Transitioning to practice from residency begins at the start of residency! As early as possible, familiarize yourself with different practice models, including ACOs and networks, that refer patients to your training setting. Make connections with new and seasoned practitioners who can share their experience and use electives to get firsthand exposure of prospective practice settings. As transition approaches, keep your geographical preference in mind.

—John A. Fromson, MD*

Strategic approach, extensive networking, and grounding in health care changes can smooth the passage.
By Bonnie Darves

For most physicians, the final year of training is exciting and challenging — and for some, a bit overwhelming because of the myriad, and sometimes competing demands on their time. Today, the rapidly evolving health services arena and constant health policy shifts add another level of complexity for physicians heading toward practice: Both are affecting practice opportunities’ structure, and employers’ and health care organizations’ expectations of physicians once they come onboard.

Despite these factors and the many decisions physicians face during their transition from training, those who develop an action plan and well-examined priority list, and maximize their network can manage the period successfully.

Most physicians interviewed for this article agreed that the first task in that transition year is to narrow two fields: The key attributes and practice scope the physician seeks in the initial position, and the geographic locations — both desired and acceptable. The second, all concurred, is to reach out to older colleagues and pick their brains about practice settings and realities.

“The hard but very important step is first determining what you want to do in your practice, and then being confident enough to voice that to your mentors. They have your interests in mind and can help guide you on what you want to achieve,” said Henry C. Lin, MD, assistant professor of pediatrics at the University of Pennsylvania and chair of the American Medical Association’s Young Physicians Section (YPS). “Once you find your focus, the key is to stay focused — which is easier said than done sometimes. It’s important to keep in mind why you went into medicine and make sure the opportunities [you consider] support that.”

Use professional society resources

To that end, Dr. Lin thinks that physicians’ specialty societies, national and state, can be extremely helpful. In many cases, those organizations have a mechanism — whether formal or informal — for connecting trainees to their older, practicing colleagues, for the purposes of exploring both practice opportunities and the different settings. “Your own home specialty society can help put you in touch with colleagues who are practicing in various settings — academic or community, and private practice- versus hospital-based,” he said.

Dr. Lin also strongly urges residents to attend their society’s annual meeting and resident conference, if one is offered, during their final year. Those gatherings are not only informative but sometimes lead, directly or indirectly, to the ideal practice opportunity, he pointed out. In addition, Dr. Lin notes that both the AMA’s main website and the YPS site offer a broad range of educational resources on preparing for the transition from training to practice (see resources at the end of article).

Orthopedic surgeon Alexander Jahangir, MD, medical director of Vanderbilt University’s Center for Trauma, Burn, and Emergency Surgery, is a major proponent of professional-society and program-alumni networking. “I encourage residents to reach out and even cold call former graduates of their training programs. I can’t imagine a scenario where someone would not to want to have a discussion with a younger colleague,” said Dr. Jahangir, who has been in practice seven years.

Dr. Jahangir notes that the American Academy of Orthopedic Surgeons is actively expanding connection opportunities for trainees. “There’s a more deliberate effort now to have more senior members of the academy interact with residents, and residents should make the effort to take advantage of those opportunities,” he said. “Residents should also realize that there’s an 80 percent likelihood they will end up practicing in a non-academic environment that could be very different from what they’ve experienced. So talking to surgeons in those environments is extremely helpful.” He also recommends that residents look for online forums and discussions groups in their specialty, as those venues are proving a valuable way to explore the realities of different practice settings.

Grasp basics of health care changes
John Cherf, MD, MBA, recent chair of the AAOS Committee on Practice Management and a sports medicine specialist at the Chicago Institute of Orthopedics, urges residents to reach out to colleagues who are still relatively new to practice. “I urge residents to connect with colleagues who have been out of training about five years. They’ll have a finger on the pulse of what’s happening in the field, and in practice settings in particular,” he said. He added that AAOS’ practice management committee members are also available to help job-searching residents sort through the practice economic and financial factors that they should consider as they explore opportunities and settings.

“We have people who can answer questions like, how much is a reasonable payment from the hospital for taking call, or who can explain employment models or productivity expectations,” he said. It’s particularly important now for residents to understand how they’ll be reimbursed for the care they provide, he added.

“Practice settings are changing, especially with the developments occurring in health care and the move toward employment. So don’t be afraid to ask questions,” Dr. Cherf said. “And if you’re looking at employed opportunities, keep in mind that hospitals today face significant financial constraints — and they don’t have the resources to employ everybody or buy all the practices.”

