Transitioning to the OR at Your New Institution

By Brian Mitzman, MD

May 18, 2020

You’ve been waiting for this moment. After more than 12 years of medical school and training, the operating room is yours for the first time as an attending surgeon. You walk into the OR, expecting the same setup and routine that you used all through fellowship. But wait a second… you see a beanbag and wonder if people even still use those. And where is the new VATS tray that you were promised?   

Despite this unexpected situation, the most important variable at the end of your first year as an attending will be surgical quality. You will need to develop an appropriate case log and comfort as an independent surgeon, all while maintaining excellent surgical outcomes. Throughout this time, you also need to adapt to your new role and setting. 

Hospitals and operating rooms can be drastically different across institutions. As a trainee, you worked in the same OR for 3-10 years with the same staff and equipment, and you got into a comfort zone. But now as an attending, whether you stay at your training institution or move to a new hospital, you must understand that things will be new and different. You must develop a positive reputation and navigate hospital politics, as well as manage your own anxieties. 

In a 2018 article, Dr. Sandra de Montbrun and colleagues described four phases of transitioning from trainee to attending surgeon: 

  1. Getting Undressed – Your previous identity as a trainee no longer fulfills your new role and duties. This is a time of self-reflection and, in many situations, significant culture shock.
  2. Exposed and Vulnerable – After 5-10 years of surgical training, you are now out of your comfort zone. You need to build a reputation while maintaining excellent patient outcomes. Anxiety is common.
  3. Suiting Up – You’ve accepted the fact that you’re now an attending, and a certain persona is required. You give off an impression of confidence and leadership, even if you don’t entirely believe it deep down.
  4. Tailoring the Fit – You have developed confidence in your own abilities by having numerous successful cases and overcoming surgical complications. You start to truly identify with your new role.

The length of time spent in each of the above phases will be variable, so be prepared. Acknowledge that feelings of self-doubt are common. 

In addition to understanding the various phases of transitioning, the following tips also will be useful:

Communication
This is key. Nobody will know your personal preferences if you don’t communicate them effectively ahead of time. If you wait until the exact moment that you need a Belsey spoon for that fundoplication and then melt down when the team has no idea what you’re talking about, you’ve just become known as the “short tempered surgeon.” Instead, before your first day, meet with the lead cardiothoracic surgery OR nurse. Review all the equipment trays. Work with them ahead of time to develop preference cards for your common cases. It is your responsibility to know what is in each tray and what will be laid out for each case.  Equipment trays may not be exactly what you were used to during your training. If they can get the job done, just go with what is already developed at your new hospital. The staff will appreciate your flexibility and the ease of working with you. There will be plenty of time in the years to come to design your own personal trays. If there is an instrument you must have to complete a case then discuss it with your division chief first and give the OR plenty of time to acquire it.

Pro Tip: In your last months of training, ask the lead OR nurse at your hospital for your favorite attending’s preference cards and tray lists. This will provide a foundation for your future setup.  

First Impression
It can take as little as a tenth of a second to make a first impression. Don’t assume that everyone will know you are the new “hotshot” cardiothoracic surgeon. Be polite. Smile.  Remain calm in tough situations. Ask when you need something, never demand. If you expect to be referred to as “Dr. X,” then be equally as professional in return. Take control of the operating room and display confidence during the procedure. Even if you perform with technical perfection, a lack of outward leadership will be equated with poor surgical skills.  Most importantly, be kind to the staff and residents. Make it so people seek you out and want to work with you.

Pro Tip: Show up to the room early; leave late. Be there for the intubation, help with positioning, and stay until the patient is awake at the end. This not only shows empathy for the patient’s well-being, but also an understanding of all the tasks that are required by the staff to make the operation happen.

It’s Like Being in Middle School Again
If you thought that the gossip was bad in middle school, just wait. Everyone talks. Many of your operating room staff may have been working together with the same surgeons for decades.  They are more than colleagues. They have developed personal relationships with each other.  You are the “new kid at school” and anything you say or do in the OR will spread like wildfire. Expect that there are no secrets, and what happens in the OR could be known by the entire hospital by the end of the day. Show good judgment, be kind, stay calm, and be a leader.  

Pro Tip: Explaining what you’re doing as you operate can go a long way. It shows that you care about the staff’s education; you expect them to be involved, and it gives off the sense that you aren’t just flying by the seat of your pants. Motivation is contagious.

Prior to my first case as a new attending, I went to the OR early. I had the best intentions – I planned to introduce myself to the anesthesiologist and scrub tech, then briefly discuss the case and what I was expecting. I walked up to the anesthesiologist, who happened to be the chief of cardiac anesthesia. With the swagger of a newly minted thoracic surgeon, I began to say, “Hi, I am…” I was cut off. “Sorry, I’m already assigned a medical student today and don’t have the ability to handle two.” Ego blown. Fast forward 2 years. We are close friends and I still like to remind him of our first interaction—often.

Your first two years as a surgical attending will be the most formative of your entire career. Take steps to make the transition easier, so you can focus on what really matters—the patient.


Connect with Dr. Mitzman on Twitter: @BrianMitzman

Dr. Mitzman is an assistant professor with NYU Langone Health and attending thoracic surgeon at NYU Winthrop Hospital. He completed his cardiothoracic surgery fellowship at The University of Chicago in 2018.

The opinions expressed in this article are those of the author and do not necessarily reflect the views of The Society of Thoracic Surgeons.