Lieff, Susan J. MD, MEd, MMan
Retention of faculty in academic medicine is a “grand challenge.”1 Although there is normal attrition throughout the years, loss of new faculty is of particular significance in the current context of medical education.2 The increasing numbers of vacant academic positions and an aging faculty further complicate the issue.3
According to some in academic medicine, inattention to the humanistic values of faculty is contributing to this problem.4 Professional development should consider faculty members’ search for meaning, purpose, and professional fulfillment and should support the development of an ability to reflect on these issues.5,6 Such self-awareness is the first step in effective career decision making.
The process of leadership involves engaging people toward goals that are shared.7,8 Academic physicians enact leadership when they engage with others in pursuit of the realization of a shared academic mission of education, research, and service. They lead, directly, by significantly affecting the thoughts, feelings, and/or behaviors of others, or, indirectly, by exerting an impact through the works that they create.9 Souba10 has asserted that ensuring alignment of the inner direction of these individuals with the context and mission of the academic health science center is critical to their professional fulfillment and effectiveness. Reflection on the directions, strengths, and values of one’s academic environment can inform decisions about how to enable an authentic fit. The premise of this article is that awareness of and the pursuit of meaningful work and its alignment with the academic context are key to the professional fulfillment and retention of academic faculty. A description of a conceptual framework for understanding meaningful work and alignment and how that framework can be applied is provided. Such awareness can inform faculty members’ career planning and action. This paradigm has been successfully used in a number of leadership and career development programs for faculty and residents in the Faculty of Medicine at the University of Toronto.
Retention and Recruitment Is a Problem in Academic Medicine
In a recent analysis, the Association of American Medical Colleges reported that, during a 10-year period, only 52% of faculty remained at their original medical schools; 10% switched medical schools, and 38% left academic medicine altogether.2 The attrition rate during the seven-year study period was 38% overall and 43% for faculty in their first appointment. In 2003, recruitment and retention were of sufficient international concern that a working party with global geographic representation, the International Campaign to Revitalize Academic Medicine, was formed to study and address the issues.11 Whereas this group has advised of the need to develop structures to support and retain faculty, what form those structures should take is not clear. Addressing faculty members’ needs for professional fulfillment is an important strategy to consider.6
The Need to Address Professional Fulfillment
Brown and Gunderman6 have described professional fulfillment as a sense of professional engagement and reward that implies feeling completed—the thorough realization of one’s potential. When physicians feel professionally fulfilled, patients are more likely to feel satisfied, to comply with treatment, and to have greater trust and confidence in their physicians.12,13 Physician dissatisfaction is associated with increased turnover and departures.14 Herzberg’s theory of workplace motivation proposes that the nature of the work has the capacity to motivate and satisfy by gratifying the need for gaining status, assuming responsibility, and achieving self-realization.15 Similarly, Maslow, in his hierarchy of individual needs, has proposed that once an individual’s physiological, safety, social, and esteem needs have been met, that person develops a desire to realize all of his or her potential for being an effective, learning, and creative human being.16 The ability to feel effective and creative, to lead a life of purpose that is balanced with one’s value system, and to realize one’s potential is an attribute of emotional and spiritual health.17 Keyes and colleagues18 and McGregor and Little19 affirmed that psychological well-being is associated with the realization of one’s true potential and with commitment to a life of purpose and meaning beyond oneself that is also meaningfully connected to being oneself. Seligman20 described the meaningful life as “knowing your highest strengths and using them in service of something larger than [yourself].” He noted that the pursuit of meaning has the strongest correlation with life satisfaction.
This need for self-realization in the form of contribution to a greater purpose or good is a foundation of professional fulfillment in academic medicine.6 It parallels the primary commitment of physicians to service and recognizes medicine as a vocation.21 Work that is experienced as a vocation has social meaning and value and provides a sense of meaning, fulfillment, and identity to the individual. Such work presumes an inner desire to engage the world in a substantive way—“a calling.” As important as is the need for self-realization through meaningful work, however, that need is rarely considered by faculties of medicine in supporting the academic career planning of their members.