New York City internist Ethan Fried, MD, former president of the Association of Program Directors in Internal Medicine and director of the residency program at Lenox Hill Hospital, shares Dr. Cherf’s view that the trend toward physician employment does not mean that other models won’t persist. Traditional group practices are not going away, he maintained, and residents nearing the end of training should keep an open mind when they look at their options. At the same time, he urges young physicians to be cognizant of the changes that occurring in health care financing as a whole, and focus their search accordingly.

“We’re still seeing a lot of residents going into traditional jobs — joining practices as junior members, with or without a buy-in option,” said Dr. Fried, whose hospital is part of the giant Northwell Health System. “But I think that the smart ones are reading the writing on the wall and joining organizations that are setting themselves up for this new way of financing health care because that’s not going away.” The emergence of accountable care organizations and networks, and the trend toward government-payer reimbursement models that “pay for wellness, not sickness, and incentivize high-quality care, is here to stay,” he said. “Physicians who understand this will be successful.”

That means, in Dr. Fried’s view, that residents should gain a basic grasp of the new finance system, the performance measurements being tracked, and the strategies health care organizations are employing in reducing prevent readmissions and hospital-acquired conditions, to avoid monetary penalties. Many residency programs now offer some training in these topics, and some are incorporating such content into the main curriculum.

“Three years ago, I’d have said that only about half of residents were exposed to these concepts, but these days, it’s really entering into the curriculum,” said Dr. Fried, whose program has 94 residents. He advises residents in all specialties who are exploring practice opportunities to gauge practices’ readiness to enter into the alternative payment systems and manage the complex requisite performance tracking. “Residents should understand that an increasingly large percentage of their patients will be [managed] in systems where physicians are getting paid for meeting performance targets,” he said.

It’s understandably challenging for residents to grasp how these complex economic, financial, and policy trends can or will affect their daily practice lives, particularly when they’re so focused on improving their clinical skills. That’s where proactive networking with older colleagues in any practice setting under consideration pays off, Dr. Fried says. “Reach out to your colleagues who went into practice a year or two ahead of you. They’ve had to work all of this out,” he said.

Maria Regina Reyes, MD, a Seattle rehabilitation medicine physician and associate residency program director who heads the University of Washington’s spinal cord injury rehabilitation program, recognized several years ago the importance of better equipping physicians in training for the “real life” of practice. A longtime consultant to the university’s institution-wide “Life After Residency” seminar, Dr. Reyes has since developed a practice management course for her graduating residents that targets knowledge that helps them make a smoother transition.

“In their final year, most residents are feeling uncomfortable with suddenly becoming a full-fledged physician. Even if you’ve worked all of your life toward that, there’s a sense that all of a sudden, it is — well — dumped in your lap,” Dr. Reyes said. “And how are you supposed to manage that? The literature has shown that there are definitely gaps in our ability to train residents in this, but the challenge is how to build in time for this training.”

Dr. Reyes’ course focuses on four key areas:

• Narrowing the field in where and how physicians want to practice. “It can feel very high stakes — that either you’re going to choose the right job or fall off a cliff. So I tell residents that their first job likely isn’t their last — that many careers evolve over time,” she said.
• Identifying personal values, and making a value-based career decision. “In navigating the transition, I draw the analogy that residents should use their gut to a certain extent, in the same way they approach a patient assessment or a research project. But they should also have strategy,” Dr. Reyes said, “and gather evidence to perform an internal assessment of what they really want.”
• Assembling a personal and professional mission statement regarding the first practice opportunity. “Many residents say, ‘I just want any job in the area that pays well,’” Dr. Reyes explained. “That’s not very helpful. I explain that money isn’t the be all and end all — that because expectations for that money can be very different, it’s far more important to understand the requirements for that compensation.”
• Understanding the various practice settings, and the characteristics and attributes of people who are happiest in those settings. “That shouldn’t be the primary driver of what physicians choose, but it can be helpful in figuring out what might be a poor fit,” she said. “If making group decisions drives you crazy, for example, a very large organization might not be a good fit.”

The course also looks briefly at business issues such as financial management and professional liability, but its primary focus is on preparing physicians to make informed decisions about the chapter ahead. Recently, Dr. Reyes added a leadership seminar, and in the residency program, trainees complete a finance project. In addition, certain rotations now intentionally incorporate “real-world” concepts.

Seek rotations, shadowing opportunities
To facilitate the transition, elective clinical activities during the final year of training should be chosen, to the extent feasible, to help residents with the “field narrowing” Dr. Reyes describes. Formal rotations can provide an excellent way to experience subspecialty options and practice settings. Sometimes, however, the timing of these opportunities — they might be too early or too late in the year, or might coincide with training requirements or priorities — makes them challenging to pursue. In such cases, residents should consider shadowing opportunities.

