“Avoid the Mind Trick”: Tips for Transitioning From Fellowship to Practice

By: Steven DeFroda, M.D., M.E.


As we round the halfway point in the academic year, it becomes an exciting but nerve-wracking time for both departing Arthroscopy Fellows as well as excited Orthopaedic Residents who are starting to interview for sports medicine and arthroscopy fellowships. While much has been discussed in this space regarding the best way to treat a meniscal tear or whether to add lateral extra-articular tenodesis (LET) to anterior cruciate ligament (ACL) reconstructions, medical education and advice for early career surgeons are not frequently discussed topics. As an attending surgeon now in my second year of practice, this area interests me and is a topic that I feel is not discussed enough: the transition from learner/trainee to attending, a transition that seemingly happens overnight (whether you are ready or not!)


But what does that mean? I did my sports medicine training at Rush University Medical Center. Rush is admittedly a unique place and an incredible place to train. All the attending surgeons are leaders in their area of expertise and had well-cultivated practices with excellent surgical teams, from their physician extenders and office staff to their scrubs in the operating room, many of whom have worked with these physicians for years. Dual operating room days flowed seamlessly, case volume was high and referral patterns within the community were well established. It was routine to have a 70-patient clinic followed by a 12-case operating room day. Our prior attending then went on to explain that for most starting in practice, this would not be real life. He urged us not to be discouraged by low patient or case volumes early on. That this is normal and to be expected.


Additionally, not only are you now functioning as a new attending surgeon, but you also must educate new staff, as well as form connections with referring providers to build a practice, often from scratch. Very few newly graduated sports medicine Fellows are going to walk into a clinic full of high school-aged ACL injuries and shoulder dislocations on their first day. The ramp-up was slow and sporadic for me as well as many of my co-Fellows. Many new trainees will have to dust off their general orthopaedic skills and take general call; forget that LET, let’s talk about dynamic hip screw (DHS) versus using a nail for intertrochanteric hip fractures! The reality is that, except for a few instances, the physicians in your community are not familiar with you or what conditions you treat, and likely have set referral patterns in place prior to your arrival.


So, what can one do to ease this transition? First and foremost, I would recommend trusting the process. Your job recruited you for a reason, and that was to fill a need. More or less, “if you build it, they will come,” but you have to put yourself out there. Build connections with nonoperative and operative providers alike. Let the trauma surgeons know you do reverse for fracture or other “cold trauma” that they may not be interested in. Let the nonoperative or family medicine physicians know if you scope hips or do injections; make their lives easier. I believe James R. Andrews, M.D. used to always say, “the best ability is availability,” and as a new attending surgeon (or any attending surgeon, really), this cannot be understated. In my experience, if someone is asking for your help with a patient, you should make it as easy as possible to accommodate them. Overbook the patient and see them the same day; this will go a long way to earning trust and building a practice. At the end of the day, if you make it easy for people to send you patients, they will send more and more. Additionally, thank referring providers for sending a patient your way. A simple text message or email could open a stream of referrals that will help you build your new practice.


Even in the age of internet and social media, the best advertisement for yourself is word of mouth. A quick example: My literal first case as an attending surgeon was a clavicle fracture open reduction internal fixation (ORIF) in a college kid. I added him onto my clinic schedule the same day of his injury because his parents called and asked that I see their son sooner. My clinic had openings and I was thrilled to get an operative patient as a new provider. He ultimately did great and healed his fracture, but wanted his hardware removed. He arrived with a knee brace on during his preoperative visit; it turns out that he had a noncontact injury a few days prior playing soccer and was waiting to get his knee checked out. Upon examination, I diagnosed him with an ACL tear. Long story short, I treated his ACL, then removed his plate a few months later. When his brother, a collegiate soccer player, tore his meniscus, his mom knew just who to call. This is how you build a new practice. Every hip fracture or patient with shoulder pain has friends and family, and one patient can turn into many very quickly. Don’t get discouraged with empty clinics early in your practice. Take this time to meet with physical therapists, refine your postoperative protocols and think about your surgical techniques as well as how to best care for patients. In a few months you’ll be too busy to do these things, so take advantage while you can.


The last piece of advice is more of a statement that’s also from one of my mentors at Rush: “Prepare for the longest fellowship of your life.” I laughed when he said this to me, but he was right; as an attending surgeon, you are constantly growing and learning. Use your resources, both prior mentors and prior co-Fellows or co-Residents, to bounce cases off of and discuss patients. One thing you lack as a new attending surgeon is the memory bank of thousands of patients treated and what works/doesn’t work. There is a lot of gray area in the field of sports medicine, and a lot of opinions on what is best for the conditions we treat, oftentimes with many correct (and incorrect) answers. This is something that will constantly change and evolve throughout your practice. Learn from every case, refine your techniques and treat every patient the way you’d want to be treated. I think any AANA Member would tell you that there is nothing more rewarding than helping patients do the things they love doing; always keep this at the forefront and you will go far!

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