Current Recommendations to Support Career Planning and Leadership Development in Academic Medicine
Bickel22 suggested that visionary leaders in academic medicine understand that nurturing the development of individuals is a smart business strategy, because employee productivity is dependent on employee satisfaction and creativity. The development of individual faculty members should begin with the faculty members’ identification of their most important personal values.23 These values become an internal guideline that should inform career decision making and goal setting. Because they can be difficult to articulate, activities such as examining daydreams, writing one’s own 80th-birthday tribute, or examining the satisfaction that one obtains from day-to-day activities can be useful. Identification of strengths should be encouraged, as a way to energize and situate one’s aspirations. In addition, deficits should be recognized so that one can attend to their mitigation. Periodic feedback from trusted colleagues or impartial individuals on one’s self-assessment and planning is critical to this reflective process, as it provides a reality check and also renews one’s energy and interest.24 A regular commitment to such reflection enables faculty members to stay in touch with their career trajectory while recognizing that this commitment is a nonlinear process that will undulate over time.
Academic physicians function in many formal and informal leadership roles in the complex academic environment of teaching, research, and clinical settings. Souba10 has reminded us that their journey of leadership begins on the inside, with the asking of fundamental questions such as “Where does my leadership come from, and what is my purpose?” How academic physicians lead will depend substantially on how they express who they are and how they derive meaning from their work.5 Effective leaders invest in developing a deep understanding of themselves.25 They develop this insight by committing to active observation of and continuous learning from their life stories and experiences in service of developing an awareness of who they are, what they care about, and why they care. They lead through the stories they tell and the lives that they live.26 They embody their values and passions in their choice of day-to-day activities and their decisions.27,28 Palmer29 has described this process as leading an undivided life. Similarly, academic medical leaders identified integrity, the need to be aware of and to act according to one’s beliefs and values at all times, as the most essential value.30 Effective leaders also focus on developing their gifts and leveraging their natural strengths.31 They recognize that their limitations must be managed and that leveraging their special talents and skills begets excellence. Specifically focusing on the development of self-awareness about their life stories, strengths, and values enables academic physicians to identify the work that they find meaningful in their formal or informal leadership roles.25 This evolving awareness of meaningful work can inform the individual’s reflections and actions on his or her career direction. To achieve professional fulfillment, however, a person’s career choices must be aligned with his or her environment.
Meaningful Work and Alignment: An Integrating Framework and Its Application
Meaningful work can be described as the realization of one’s potential and purpose—the point at which a person’s passions, strengths, and core values interact synergistically in his or her work. Buechner32 defined this point as “the place where your own deep gladness meets the world’s deep needs.” Reflecting on one’s past, current, or aspired-to activities can yield information about the occasions when one’s passions, values, and strengths connected in a synchronous way. Such occasions are opportunities for recognizing and reflecting on what is personally meaningful work and what are one’s core beliefs about meaning and purpose in work life. For professional fulfillment, meaningful work and one’s core purpose must be aligned with the interests, strengths, and cultural context of work (Figure 1). The multiple contexts of academic medicine can include the university, faculty of medicine, academic departments and programs, and the variety of clinical settings, programs, and departments.
Exercises to Identify Core Elements of Meaningful Work and One’s Core Purpose
A number of sequential exercises can be used in professional development programs to assist faculty and trainees in teasing out the elements of meaningful work and in reflecting on the connection of the elements with each other and on their alignment with their academic setting. Faculty members should be advised that the focus of these exercises does not address the equally important personal and family roles that they occupy. They need to reflect on their personal and family goals on other occasions and consider the compatibility of these goals with their career direction. Such alignment may ultimately require trade-offs or revision of their goals.
Crafting a brief (two-page) autobiography that celebrates a successful career at the time of retirement can tap into hopes, dreams, values, and aspirations. This narrative must be guided by the recognition that a variety of personal and professional life experiences shape one’s choices and pathways as physicians and academics. The faculty member’s exercise of describing his or her story to an appreciative listener can assist the faculty member in clarifying the meaning of these life experiences with respect to his or her career path. The listener’s role in this exercise is to share what he or she appreciates and to learn about the passions, strengths, and values that are embedded in the story, so as to further enrich career reflection. This exercise can be conducted with a mentor or faculty advisor, in pairs with a colleague, or with several colleagues as part of a career development workshop.
Values are beliefs about what is right and what conscience dictates as the highest priorities in life. Values guide or qualify personal conduct, interaction with others, and involvement in one’s career.33 Lists of personal values can be developed from a variety of sources.33–35 It can be helpful for faculty members to peruse such lists to enable them to recognize the values that dominate in their life stories. They can then be asked to identify the values that are most important to them and select the top three or four as their guiding principles.
