Insights After Five Years in Practice: What I Have Learned in Practice That I Didn’t in Fellowship

The transition from being a fellow to an attending is a time of great excitement and accomplishment, but brings with it a great deal of anxiety as well. While the learning curve within fellowship training is steep, that of the first 5 years after graduation will set your practice pattern for the rest of your career. Here are some things we have learned from our first years as attendings:

1. It sounds trite, but warrants repetition; do not be afraid to ask for help. Your new partners will be de-facto mentors, even if they are just 1-2 years more experienced than you. If you are joining a practice where you are the only NIR, do not hesitate to phone your fellowship mentors.

I remember in my first day of call I had a “straightforward” ruptured PCOM aneurysm. However, I was dealing with an angiography machine I had never used before, I was unfamiliar with the 3-D angiography capabilities, I had a new staff, new set-up etc. So I asked my partner to join, and we did the case together, and the patient did wonderfully. – MEG

Krishna Amuluru, MD

Mohammed El-Ghanem, MD

2. Ignore the adages; whether in conferences, or from the mouths of our mentors, we all have heard something along the lines of “Do not make a mistake for your first 50 cases”, or “avoid very complex procedures in your first 6 months.” While performing extremely dangerous maneuvers and techniques that you did not learn in training is inadvisable, adages like this imply that we have control over the pathologies presented to us. If a patient with a complex pathology lands on your doorstep in your 1st month, many conflicting emotions are at play; you want to help the patient, you are excited at the opportunity to finally perform a neurointerventional procedure as an attending, you may be nervous, you may feel implicit pressure from your administration against transferring a patient to an alternate institution, you want to instill confidence amongst your peers and co-workers etc. At the end of the day, our ability to “pick and choose” our cases is limited, especially in a field that manages hyper-acute pathologies. A mistake in your 20th year of practice is neither better nor worse than in your 1st year; accept this and the fact that you do not control pathologies presented to you.

KA: In my first month in my 1st job, a young patient came in with a ruptured complex anterior communicating artery aneurysm. She ultimately required a double-balloon-assisted coil embolization. However, on balloon deflation, one of the coils herniated into the parent vessel, and she sustained a distal infarction complicated with eventual vasospasm. The patient ultimately recovered well, and this was a great learning experience for our program. If I had listened to the adage “do not make a mistake or perform a complex case in your first 3 months,” we would have transferred the patient, and not even attempted this procedure. I am glad we didn’t do that.

3. Trust your training, but also be open to new environments; the NIR staff will inevitably be curious as to your specific angiographic procedural setup, and some of the more experienced ones may give you push-back regarding your setup. If you are faced with a challenging situation, perform the case in the manner you feel is safer and are more comfortable with. Remember you can probably do the same difficult case with several different access systems, and they probably are all reasonable. That being said, the same experienced technicians and partners may also have a system that you have never seen before; take time to learn several new systems, and ultimately create the one you are most comfortable with.

4. Do not assume anything regarding the ancillary staff: more specifically, do not assume the radiology technicians are as confident and skilled as those in your training. This is especially true if you go to an institution with a fairly new Neurointerventional radiology service, or you are the first and only attending. Pay attention to details, double check all your own equipment and ensure that you are well familiar with prepping all equipment (i.e balloon microcatheters, stents, liquid embolics). You will be responsible for everything during the procedure, even the smallest of details, so make sure you take the time to learn during fellowship – what type and osmolality is the contrast you want? What PSI and injection parameters do you want on your DSA runs when using a machine injection system? “I don’t know” is not an acceptable answer as attending.

5. Consolidate your learning; Use your early career in order to gain further confidence in devices you worked with in fellowship before transitioning to new devices.  For example, there are multiple flow-diverting stents on the market, and it is tempting to use all of them. Remember that each one has its own learning curve and using multiple devices will require a large case volume in order to become truly comfortable with each. Our field is rapidly emerging and opportunities to trial new devices will always exist; don’t be impatient.

6. Help with scut; In your first few months (and really for the rest of your career), make every effort to show appreciation towards the radiology technicians, nurses and ancillary staff; they will be your best friends.  The easiest way to do this is to help with patient transport on/off angio tables to/from the patient bed. Other ideas are to help with the opening of devices, helping to prepare the pressure lines etc. Too often, we graduate from training and delineate those duties to the ancillary staff, and it goes a long way to show them that you care and are willing to do the “scut” work even as an attending. It will pay off in the long run; when you have to do a stroke at 3 AM, the same people you previously helped will return those favors in order to get you home faster.

7. Do “over-the-top” in-person sign-outs; In the first several months of your new job, not only will you be navigating the responsibilities of being an attending, but you will also try to gain the respect and trust of your colleagues in other services. An easy way to gain trust and respect from other services is to do complete and thorough sign-outs to the ICU, neurosurgery and/or neurology service, hospitalist, ENT service, trauma service etc. whenever you finish a case. It will give you an opportunity to showcase your knowledge of the case and imaging findings, and it also puts a voice and personality behind the name. As a corollary to that, try to review the angiographic imaging with referring services – the more you include them, the more they will trust your judgment.

8. Know what you will, and will not tolerate; Procedural nuances are extremely important to us as neurointerventionalists; we all consider ourselves to live at the far end of the Gaussian distribution of type-A personalities. This is understandable in a field where even a single micro-bubble in a syringe is intolerable. However, you must accept that the procedural nuances you were accustomed to during fellowship most likely will not exist in your first months as an attending. For example, your pressure bags will not be prepared as you are used to, the angiography machine may be a different make/model, the back table will definitely be structured completely different, your “favorite” microcatheters and wires will not be available etc. While patient safety should always be the #1 priority, try to adapt flexibility in terms of procedural details. Additionally, recreating the same procedural nuances as your training may not be feasible, and demanding such details may lose your favor with the procedural staff. Recognize what you are, and are not, willing to tolerate when it comes to technical details.