CHESTThought Leader BlogTop 10 Things I Wish I Knew When Starting Fellowship

Top 10 Things I Wish I Knew When Starting Fellowship

By: Meredith Greer, MD

10. “Basic” Stuff May Not Be Basic Stuff to You

The expected differentiation of bronchoalveolar lavage is:

80%-90% macrophages
~ 15% lymphocytes
~ 3% neutrophils
~ 1% eosinophils

I had no idea prior to starting fellowship! There is so much stuff that attendings are going to think of as “basic” that will be brand-new information to you—and that’s OK! You’re here to learn.

9. Fellowship Is Lonely

You may be in a new city, a new institution, and be surrounded by new people. You might be feeling alone in your thoughts, differentials, and medical decision-making. You might also be feeling like you’re living in limbo because you’re no longer a resident, but you’re not yet an attending. But you are not alone: we all feel this way!

The more we specialize, the smaller the world gets. Make your program members your family and put yourself out there to find your extended family. Go to annual meetings, attend webinars, and reach out to the physicians with your same interest via email or on social media. Join #medtwitter, and join CHEST! For more on loneliness during fellowship, see my blog post from last year: Fellowship: It’s Lonely at the Top

8. Self-Studying Is Key

Since you’re a loner now, you’re going to be doing a lot of self-studying. Take initiative! Ask questions! It can be hard to admit that you don’t know something, but, if you don’t ask, you’ll never learn. Work to pull yourself out of the “valley of despair” of the Dunning-Kruger curve. It may feel like everyone around you knows everything, but they don’t, because nobody does, and that’s OK. The most important thing to know is that there’s always more to know!

7. Make a Role for Yourself

Many times during my fellowship I found myself looking from the residents to the attending and thinking, “Why am I here?” Instead of turning that into, “I don’t need to be here!” ask yourself, “What can I add to this rotation?” Are you the organizer (runs rounds, involves nursing/RT), the educator (teaches didactics, engages residents), the engineer (masters procedures, utilizes technology), the nurturer (leads meetings, comforts families), or a combination of all these? Find the roles that play to your strengths and make yourself indispensable. This way both you and your team will get the most out of having you on the rotation.

6. Learn How Stuff Works

From transducing your own A line to setting up the continuous renal replacement therapy machine to perfectly positioning that C-arm, now is the time to figure it out! One of my attendings used to say, “The residents, nurses, and respiratory therapists can do everything, so what’s the point of the attending if we can’t do all the things?” Don’t kid yourself: You’ll never be able to take on the job of an RN or RT, but you should be able to help them out when needed. The better you understand the details of all of the work that goes into caring for your patient, the better care you’ll be able to provide.

5. Ask Specific Questions and Give Specific Instructions

A lot of times I start a consult conversation with, “Before you start, can I ask if this is for a bronchoscopy, thoracentesis, abnormal chest CT, or something else?” This helps the caller format his or her question, and it helps you listen for the right stuff when the caller is telling the story. When it’s time to give your recommendations, remember that you earned this fellowship for a reason! Don’t expect the interns/residents to know what you know. On consults, don’t just say, “Give a steroid taper.” Write it out for them! On ICU, it’s not, “Do all the acute liver failure things.” Show them the order set! Giving exact instructions with names of medications, doses/dosages, timing, start and stop dates, and all the rest will make everyone happier and keep patients safer.

4. Taking the Consult Is Always Easier/Faster Than Blocking the Consult

You’ve been waiting all of your medical life to be on the other end of the phone, and now is your chance to be the voice people are happy to hear. When people call, they’re calling because they need help, and it’s your job to help. If you think it’s a “dumb” question, then they clearly need help; if you think it’s easy, then it should be easy for you to help; if it isn’t dumb or easy, then that must mean it’s hard—in which case, they really need help! Just help them already!

3. Kindness Goes a Long Way

Assume the basic premise that everyone means well, everyone wants to help, and everyone is doing their best. Don’t forget where you came from, and remember that you, too, were an intern once. Whether it’s how you answer the phone, what you offer when you walk into a patient’s room, or what you say to your team at the end of a long day, remember that, “How can I help?” are four welcome words that mean more than you know. Show your team that you are there for them—support them, push them to their potential, have their backs, catch them when they fall, and always tell them “strong work!” before they go home.

2. Being Triple Boarded Is Enough

A lot of times in the world of academia we can get wrapped up in feeling like we always need to do more. Well, guess what, you already are doing more! Definitely pursue subsubspecialties, research, and/or medical education if that is something you are interested in, but don’t feel like you have to. It is OK to be a “general subspecialist”!

1. You Can Do It

Finally, just know this: you can do it. It won’t be easy, but you will get through it and be better for it in the end. Long days, longer nights, failing and trying again, thinking you’ve mastered something only to realize you’ve just gotten your feet wet, feeling stressed, crying sometimes, and wanting to quit—but you won’t. Because today your favorite patient quit smoking, your most timid intern got their first central line, and that really sick patient in the ICU is finally turning the corner. You remember that, at the end of the day, this really is the best job in the world.

Meredith Greer, MD

Meredith Greer, MD, is a current third-year pulmonary and critical care medicine fellow at Emory University. She is a native Texan and completed her internal medicine residency at the University of Texas (UT) Southwestern Medical Center in Dallas, TX, and medical school at UT Health in San Antonio, TX. She is passionate about medical education, is in the clinical educator track in fellowship, and helps teach the physiology and pulmonology courses at the Emory School of Medicine. Upon completion of her fellowship in July 2020, she will begin pursuing a sleep medicine fellowship also at Emory University, where her clinical focus will be in neuromuscular pulmonology and chronic ventilation.