Passion is defined as strong liking or desire for, or devotion to, some activity, object, or concept. Passion has an emotional element that implies joy or pleasure. Deriving joy or pleasure from one’s work is critical to sustaining motivation and vitality in one’s career. A number of questions can stimulate faculty members’ reflection on work situations that are pleasurable: When are you energized or drained? What would your ideal day look like in five years? What would you do if you won the lottery? What professional legacy do you want to leave? What do you voluntarily read? What do you definitely want and not want?
Strengths can be more difficult to identify because of the difficulty of accurate self-assessment and a natural tendency toward modesty in thinking or talking about oneself. Faculty members need to be encouraged to reflect on rewarding, successful, or “flow” experiences at work to identify their unique strengths. When an individual is working in a state of flow, he or she is engaging his or her highest strengths and talents to meet difficult challenges that stretch his or her physical or mental capabilities.36 This mental state is experienced by the person as a full immersion and involvement in what he or she is doing, a feeling of timelessness and energized focus, and a sense of success in the process of the activity. Directing faculty to identify when they felt that they were “in the zone,” when they lost track of time and felt rewarded, can help them to pinpoint a flow experience. Scanning such experiences can help faculty members pick out their best qualities or experienced strengths. The “reflected best self” exercise of Roberts and colleagues37 is also a useful process that directs participants to solicit feedback from a variety of people within and outside work about their strengths as well as to provide specific illuminative descriptions of when they observed these strengths in action. Through a process of thematic analysis of this feedback, participants construct a description of their best self as observed by others. This exercise can tap into unrecognized areas of potential, highlight areas to be further developed, and provide useful feedback on the faculty members’ self-assessment.
Identifying meaningful work and recognizing one’s core purpose
A journal or workbook can be a useful venue in which faculty members can record the passions, values, and strengths that they discover through reflective exercises such as those described above. The connection or synergy of these elements with each other exposes areas where meaningful work occurs or is occurring. Work is meaningful when one is engaged in activities that are enjoyable, that tap into areas of strength, and that are consistent with one’s core values. Faculty members should try to remember or imagine experiences in which these elements are or would be in harmony with each other. One’s core purpose is the driving force behind these experiences and is typically not readily apparent. Questions can stimulate reflection on this issue: What is the contribution you feel that you are meant to make or the legacy that you want to leave? What sense do you have about what you are supposed to do with your life? For ideas to eventually emerge, a person must make a commitment of time to reflect and revisit the questions. From these ideas, a personal vision can be crafted that is informed by the desire to align personally meaningful work with the academic context. This personal vision can take the form of one statement or a few statements that capture the meaningful direction that the faculty member wants to take. An example could be, “I want to contribute to a culture of caring by modeling, teaching, and studying the professional values and behaviors of medicine in service of high-quality care.” This vision can then become a guiding compass for examining opportunities and current and future contexts, as well as for proactively planning development.
Examining the context for alignment
Whether the context of interest is the academic department, program, faculty of medicine, university, or clinical setting, personal and institutional direction should be aligned in order to maximize professional fulfillment. These complex settings often have competing tensions in their goals, and these tensions need to be understood. Competing priorities, such as excellence in research, education, and clinical service and the need for sustainability and profitability, can be confusing and, at times, troubling, given the multiple demands they exact in terms of time and effort. To fully understand, the faculty member must scan the department, program, or institutional context for information about directions and must interview key individuals. The faculty member could ask several questions about such contexts: What does this program or department need? What are the program’s or department’s interests and goals? What opportunities and challenges is this institution or setting currently dealing with? What are the culture and values of the institution or setting? What are its strengths? The answers to these, and other questions can inform reflection on the fit of personal vision and institutional direction and values and, therefore, can inform subsequent career decision making. For example, a faculty member may discover that he or she enjoys and is good at teaching in a clinical setting that supports his or her desire for flexible work hours to accommodate family needs. In contrast, the faculty member’s academic setting has a culture of having dinner meetings at the end of the day and sees teaching as a support function to the research enterprise, rather than as a function with value in and of itself. This faculty member’s vision would not be aligned with the academic setting’s context. Specific goals and strategies to reach those goals can then be developed. Such strategies could include considering a transfer to a setting that has more-aligned values and a need for clinical teachers or having a discussion with the leadership about the challenges of dinner meetings for faculty with young families and about future options for clinical teachers in the department.
The following vignettes illustrate how faculty members have used this framework to enable career reflection and decision making.
