Fears of a new family medicine graduate

This year hundreds of family physicians started independent practice across Canada. These graduates are entering a challenging landscape in family medicine. I will have finished my first full year of practice by the time this article is published. I know how exciting and scary it can be to leave formal education, so I wanted to share with you 3 fears I had as a new family physician.

Fear 1: I will not know what to do

Before a shift at the hospital or emergency department, I would often feel sick with anxiety. My mom likened my reaction to an actor’s butterflies before going on stage. I would be worrying: What will happen if there is a case where I do not know what to do? What will happen if I miss something or provide the wrong treatment?

During residency 2 helpful pearls were shared with me: Practise in a way that helps you sleep at night, and practising will get easier once you establish your own approaches to cases. In training we learn basic approaches to various cases, but the final decision is buffered by your preceptors and their comfort levels. After graduation it took me time to build the confidence to make my own decisions. To bolster myself I would study at night, attend conferences, and frequently refer to my notes and to resources available during work. I was also lucky to have had highly supportive preceptors who told me before I graduated that I could call them anytime … and I have taken them up on their offers.

I also quickly found out I was naturally more cautious than many of my experienced preceptors. This meant I asked patients more questions, sometimes ordered more tests, bounced ideas off colleagues more frequently, and had a low threshold for getting a specialist’s opinion. One of the most helpful tools I have used to obtain specialist guidance is the Ontario eConsult Program (https://otn.ca/patients/econsult), a virtual platform run through the Ontario Telemedicine Network. It allows physicians to consult with other specialists across the province. Sometimes the specialists provide reassurance that no other steps are needed; at other times they suggest further options for a workup or treatments; and sometimes contacting them confirms to me that my patient needs to see a specialist in person. Response times are within hours to days. I always learn something new using this program and I keep notes to refer to the next time I encounter a similar case.

There are many things I still do not know, but I have built systems so I know where to turn when I do not have all the answers. As time passes I am becoming more comfortable with not knowing everything in the moment of the patient encounter and the anxiety I always used to feel before a shift is subsiding.

Fear 2: I will make a mistake

We are told in training the question is not whether you will get a regulatory college complaint, but rather when it will happen. Thus, the 1 word I would use to summarize my feelings during my first year of practice is rumination. Did I do or say the right thing? Did I miss a diagnosis or recommendation? I spent many nights lying awake running cases through my head, and during work hours I occasionally left extra notes in charts or called patients to check in on them days later.

Looking back on my first year of practice, I can see I made my share of mistakes. In hindsight, there are many cases that I would approach differently now. Sometimes you simply do not know what you do not know, or decision making is affected by time or energy constraints. I had a wise emergency medicine colleague who reminded me to concentrate on not missing the big things, and this advice has helped me hone my focus. As a safety check I try to list differential diagnoses at the end of most of my notes.

The second support I have recently used is a Balint group. Balint groups are semistructured meetings among family physicians to review emotional aspects of challenging cases.¹ The focus is not necessarily on clinical details of the case or to review mistakes, but rather on how to process your emotions surrounding those cases that keep you up at night. It is validating to hear how other physicians experience the same feelings that I do, but my favourite aspect is that the group discussions push me to look at cases from different perspectives. It has given me the space and the framework to process cases such that I spend fewer nights replaying them in my head.

Fear 3: I will burn out

Throughout training we are taught about burnout and we see colleagues who struggle. There is high demand for your skills as a new graduate. It is easy to overcommit. I was surprised how mentally and emotionally taxing clinical duties could be in independent practice compared with residency. There is much more stress when you are making the final decisions, and there is a lot of paperwork to be done behind the scenes to ensure patients obtain optimal care.

Knowing myself, I recognized before graduating that there would be a real risk that I would take on too much. So, for various reasons, I decided to begin practice as a locum, a decision I am very happy with a year later. It let me start out slowly, gave me the flexibility to work in different settings, and allowed me to see how different physicians organize their practices. I also tried to check in with myself every few months to reassess my stress levels based on the most recent work period; I then adjusted my bookings accordingly so I could work sustainably going forward.

Another piece that was important to me was to be involved in nonclinical roles, such as serving on the Ontario College of Family Physicians’ awards committee and working with a research team on a study related to early-career physicians. These roles provided a break from the stress of decision making and gave me a sense of control, knowing that I was improving things for patients and physicians in the future. I am often inspired by other physicians I work with in groups and who push me to do better both in and out of clinical settings.

Additionally, spending time in my daily life doing nonmedical activities—such as exercising, connecting with friends and family, and revisiting old hobbies—was essential. Checking out of the medical world from time to time gave me new motivation to get back to it again.

Conclusion

The first year of practice can be tough. It comes with new challenges and rewards, just like other stages of a career in medicine. Each graduate will have their own set of fears. I would argue the best way to overcome fears is to face them head on. My set of fears might always be with me, but I will become more comfortable with them over time. The transition to independent practice is also made easier when you are surrounded by supportive colleagues. There is no amount of money that can replace the support and guidance of a trusted colleague. Thus, the biggest take-aways from my first year of practice are that I am not alone and I can provide better care when I lean on my team.

First Five Years is a quarterly series in Canadian Family Physician, coordinated by the First Five Years in Family Practice Committee of the College of Family Physicians of Canada. The goal is to explore topics of particular relevance to new-in-practice physicians and of interest to all Canadian Family Physician readers. Contributions up to 1500 words are invited from those in their first 5 years in practice (https://www.cfp.ca/content/Guidelines) and can be submitted to the First Five Years in Family Practice Committee at firstfive@cfpc.ca.