4 Perspective

Entering my final year of medical school, I was still uncertain of my career path. While a residency in pediatrics or internal medicine still seemed to make the most sense, my surgery and critical care rotations had started to open the door to anesthesiology as a preferred specialty. As I would need to do a primary care internship prior to beginning an anesthesiology residency, starting my postgraduate training in a primary care specialty seemed like a reasonable plan.

My faculty advisor at the University of Virginia had established a collaboration with the Indian Health Service at the Navajo Indian Reservation in Arizona, where fourth-year medical students could do elective primary care rotations at the Indian Health Service (IHS) Hospital in Fort Defiance, Arizona. I had applied and was selected to do an extended pediatric primary care rotation there in the Fall of my final year in medical school. Given this rotation would be during the Fall interview season for residency programs, I had concentrated my applications and interviews with residency programs in the West.

As a young child, I had been fascinated by stories of the West in the 19th century. At the time, I had little insight into the dark history of the American government’s treatment of Native Americans. I was looking forward to spending several months on the Navajo reservation to learn more about their culture and hopefully develop a better understanding about primary care practice in a community hospital. It was remarkable how dedicated practitioners were at the IHS Hospital, providing care in a remote area with limited resources. I was also amazed that the staff there were so welcoming, unlike many fast-paced clinics where medical students were considered a burden. In the pediatric clinic, the physicians and staff soon became early role models for cultural sensitivity and compassionate care as many Navajos were apprehensive about coming to an IHS Hospital. This was my early exposure to the concerns Native populations could have with traditional medical practice due to the history of abuses to Native populations.

I spent my weekends exploring the Navajo reservation and the breathtaking landscapes of Northern Arizona and Southern Utah. This was before the age of cell phones or GPS, so I relied on hard copies of maps and the guidance of my Navajo colleagues at the hospital to navigate the remote highways of the reservation. Each recommendation was often accompanied by a personal story of a family member or significant event related to the tribe’s history and stewardship of the land on the reservation. Seeing the vastness of the reservation and isolation of its small communities provided perspective and nurtured my empathy for families while working in the clinic at Fort Defiance. I became better able to understand the reticence of families to access medical care as I learned of the hardship involved in traveling to the hospital and their apprehensions associated with receiving care from “Anglo” physicians. For the remainder of my career, I have retained a desire to learn more about the cultural background of my patients to better understand their unique concerns. I tried in earnest to learn some basic phrases in Navajo so I could introduce myself to families in the clinic and explain my role in their medical care. The only Navajo phrase I still remember is the greeting “yá’át’ééh”, which translated means “it is good.” I regret not learning more of the language and especially not retaining what I had learned.

Despite my love for many aspects of primary care and pediatrics, I continued to be attracted to the science and practice of anesthesiology. It is notable that I did eventually pursue subspecialty training in pediatric anesthesiology and practice at an academic tertiary-care children’s hospital, where I could maintain longitudinal relationships with children and their families. I think my love for pediatrics was only strengthened by my formative rotation in Fort Defiance on the Navajo reservation. My positive interactions with the children and families in the clinic as well as my observations of the practitioners provided a firsthand perspective on the unique nature of the physician-child-parent relationship.

On my last day, the staff hosted a farewell luncheon serving local cuisine with each staff member bringing their special dish. While I enjoyed each unique dish, the Navajo fry bread from the hospital cafeteria remains one of my favorite foods. At the luncheon, I was presented a handmade Navajo blanket by the nurses in the clinic and a pair of moccasins by one of the senior nurses. This nurse had taken me under her wing and patiently helped me learn some Navajo phrases. She proudly gave me the moccasins stating she had made them by hand, which was followed by the longest embrace I received from all the staff. She explained the Western shoes I had been wearing looked very uncomfortable, and she had made the moccasins for me by guessing my foot size. They fit perfectly. I remember the profound sadness I felt saying goodbye to her and others at Fort Defiance, knowing I would probably never see my Navajo colleagues again or have another experience where I was immersed in another welcoming culture for such an extended period. I now believe my desire to understand other cultures and establish international teaching sites for students and trainees began at Fort Defiance.

A principal component of your professional development is finding experiences that provide perspective and inform your career planning. This entails self-reflection at the end of each experience to confirm your personal and professional values remain well-aligned with your chosen career path. The hallmark of such a formative experience is that you become better informed after a different and deeper exposure to a facet of your chosen career, leaving you with a better understanding of your interests and aptitudes. In-depth exposures or “deep dives” into specific aspects of a profession such as a mentored research project in an area of interest, a longitudinal shadowing experience with a particular role model, or a novel elective rotation open the door to a specific career focus within a profession.

