Archive for category Career

Moving on up

Flashback: sitting with my mentors and Attendings as a new ID fellow. The division chief asks the question – “Where do you see yourself in 10 years?”

“Doing something like your job, ” I tell him.

He chuckles.

My boss, the Division Head for Infectious Diseases, has always had my career interests at heart. Several times during my first year here we talked about 5-year and 10-year plans for myself and the division. He would share difficulties, ideas, insights and experience – always with an implication that someday, maybe “all this could be yours”. As a junior faculty, fresh out of fellowship, it was somewhat flattering and dare I say intoxicating.

I remember the day, now nearly seven months ago, when he sat me down in his office. There had been unforeseen difficulties in the recruitment for the new Chair of Pediatrics. At the last minute the carefully crafted collaboration between hospital, university and State fell apart and with the existing Chair well on the way to his new role there was an upcoming void to be filled. Fingers pointed to my boss to act as Interim Chair – a role for which he was ideally suited, having been on the selection committee and knowing the needs of the role intimately, being a genuinely nice guy, and having buckets of respect from faculty and staff in the institution.

He was very frank – “That five-year plan? I need you to start next month.”

Despite being the most junior member of the Division (one other doc there in fact has been practicing medicine longer than I’ve been alive) I was, ironically, the one best suited to run the day-to-day business of medicine. I’m the only other full-time physician in ID, my colleagues all having responsibilities to other areas of academic medicine or simply working off-site most of the time. My office is located next to the clinic, next to the administrator, the nurses, and the office manager. I’m on service and in clinic more than any other ID Doc (again, the whole junior member thing). For minor issues and questions, people were already used to just popping in to run ideas by me. He assured me the role would mostly consist of organizing the faculty meetings, making sure everyone did what they were supposed to do and be where they were supposed to be. I saw it as a prime opportunity to test the waters, see what I could do, and get some experience. Expectations were a six-month temporary situation while the hospital worked on recruiting a new Chair, and I figured I didn’t have much to lose.

Within a week it was clear there was more to the role – I was handed a survey to complete, detailing expected 5-10 year staffing and office requirements, for a division that I was just getting to know in its current form. People came to me with personal issues within and between divisions, professional concerns, financial concerns. I suddenly had a budget to keep to and five (later eight) physicians to keep on track to meet it. We had a visit from the Joint Commission, and we were still in the middle of a rollout of our new EMR, for which our division was one of the very first areas to go live, and we were still not back up to predicted visit numbers. There were meetings – where I was not only privy to the inner workings of the hospital, but also expected to contribute meaningfully and bring new things back to the rest of my group, and make it happen. Organizing the other ID docs (a task best described as akin to herding cats) turned out to be the least of what I was doing.

The most surprising thing of all was just how readily everyone accepted me as the person to go to. I think it speaks a lot to the attitudes and spirit of the institution that at no point did anyone make me feel undermined or inadequate, and that was somehow very humbling. I think some of that was because there were already several other young physicians in leadership roles – our hospital is less than 20 years old, and much of the growth has come from people like myself.

I found myself going in earlier and coming home later – plans to work on my research goals and apply for funding were simply shelved as my time was sucked up by the administrative tasks needed to ensure that we could take care of our patients. But with all of this extra work (I later discovered they’d allocated me 4% of my time to do this – I laughed out loud on the conference call at that piece of news) I was genuinely enjoying myself. I’ve always been one to want to know how things worked and the inner, secret details of things. Here I was, handed all this on a plate – and more, being given freedom (a shocking amount of freedom I felt) to make changes as I saw fit. Initially reluctant to do much without checking in with The Boss first, I later reveled in the opportunity to take the division in new directions and start up new initiatives that hadn’t been on the cards. I felt my wings stretch.

