Career Talk is an on-line resource initiated in 2002 by the ATS Women's Mentoring Program. It is designed to serve physicians and other professionals seeking to establish a career in pulmonary medicine. While many articles are written with an academic focus, most are applicable to professional advancement in any field. This site aims to define the values and expectations important for professional and personal success, alert the reader to potential pitfalls along the way as well as discuss strategies for navigating these problems. The columns feature links and bibliographies that will aid you in obtaining the information you need to proactively manage and negotiate your career. Many of the original articles were written between 2002-2005. This year, in addition to updating the archive, occasional new articles will continue to appear. Please send me your ideas and comments. The feedback I have received has been very valuable.
Please send comments and ideas for future topics to Dr. Wang at email@example.com.
The opinions expressed in this article are those of the author and not those of the American Thoracic Society.
Professional Development: Not Just For Fellows
In October 2003, an anatomy professor at a major California academic medical center committed suicide by hanging himself from an oak tree. According to a note found in his pocket, he said he was unable to cope with his "impending failure" in a course he was teaching. A series of focus groups met regularly over the next few months to try to understand the role that academic stress played in his death. One question they asked was, “Why didn’t he reach out”? Part of the answer was revealed by the “only the tough survive” attitude expressed by comments made to junior faculty after the incident: “you bring work stress on yourself,”and “he shouldn’t have been at [....] if he couldn’t cut it” (1).
Unfortunately, these comments are not surprising. Their apparent callousness merely reflects the harsh environment in which most physicians train and work, regardless of whether they are in academics or not. For many physicians, the principles of altruism and self governance are the heart of what it means to be a professional. In medicine, altruism means placing the patient’s interests above the physician’s interest. But this selflessness and independence comes with a price. The competitive nature of jobs in practice and academia, combined with our own compulsiveness, our perfectionism and fear of failure combine to create a “don’t ask, don’t tell” culture that, instead of promoting well being, tends to punish those who falter or who doubt. Struggling physicians are treated as weak, lacking in attitude or motivation by both their peers and supervisors.
Altruism also implies the responsibility of physicians to teach our profession and values to our students. Traditional medical training defines success in terms of achieving mastery, recognition and respect. Success is equated with achieving tenure, getting that first R01 or becoming partner in a practice. Career development programs further promote this narrow definition by focusing on practical skills like grantwriting with a token talk or chapter on “balancing” family and career. Furthermore, by focusing on the initial phases of a career when issues revolve around getting a job and exploration of career paths, we promulgate the concept that professional development is a topic that concerns fellows or junior faculty only. But, as the victim’s case points out, your responsibilities and burdens only grow as your career progresses. Ironically, as one’s expertise increases, one’s sense of achievement seems to diminish as work becomes less challenging and more mundane. Physicians in practice often feel like targets in a shooting gallery as they struggle to deal with increasing regulatory and documentation demands placed upon them by multiple bureaucracies and shifting reimbursement requirements. Faculty physicians, in turn, struggle to fulfill clinical, research and administrative responsibilities in the face of decreasing NIH funding.
The failure to address personal/professional conflicts as they evolve throughout mid and late-career can lead to burnout just when physicians should reaching peak productivity whether they be in practice, research, education, administration, industry or community service. Given these pressures, it is no wonder that traditional sources of support such as family, community and church often seem like additional burdens instead. Obviously, this can have disastrous consequences for the individual, his/her family and community. Numerous studies and surveys document the increasing rates of dissatisfaction and accompanying physician/scientist distress and impairment in academia and practice. Without insight into their strengths, values, and motivations, without the knowledge of how to take responsibility for their own career development as their careers mature, without knowing how to stay resilient in the face of change, the trainee is poorly prepared to face the ongoing challenge of how to stay vital and productive as his/her career matures (2). If vitality is not only the ability to persist but the ability to start over, then the loss of vitality leads to despair. Physicians as a whole commit suicide at twice the rate of the general population. Suicide rates for women physicians are approximately four times that of women in the general population (3). Physicians also experience excessive rates of depression, substance abuse and divorce (2).