Figure 1. Steps for selection of an elective experience

When choosing elective experiences to explore a future career path or simply improve your clinical competence, you need to establish objectives (Figure 1). While you are probably unable to achieve all your desired objectives with any single experience, accomplishing your primary objective should be a priority and achievable in the timeframe available for the elective. Traditional and established elective rotations already have rotation objectives available for review. It is important to decide if the established objectives align with your goals, which can involve inquiring if there is any flexibility to customize the rotation. Some programs and institutions have created opportunities for students and trainees to propose novel rotations. If this is to be considered, identify and engage a faculty sponsor with both expertise in the desired area of study and experience with creating rotation objectives and assessment criteria. Given the additional collaboration and effort required, faculty that are open to designing a novel experience with a student often prove to be among the most committed and engaged supervisors. In some institutions, faculty sponsors need to advocate and endorse the merit of the elective to program leadership. Part of their endorsement is confirming to leadership that the experience provides a unique opportunity to explore a future career focus not currently available at the program or institution.

Prioritizing your primary objective assists with evaluating the available options as well as assessing the merit of possibly creating a novel elective. Research opportunities are more challenging to assess as they are often unique and customized experiences determined by your area of interest. Counsel from mentors is especially helpful in determining the value of any experience for your career development and assessing the feasibility of a project-based elective. If an established elective is being considered, reaching out to colleagues who have already completed the rotation provides an insightful perspective regarding its value for your own professional career development.

Your choice of a preceptor is an important component of ensuring your elective is successful. Not unlike choosing a professional and career mentor, an elective rotation or research preceptor needs to provide ongoing guidance and supervision as well as organize feedback for the duration of your experience. Constructive and actionable feedback is important as you work to achieve your objectives and reap the maximum benefit from your elective experience. This is especially true for a novel clinical rotation or project-based elective where there is not an established curriculum with rotation objectives and assessment criteria. At a minimum, your preceptor should provide regular feedback about your progress and recommendations for areas of improvement with a summative evaluation upon completion of your rotation. Select faculty preceptors that are accomplished in your area of interest with a track record of success serving as a preceptor for other students and trainees based on previous reviews.

The Accreditation Council for Graduate Medical Education (ACGME) has established six core competencies with specific milestones under each competency. A proposal normally includes rotation objectives and assessment criteria that address one or more of these six core competencies. Most rotations will be able to include medical knowledge, professionalism, interpersonal and communication skills, and practice-based learning and improvement competencies in the rotation objectives, including research electives.

Figure 2. Pathways of discovery

Many undergraduate and postgraduate training programs are providing integrated pathways within their standard curriculum for students and trainees to explore a specific focus for their career. Areas for career exploration can include a clinical subspecialty, research, education, administration and leadership, and global health (Figure 2). Your decision to pursue clinical subspecialty fellowship training to focus on a specific patient population and set of medical conditions takes additional training time and effort but could have a positive impact on the remainder of your career. For many physicians, there is professional satisfaction in distinguishing yourself within a clinical area of practice or in a nonclinical area of interest that may be rewarding, such as research, education, and leadership. A few physicians ultimately decide to exclusively focus on one or more non-clinical areas such as research or administrative leadership later in their careers.

An example of an integrated approach to career development during undergraduate medical education would be the EXPLORE program, which is a part of the Gateway curriculum at the Washington University School of Medicine. This program encompasses four broad pathways: advocacy and global health, education, innovation, and research. Students select and enter these pathways early in medical school and continue to participate in focused activities within each pathway throughout their four years of education.

Many medical schools have created dual degree options in conjunction with their business school and school of public health. These dual degree programs provide another option to traditional medical scientist training programs that provide the opportunity to obtain both Doctor of Medicine (MD) and Doctor of Philosophy (PhD) degrees for candidates who have a strong interest in pursuing a career as a clinician-scientist. It is reasonable to delay obtaining an advanced degree until a later stage of your career when you are better positioned to invest the necessary time and funds in a master’s degree program in science, business, public health, or education.

Residency training programs have also begun to create innovative programs to foster the careers of future clinician-scientists. The Department of Anesthesiology at Washington University offers applicants the opportunity to apply to a five-year program that combines residency training with dual clinical and research fellowships in an accelerated continuum of training. An important component of these continuums of training is targeted seminars and robust mentorship programs to introduce trainees to their future research community. The purpose of these career development activities is to foster each young physician’s professional identity formation and understanding of their future career path.

The Departments of Pediatrics and Internal Medicine at Washington University have created global health pathways for residents interested in exploring careers in global health research, education, and advocacy. These programs are career development pathways within a formal residency training program with focused coursework and rotations. A mentored project is often an important component of these postgraduate programs and provides an opportunity for participants to identify and explore a particular area of interest within each pathway. Like other pathways in undergraduate or postgraduate programs, socialization within the global health community is enlightening to a physician contemplating a career focused on this area of medicine.

Medical schools and postgraduate training programs continue to innovate and offer more opportunities for physicians-in-training to enroll in integrated career development pathways as a way to attract highly motivated individuals who are committed to a focused career path.