American College of Physicians: Internal Medicine — Doctors for Adults ®

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Tales from the trenches: tips to revitalize your career

From the May ACP Observer, copyright © 2003 by the American College of Physicians.

By Phyllis Maguire

SAN DIEGO—As director of medical inpatient services and assistant internal medicine program director at Tripler Army Medical Center in Honolulu, Stephen M. Salerno, FACP, has come a long way from the small clinic in Georgia where he began his career. While he loved patient care at the clinic, he couldn't face the prospect of having the same call schedule and work hours for the next several decades.

"I chose medicine because of the variety it offered," he said. Instead, he found himself chafing under a crowded care schedule that left no time for other pursuits.

In his quest to rejuvenate his career, Dr. Salerno is far from alone. Many physicians are searching for ways to retain their enthusiasm and love for medicine in a tough practice environment-and organizations like ACP are looking for ways to help them.

At an Annual Session presentation, Dr. Salerno, who is past Chair of the College's Young Physicians Subcommittee, joined a panel of physicians who described how they have reshaped their careers and practice settings to regain a sense of satisfaction.

While the changes were sometimes difficult and required some sacrifices, the panelists said their actions helped them renew their careers.

Exploring different careers

To get the professional variety he needed, Dr. Salerno decided to replace some patient care duties with teaching and administration. He urged physicians who feel dissatisfied to consider possibilities in teaching, administration or research.

To see if a pathway is a good fit, Dr. Salerno recommended taking on responsibilities in that area for one afternoon a week. (He suggested negotiating appropriate compensation or time away from patient care in exchange for performing new activities.) Here are other tips he gave physicians who are considering redesigning their careers:

  • Find a mentor. When choosing a mentor, Dr. Salerno suggested finding someone with whom you have personal and intellectual chemistry, who is close enough for you to maintain a personal relationship, and who has enough influence to help you engineer a career move.

  • Get training. Once you find a new career path you want to pursue, get additional training. If you're interested in teaching, he explained, you can attend CME courses on bedside teaching, evidence-based medicine and curriculum organization that academic organizations such as ACP, the Society of General Internal Medicine and the Association of Program Directors in Internal Medicine offer. If you're considering a research career, look into an MPH or PhD degree. And if you're interested in administration, consider a master of business administration (MBA) or another medical management degree.

  • Build your reputation. One way to advance is to provide some high-stakes leadership, Dr. Salerno pointed out. Volunteer to take a leadership role in your hospital's Joint Commission on Accreditation of Healthcare Organizations inspection process if you want to move into administration, for example. Or if you're interested in teaching, help a local residency or fellowship program prepare for an American College of Graduate Medical Education Residency Review Committee inspection.

    Assisting training programs with curriculum planning, lecturing or organizing an elective may lead to an appointment as a key clinical faculty member. Once you start assuming highly visible roles, he added, your organization will consider you for other positions when they arise.

  • Network. While your boss can serve as an important ally, try to find additional mentors who are a level higher in your organization and involved in areas outside your immediate specialty.

Let mentors know that you are open to new career possibilities if positions open up, which can put you in the running for an available slot at an early stage. Many mid-career positions—especially in education administration—are not filled through a formal selection process.

Also try serving as a mentor yourself as you gain more experience. Frequently, the people you help will move to other local organizations and expand your reputation there as well.

Dr. Salerno pointed out that the easiest time to develop a career plan is in residency, when you have easy access to mentors from a variety of medical careers. He pointed out, however, that it's never too late to draw a new "career road map" that lets you adapt to new circumstances and pursue new interests.

"The biggest danger," Dr. Salerno said, "is not being open to change."

Escaping a 'toxic boss'

Panelist Daniel C. Randall, FACP, provided ample evidence that physicians have many options to choose from when they feel it's time for career change.

Since finishing his training in 1995, Dr. Randall has held five different positions. He moved from a community hospital to an academic outpatient practice to a hospitalist position. (All three positions were in the military.) He then worked for an outpatient charity clinic and is now with a university-based practice in central New Jersey.

