When dispensing career advice, the quality of the dialogue matters. This seems obvious, but recently I overheard two conversations that made me wonder whether leaders in academic medicine should be more concerned about the career advice being offered—free of charge and unencumbered by guiding principles—in the hallways and elevators of medical schools and teaching hospitals and on the pedestrian bridges that connect them.
The first conversation occurred some months ago on a pedestrian bridge at my medical school. I overheard a medical student telling a resident that he planned to pursue primary care. The resident responded, “Well, if you want my advice, you'd better pick something else soon, because primary care is going to be delivered mainly by nurse practitioners, physician assistants, and pharmacists.”
The medical student protested a bit: “But I love primary care, that's what I really want to do. And there's a shortage of primary care physicians.”
The resident replied, “Yeah, but that shortage is not going to be filled by physicians. So, you better make a decision quickly. Specialty residency slots are going to become even more competitive when all the other students figure this out. I mean, I'm just trying to help you.”
But was the resident really helping the student? Or was the resident simply conveying her own anxieties, fears, and biases? And if the resident were really to help the student, what could she have said?
I'll come back to that after I tell you about the second conversation, which occurred less than a week later during the question-and-answer session that followed a plenary presentation at the 2010 annual meeting of the Association of American Medical Colleges. This time it was a faculty member advising a resident, but it was a similar story. A woman approached the microphone and identified herself as a medicine resident planning to practice primary care. She complained that her mentor warned her not to go into primary care, and that her conversation with her mentor left her confused, anxious, and uncertain. She asked the panelists what they thought she should do.
Again, was the faculty member really helping the resident? Could the faculty member have provided better guidance? What could he have said that would have been more helpful to this resident?
While I will not use this editorial to debate whether or not the two advisees should pursue a career in primary care, I am concerned about the nature of the advice they received. Although I am confident that many faculty and residents are providing sound and helpful career guidance to their junior colleagues, hearing the above two conversations in less than a week made me wonder how we might improve the quality of our thinking about career advice.
In each conversation, the advisor prescribed a career for the advisee based on the advisor's fears of one possible future scenario1 for primary care, at least as far as the advisor could see it. But the advisors neither sparked the advisees' imaginations nor inspired them to apply their creativity to thinking about their career aspirations. Each advisee left the conversation with no greater knowledge of primary care as a career, or how to make a good career decision, than before. The advisors did not engage the advisees in dialogues about current trends and future directions in medicine, the opportunities that abound in times of turbulent change, and how the advisees could match their unique sets of strengths and talents to these opportunities. If they had, the conversations would have been quite different.
The advisors could have begun by acquiring a sense of the “starting point” of the advisees: their hopes and fears, their motivations and anxieties, what comes easily to them, and what they have to work at.
The advisors could have initiated a conversation with the advisees that could have expanded their knowledge and deepened their understanding of medicine, so they could make more informed decisions. For example, each advisor could have asked the advisee questions like “What do you think are the big problems facing primary care? What talents and skills do you bring to bear on these problems? How do you hope to make a difference?” The advisor then could have built on the advisee's responses to these questions and offered insight, wisdom, and direction.
But, in each case above, the advisor missed an opportune moment to engage the advisee in a dialogue that would have empowered the advisee to approach his or her career decision with a richer and more profound sense of the problems facing medicine.
I want to be clear. I am not advocating a Pollyannaish advising session but, instead, a more discerning and profound dialogue between advisor and advisee so that the advisee emerges with a more effective way to make sound decisions and to navigate an uncertain future.
Several articles in this issue of the journal explore topics that extend the breadth and depth of our thinking about career choice. Rabinowitz and colleagues report the success of a medical school's program to increase the distribution and supply of rural family physicians, while Barrett and colleagues review the literature on rural training experiences for medical students, established to achieve a similar goal. Johnson and colleagues look at the work satisfaction of physicians in an ambulatory practice, while Fancher and colleagues examine how several factors, including residents' practice satisfaction, have the potential to stimulate interest in primary care. DeZee and colleagues studied how potential financial incentives might influence medical students' decisions to pursue primary care. And Durning and colleagues note that a medical student's sense of how satisfied the internal medicine residents are with their decisions to pursue internal medicine influences whether or not the student ends up pursuing that specialty as a career choice.
If we are to continually improve our ability to give sound career advice, reading articles such as the ones above is a start. But we must do more. We have a special responsibility to prepare residents and students for a world that does not yet exist. They will encounter a different set of problems, obstacles, and issues than those faced by the generation before them. So we must not base career advice solely on our own current frustrations, fears, and biases and dole it out in the time it takes to walk down a hallway, traverse a pedestrian bridge, or ride an elevator. We must offer advisees sufficient time for meaningful dialogue and explore with each one how to apply his or her unique set of talents and capabilities to the most difficult problems—and the most exciting opportunities—that may lie ahead.
Steven L. Kanter, MD