Joe’s Career Blog
Career development observations and advice for medical professionals from Dr. Joseph V. Simone.
Wednesday, February 26, 2014
The issue of physician burnout seems to pop up every few years. Two articles published recently have addressed this topic from very different vantage points:
The first, “Burnout and Career Satisfaction Among US Oncologists,” by Tait D. Shanafelt and colleagues, is in the 1 March 2014 issue of the Journal of Clinical Oncology. The authors contacted 2,998 oncologists; 1,490 returned the surveys, and 1,117 completed full-length surveys. About half were women and slightly more were in private practice compared with those in academic practice. The measures of burnout were based on the standardized Masiac Burnout Inventory. Overall, 45% had at least one symptom of burnout on the emotional exhaustion or depersonalization categories, slightly higher for those in private practice. Hours per week working in direct patient care were positively correlated with increased burnout. On the other hand, overall career satisfaction was high -- about 82%, slightly lower in private practice.
The remedy suggested is fewer work hours, especially in patient care. However, the common use of “productivity” in both private and academic practices incentivizes oncologists to work more hours and see more patients. This creates a classical double bind, especially since oncologists already work more patient care hours than most other physicians.
A more global approach to the issue of burnout is taken in “Medicine’s Search for Meaning,” by David Bornstein, which appeared in the New York Times (18 Sept. 2013). He begins by saying that the health care system is in crisis -- “We are going bankrupt,. There are too many lawsuits. We practice defensive medicine. We restrict access.” But he says doctors face a more serious problem. Almost 50% of practicing physicians report symptoms of burnout, such as emotional exhaustion, low sense of accomplishment, and detachment. He believes medicine is facing a crisis that is not about money, but about meaning.
Bornstein points out that, “Great doctors don’t just diagnose diseases, prescribe medications and treat patients; they bring the full spectrum of their human capabilities to the compassionate care of others. That is why doctors, upon entering the medical profession, speak noble words like the Oath of Maimonides: ‘May I see in all who suffer only the fellow human being.’”
Nice words, but he says that almost half of medical students suffer from some form of burnout before they even enter residency training. There is convincing evidence that this problem has a negative effect on the quality of care. Dr. Bornstein then introduces the reader to Dr. Rachel Naomi Remen, who is at UCSF. She gives a course called The Healer’s Art, which is now taught in 71 schools in the U.S. and in 7 other countries. The course is very popular because it addresses the difficult issues of gaining the confidence of patients and recognizing the dignity and nobility that should be a part of medical care. It also helps students keep their spirits alive as they go through training.
Burnout can be addressed in practice, but in the current reimbursement environment, only with the prospect of lowering one’s income, and it may be worth every penny lost for longevity and inner peace. But it seems that starting earlier is an even better idea, and action at both opportunities would be a prudent mechanism for avoiding burnout.
Wednesday, February 12, 2014
I’ve had a newspaper clipping on my desk for several months that continues to resonate with me. In that article, in the business section of the Atlanta Journal Constitution (19 May 2013), Henry Unger reported an interview he had with a local banker, Joe Evans. It was unusual because most of such interviews are vapid vanilla regurgitated from some business book, but this one impressed me.
Evans grew up on a dairy farm in rural Georgia and his parents saw to it that he got a good education. His specialty became acquiring a group of failing small banks and turning them around. He has been very successful and sold two groups of banks at a premium, and is currently in the process of developing a third group.
His father had 50 cows and decided to build the herd up to 400. But after a time his father soon calculated that he could make more profit with less work with a herd of 200, so he scaled back the herd. The lesson was that it is not the top line (total revenue) that counts, but the bottom line (profit in the pocket). He said the same was true in banking. Past a certain point in growth, one needs a different, more complex management structure to effectively deal with the larger size, but the growth and income must be able to justify that step. They had a saying on his farm, “You don’t name your cows” -- meaning don’t become wedded to an idea or direction, and be willing to admit a mistake.
This lesson is applicable in many organizations. Leaders of hospitals and academic medical centers also make what turn out to be bad, and often expensive, decisions. Some behave like Evans’s father, but others keep pumping money and time into a program that just isn’t profitable financially or because of a lost opportunity. Growth beyond the point of financial and administrative efficiency is not rare in the health care world. No one bats 1,000 in baseball or health care administration. But good players and administrators learn from the unfortunate decisions and move on.
Evans also taught me something about recruiting: “In job interviews,” he said, “I typically ask people to share with me something that they really botched. It’s not what people tell me, but the ease with which people tell me, that makes an impression on me. You want self-reflection, but you don’t want someone saying it with a cavalier attitude. I look for somebody who can comfortably learn from their experiences and grow from them.”
I get the sense that Mr. Evans is a rock-solid individual with high standards and values. It is clear he has learned many lessons along the way, taken them to heart, and I am delighted he was willing to share them.
Wednesday, January 22, 2014
If you are in a leadership position, you will undoubtedly face the unpleasant issue of whether to fire an employee. If the employee has been coached and several chances have been given, they may be incompetent or, worse, troublemakers. What you must not do is transfer them to another area because they most likely will continue to be incompetent or troublemakers. They force others to pick up the slack or repair their mistakes, reducing everyone’s efficiency.
