition into the second and third year of fellowship, you become more and more subspecialized, especially as an aspiring academic and for those who train at large tertiary centers.

I enjoyed all aspects of fellowship, even clinics that were unrelated to areas of my research or eventual career. So much of that [enjoyment] depends on the individuals you work with. For example, in a neuro-oncology [rotation], you’re not working with every neuro-oncologist in clinic for months; you’re working with probably just one once a week for a few months. [Therefore], what they have going on in their professional sphere, what their clinic staff has going on, and who their referrals are during those few months can make or break how much you learn and how much you’re able to contribute to the team.

Going to a fellowship where the culture is good, you enjoy your training, and [you] have a successful training experience with all the attendings is aspirational but not always feasible. I believe individuals must be proactive
to ensure that a few different things don’t happen during your fellowship. It takes investment by both the trainees and the program to accomplish it.

The first [factor] is letting [trainees] operate at the highest level of their training. How much of your time as a [trainee] is spent doing physician-level tasks as opposed to non–physician level tasks? Let’s say you’re the first-year oncology fellow on the inpatient oncology consult team. These are patients with new diagnoses of cancer getting evaluated in the hospital, or they [may] have a prior cancer diagnosis. For example, if they have a known history of colon cancer treated 4 years ago at a community site, how much is it the fellow’s job to track down the clinic notes, pathology reports, and radiology reports from that patient’s prior cancer journey from another hospital years prior? [Comparatively], are there nurse coordinators or medical assistants whom the fellows have access to help accomplish that?

Those are the [individuals who] would do all that vital work in the outpatient setting so that the fellow is not personally faxing the records request form, receiving the fax, and filing it. Many institutions don’t offer their inpatient fellows any of these support services, but it can potentially ruin your training if you spend half of every day following up on faxes, sending records requests, and trying to track things down. Having individuals to help you delegate is very important.

The second [key preparatory factor during fellowship] is [patient] volume. It’s easy to get into a situation where you want to focus on education over training. [A fellow] can be very well educated about cancer from didactics, textbooks, and clinic experiences, but the muscle memory and the decision-making [skills must develop] with volume. As a third-year fellow, you can’t just see 4 patients in half [a] day of clinic and become an expert.

To be able to [practice] on your own, you need to be seeing 6, 8, 10, [or even] 12 patients in a half day [during fellowship] to see the breadth [of] that disease area and get comfortable with not only making the cancer management decisions but also dealing with all of the secondary factors. Let’s say you see 4 patients in a half day as a fellow because you want to learn as much as you can about that patient, their disease, and all the treatments for them. What you’re not learning is what happens when the first 2 patients on your schedule show up 20 minutes late and your whole day is multiple steps behind. How do you balance giving these late arriving patients the care they need while not punishing the rest of your schedule because you’re behind?

There are fellows who nudge their training toward lower volume but greater depth into those individual cases, and there’s a spectrum of how to balance that. On one end of the spectrum, seeing too many patients as a fellow and being unable to read about them and deliver good care is too chaotic, but there’s another end of the spectrum where you’re not seeing enough patients and [don’t become] truly skilled enough after training.

What did you do well during your transition from fellowship to your current position, and were there any aspects you found especially challenging?

Toward the end of fellowship, I tried to push my efficiency and volume, [including] volunteering to see more patients in clinic. Often in your continuity clinics as a fellow, there are the 6 return visits from patients you already know, and there’s 1 new referral. [However], if 2 of the return visits cancel, instead of just seeing fewer patients, you should ask [whether] you can see others. Being able to think on your feet and see a patient you don’t know anything about other than reading their chart for 5 minutes has to be an intentional challenge you give yourself.

[Because] most academic and private practices do a decent job of not overwhelming you with volume at first as an attending, it gives you the opportunity to slip into a micromanaging perspective where you’re clicking refresh on someone’s labs multiple times a day or you’re double-checking their charts unnecessarily. Understanding that you need to let the clinic operate as it needs to is important, without swinging too far toward the perspective of a subconscious worry that “I’m a novice, so there’s a small chance that I missed something or made a small mistake, but if I micromanage it, maybe I’ll catch that mistake or avert something from going awry.”

There’s a certain level of neuroticism that is helpful early on when you’re independent, but you don’t want to be overconfident. You also can’t be all consumed by micromanaging everything that happens in your patient’s chart and every message that your nurse is or isn’t sending them. In hindsight, I wish I could have let go a little more. I did a decent job, but I probably could have deescalated even further.

What advice would you have for fellows who are about to make the transition to attending physicians?

There are aspects of volume [needed during fellowship] to be ready for busy clinics, and [there are] aspects of bandwidth in terms of how much you micromanage or not. Another aspect is independence of decision-making. I now have fellows and residents in the clinic with me. The default for them might be to defer to me as opposed to going out on a limb and saying, “I would like to do this for the patient today.”

Fellows must accept that sometimes they will be wrong or suggest things that the attending disagrees with. When I see a new or a [returning] patient with a fellow, I say, “What’s their plan for today?” If we are signing their R-CHOP [rituximab, cyclophosphamide, doxorubicin hydrochloride, vincristine sulfate, and prednisone] orders today, I want the fellow to consider: What are their premeds? What are their prescriptions they’re going home with? Are there any other things we need to worry about today? [I want fellows] getting into the nitty-gritty and trying to own all of the little decisions you have to make as an attending.

It’s important to practice flexing those muscles as a fellow, where a patient comes in and they have some lab abnormalities in clinic and you’re deferring their treatment. As opposed to reading about what to do with elevated liver function tests [LFTs] for a given drug, you should be able to give a guess. Should we get hepatitis testing? Should we do an ultrasound? Do I need to send them for a CT scan? Should I recheck their labs and if so when? Is there a medication I should hold now that their LFTs are elevated? Those are often secondary to learning the nuts and bolts of oncology. Getting in the practice of owning all the decisions for your patients, [and] trying to propose the full plan as a third-year fellow helps get you in the perspective you need when you’re independent.

What could hematology/oncology programs do to better prepare trainees for the transition to attending physicians?

It’s a 2-way street. Fellows and their programs need to be aware of what each other’s goals, intentions, and needs are, and understand what each side’s areas of improvement could be. The fellows [need to] understand how much more or less stressed they’ll be based on how many patients they are seeing in the clinic. The program could probably oscillate every few years to increase the workload or peel it back to try to work on a wellness perspective for the fellows.

But sometimes it’s not as simple as just turning the dial on the volume of the workload. It’s things [such as] identifying at a fundamental level what resources fellows need to succeed at this higher level of work. For instance, if you’re trying to see more patients in clinic, you need to have a medical record system and a nursing support system that allow them to do that successfully and not add busy work. You should be adding the doctor-type of work for the fellows, including more medical decision-making and more difficult conversations with patients about prognosis and end of life. Our program does a good job of protecting doctors from having to do busy work. Our fellows have access to the secretarial and administrative staff that the attendings have access to. Ensuring your fellows are treated this way makes it easier to optimize their medical training.