Dr. X was a 34-year-old junior faculty member of three years’ duration at the time of her participation in this workshop. Since her appointment as a clinical teacher, she had primarily focused on developing her clinical practice, expanding her sense of professional expertise, and fulfilling her teaching commitments. She participated in her department’s grand rounds and practice plan committees, but she was not clear on what she wanted her academic pathway to be. She had attended some faculty development programs in teaching and education. She related that her reflections on the elements of meaningful work for her had identified the pleasure, ability, and curiosity that she found in teaching and educational program development. In scanning her context, she had identified a group of colleagues who were interested in curriculum renewal in her field. She was currently collaborating with them in the development and study of specific educational programs. She had given up certain committees that were not aligned with this interest and was considering engaging in a faculty development program to further develop her abilities and increase her opportunities to move into an educator role.
Dr. Z was a 44-year-old faculty member who had been on faculty for 12 years as a clinician administrator and teacher. Having completed a masters in health administration during his residency training, he subsequently had successfully developed and implemented a curriculum for residents in medical administration. In his clinical work, he focused on providing care and developing services for the homeless. He was particularly interested in evaluating these services to ensure their effectiveness. He stated that his conceptual framework for meaningful work had become a lens through which he screened opportunities and defined his career pursuits. He realized that his vision involved a desire to have a sustained impact on the health system for the homeless. His experience with studying interventions in the health system was rewarding and, he felt, was making a difference. He focused his efforts on pursuing a career in that area and was able to win an award and to negotiate with his department head for support of his work as a health systems researcher.
How Can Medical Schools Adopt a Meaningful Work Approach?
Integrity, the leadership value that deans of academic medical centers have called “most essential,” has been linked to creating and developing meaningful work.30 Souba has reminded us that future leaders should be coached on the practical relevance of getting faculty members to identify with faculty values, so as to increase the chances of their message being embraced. Inner and outer alignment is the key. Deans can play a vital role in creating the conditions that will help people make choices that mitigate the potential for clashes between humanistically and economically oriented values. Valuing the humanistic elements of academic medical work, as well as the need to authentically align with the cultural context, should be considered a core value of academic medical culture. When academic physicians do not feel a sense of meaning in their work, they may be left to seek their rewards from status, recognition, or financial gain. Pursuit of these secondary rewards can breed competitiveness in a person, which may undermine that person’s alignment with the desired directions of his or her faculty.
Ideally, faculty members should reflect on these issues as part of choosing an appointment. Addressing these issues within the first couple of years of appointment should be an essential component of any faculty orientation, mentorship, career, or leadership development program. This approach can enable informed decision making about the faculty member’s career trajectory as well as about his or her mentorship and development needs. One’s context and feelings can evolve over time, and thus a periodic revisiting of and reflecting on the framework at times of transition, such as changes in leadership, structures, programs, or personal well-being, can help faculty members redefine or reaffirm their direction. It is not clear that the application of this framework would differ according to the various academic roles that faculty members play as teachers, educators, clinician-researchers, or basic researchers. The offices of faculty affairs, academic affairs, faculty development, or professional development could implement this framework and provide education about it in the context of group or individual career-advisory sessions, workshops, or existing faculty and leadership development programs. This framework has been taught in intensive workshops of 1.5 to 3.0 hours, and the teaching has been supported by workbook materials and either recommendations for follow-up with career advisors and mentors or periodic group discussions to enable reflection on the issues. Because a safe learning environment is essential for these formative development activities, those activities should be separated from the performance review process. An additional consideration for program developers is that this reflective process can illustrate to the faculty member a discord between what is meaningful for them and their context. When such a realization is reached, a decision to leave the current appointment may be in the best interests of the faculty member as well as of the academic health science center. Faculty and professional affairs offices need to be prepared to support a successful and professional departure.
Because this approach to career planning is a novel integration, its impact has not yet been systematically studied. If such development activities became part of the usual business of academic medicine, a meaningful work culture could be created in which these conversations become part of the norm. This possibility is consistent with Cooperrider and Whitney’s38 view that human systems grow toward what they persistently ask questions about. Future evaluations need to address the potential for such initiatives to affect faculty well-being, satisfaction, utilization of reflection activities, and organizational culture.
