My flight slowly lifted off from Honolulu. It was 1996. Oahu was slipping away. My wife was crying next to me. Our beloved dog was stoned on Valium in the cargo hold. I was moving away from the one place I wanted to live forever. I was 33 years old, and I had never wanted to leave since I first landed in Hawaii at 25. I had the great fortune to live there for three amazing years courtesy of the U.S. Army. A dream come true for me.
But my obligation to the military had been fulfilled. I could continue to live and work in paradise as a civilian, but then I would have to confront a difficult reality. Any work I could find with my current skill set appeared boring and routine. I would never ascend beyond a pit doc working for someone else. Even as a physician, my opportunities there seemed like dead-end jobs.
I ended up in South Carolina. I am the first person to say no one wakes up in the morning and says, “I have to live in Columbia.” Shortly after I moved, one of the local radio stations had a contest to come up with a catchphrase for the city. My favorite was, “It's halfway to wherever you're going.”
So why would I trade paradise for this? Columbia was a little rough at the time. It wasn't much in terms of the restaurants or shopping to which my wife was accustomed. My new chairman joked that he wanted me to get a psych consult before I started working. Even today, my kids complain about how we should not have left Hawaii (even though they were years away from existence).
Money, Geography, Potential
The decision I made is one that many residents ponder as they consider the next step after residency. How does a 30-year-old finishing residency with lots of debt, lots more income potential, and unparalleled opportunities make this decision? The calculus to determine the right choice seems complicated.
When confronted with complexity, however, I advise simplicity. It's a formula with only three variables: money, geography, and potential.
Money is powerful. The lowest student loan debt of our current interns is $96,000. The average is a quarter-million. Numbers like that create panic that make you want to fix it now. And when potential employers start waving bags of gold in front of you, you want it.
Geography is also a strong pull. Most of the time this is related to extended family. Young adults procreate, and family nearby is comforting. The opposite can also be true. Now you have cash flow and enormous opportunity. Provided you will work weekends, nights, and holidays, you can literally get a job anywhere for hundreds of thousands of dollars. Who else gets to do that?
But I have always told residents to make potential the priority. The problem is that this variable is the most difficult to envision and is perceived as having the most risk. I ended up going to a place that didn't look that great from the outside. Open bays, thick stacks of paper records, x-ray view boxes, and a trauma bay the size of an average bedroom. Combine this with a small southern city far from family, and my wife was wondering why she was putting up with me.
A review of my lifetime list of failures and bad decisions is long and painful. But what I saw in Columbia was incomparable potential. The group running the residency had just gone private, which was an incredibly novel concept at the time. This group could collectively bargain to control our professional lives and not be handcuffed by a medical school dean or a university president. We were empowered to negotiate win-win solutions. We could move assets quickly and be innovative problem-solvers for the hospital while other departments ground through administrative red tape to accomplish modest tasks.
Two decades later, we have gone from six to 13 residents per class, started four fellowship programs, have two graduates in vice president positions, and the past two chairmen have served as chief of staff. We are the biggest program in the hospital and in a position to innovate in amazing ways to fill the short- and long-term needs of our health care organization.
Of course, I could not have predicted all of this would happen, but I really did sense the possibilities all those years ago. The net effect for me is that I am still excited about what I am doing. This is priceless.
All of you will be in a position to make similar decisions in the relatively near future. Prioritizing potential is scary. But whether it is a fellowship, another advanced degree, or a unique practice opportunity in a faraway place, I encourage you to move in this direction.
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