Unsolicited advice for newly minted paediatricians

Today's new paediatricians are entering a very different work world than the one I first experienced nearly 50 years ago. They arrive armed with a wealth of technology and a larger knowledge base than I ever possessed, so it's not clear whether I have much of value to offer them in the way of suggestions for their careers. Still, I cannot resist this invitation to offer some advice on their conduct of clinical practice, their pursuit of an academic career and their personal lives. My clinical career consisted of a brief stint in rural general practice and then a hospital-based consultative practice in paediatric gastroenterology, so I have a somewhat skewed view of life in the trenches. Once you emerge from the cocoons of medical school and residency, clinical practice may be your first real job. Its demands and responsibilities are very different from those of a resident. Your availability and, as a consultant, the quality of your feedback to referring doctors are still important attributes, but I urge you to pay attention to a couple of additional issues when establishing your practice. First, position yourself with a compatible team whose members relate to other people with an approach similar to yours. When you first encounter your patients, it's best if they have not been enraged by inappropriate behaviours of your colleagues. Also, work hard to function efficiently and to develop good time-management skills, which are seldom emphasized in resident training. It's time to move on from the student manual and the oral examination approach to streamline your clinical assessments. It may sound trite, but you really can collect important historical information during the course of a physical examination. These efficiencies should free up your precious time to make considered, wise decisions. Does this fever require an antibiotic? How could blood work or imaging contribute to this case? Should a neurologist see this child with a headache? Try not to make these decisions in haste or as though there is a pack of litigious lawyers looking over your shoulder. New knowledge and new technology continue to spur progress in health care, but the mindless application of tests and involvement of legions of physicians can be counterproductive. The best antidote to these trends will come from your calm, thoughtful approach to their application. I have offered these suggestions in the name of quality of care, but also, they are central to your enjoyment of clinical responsibilities and to the establishment of an ongoing relationship with your patients and their families. Don't forget that patients or referring doctors are now choosing you, not the other way around. That is a different dynamic than you experienced as a resident. Dr Richard Hamilton I chose paediatrics partly because of the nature of its clientele, but also as a base for the pursuit of an academic career; it's a choice I have never regretted. The downside of a full-time hospital-based career is the loss of independence. If you are uncomfortable relying on others for the resources to support your career, you should think twice about this career choice. Its upside is the intensely stimulating blend of responsibilities involved and the proximity to an ever-changing collection of bright young minds. My favourite uncle – a very successful businessman – could never understand how I could willingly give up a private practice situation to be in such a dependent position. Taking his concerns to heart, I vowed that I would do everything in my power to develop my standing in a full-time hospital role so that I could move to another institution if I found working conditions unacceptable where I was. That never happened, but this attitude has seen me through some rough patches. As a resident, I became attracted to research, guided by some outstanding mentors and role models. I learned that scientific research was a tough proposition, that to succeed one must be open to discussion and criticism, that to produce research findings in a publishable form is a time-consuming endeavour, and that if it hasn't been published, it hasn't been produced. There is little room for ‘Lone Rangers’ in contemporary research, so it's important to find a supportive but critical environment in which to build a productive research career. In most circumstances, even if your commitment to research is major, you will have some clinical responsibilities. The quick gratification of clinical duties can be very seductive, but that is not a valid excuse for avoiding your research obligations. If you find yourself gravitating toward the clinic and away from your research, take stock, because you may be losing something important. Where does teaching fit in? Fortunately, overdue attention is now given to the instruction and evaluation of medical teachers; most medical schools factor quantity and quality of teaching into their evaluation of staff. Over and over, I have seen that the best teachers are those who are best prepared. If teaching becomes a burden to you, it is time to take stock of yourself. It should be a process that not only stimulates but also informs you; the preparation is not always fun, but when you ‘nail’ the assignment, it is thrilling. Ça vaut la peine. Most of us in academic positions are called on for some administrative roles. Early on, I advise you to be very selective in taking on committee work or other administrative positions. It may be good for the ego to join a hospital committee, and some may think it prestigious, but the ratio of productive actions to hours spent can be very low. In your early years, your priority should be to build your professional experience and credentials. Here, I may be stepping into quicksand. Your personal life is none of my business, but I'll comment anyway. How is it that many young Canadian physicians are unhappy with their lot? A valid analysis of the question is beyond the scope of the present essay, but you might consider some simple measures to raise your contentment index and to prevent future burnout: Pay attention to your family, many of whom will have made sacrifices to allow you to be where you are today. Your time with them should be of high quality and written in ink in your agenda. Please listen and respond to their needs. Try to ensure that financial problems don't become a cause of anxiety or conflict. Engage a financial consultant to help you with a budget and savings strategy. You are a sitting duck for sharp financial advisers who know that you are naive about money and that you will have a good income, so choose your consultant with care. Cultivate friends outside of medicine. You will be refreshed by their activities and insights, and probably surprised to learn that some of them are smarter and work harder than you. Find yourself a primary care physician. Your health matters. Work on establishing a special niche or area of expertise for yourself. When I moved to Montreal, I acquired more than an allegiance to a better hockey team – I took on responsibilities for an excellent, large medical staff. Working with them raised my awareness of ‘burnout’ – a threat we all face – and the need to adopt strategies to neutralize it. Try to establish a special niche or area of expertise for yourself over and above your regular day job. Some people develop specific interests within paediatrics, some take on international commitments, and others write novels or join an orchestra. I strongly advise you to seek out these opportunities for their own sake, and for what they can do to enrich your long-term career and mental health. In conclusion, let's remind ourselves that we have all joined a marvelous profession and chosen a great specialty. You have met the formidable scholastic challenges put before you, so I am confident that you will succeed provided, of course, that you follow my advice! I jest, but I do wish you a fulfilling, challenging professional career and a healthy, contented life. Dr Hamilton is Emeritus Professor of Pediatrics at McGill University in Montreal (Quebec). He was a professor and the Chair of Pediatrics at McGill University, and Physician-in-Chief at The Montreal Children's Hospital from 1986 to 1996. He founded the first pediatric gastroenterology unit in North America at The Hospital for Sick Children in Toronto (Ontario) in 1965. His 40-year research career focused on the developing intestine, and its cellular responses to infection and malnutrition. These interests prompted international activities through the WHO and in Bangladesh. He was involved in the training of approximately 45 paediatric gastroenterologists who established careers throughout North America, Latin America, Europe and Australasia. He was an assistant editor of the Nelson Textbook of Pediatrics, and founding editor of Pediatric Gastrointestinal Disease. In 2002, he received the Order of Canada. Dr Hamilton was Senior Editor of Paediatrics & Child Health from 2006 to 2008. In retirement, he is involved in developing an International Maternal and Child Health Research Network. He also chairs the Programs Committee for a thriving community centre in the Little Burgundy region of Montreal.

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