Of course, some physicians simply choose to leave. Faculty shortages are a major problem for academic medical centers. A recent study examining 10-year retention rates of fulltime medical school faculty from 1981 to 1997 found that for all faculty, 38 percent left academic medicine (4). Not surprisingly, the attrition rate for first- time assistant professors is higher than for medical school faculty overall (43 percent). Women and non-white faculty have an even higher departure rate. And although the percentage has stayed the same, there are actually more positions to fill. In 1980, there were 53,552 medical school faculty positions. In 2006, 121,468. (4) Many academic medical institutions have traditionally relied on recruiting “cheap” junior attendings. However, as academic medicine has become steadily less attractive as a career option, the strategy of treating junior faculty as expendable is increasingly unviable, as there are simply fewer junior faculty to replenish the ranks. For instance, in 1980 there were 1843 NIH new principal investigators (PIs) with an average age of 37.2. By 2006, the number of new PIs had dropped to 1346, while the average age had risen to 42.4. Given the predicted shortfall of MDs, this places a huge burden on academic medical centers at a time when faculty are needed to train new physicians (6). While some may view the “winnowing of the weak” as necessary and reasonable, the loss of highly trained faculty is costly. The costs of faculty turnover have been estimated to be 5 percent of Academic Health Center budgets (not including costs of lost opportunity, lost referrals, overload on other faculty and reduced productivity and morale) (5).
What can we do to improve the supply and retention of physicians, promote well-being and sustain vitality? Vitality and resilience are closely tied. Resilience has been found to depend on: (a) remaining free of denial, arrogance and nostalgia; (b) sound risk-taking and strategic experimenting with alternatives; (c) building one’s community; (d) remaining guided by high professional standards and one’s core values and (e) reflection and renewal (5). While the individual must be committed and be willing to realistically assess his/her priorities, behaviors and goals, individual strategies for balancing work and family are of limited value, given the external pressures to produce papers or relative value scale work values (RVUs).
Institutions need to consider their own culpability and consider what they can do to prevent physician burnout and attrition. Simply mandating that physicians undergo a specified number of hours related to professional development is counterproductive and again shifts the cost and responsibility onto the individual. The creation of professional development and mentoring programs must also include meaningful participation by institutional leaders and administrators. If clinical work and teaching continue to be undervalued during promotion evaluations, if department chairs and division chiefs fail to evaluate academic progress regularly, if RVUs remain the only measure of practitioner’s success, then these programs will fail or be of only marginal benefit. Career development as defined by both professional and personal goals (Figure 1) should be made a priority for division chiefs and department chairs. There should be mechanisms in place for holding leaders accountable and for rewarding those chiefs who are effective mentors by providing incentives and educational opportunities to encourage awareness of the long-term benefits of professional development and to teach guidelines for performance reviews and goal setting. (7)
Figure 1: A Model for a Faculty [Physicians] Affairs Department (8)
Professional organizations, academic and private institutions must empower, motivate and encourage physicians to engage in professional development by creating an environment where professional development activities are integrated into the normal work schedule. Some may be reluctant to give up time that could otherwise be devoted to more financially lucrative work. However, professional development programs that go beyond mere career skills and focus on engagement throughout the professional life cycle (8) succeed at improving faculty satisfaction, promoting institutional loyalty and retention. Such programs recognize that professional development includes personal growth. Even when fully funded to serve hundreds of faculty members, these programs are less expensive than the costs of faculty turnover (5).
Physicians in practice have even fewer professional development resources available than their academic counterparts. While private hospitals may balk at the time and cost of supporting well-being programs for their medical staff, it is likely that productivity and the quality of patient care will actually improve. It seems intuitive that optimal practice would depend on having manageable workloads and sufficient resources to accomplish the work efficiently. Although there is a paucity of data regarding appropriate physician workload (e.g., number and severity of patients) (9) and its effect on workload-associated fatigue and medical error (10), not to mention stress and job satisfaction, the typical 50-60 hour university workweek or a full-time practice schedule clearly does not begin to account for the physical and emotional toll of a career in medicine, especially in demanding subspecialties such as critical care. Another popular misconception is that faculty work long hours because of their passion for their jobs. While faculty who work the longest hours are the most productive in terms of publications, they are also the least satisfied with their workload and work-family balance (11). As one junior faculty person asked following the anatomy professor’s death, "Are there any senior faculty who have children/families who are truly happy as opposed to just making it"? (1)
Professional vitality requires a sense of personal growth, without which the individual cannot sustain either motivation or hope. True success is not measured by achievement alone but by the fulfillment an individual experiences as a result of having accomplished something. As Nelson Mandela wrote, "But I have discovered the secret that after climbing a great hill, one only finds that there are many more hills to climb. I have taken a moment here to rest, to steal a view of the glorious vista that surrounds me, to look back on the distance I have come." (12) Perhaps the true tragedy lies not in the fact that we all know colleagues who have succumbed to despair and taken their lives but that we simply accept it as the cost of our profession. We need to take a step back and rethink the culture that we have created for ourselves. Instead of merely surviving, can we not seek to thrive instead?
Dr. Wang is Staff Physician, Division of Chest and Critical Care, Scripps Clinic, San Diego and Voluntary Clinical Associate Professor of Medicine, University of California, San Diego.
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