6 Strategy

One of the responsibilities of a residency program director is assisting residents with their future career plans by providing counsel at critical periods in their training, especially when residents are applying for fellowships or considering job offers. A resident who has self-doubt about their career choice will sometimes seek advice regarding alternative career paths once they become more familiar with the clinical specialty. A reassessment of their aptitude for a new clinical practice and an interest in the basic and clinical science related to another specialty, or disappointment with their current quality of life, may lead them to explore an alternative career.

Emily was a second-year emergency medicine resident. Her program director had contacted me asking if I would meet with her to discuss her interest in anesthesiology. He stated that she had his blessing and was a terrific resident. Emergency medicine was a strong program at our institution so I felt confident she would be an acceptable candidate to consider following such a strong endorsement from her program director.

The next day I met with Emily in my office. Emily had what I could fondly describe as a bubbly personality. She was outgoing and very talkative. I had expected someone more somber given we were about to discuss a major potential change in her career. Emily preemptively offered that she had already spoken with several residents in our program to find out more about anesthesiology training. She also had recent exposure to anesthesiology, having completed a clinical rotation in our department earlier in the academic year as a part of her emergency medicine training.

Our initial discussion explored why she decided to match into an emergency medicine residency program rather than anesthesiology. My approach was one of interest rather than of challenging her decision. Emily recounted her love for acute care medicine and how the opportunity to care for a diverse population of patients with a variety of medical conditions immediately attracted her to emergency medicine specialty. It also happened to be her favorite rotation in medical school. She lamented that she had tried to do an elective rotation in anesthesiology, but there were not enough positions available for all the medical students at her medical school. She liked the fact that emergency medicine training could provide her the opportunity to do a critical care fellowship, which was another of her favorite rotations in medical school. She stated one of the things she loved about anesthesiology was its similarity to emergency medicine with an added focus on cardiopulmonary physiology and critical care medicine. As we spoke, Emily became more excited about the prospect of switching to anesthesiology.

I would normally go through the exercise of challenging her decision by citing many of the conventional wisdoms and misconceptions about anesthesiology, but Emily’s enthusiasm and proactive stance had convinced me that any challenge of her commitment to this career path would be politely dismissed. Fortunately, our program had an open position. At this point, I needed to have a follow-up discussion with her program director to ensure we could proceed with an acceptable timeline that would not adversely impact either department from a staffing or financial standpoint. I felt comfortable sharing this with Emily, who stated she only wished she had discovered her love for anesthesiology sooner. Using a soft and paternalistic tone, I responded she will now have a greater appreciation for her newfound career path. I then shared my personal story of completing a pediatric anesthesiology fellowship and my mid-career discovery of academic medicine and teaching. I closed by stating that my earlier training and private practice experience continued to provide perspective as an educator and inform future career decisions. Emily listened intently and then nodded in agreement. She had just checked my box for being intentional in her career decision-making.

The following day I contacted her program director to update him on my meeting with Emily, sharing her strong desire to switch programs. He sighed and said, “We will miss Emily” and “Please take good care of her because she is special.” We finished our conversation by concluding we both needed to do a better job of getting to know medical students and residents to assist them with discovering their career path.

Emily was ecstatic when I shared the good news. I was not surprised a few years later when Emily was selected to be a chief resident in our Department. As a chief resident, Emily developed her administrative leadership skills, gaining experience managing conflict and professionalism issues in our program. She also assisted me with the peer review of other residency programs at the University. Following graduation, she completed a fellowship in critical care medicine, and now she is a recognized leader and educator at a well-regarded academic anesthesiology department.

While Emily’s determinative rotation in anesthesiology occurred during her emergency medicine training rather than medical school, she was self-aware, sought counsel, and was willing to redirect her training to better align her values with a new career path. She also became a role model and mentor to others. Among my most gratifying mentor experiences were the regular meetings I had with Emily during her residency to explore her evolving academic interests and career aspirations. I continue to counsel undergraduates, medical students, and postgraduate trainees to pursue formative experiences and find mentors as early as possible in their careers, referencing my own nontraditional career path as well as Emily’s deliberate decision to change specialties and pursue fellowship training.

Your career direction remains tentative until you have progressed to a pivotal point in your education and training. Meaningful exposure to various aspects of a professional and clinical practice is needed to fully assess your suitability for a specialty or specific academic focus.

Your medical career often begins with a series of short excursions or “deep dives” where you are exposed to various aspects of medicine to gain needed perspective. The decision to change long-term career plans can follow specialty and subspecialty elective rotations in medical school, career counseling, and self-reflection. An early career decision is selecting a specialty for your residency training. My career journey included the mid-career completion of a subspecialty fellowship in pediatric anesthesiology following several years of private practice. It is more desirable for your formative experiences to occur uninterrupted under the stewardship of an academic department during a postgraduate training continuum where you have role models and mentors. Emily’s decision to proactively investigate an alternative career path and subspecialty training illustrates how a difficult career decision is ideally made with the assistance of colleagues and guidance from program leadership. Because of such resources, she was able to discover her interest in leadership and education and then decide to pursue advanced fellowship training in critical care medicine.

Medical schools and postgraduate training programs regularly assess the well-being and career satisfaction of their students and trainees. Assigned advisors and coaches often meet with students and trainees individually or in small groups that provide safe forums to share feelings and receive career counseling. It is becoming more acceptable to provide compassionate “off-ramps” when a young physician finds they need to change their career path or academic focus. It is widely known that medical student and resident burnout is common during long and rigorous training continuums. You should stay self-aware of your own mental state and remember that important career decisions must not be made during periods of crisis. Rather, you should seek support and counsel during acute crises or episodes of career self-doubt. Ombuds, who are trained crisis counselors, and psychologists have become an integral part of institutional wellness programs.