So what has happened over the last six months? We became the division of Infectious Disease and Immunology, as we added two clinical immunologists to the team (a process admittedly envisioned and started long before I was on the scene), and then had to work on promoting the new services to community physicians and hospital faculty alike. We changed outpatient clinic scheduling policies and inpatient consult practices, improved billing patterns and brought the division back to year-on-year growth. We’ve been added to the State newborn screening program for SCID (severe combined immune deficiency) and accepted as a site for an antibiotic clinical trial. I started building a collaborative program to care for kids with velocardiofacial syndrome (a particular immune deficiency syndrome I’m extremely interested in). Along the way a myriad of tweaks, reminders and attempts at cat-herding have kept us on track for what has been a pretty successful year. I began to wonder what would happen if my boss stayed on in his interim role – what would that mean for me?

I look back at all this because last week marked the end of my tenure as Interim Medical Director for the division. The boss and I spoke on the phone (in-person meetings are horrifically difficult to schedule nowadays) about what we would do next. Cold hard facts and practicalities were brought up. I’m not even two years out from fellowship – running a division is really for an experienced academician, ideally one with research funding to take the division down a new path towards a fellowship program of its own. How could we attract new faculty – more experienced faculty, faculty with funding, when they would have to work under me? In contrast, my research background placed me ideally to start working on establishing a lab and getting some grant money in – it would take time but he would help me apply for funds and get lab space. He also recognized my teaching skills and rapport with the residents – perhaps I should focus on medical education and curriculum development?

I let him speak – I wasn’t sure if he was just letting a stream of consciousness flow or trying to convince me of something.

Eventually, after about 45 minutes, he stopped and asked the question, “So what do you want to do?”

I realized with sudden and utter clarity that I was at a crossroads. I was being given my future career choices, with the full support of the future clinical head of the hospital. In a weird flash-forward dream-sequence I saw myself in these roles, feeling them out, trying to experience what it would be like. What dreams could I fulfill, how long would it take for me to get there, what would I have to give up…? And then the obvious hit me.

I would miss this job. I’d never intended to find myself so soon in the position of having to lead and make decisions, interpret data and trends and make policy that would impact the working life of my colleagues and the care of our patients, but if I left it I could see myself learning about problems and *wanting* to intervene and take the reins, and there would be a part of me that would be empty after “stepping down” from doing it for these past few months. How would the other faculty feel about another change of leadership? Would they still come to me regardless?

So I drew a deep breath, and I told him what I wanted to do.

And here we are. The announcement has been made. My boss is now the Chair of Pediatrics, and my role as the Interim Medical Director of ID and Immunology….is no longer interim. We have much to do – we have to think about finding an academic Division Head, expanding faculty further, working again towards our goals of expanding research and building a fellowship program. The last six months have been a transitional period as the cards were shuffled and a new hand dealt out.

And I like to think it’s a pretty awesome hand.

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The redundancy of being called a “Medical Educator”

Incredibly, since I have been in my new position for over 6 months, this morning was my first lecture (but I use the term loosely) to the residents here. It was ostensibly on “infectious rashes and infestations” – but I entitled it “Nasty skin infections – cos there really aren’t any nice ones”.

It was apparently well received.

I have a knack for teaching. I’m not saying that because I think I have a knack – other people have told me so. I have various awards to show for it. I have people ask me to teach, and I assume it’s not just to hear my awesome accent. It has a history going back to high-school where my friends would ask for help with their homework. I had the annoying habit of not giving them the answers – rather I would try to help them figure it out for themselves – responding to their questions with questions of my own. I don’t remember whether I did this out of a sense of mentorship – the benign guidance of a sage helping them to reach their potential – or out of sheer bloody-mindedness and for my own amusement. I do know I simply didn’t think it was “fair” that I had to figure it out for myself but they wanted the answer simply given to them. I can’t blame them – we all want that at some point.

