In recent years, medical education has upped its emphasis on giving medical students the tools they need to negotiate the transition from pre-clinical to clinical training, as well as the transition to residency. But the transition to attending physician also can produce varying levels of stress—and success—by specialty.

A study published in the Journal of Cancer Education highlights the challenges faced by junior radiation oncology attendings because of the specialty’s unusual residency format. Researchers surveyed radiation oncologists in their first five years of practice and identified crucial deficits in their residency education, as well as ways to smooth the transition.

“Due to the complexity and disease-site-specific nature of the field, radiation oncology residency training has traditionally adopted an apprentice-style format, which affords limited opportunity for independent practice prior to graduation,” says the study, whose lead author is Jenna Kahn, MD, BSc, assistant professor of radiation medicine at Oregon Health & Science University.

"In other specialties, such as internal medicine, trainees gain greater independence and incremental oversight of junior residents as they progress through their training,” Dr. Kahn and her co-authors noted, adding that new radiation oncology attendings often perform tasks they are unfamiliar with.

The study’s results are based on responses from 19 junior radiation oncology attendings at 18 academic institutions to open-ended questions developed from recent literature describing the challenges junior attendings face. Thematic analysis was then performed by two independent reviewers—a radiation oncologist and an organizational psychologist.

Results are organized into the following problem areas.

Physicians who stayed at the institution where they did their residency said they experienced a challenge in being acknowledged as an attending. Being polite and assertive often worked for them. Physicians who went to a new institution, on the other hand, found their knowledge being tested.

They described using literature references in treatment decisions, as well as being humble and hard-working, and developing relationships with clinicians inside and outside of their departments.

“Most respondents not only felt that there were changes that they would like to implement but also found that there was a benefit to accepting variation in practice patterns,” the study says. “Overall, bringing an open mind, balance and learning to adapt and remain flexible through their transition was considered crucial.”

Most respondents stated that keeping up with the literature after completing oral board examinations was difficult, but subscribing to online review courses and journal emails and monitoring social media helped.

Just 42% of respondents said they had a formal mentor-mentee relationship, and numerous physicians felt that it took six to 12 months to generate one. They also noted that both parties needed to be invested for it to thrive.

Most physicians were not involved in the billing process in residency and felt that it was significant and wished that they had spent more time or learned about it prior to becoming an attending,” the authors wrote.

“Physicians who had some training and feedback about billing in residency felt more comfortable with billing, but a vast majority wished that this was taught in residency and medical schools,” the study says.

Respondents noted that studying for oral boards ate up a large proportion of their free time in the first year, but these elements helped mitigate the disruption:

• Having added control over their schedules.
• Learning to delegate responsibilities and tasks.
• Establishing boundaries at work.

“Unanimously, physicians in radiation oncology wished that they had more autonomy during residency to prepare for independent practice,” the authors wrote. “Some felt that a rotation at a satellite or community practice would be helpful. Also, they suggested that a formal course in billing and coding, contract review and negotiating a contract for practice would be valuable.”