Attention to the pursuit of meaningful work that is aligned with the academic medical context is critical to the professional fulfillment of academic physicians. Personal reflection on the synergy of one’s strengths, passions, and values can help faculty members define the nature of meaningful work for themselves, so as to be better able to reflect on how they can ensure alignment with their context. The hope is that, by emphasizing the need to engage in aligned and meaningful work, such an effort will enable faculty members to feel more fulfilled and, therefore, more likely to continue to commit to a sustained career in academic medicine.
The author would like to thank Professors Karen Mann, Richard Frankel, and Brian Hodges for their thoughtful reviews and feedback on the manuscript.
3 International Working Party to Promote and Revitalise Academic Medicine. ICRAM (the International Campaign to Revitalise Academic Medicine): Agenda setting. BMJ. 2004;329:787–789.
4 Pololi LH, Dennis K, Winn GM, Mitchell J. A needs assessment of medical school faculty: Caring for the caretakers. J Contin Educ Health Prof. 2003;23:21–29.
5 Souba WW. Academic medicine and the search for meaning and purpose. Acad Med. 2002;77:139–144.
6 Brown S, Gunderman RB. Viewpoint: Enhancing the professional fulfillment of physicians. Acad Med. 2006;81:577–582.
7 Souba WW. New ways of understanding and accomplishing leadership in academic medicine. J Surg Res. 2004;117:177–184.
8 Raelin JA. Creating Leaderful Organizations: How to Bring Out Leadership in Everyone. San Francisco, Calif: Berrett-Koehler; 2003.
9 Gardner H. Leading Minds: An Anatomy of Leadership. New York, NY: Basic Books; 1995.
10 Souba WW. The new leader: New demands in a changing, turbulent environment. J Am Coll Surg. 2003;197:79–87.
11 International Working Party to Promote and Revitalise Academic Medicine. Academic medicine: The evidence base. BMJ. 2004;329:789–792.
12 Haas J, Cook E, Puopolo A, Burstin H, Cleary P, Brennan T. Is professional satisfaction of general internists associated with patient satisfaction? J Gen Intern Med. 2000;15:122–128.
13 Grembowski D, Paschane D, Diehr P, Katon W, Martin D, Patrick D. Managed care, physician job satisfaction and the quality of primary care. J Gen Intern Med. 2005;20:271–277.
14 Buchbinder S, Wilson M, Melick C, Powe N. Primary care physician job satisfaction and turnover. Am J Manag Care. 2001;7:702–713.
17 Quick JC, Macik-Frey M, Cooper CL. Managerial dimensions of organizational health: The healthy leader at work. J Manage Studies. 2007;44(2):189–205.
18 Keyes CL, Shmotkin D, Ryff CD. Optimizing well-being: The empirical encounter of two traditions. J Per Soc Psychol. 2002;82:1007–1022.
19 McGregor I, Little B. Personal projects, happiness and meaning: On doing well and being yourself. J Pers Soc Psychol. 1998;74:494–512.
21 Hansen DT. Revitalising the idea of vocation in teaching. Educ Theory. 1994;44:259–275.
22 Bickel J. Whose mission are you living: The whys and wherefores of goal-setting. Acad Physician Sci. March 2004:1–3.
23 Pololi L. Career focus. Career development for academic medicine? A nine-step strategy. BMJ Careers. January 29, 2008:38–39.
24 Bachrach DJ. Career watch: Leadership lifecycles. Acad Physician Sci. April 2004:1–3.
25 George B, Sims P, McLean AN, Mayer D. Discovering your authentic leadership. Harv Bus Rev. 2007;85:129–130, 132–138, 157.
26 Gardner H. Leading Minds: An Anatomy of Leadership. New York, NY: Basic Books; 1995.
27 Kouzes JM, Posner BZ. The Leadership Challenge. 4th ed. San Francisco, Calif: Jossey-Bass; 2007.
28 Sull DN, Houlder D. Do your commitments match your convictions? Harv Bus Rev. 2005;83:82–91, 118.
30 Souba WW, Day DV. Leadership values in academic medicine. Acad Med. 2006;81:20–26.
31 Buckingham M, Clifton DO. Now, Discover Your Strengths. New York, NY: The Free Press; 2001.
32 Buechner F. Wishful Thinking: A Seeker’s ABC. San Francisco, Calif: Harper; 1993.
36 Czikszentmihalyi M. Flow: The Psychology of Optimal Experience. New York, NY: Harper and Row; 1990.
37 Roberts LM, Spreitzer G, Dutton J, Quinn R, Heaphy E, Barker B. How to play to your strengths. Harv Bus Rev. 2005;83:74–80, 117.