In medical school I found myself struggling in a competitive, highly academic and esoteric system which I was pretty unprepared for. I remember writing a scathing review of the teaching I had received there for my college magazine. I “dropped out” of one tutorial class to do self-study instead, and brought my grade up two points as a result (on a 4 point scale, that’s not bad…). I laid down the mental framework for how I wanted to be taught, and applied that to others where I could. I was lucky to be asked to supervise (teach, in Cambridge lingo) genetics and virology to two of the university colleges for two years. Ironically I found myself as a flawed part of the very system I had complained about – flawed in that I was teaching without any training in how to teach!

It was in my residency however where I really found a role for myself in teaching. My wife tells me that I “like telling people how it is”. She may be right. In any case, there are ample opportunities for teaching medical students, junior residents, peers and colleagues during the years that you yourself are getting educated and trained in medicine. I developed my own style – honed through trial and error, practice and observation. My research years had taught me a lot about how to teach and how NOT to teach effectively – and also removed whatever fears of public speaking I might have harbored. We all know that “teachers teach how they were taught, not how they were taught to teach”, but I made a conscious effort to TRY to teach using techniques that I knew to be effective, even if I hadn’t experienced them directly. I cherry-picked those I liked and adapted them to my own personality.

The techniques weren’t all that became developed – my repertoire of content grew and was refined. For most of the topics I was asked to teach about I got to the point where I could grab a pen and paper, or whiteboard, and put together an interactive case-based 1-hour teaching session with no notice.

After today’s success I thought a little about my role as a medical educator, and I remembered something.

Doctor. We all know what it means. Or do we?

It means “Teacher“.

The word “Doctor” has been hijacked by the medical profession (and other related careers), where in fact it was intended to mean someone with sufficient learning in a subject area to teach others. Technically in fact, most medical degrees aren’t “Doctorate” level at all, since they are “first degrees” in medicine, regardless of whatever degrees a person may have in another subject. My own medical degree reflects that: MBBChir, Medicinae Baccalaureus, Baccalaureus Chirurgiae – Bachelor of Medicine, Bachelor of Surgery. An MD in the UK (and almost everywhere except the US) is a true post-graduate degree with a research dissertation.

Ironically the medical profession seems to have forgotten that. Medical education in the US is an oft-neglected role, poorly reimbursed, run by those with a passion for teaching while feeding off the table scraps that their procedure-driven peers feed to them through the teaching hospital income. Until recently, there were few real incentives to teach or contribute to medical education – promotion and bonuses were linked to clinical revenues and research grant dollars. I am fortunate to work in one of the (apparently) few places that does place a value on medical education such that I can use it for career advancement rather than a hobby in my spare time. People go into medicine for all sorts of reasons – to help people, to heal, to make money, to do cool procedures and surgeries – but I doubt very many go into medicine to teach.

And yet they carry the title of “Teacher”. My own career track is that of a “medical educator” – which seems to me to be a redundant phrase, if you think about it. The fact that we have to label medical educators as something special shows how we have drifted away from the true meaning of “Doctor”.

To go back to our roots, we should ALL be educators. Every year there is a wave of students leaving their education and entering training, and a wave of residents leaving training and entering the real world. These men and women need guidance. Beyond the academics and pearls of wisdom, they need mentoring, career and business advice, insight into work-life balance and their options beyond the ivory towers. They need to know how to recognize meningococcemia, but they also need to know how to get a parent to recognize it over the telephone. They need to know when to admit a patient, but also how to bill for that admission. They need to know how to convince a skeptical teenager of a treatment plan, and how to negotiate a partnership contract.

Physicians don’t have to work at a medical school to teach – they can contribute to career fairs, social media, newsletters, take on elective students in their practice…anything is possible. There are literally hundreds of thousands of years’ of experience out there waiting to be tapped…

So I urge my medical colleagues – reflect on this. Remember your title, your role in history and the potential you have for leaving a legacy of medical practice in your wake, in the form of the next generation of Medical Doctors.

