My first year as an attending physician almost broke me

I can finally write this essay almost five years out. That’s how long it took me to fully heal. To process. To gain perspective.

I graduated residency in June 2020 at the height of COVID. I, along with my family, including my husband, two preschoolers, a four-month-old infant, and two dogs, drove from Miami to Chicago to complete an amazing fellowship. The year was perfect, though masked, sometimes scary, and full of pivots.

I then graduated fellowship in June 2021 and entered a terrible job market. No one was hiring. Jobs were frozen. Institutions were on pause. Without a great alternative, I decided I wanted to go home to Southern California. So I scoured Indeed, Doximity, and LinkedIn, relied on my network, and accepted the most reasonable job offers I could find. I then completed my road trip across the country to start attending physician life.

The next year almost broke me. I worked two different jobs. One as a nocturnist within a large private equity-owned system, and the other with a group that staffed two small, underserved, under-resourced community hospitals in an industrial area.

At the larger hospital system, I was immediately struck by the difference between the academic values of my training institutions and the business of medicine that identified my new practice. My medical director was kind, approachable, and responsive, but was subject to the whims of private equity and metrics, and at the mercy of a system that consistently prioritized image, metrics, and money over patient care. With a shiny lobby and excellent marketing, the standard of care was expected to be a 10/10; the resources provided, especially as a nocturnist, were at times inadequate and dangerous.

While blasting music to stave off sleep on my 1 hour and 45 minute commute home in morning traffic after my nocturnist shifts, I thought about my notes I still had to finish within the 12-hour post-shift window. I questioned the decisions I made about admission or discharge, with the clock of dispo time ever ticking. I worried for the man still boarding in the chair in the waiting room, technically “admitted,” awaiting his stroke MRI. I felt like an awful doctor in every metric.

My other job caused deep moral injury that still haunts me. The two hospitals I worked at serve a majority immigrant population, working poor, underinsured, or uninsured. The standard of care provided and available is vastly different from the resourced academic institutions I trained in. Without the immediate access to specialists, I became a better doctor, proceduralist, and facilitator. I learned to balance the sick with the not sick, the social problems and life-threatening emergencies. I loved the people I worked with, the feeling of camaraderie buoying me through every shift. But discharging someone to navigate a system of specialists, referrals, and higher level of care, in a language they did not speak, broke me in small ways every time. Calling multiple other larger centers for transfers for higher level of care, and watching patients decline while waiting, broke me even more.

The stressors started piling up:

• Moral injury
• The commute
• The metrics
• The shifting schedule
• The sensation of drowning, flailing, grasping

I was sad and mad and confused and angry and burned out. Was this the reality that I had worked so hard for since college? Since high school? This existence of being tired, stressed, exhausted, angry, anxious, and helpless could not be my life. I was an attending! This was supposed to be the reward of the training journey! How could it feel so terrible? What had I done wrong? Was I stuck like this forever? As an independent problem solver, I buckled down and suffered (I imagined) silently for a year. In truth, my suffering was not so silent. My husband bore the brunt of it and our marriage almost became a sacrifice to the awfulness I felt.

So I changed course. Pulling off the freeway to safely sleep in my car after I left late after a shift is what ended my work at the larger hospital system. I shook when writing the email to set up a call with my director to quit after my year contract ended. A people pleaser and perfectionist by nature, I didn’t want to let anyone down. Only narrowly avoiding falling asleep at the wheel is what finally bolstered me to make that call.

I procrastinated, negotiated, and held on way too long to leave my other job. I went down from eight shifts, to four, to two, and then one shift a month. I stayed because the community was so amazing, I felt meaningful with my work, and when it wasn’t my full-time position, the moral injury stung less. I finally became per diem because they consistently scheduled me on weekends and I wanted to coach my kid’s soccer team. When they scheduled my only shift that month on Mother’s Day, I realized the sacrifice was not worth it.

I now work in my dream job. I am a nocturnist at a Level I trauma center, one of the best hospitals in the country. It is a 10-20 minute commute, even with traffic. It is the hospital my mother was born in, my siblings and I were born in, and three of my children were born in. It has the resources and the culture and the ethos to treat everyone. Social work. Substance abuse navigators. STEMI, stroke, ECMO, subspecialists, quaternary care. I have supportive colleagues, a schedule that supports my family life, and opportunities to educate. After five years, I am still grateful for the opportunity and love my work.

So as new attendings settle into their positions this fall, don’t despair if your first position is not what you imagined. If I can impart a few tips for any new attendings, my top three include:

• Always have a backup. Keep credentials at a few hospitals in case you need to make a change. Maintain your networks. Update your CV.
• Have at least three, but ideally six, months of savings. That emergency fund can be a lifesaver when you feel stuck. Credentialing at a new hospital may take time, and you do not want to have to stay somewhere unsafe or toxic just for a paycheck.
• Don’t be afraid to reassess and make hard choices. Imagine your life five years from now. If you don’t act now, nothing will change. Don’t be afraid to make that change if your present situation does not feel right.

Elizabeth Rubin Ribak is an emergency medicine physician.