If this continues for long, those that are consistently unproductive may become the majority because the competent learn that the institution sees no virtue in hard work and collaboration. As difficult as it may be, the best solution for all parties is to fire the individual. This is true even though one often must deal with unrealistically positive evaluations of the past, complicated and unpleasant grievance procedures, bureaucratic barriers, and the unpleasantness of confrontation.
I have been burned several times on this issue and have developed some safeguards. For non-faculty, at the hiring interview I usually tell them that the job may not work out because of them, because of me, or just because of bad chemistry. Therefore if I must terminate them, it is a bit easier for both of us. If possible, it is best to do this in the probationary period. With faculty it is more complicated. There may be contracts or understandings and a person’s whole career to consider along with all the other issues noted above. One can begin with the same approach described above -- i.e. coaching and second and third chances.
There is another important possibility to consider when deciding about letting someone go. Are they simply a bad fit for the job they were hired to do? I didn’t realize this until an underperforming lab technician, a recent college graduate, came to my office one day saying she knew she wasn’t doing well and she felt she wasn’t suited for the job. I realized that explanation might account for many underperformers. In that case, both the institution and the employee are responsible for the situation. She resigned and her record indicated she was a very hard worker, but the job and she were just not suited for one another.
This also happens with faculty. The job may have fit well at the beginning, but despite the person’s hard work and perseverance, the requirements for continued productivity grew but the person was unable to compete at that higher level. In that case, the person and the institution are better off if he/she moves on.
My experience with several cases like this is that the faculty member usually gets a better job at higher pay because the new job is a better fit for their current skills. Those individuals did not return to thank us for firing them, of course, even though they were much better off in their careers. That is the best outcome!
Thursday, January 09, 2014
Negotiating the terms for one’s next job can be especially daunting for fellows and early- and mid-career faculty. I remember very clearly my first few attempts at understanding the terms and environment of jobs that I was considering. The experience was a bit bewildering, because at that time in my career I had no experience to guide me. I often didn’t know what questions to ask, and there were other questions I didn’t ask for fear of offending the recruiter.
I also found that it was not easy to find an unbiased, experienced advisor. I did not know senior faculty very well and was not sure whether their advice might be biased because they wanted me to stay at (or leave) my institution or had strong feelings, good or bad, about the place I was considering.
Over the last few years I have lectured on this topic, and not long ago when I was asked by the American Society of Pediatric Hematology Oncology to lead a webinar on this issue, I developed a fairly simple list of the fundamentals of negotiating in the medical environment. What follows is a summary of the webinar.
The common sequence of events, though not uniform every time, starts with an informal chat at a meeting and/or an invitation to visit an institution. Usually you are asked to give a lecture on your work. You should speak of work that you know very well instead of something you only recently started. Answering questions with confidence makes a good impression. A recruitment invitation is often camouflaged as a simple invitation to describe your work.
You should meet and speak with as many people possible in the program that you are considered for. Always get phone and email contacts so you can call or write with questions later. You may be asked if you would consider a move – best to answer vaguely: “It depends on the terms and opportunity” is the true and acceptable answer. The first visit incurs no obligation to make another visit. You may find that you wouldn’t move there no matter what – if so, thank the invitee and simply say you aren’t ready for a move.
The invitation for a second visit usually includes the spouse and should not be accepted unless there is a reasonable chance that you would take the job. Before this visit, you should do a ton of homework. Prepare a list of your professional short- and long-term goals and be able to describe what added value you bring to the program. You should practice describing these goals with a colleague at home before the second visit.
Sources of information could be your current boss and faculty (caution: if they want to keep you, they may denigrate the job) and those you met on your first visit, especially those around your stage of career. Find out about the working environment -- such as whether the boss keeps his/her word, if the clinical schedule is overburdened, if there are enough patients for clinical research, the efficiency of the clinic, and whether there are solid nurse practitioners. You should also check the inviting institution’s websites and the CVs of key players in the program to judge their productivity and the tone of the program.
If you have plans for a serious research effort at the new institution, be sure you are prepared to describe your needs and what startup support would be provided. Speak one-on-one with many people in that division, especially those you would be working with, to get a grasp of what it is like to work there and for the boss. The boss may start negotiating informally, so be prepared to ask detailed questions about clinical assignments, laboratory startup support (if you will have a lab), time allocated for lab work, requirements for promotion, etc.
You should be prepared for a discussion of salary. Get the ranges of salaries for the position you are considering from your current institution and, if possible, from the recruiting institution. Check on the cost of housing and the cost of living there compared with where you are now, and add into the mix any special financial needs your family requires -- e.g., a chronic illness. Consider the cost of schools, the commute, insurance, retirement programs like TIAA-CREF, and so forth. Get as much objective data as possible -- data speak louder than wishes. You must gather this information to arrive at an estimate of what income your family needs to live comfortably in that environment. Have a “deal-breaker” salary level in mind that would be so low that it would kill the deal. Now you should have a good range of possible offers.