What were the driving factors behind all those moves? Dr. Randall, who is Chair of the ACP Young Physicians Subcommittee, said he made one change to escape a "toxic boss" who punished employees for giving any negative feedback.

Ethical considerations were behind another change: The nonprofit clinic where Dr. Randall worked was sold to a for-profit company, which instituted "unacceptable" patient care shortcuts to cut costs.

He made his latest move to a university health care system to gain more time for his new role as a father. While he was initially concerned that the position might not provide enough medically challenging cases, he said he's been pleasantly surprised.

"I now care for patients who have myasthenia gravis, immune thrombocytopenia and transplantations," Dr. Randall said in a follow-up phone interview. "I never would have considered this kind of practice before, but by thinking outside the box I'm able to spend more time with my family."

Balancing work, family

Family considerations were also behind a major change made by Lisa K. Madren, ACP Member, who is part of a hospitalist practice in Norfolk, Va.

Now four years out of residency, Dr. Madren said she was successfully balancing two full-time careers: her hospitalist position, which she solidified by "never saying 'no' " to hospital committee work, and her role as mother of two small children. She was forced to rethink her schedule two years ago, however, when her older child was diagnosed with autism.

Rather than feeling entitled to demand a part-time position, Dr. Madren took a different tack. "I approached both the hospital and my practice and asked, 'How can I make a part-time position valuable to you?'"

She focused on what she identified as the bane of all hospitalists: undesirable night and weekend shifts. She proposed a part-time business model where she would take on some of those shifts while continuing her full-time hospital committee work, much of which she can manage at home through what she called "cyber meetings."

Dr. Madren now works up to seven hospitalist shifts a month. The part-time model she designed has been so successful that her practice has hired three other part-time hospitalists, allowing the full-time physicians to limit their practices to 9 to 5 weekday shifts.

She extended that same creativity to child-care arrangements. When she was working full time, she and several other full-time physicians pooled their child care resources to avail themselves of each other's caregivers if their own called in sick. Dr. Madren has now created a similar backup caregiver group among her part-time colleagues.

"You have to be innovative and aggressive when it comes to child care arrangements," she explained. "You also have to be creative in designing the kind of practice that works for you and selling its advantages as a business model."

Improving an existing position

Maher A. Roman, FACP, didn't want to change jobs, so he instead enhanced the position he had.

A primary care physician with the Loma Linda Veterans Affairs (VA) Medical Center in southern California, Dr. Roman said he knew he needed more training to be "a better physician manager." For him, the answer was an MBA degree.

Earning the degree required short-term sacrifices, but he said the payoff has been a greatly expanded role in designing programs to enhance primary care. Since he received his MBA, he has been able to design quality improvement programs for the VA medical center.

Dr. Roman


Dr. Roman explains how business training can open new career opportunities for physicians.


His final MBA research project explored the feasibility of enrolling all eligible veterans in primary care via an open access system redesign. He determined that the concept was feasible and would eliminate several months of delays for patients trying to see primary care providers and several hours of waiting in urgent care or first-step clinics.

Instead of seeing a primary care doctor for the first visit then transferring to another doctor in the group, new patients now enroll with a primary care physician at their first visit and stay with that doctor. The system improves efficiency, provides better continuity of care and, Dr. Roman said, has the potential to save the VA system millions of dollars.

He pilot tested the concept at his hospital, which later implemented the program. And he predicted that other VA medical centers will adopt his concept.

Dr. Roman noted that since 1999, the number of physician executives with MBAs has increased 23%. Younger physicians are drawn to MBA programs because they believe business degrees give them more career options, he said. And older physicians often enroll in MBA programs because they've moved into management positions and want to enhance their ability to manage human resources or workflow issues.

(For more on physicians getting business training, see "For physicians in search of an edge, MBAs are an answer.")

"For me, the lure of getting an MBA wasn't financial," Dr. Roman said, pointing out that the average salary for an assistant medical director is now about $170,000. "I thought the degree would allow me to be a better patient advocate."

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