Guidance for a Career in an Academic Medical Center

I have spent the past 41 years as a trainee or physician/scientist faculty and administrator at private and state academic medical centers (AMCs) in the United States and Canada. Along the way, I have been the grateful recipient of much wisdom about how to succeed in this setting.1,2 While others have published perspectives on how to navigate different facets of AMC careers,3-5 these articles have been published in subspecialty journals and may not have reached all graduate medical education faculty members and trainees. Although not exhaustive, the guidance here represents some time-tested perspectives I have obtained during my career at several AMCs.Complex biological and social factors underlie health and disease, and both undergraduate medical education and graduate medical education (GME) prepare the next generation of physicians to meet these imperatives across a wide range of institutions, including large health systems, small community hospitals, and AMCs. Challenges to the GME community are many and include translating the ongoing biomedical revolution into clinical practice, addressing social influencers of health, and managing changing political and financial landscapes. Although AMCs are only one piece of GME, they have a disproportionate impact on medical education, health care, and innovation.6Universities value knowledge and have the inextricably linked missions of discovery and education. Medicine values beneficence, defined as using one’s talents and abilities for the benefit of others, and has the mission of health care. Modern universities are among the most resilient institutions, with some in continuous operation dating back to the 11th century. Modern medicine has separate roots with some recognizable features dating back to prehistory. The mingling of universities with medicine is relatively new, starting in the mid-19th century and evolving into their current form by the mid-20th century. AMCs, therefore, face the relatively new challenge of aligning the often-competing values of knowledge and beneficence while optimizing resource allocation across the missions of discovery, education, and health care to hasten innovation and its equitable deployment in the care of others. The distinct values and derivative missions of universities and medicine are by far the greatest source of friction within AMCs. Successful AMCs recognize this inherent conflict in values and create synergy by aligning their differing missions within the local context.To fulfill their missions, both universities and medicine require professionalism to be a foundational principle. There are many varied definitions of professionalism, but its essential facets are honesty, respect, and excellence, in that order. This means that honesty is the foundation upon which first respect and then excellence are built. Knowledge, beneficence, and professionalism are the foundation of academic medicine, and the balance struck among them establishes the culture of an AMC.I find a few “equations” useful in stepping back from the day-to-day details and considering enduring principles.Ambition is necessary for success, but it must not exceed ethics. Talent and diligence breed success that fuels ambition, but when ambition is greater than ethics, it invites guile and mendacity that ultimately subvert success.Identifying challenges is not difficult. Entitled individuals get stuck at this first step in problem solving. Entrepreneurial individuals achieve more success as they follow through by prioritizing challenges, building a consensus plan, and working collaboratively. Resources flow to the entrepreneurial approach.The Gibbs free energy equation can serve as a metaphor for useful human effort (ΔG) being equal to total effort (ΔH) minus useless effort (TΔS). There is much work to be done in an AMC, and faculty quickly find themselves giving their total effort. At this point, the only way to increase useful effort is to reduce useless effort. This can be done by improving time management, suppressing needless anxiety, and understanding when and how to recharge. Developing judgement for what is useless effort and declining its often-seductive invitation is key to maximizing effectiveness, as is distinguishing activity from accomplishment.“What do I need to do to advance?” My answer to this difficult question from a fellow is to perform as an assistant professor. For an assistant professor my answer is to perform as an associate professor, and so on. This is a high bar, but it gives aspiring individuals a relatively concrete set of goals that, when reached, ensure successful advancement to the next step.Each recruit needs to prioritize the job, personal considerations, and timing, and then work down this priority list. Any new position always should satisfy fully the top priority, and you should hesitate to accept a position that does not also mostly satisfy the second priority. Expect to compromise on the third priority.Expertise is the sum of knowledge and experience. At the conclusion of training, the newly minted trainee is full of cutting-edge knowledge but has limited experience. About 3 to 5 years of independent experience engenders a sense of expertise, after which, ideally, knowledge and experience continue to grow together. Evidence of growing expertise is the essence of promotion.If you do not trust your institution’s leadership, then it’s best to leave. Also important is alignment between your priorities and your institution’s culture, both of which can shift. Misalignment can be the “push” to relocate. Superior alignment should be the clear and obvious “pull” of the new job, lest you trade the current set of known challenges for those awaiting you in the new position.One of Simone’s Maxims states that any major leadership responsibility should be undertaken for 10±3 years.2 Enthusiasm, energy, ideas, flexibility, and resources all wane with time, and most effective work gets accomplished in this 7- to 13-year period. An alternate rule for when to stop a leadership position is when you are spending your time fixing problems created by your own past decisions.Mismatches in authority and responsibility are the second major source of friction in AMCs after values and missions. Authority greater than responsibility is disruptive and often leads to resentment among those affected by consequence-free decision-making. Responsibility greater than authority contributes to burnout and job dissatisfaction. Authority matched to responsibility enables strong, independent, and effective leadership.If you permit or allow disrespectful behavior in one person, then you are effectively promoting it in others and establishing a toxic culture. The same is true for honesty and pursuit of excellence. Deal with unacceptable actions now on an individual level and reinforce the culture, or deal with them repeatedly in the future with multiple people.Once you accept that effectiveness in a leadership role lasts 10±3 years, then limiting administrative appointments becomes obvious. Exceptions to this rule exist, but are rare. I am more focused and work harder under time-limited positions because with an end in sight I am motivated to finish strong, and I think this is true for most others. Also, if things do not work out well, then the appointment simply ends in the not-too-distant future with a dignified transition.Physicians must manage changing political, social, and financial pressures. These can be daunting and can change from generation to generation, but do not let them obscure that the values of knowledge and beneficence are being fulfilled today more than at any other time in history; they will advance even further tomorrow, fueled by our successors’ ingenuity and industriousness, and grounded in enduring principles as they face their generation’s challenges.These perspectives may be helpful to those who pursue careers and leadership positions in AMCs and beyond. Across the GME community, effective leaders serve as role models, mentor their successors, and establish the culture. They do so knowing that they are temporary stewards of an enterprise built by the intelligence, hard work, and commitment of their predecessors, which they are entrusted to grow and improve, and pass on to the next generation.

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