When negotiating the terms, understand that you are in the strongest position you will ever be in before signing anything. Also, in some cases the recruiter may have limits of what he/she can offer. Don’t feel sorry for the recruiter! That is their problem and you should be reasonable for a very modest reduction, but reluctant to accept an inferior offer in salary, research time, working conditions, etc. because of some institutional “rule.” A truly inferior offer with an explanation of “this is the best I can do,” should make you consider other options. Once you sign up, you are committed and don’t get a mulligan (in a friendly game of golf, a second try after a bungled shot).
Finally, don’t spend a lot of energy fighting for a relatively insignificant issue. Sometimes it is better to cede that, showing your reasonableness.
There is no substitute for aggressively gathering information and data in advance about the place, people, and position before you commit.
Comments on these “fundamentals” are welcome!
Wednesday, January 08, 2014
I began writing this on New Year's Day, 2014. When I was much younger I made New Year’s resolutions, but after a few years I became so discouraged by my consistent failures that I stopped making them. Like most people, I still resolve to act on new insights now and then, but they are unrelated to the time of year.
Though I no longer make resolutions, I shamelessly suggest resolutions to others. In a sense, my book (Simone’s Maxims) essentially provides a list of opinions and insights that could encourage readers to take a fresh look at people, institutions, and jobs. So this year I am offering you two new Maxims that have not yet been published. My hope is they may be useful to you.
1. If you are clearly the best guy by a wide margin (not just at the top of the list) in your organizational unit, you should consider a job change because it is very easy to become complacent and fail to grow. New challenges and opportunities help one develop skills and broaden the scope of talents. The move may be to a position within your own institution or elsewhere. The person you report to should recognize that your growth (and value to the enterprise) is constrained by a current role that can almost run on autopilot. In the best of worlds, he/she then provides you with an expanded scope of operation or a broader leadership position. Too often, though, that is not the case.
Of course, changing jobs, even within the same institution, is a serious business. A trusted mentor or senior faculty member should be consulted before serious thought is given to a move (don’t forget a prior mentor or supervisor in a former institution). They can provide advice based on their own experiences as well as suggesting where your best opportunities may lie. They also should be persons who will keep your conversations in confidence.
Some of the many possible outcomes of such a job review are: (1) you come to see that you are in a good position that you can build on over time and decide to stay where you are for now; (2) you decide to go to your boss and express your concerns and ask his/her advice on the development of your career -- in other words, give your boss a chance to respond; or (3) it becomes clear that there is no foreseeable upside in your current position due to the institutional structure, leadership, or other reasons. In this case you begin exploring other opportunities.
2. Titles and ranks do not necessarily equal great leadership and accomplishment. Too often we assume that a person with a major title—dean, chair, vice-president, CEO---are great leaders and/or have a long list of wonderful accomplishments in their wake. He/she is often a stranger to us so we judge by indirect means, such as titles or training at an elite institution. You surmise that since persons achieving those positions have been carefully screened and their CVs combed for significant publications and appropriate experience, they should at least be good, if not great, leaders and capable of major accomplishments. With embarrassing frequency, I have made and watched others make this mistake.
A search committee, for example, often includes people just like you who are capable of making the same misjudgment. In the oncology world, a committee member might overlook shortcomings if a candidate is currently at, for example, MD Anderson or Memorial Sloan-Kettering, believing that “they must be good.” A 60-page CV (I kid you not, I have seen several!) that includes 200 publications and a list of “accomplishments” that includes every lecture given, every tumor board, and every abstract submitted to a meeting, whether or not it was accepted for presentation. I have even seen a CV reference to becoming an Eagle Scout. Seasoned reviewers of candidates won’t be fooled by a CV weighing a couple of pounds and, in fact, may be immediately turned off.
One way to assess accomplishment is to add up the number of papers published in elite scientific journals, such as Science, Cell and Nature and their many spinoffs. A wise assessor will try to glean the specific contribution made by the person in question. But this approach often doesn’t work as well when reviewing physician-scientists or clinical investigators because so many publications have a large number of coauthors and it is hard to know what contribution any one individual has made. Tradition says the first author contributed the most and the last author is the most senior and often provided the basic idea, resources, and leadership for the project. But this yardstick may not work. First authors are sometimes the primary writer of the paper, who then gathers comments or suggested changes from coauthors and makes revisions in the manuscript.
One of my favorite ways to assess accomplishment, which is also imperfect, is to use the old-fashioned method of making phone calls to friends, colleagues, or acquaintances, who may know more about the work of the person in question. A letter of recommendation rarely provides a clear picture because the writer may not know sufficient details, wants the person to leave his institution (or stay), or is concerned that the candidate might see the letter. In my experience, even a short phone conversation provides some useful non-academic information about the individual, like character traits or work ethic. A person who has worked with the individual in question is the best source.
When evaluating a person you may work with or may recruit, judging whether he/she will be an effective leader or highly productive scientist or clinician is not easy. One confounding factor that is almost impossible to account for in a job change is whether you or your new boss will function as well as before. But the spadework necessary to learn as much as possible is well worth the effort.