“Shadowing can be very helpful because what you see in your short rotation might not be what you actually do in another [non-hospital] setting,” Dr. Lin, a pediatric liver specialist, explained. “For example, even though I do GI, I would have little idea of what being a GI physician really entails just based on my inpatient exposure.”

Residency programs are increasingly recognizing that their trainees might benefit from more exposure to both non-academic settings and the business basics of modern practice, and are trying to address that. In family medicine, for example, many programs are now offering a broader selection of rotations with community or rural providers, notes Marie-Elizabeth Ramas, MD, a new member of the American Academy of Family Physicians’ board of directors. “Doing rotations in the ambulatory setting is a great way to experience different practice environments, and the AAFP also offers a plethora of opportunities for residents to connect with colleagues in non-academic settings,” she said, citing a relatively new resident-connection section on the AAFP website. “I also recommend that residents check out forums on social media sites like Facebook and Twitter. Those offer a great way to get a sense of what your colleagues are experiencing, and to network.”

Dr. Ramas used her state AAFP chapter network during residency to talk to family physicians about different settings, and found those discussions extremely helpful. She chose her first position a few years ago, working as an independent contractor running at rural health center in tiny Mt. Shasta, California, based in part on those conversations. She recently tapped her network again in making the transition to a different experience — a New Hampshire community health center where she’ll be working in a far more densely populated area.

Brandi Ring, MD, a Denver obstetrician-gynecologist, used networking as her primary strategy when she was nearing the end of her training. She sought out colleagues in the region and asked to shadow them. To identify potential opportunities, she tapped her professional society and the American Medical Association connections she had made throughout residency.

“Making a practice [setting] decision about what you’re going to do is probably one of the hardest things to know as a resident, because all you know as a resident is residency,” Dr. Ring said. “You get a lot of exposure to employed practice and to hospital-based practice, but very little exposure to private practice and ambulatory practice. And as OB/GYNs we always have both.”

To bridge that gap, Dr. Ring spent short blocks of time — often during the afternoons when she was coming off call — in local colleagues’ offices. “I just called and said, Hey, can I come shadow you for a day or two, to see what it’s like to rush out in the middle of clinic to go deliver a baby, when you’re in the hospital 24/7?” she recalled. “I wanted to see how that worked.”

During those experiences, Dr. Ring, who is doing a fellowship in wilderness medicine, also gained valuable practice management guidance that she hadn’t expected. In conversations with her established colleagues, Dr. Ring learned about how best to use support personnel such as ultrasound technicians, and she picked up helpful time- and resource-organization tips. “When I found a system — a patient-flow sheet, for instance, or a standard operating procedure — that I liked, I asked if I could copy it,” said Dr. Ring, chair-elect of the AMA’s YPS and a volunteer faculty member at the University of Colorado. “Then I put those in my when-you-become-a-real-doctor file, so that when I went into practice I already had a selection of best practices.”

Based on her own positive experiences, Dr. Ring now counsels her residents to seek those shadowing opportunities before they decide on a practice setting, particularly in light of the changes in her specialty prompting the move toward the “laborist” model. “I advise them to start thinking about this in their third year, if private practice an option they want to consider. If it is, they need some experience to get a picture of what private practice is like,” she said.

Shani Muhammad, MD, who started practicing a few years ago in a community health center in central California and recently took a position with Kaiser Permanente, encourages her younger colleagues to let what they enjoy most about their specialty drive activities during the final year. She advises making a spreadsheet of personal and professional needs and wants, and then trying to strike a balance among those in the opportunities considered. “You might not get it all in your first position, but the exercise is worth doing,” she said. Then, residents should evaluate practice settings with an eye to those that best support the ideal position. “These are the kinds of things that it’s helpful to ask colleagues about before you start interviewing,” she said.

In Dr. Muhammad’s case, the ideal job included the opportunity to do some obstetrics and teaching, and to work four days a week. She also wanted a robust practice support system, which she knew was a given with Kaiser. “One advantage of the HMO setting is not having to worry about whether something is covered or about prior authorization,” she said, “which are huge benefits you might not have in community practice.”

Resources

NEJM Resident 360: https://resident360.nejm.org/pages/home
American Medical Association:
Young Physicians Section — www.ama-assn.org/ama/pub/about-ama/our-people/member-groups-sections/young-physicians-section.page?
Adventures in Medicine — http://aimresourcelibrary.com

*Dr, Fromson serves as the editor for Career Resources and is Vice Chair for Community Psychiatry, Brigham and Women’s Hospital; Chief of Psychiatry, Brigham and Women’s Faulkner Hospital; Associate Professor of Psychiatry, Harvard Medical School.