As Hippocrates himself said:

“…I will impart a knowledge of this art to my own sons, and to my teacher’s sons, and to disciples bound by an indenture and oath according to the medical laws…”

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I didn’t get the job I wanted…

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I didn’t get the job I wanted.

And it rocks.

When I was three years old, I told my family I wanted to be a doctor. My grandparents gave me one of those plastic doctor’s kits – the kind with the flimsy plastic stethoscope in a little white bag with a red cross on it. I’ve told people I wanted to be doctor for as long as I can remember. Aside from brief flirtations with the idea of a killer music career and dabbling in astrophysics (!) it would seem as though it’s been a straight line for me.

But, as any medical student or resident can tell you, it’s not quite that simple. What is classified as “a doctor” varies tremendously. I used to think it meant the doctor I saw for my regular childhood checkups, but then I discovered the exciting TV ER dramas and saw a different side to things. My first “specialty” decision was to be “a heart doctor” – and by that I meant a cardiac surgeon I suppose. My rationale for that was simply that while neurosurgery was more complicated there wasn’t much you could actually fix doing that. It was just cutting things out after all 😛

Then I went on a medical student career conference….and loved the idea of pathology. Sorting through disease causes, an intimate understanding of pathophysiology and anatomy…and really yucky cases. Yeah, that sounded cool.

And then I hit medical school, and somewhere along the way I fell in love with viruses. Bacteria were ok, I guess, but I had a real problem remembering all the damn antibiotics and what they did. My categorization for the cephalosporins consisted of “Cephalo-kill-a-lot”, “Cephalo-cost-a-lot” and Ceph-du-jour”. It was pretty pathetic. I also realized that while surgery was indeed incredibly technical and cool…it consisted of a lot of standing up or running around…and I liked to sit down. I also had difficulty putting things back together after I had taken them apart, something which I understand is a prerequisite to being a competent surgeon. So…medicine it was for me.

But then what kind? Kids didn’t like me – I would walk down the street and make them cry. Maybe I had some kind of weird expression on my face – I never figured it out. But old people didn’t get better, at least in the hospital. Each admission added another diagnosis to the list, and the slow downward spiral was a constant reminder of my own mortality. A selfish thought perhaps, but a valid one when it comes to job happiness. I was in a bit of a quandary.

And then what about teaching and research? Well, I did like teaching, so that would be nice. I had some practice at that during my PhD years. But I had been told that “Those who can, do – those who can’t, teach.” I wasn’t sure I wanted to get lumped in with that.

And as for research – well, I really like bench research. Don’t ever call it “basic science”. It’s not “basic” – it’s actually quite complicated 😉 I remember several people telling me that with the mix of PhD and MB I could go into clinical trials. I pooh-poohed the idea, since I didn’t want to work for the evil money-grubbing pharmaceutical companies. I wanted pure science.

I gradually found myself gravitating to an outpatient office-based way of life. General Practice or Psychiatry interested me – treating the patient instead of the disease (but wait, didn’t I like pathology…? How did that happen..?) Maybe I just liked to talk a lot. I dunno. In any case, at some point when I was planning on moving to the US I sent an email to a pediatrician here – a contact of my wife’s family. He replied that he couldn’t help me with psychiatry or family medicine (as it is called in the US) but I could come over for an elective.

I rather cunningly selected Pediatric Infectious Disease as my rotation, since I would get to work with him. It turned out well. At the end of it I was offered a research job with him for a year, while I worked on the USMLE exams. His boss, the division chief, asked me if I wanted to do clinical trials work. Torn between my thoughts about Big Pharma and my future job prospects…I said yes.

Fast forward 7 years. What did the medical student who didn’t get on with kids, hated antibiotics, didn’t want to do clinical trials and who loved bench research end up doing?

Here I am, an Attending in Pediatric Infectious Disease. In charge of, of all things, an antibiotic stewardship program. I have taken part in over a dozen clinical trials for pharmaceutical companies, and not done any real bench research since I left the UK. I have created a new curriculum and won awards for teaching. My first week on service as “the real thing” has been at times stressful, busy, fun frustrating, but at every step of the way IT FEELS RIGHT. This is what I feel I am meant to be doing.