Figure 1. Steps in professional career development

When you embark on a career path that includes postgraduate training, most of your immediate efforts will be devoted to developing content and clinical expertise in your specialty (Figure 1). The aim of residency training is to achieve global competence in your chosen specialty with a goal of becoming an expert clinician. A necessary objective is to pass the required examinations to achieve board certification in your chosen specialty. An interest in a specific clinical area of a specialty commonly inspires a physician to explore and pursue subspecialty fellowship training. The added time, commitment, and financial sacrifice attached to extending your training is best made following subspecialty rotations during residency training and consultation with trusted advisors.

The selection of formative experiences, which has already been discussed, will be another important part of your training. Take advantage of program advisors and mentors as well as institutional resources to explore leadership opportunities and projects. In Chapter 4, we presented the various career development pathways provided in undergraduate medical and postgraduate training programs. I would encourage you to explore and participate in career development activities during your undergraduate and postgraduate medical education. One strategy is to select electives and projects that are formative and inform your decision to pursue a secondary career focus or advanced degree. Seeking a leadership position in your training program or serving on a department committee can be determinative in assessing your interest and aptitude for a realm of leadership.

When you make a firm commitment to a specialty with a specific academic focus, become like the many proactive professionals who seek out collaborations with thought-leaders in areas of shared interest. Early in my career as a medical educator, I reached out to established residency program directors and thought leaders in postgraduate medical education. I also pursued membership in both education-centered professional societies and working groups focused on the development of curriculums and examinations in my anesthesiology specialty and pediatric subspecialty. A collaborative project provides a future roadmap for additional academic endeavors and future professional associations. Accomplished colleagues can serve as career advisors, sharing their insights about past career decisions and providing expert guidance regarding future areas for career development. Stay open-minded about your ultimate career path until you have participated in a variety of career development activities and collaborations.

An important step in your career development is identifying mentors. The core attributes of a good mentor are a commitment to their mentee and a willingness to invest the time to understand a mentee’s career goals. Trusted mentors remain objective and receptive to your evolving professional identity. In mentoring relationships that endure and mature over the course of many years, the mentor-mentee relationship often becomes transformative, with both the mentor and mentee receiving long-term benefit from their association.

Mentors often possess characteristics and talents that do not mirror your own, opening the door to approaches for your career that you would not have discovered independently or with counsel from someone with a similar background and philosophy. In another chapter, I introduce you to Dr. Walker, who falls into this category for me. Dr. Walker proved to be an influential and memorable faculty preceptor during my residency training. While he was abrupt and very directive, he taught me to accept criticism, adapt, and ultimately become more resilient. He also demonstrated a commitment to his practice and patients, which has had an enduring impact on my clinical practice.

Figure 2. Characteristics of an effective mentor

Once you have determined your education and career path, seek counsel from colleagues and advisors to identify senior professionals that are established in your area of interest. As you consider your possible future mentors, there are certain desirable attributes you should look for (Figure 2). Senior colleagues who are knowledgeable with expertise in your area of interest are well-positioned to provide a seasoned perspective and share their own roadmap for success with navigating the challenges of a professional career. They have usually achieved respect and recognition in their respective field. Often a prospective mentor holds a leadership position and has experience serving as a mentor to younger colleagues in the past. A recommendation from a recent mentee who had a good relationship with the mentor and is on a positive career trajectory provides reassurance. While less accomplished mentors provide useful insights that are more relatable early in your career, they often lack the longitudinal experience and perspective that is sometimes needed during a long-term and evolving mentor-mentee relationship.

When you have identified a potential mentor, the next step is to determine if their personality and manner is compatible for a long-term mentor-mentee relationship. Early signs of a fruitful collaboration include a mentor who listens, asks probing questions regarding your career aspirations, and shares insightful perspectives. Just as important, is that they remain objective about your career trajectory and put your career ahead of their own self-interest. Mentors are sensitive to the uniqueness of their mentee. A mentor should be adaptable, willing to adjust their guidance as needed to best promote your future career objectives and open to novel career paths that may not be familiar to them. A flexible and opportunistic mentor embraces the prospect of expanding their knowledge regarding new and innovative career paths. The teacher can become the learner, and when they do, both teacher and learner grow professionally and benefit.

Over the course of a rigorous education and training continuum, there are professional and academic challenges. A vested mentor is supportive of your continued professional development as you learn to adapt to future career challenges, and become more resilient. An accomplished mentor also provides a reservoir of valuable knowledge regarding how to approach future obstacles by sharing their own adaptations to prior challenges and acquired coping skills.

Serving as a mentor is a true commitment to another colleague. Very early in your search for a future mentor, explore each candidate’s current obligations and available bandwidth to ensure they can devote sufficient time and effort to meet with you on a regular basis. Consider reaching out to prior mentees of a potential mentor and determine the historical level of commitment to the mentor-mentee relationship. Reliable mentors are an accessible and trustworthy advocate for your professional development. As many mentor-mentee relationships last for several years, it is important to develop a trusting relationship that continues to evolve and be mutually beneficial.

Following the completion of a training continuum, it is desirable to schedule time with your mentor to review your collaboration and discuss what you have learned with them and explore a future peer relationship. Many mentors and mentees maintain lifelong friendships following the completion of a close mentor-mentee relationship.