PracticalDermatology

I appreciate that medical training and the early years of practice are stressful. Patients consider you an expert, but you still have many years ahead of you before you will build the experience necessary to be justifyably confident. You are balancing work, study, family, and friends. Many of you are burdened with overwhelming financial debt. You worry about the future of medicine and whether you will be able to create a long and satisfying career. I know. My colleagues and I were once where you are now.

However, we—your attendings, mentors, employers—have our own stressors that, if only because we have had more time to accumulate them, are often exponentially greater than yours. We have responsibility for ourselves, our patients, families, employees, businesses, community, organizations and you—our residents, fellows, and associates. The changes in medicine—EMR, MU, MOC, MACRA, and ACA—have ranged from expensive nuisances to physically and emotionally overwhelming challenges to those of us with already established practices.

Your brains and tenacity got you to this point. But despite being deserving, do not forget you are privileged to have gotten a position in our training program or office. For your first several years, you will cost more than you produce both in dollars and our time. This isn’t to complain; our goal is for you to excel.

It is in that light that I offer the following advice, much of which my generation thought was common sense, but which recent interactions with yours suggest has been lost. If they are obvious to you, fantastic! Pat yourself and your parents on the back. If not, as you read this, remember that my goal as your attending, mentor, employer and as editor of this magazine’s sister publication, Modern Aesthetics®, is to help you build a productive and satisfying career and to become a valued colleague.

1. Never speak badly about your attending or employer to their staff. You are doing a disservice to the physician for whom they work and to yourself because it will certainly get back to the boss.

2. Never do “favors” or other work-arounds to treat your program’s or employer’s staff or your family and friends without the physician in authority’s express consent. Every syringe, needle, cc of triamcinolone, laser pulse, disposable device tip, piece of gauze, and hour of staff time has a cost, so using it without permission is, in fact, stealing. Freebies from pharma reps also belong to the primary physician(s) who own or run the office that rep serves.

Before you get product or offer to treat anyone, tell the appropriate physician in the office that you would like to ask the rep for free product to train, who you would like to treat, whether any staff would be involved during or after hours or lunch break, and when you’d like to do it. The likelihood is that she will say it’s okay, but don’t be surprised if there are very specific guidelines about when and on whom. Those extras serve to reduce overhead and to treat staff, family, and friends. Offices have policies monitoring their use and must comply with federal regulations.

3. Never copy educational pamphlets, instructions sheets, or other work product from someone else’s workplace without asking their permission. Certainly do not copy it for your own use without same. Most mentors, directors, and senior physicians will be happy to allow you to use them as you start your practice but there can be ethical and legal copyright issues.

4. Never suggest to a patient that you are better than someone else with whom you work or who is senior to you and works elsewhere. Do not state or imply that another physician’s recommendations are incorrect or dangerous. Do not attempt to entice a patient of your attending, associate, or employer to switch to you. Patients almost always report back to their original physician. You can certainly give a second opinion that differs from someone else’s, but be sure to preface it with, “I respect Dr. Smith’s opinion. There are many ways to get to the same outcome. In my experience, I might do it differently.” Then explain your alternatives. Suggest the patient may want to speak with the original physician again before deciding. And then reach out to that physician personally to give the heads up.

5. When joining a new practice, don’t expect to be handed patients. The senior physicians who founded the group went out and shook hands, joined organizations, and gave lectures to meet physicians and potential patients in the community. You can do the same.

6. Never promote yourself as an expert in the press or on social media without the permission of your program director or employer. You are their representative; outreach should be done under the umbrella of their organization, not you individually. Doing so gives your employer the idea that you care more about promoting yourself than about the practice.

7. Never use a patient’s photos without a signed HIPAA-compliant consent. Even with that consent, do not use those photos if you saw the patient with your supervising physician without her or his authorization. Consent is given only to the physician of record, regardless of your signing the form as a witness.

8. Never suggest directly by what you say or indirectly by what you don’t say that someone else’s work is your own whether discussing it with patients, the public, or the press. If your experience is limited, be honest. Patients in particular will often agree to be your teaching patient for a free service or at a significantly discounted fee. And colleagues and the press will respect your honesty.

9. Never dump your complication on another physician. If you need help, ask for it but, then be available to speak with that physician and to take further responsibility. Your patient will know that you care/your colleague, that you are trustworthy. You will be able to figure out how to treat—and better how to avoid—that complication in the future.

10. Never submit or present anything—a poster or presentation to a meeting, paper to a journal, or press release—you’ve done with anyone else without discussing it with those colleagues. This is especially important when dealing with a mentor or employer. You may not be aware of proprietary information or agreements regarding where it will be presented first.

11. Never leave anyone’s name off a presentation or paper unless you have been specifically told to do so by that person. You will see that many groups even include everyone in the lab or office on their papers and presentations. That decision is up to the senior member of the investigative group.