The bottom line is that whatever you think you want to be, you never can tell where life will take you. Keep your options open and give things a try. Even a couple of years ago the idea of heading up a stewardship program wasn’t on my radar. Who knows what the next 5 years will bring…

Oh yeah, and kids smile and wave at me in the street now. I still don’t know why.

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Nearly done

I’m awake.

It’s early.

I don’t have to be awake, but I can’t sleep. You see, this is my last day of service.

Not my last day of work – no, I have that tomorrow – but for whatever reason my mind is aglow with whirling transient nodes of thought (Blazing Saddles reference for you) and I can’t get back to sleep. I’ve just caught up with some outstanding dictations (outstanding in that they are late, not that they are in any way good) and so I thought I’d reflect a bit.

I’ve been at Upstate for the past 7 1/2 years. I showed up here as a medical student, post-PhD, not yet done with my medical training and not yet certain about even doing Pediatrics as a career. I had set up a month-long elective in Pediatric Infectious Disease because (A) my one and only US medical contact was a Peds ID faculty member and, er, that was it. I figured I should brown-nose a bit.

No seriously, that was it.

At the end of that month I had somehow got the next 7 years all planned out… This guy hired me to work for him doing research and clinical trials for a year. I took my USMLE exams. I applied for residency (Upstate was the only place I applied to). It was taken for granted that I would transition into the ID Fellowship, which I did, so I have just been part of the furniture here for all that time.

I'm second in from the left, back row...

I have seen the new Children’s Hospital grow from a mythical idea to scaffolding to wonderful newly equipped spacious rooms. I have supervised medical students, watched them grow as Residents and young people, and seen them graduate and start work as Faculty. I have made mistakes, learned a lot, learned that I have a lot still to learn, and I like to think that somewhere along the way I saved a few lives. I’m not sure I’ve actually achieved anything quite so grand – but I’m pretty sure I had a positive impact on an awful lot of kids.

I certainly can’t claim to be the world’s best resident – I have had plenty of peers and colleagues who were better doctors than me: more knowledgeable, more intuitive, harder working, better at getting IV’s started…but I have found that I am good at what I do. I am good with patients and families, I actively practice patient-centered care, I can teach effectively and I can do research. Give me a database and a few hours to code and I can churn out some cool stuff.

It’s a weird feeling to move on – to a job where there are things to get done, where I won’t have the kind of supervisory backup that I’ve enjoyed as a trainee, but where I’ll also have the freedom to practice medicine and work more along my own path. The light at the end of the tunnel has turned out to be an oncoming express train…and I don’t think it truly hit me (pardon the expression) until the past few days. My last 2 weeks of service have been too busy to think about it! Now suddenly, here I am, wrapping up my last dictations and preparing my last lecture. I need to bring boxes to my office to empty it: how weird is that? There are an awful lot of really, really cool people I’m going to miss at Upstate. Nurses, lab techs, pharmacists, Docs – so many people who I’ve worked with over the past few years and got to know. They shaped how I practice medicine. I think that may be the most intimidating thing about having to move – having to re-learn all the ways and intricacies of a new system, a new place. I’ll be flying blind for a bit. I figure it’s worth it.

The thing to remember, and this is a crucial thing for any aspiring doctors to realize, is that I really enjoy what I do. Whatever fluke of fate brought me to Upstate and Peds ID, I can truly say that I don’t think I’d be happier doing something else. Pediatrics wins over any adult care for me, every time. And Infectious Disease…? There’s just something about finding a cause for a disease and killing it. You can’t do that for hypertension, or asthma, or obesity, or diabetes – “You’ve got the bugs, we’ve got the drugs” became my catchphrase.

Confucius said “If you love your job, you’ll never work a day in your life.” He was right.

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