12. The acknowledgements list in a presentation or paper is meant only for support staff who performed a function that was part of their job, like preparing slides. However, there are times they are included as investigators, also, so ask their boss/supervisor how to handle.

13. Always err on the side of directly crediting the work of others, including things borrowed or taken from publications.

14. Never use anyone else’s work without getting their approval for that specific use.

15. Never lend anyone else’s work to other people without the express approval of the creator of the work.

16. Always make sure you can summarize the take-home points of your paper or presentation in one to three sentences. Prepare your presentation so that it tells the story. But don’t fudge the facts to make your story. If there are problems, explain them. Remember the audience considers a presentation great if they can take home even one pearl of knowledge.

17. Always give attendings, mentors, collaborators and employers clear information about your deadlines in advance, and then remind us if we don’t get back to you in a timely manner. We have so much on our plates that adding your stuff requires juggling. Think of trying to get a drink for your spouse while holding your own drink and hors d’oeuvres. You need to put something on the table.

18. Never tell someone more senior than you when you will meet them. Instead ask when they are available or if they are available at several times you know you can make yourself available.

19. If you schedule a time but then can’t make it for a call or meeting, always reach out to inform the person with whom you were speaking/meeting. Don’t assume you can call or show up whenever your plans allow or that the other person will know your schedule.

20. Do not call a mentor or senior colleague during or after dinner for a non-emergency (i.e., not a patient or personal emergency that needs immediate attention) unless he or she has specifically asked you to do so. Certainly do not call after 9pm for a nonemergency without an appointment to do so. We are not your parents or grandparents who are pleased just to hear your voice.

21. If a training or employment situation is not working out for you, do not whine about it. Make a list of positives and negatives and discuss them with someone you trust who has more experience. Find out if those negatives are truly bad things specific to this physician, practice, or program or if they are simply expected unpleasantness everyone must face in the real world. For either, consider what role you might be playing in creating or aggravating it and whether it is fixable.

Rather than being withdrawn, sullen, or angry, plan a calm adult conversation with the appropriate person. If you do plan to leave, be sure to give the amount of notice required in your contract or more if you are already buying or leasing space elsewhere. Better to be the bearer of news than it being discovered.

22. Recruiting patients from the office you are leaving to your next is frowned upon, unless they are clearly patients you brought in the door. It takes two to five years to build a practice. The range depends on your success in distinguishing yourself in your community. Before that, most patients have come to you because of the practice. After that, they are coming for you; they should be considered your patients. The caveat is for trainees: Never directly recruit patients from your program or attendings.

23. Don’t dismiss it if any colleague, or particularly a physician senior to you or your attending or employer, is upset with you. First consider the fact that you may well have acted inappropriately or done something wrong. Second, consider that even if you did nothing wrong, whether it is more important to prove you were right or to apologize for how you made the other person feel. How you answer that question can make or break a relationship and impact your career. Note that “hugging it out” is for friends, not a senior physician.

24. You are not a colleague or peer of your mentors, directors, senior physicians, or employer. You may be one day, but not now. This isn’t about calling someone “Dr.” You can always call me by my first name. I called my attendings by theirs. But I showed clear respect.

Ultimately, please appreciate that however hard you worked, you have been coddled as a resident and fellow in this century. Laws regulate how many hours trainees can work without a break, and attending physicians are required to supervise or at least sign off on your work, so they carry most of the liability.

If you join an established practice, you are entering someone else’s “house” that was built on their sweat and tears. They developed procedures and practices, ensured compliance with regulations, hired and trained staff, researched and purchased equipment, and brought in patients. Generally, the office you join will either take care of the necessary paperwork or forward it to you to expedite your licensure, malpractice, society memberships, insurance plans. Once they know your start date, they may even start booking patients for you before you even move to the area. You arrive and are able to function from day one.

This is not an “in my day we walked uphill in the snow to school barefoot” story. These are facts. You are quite lucky, but apparently many of your generation have not internalized these common sense and common courtesy concepts. If you did any of the above in the real world, i.e., outside your very cushioned safe world of training or a first practice, you could make permanent enemies, hurt your career, and permanently mar your reputation. On the other hand, acting with respect to others above and below you will certainly lead to lifelong, trustworthy friends and colleagues.

All is not lost. You would not have gotten this far if you were not smart and pleasant. If you base your future decisions on appreciation rather than entitlement, you will do very well. I think about a derm attending at the Philadelphia VA who admonished me as a medical student for chewing gum while seeing a patient. I was mortified but I took it to heart and extrapolated to be sure that I showed respect to my patients. Her admonishment had a positive effect on my future. I hope you take this in the same way.

Best wishes for a long, happy, successful career,

Heidi