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Generalist physicians often pursue fellowship training to develop skills and expertise that will help them toward establishing academic careers. In part 1 of this two-part series, we discussed issues relevant to effective learning and development during the early part of fellowship.1 Here we offer advice, from our experience as former general medicine fellows and a fellowship program director, for planning during the latter part of fellowship, when trainees are preparing to make the transition to junior faculty.
As a general medicine fellow, you should aim to finish at least one project by the middle of the final year of fellowship, before interviewing for jobs. As discussed later, most academic employers will ask you to present your fellowship work in a formal “job talk” during your interviews. Having finished a project or having collected enough data to be able to present results will enable you to give such a talk.
You should also try to present your scholarly work at a national meeting at least once during fellowship. If you are able to finish a small project early on, you may be able to present your work as an abstract during the first year of fellowship. Early experience presenting your work is rewarding and provides visibility among potential future collaborators and employers. In the second year, plan to have one or more abstracts or an educational workshop ready for presentation before the end of fellowship. Although presentations are not a substitute for publications in terms of demonstrating your productivity, they serve as intermediate outcome measures that increase confidence among prospective employers that publications are forthcoming. Others have published guidelines for writing abstracts 2,3 and for presenting work orally 4,5 or in poster format.6
While preparing an abstract for presentation, begin writing the manuscript for your project. Publications in peer-reviewed journals provide “gold-standard” evidence of your productivity and of the quality of your work. As a fellow, you should plan to write and submit at least one manuscript. You should not, however, necessarily expect to have a manuscript in print before leaving fellowship. Because of peer review and the usual need for multiple submissions and revisions, the time from initial submission to publication often exceeds 1 year. If you are able to complete a small, low-risk project early, 1 you may be able to have a manuscript accepted or even published by the time you are looking for a job. This will make you a more attractive candidate for most academic positions. Prospective employers, however, will not expect you to have published fellowship work by the time you are interviewing. Others have discussed effective strategies for writing and publishing manuscripts.7,8
Learning how to write grant proposals is a skill that future clinician-researchers should consider acquiring during fellowship. Writing a good grant proposal, however, takes time and effort, which, for many fellows, may be better spent working on projects and writing manuscripts. We suggest asking yourself the following questions when considering whether or not to commit time to grant writing:
Should you choose to write a grant proposal during fellowship, think small. Proposals for small grants are more likely to be funded and often take less time to prepare than large grant proposals. Small private foundations and institutional intramural funds are a good source of funding for young investigators. Writing a grant proposal is a valuable learning experience even if you are not successful in procuring funding. Some prospective employers may ask if you have experience in grant writing when you are searching for jobs. Moreover, nonfunded grants frequently form the basis for subsequent fundable ones. Other issues to consider when writing a first grant proposal have been reviewed.9,10
For many general medicine fellows, the goal of fellowship training is to obtain an academic junior faculty position. What many fellows do not realize, however, is how much planning, time, and effort securing such a position may require. The “job search” might be considered a separate fellowship project in its own right. Depending on the breadth of your search, you may spend substantial time traveling, interviewing, and negotiating. Budget time for this process, and begin early. In the following paragraphs, we offer a generic description of the search process, with advice drawn from our collective experience.
Perhaps the most important aspect of your job search is determining what you want. Ideally, this should occur long before you begin searching. As early as possible, but no later than the beginning of your final year of fellowship, write a description of your “dream job,” defining the aspects of a position that will afford you the greatest chance of happiness and personal fulfillment (Table 1), not only in your career but in your family life and non-work-related activities. Even if such a job does not exist, and even if you do not yet know exactly what you want, the exercise of describing your dream job will help you define your priorities and discern information gaps that need to be filled through conversations with your mentors, your family, and yourself.
Before you begin searching, it is vital that you ascertain whether you want to be a clinician-researcher or clinician-educator, or if a nonacademic job (e.g., in clinical practice, public health, or industry) is right for you.Table 2 outlines generic job descriptions for junior faculty.
Having decided what type of job you want, list specific features of the job that will be most important to you and prioritize them. Specifically, identify “nonnegotiable” items. Ask for advice from mentors and junior faculty members who have recently been through this process. Also enlist the help of your family and friends who know you well. Determining what you want in a job is essential before you begin your search.
As you sort out the parameters of positions that you will consider, keep abreast of what jobs are available. Fellowship program directors should circulate announcements of job openings across the country. Also look at the classified advertisement sections of journals and newsletters. Talk to your mentors, division chief, and other faculty, and let them know what you are looking for, so that they can keep their eyes out for you. Speak with faculty and colleagues during national meetings to find out what is available at their institutions. When you come across a job that may be a good fit for you, call to find out more and to communicate your interest in the position. Do not worry if it is not the “right time” for you to be searching. Often there is not a strict timeline for filling an advertised position, especially for clinician-researchers, and if you appear to be an excellent candidate, the position may be held open until you finish fellowship.
In most instances, the right job will not fall into your lap; you will have to search for it. The search begins with advertising yourself to prospective employers. If you are hoping to begin a junior faculty position in July after finishing your fellowship, this process should ideally begin around September or October of the preceding year (Table 3).
First, make a list of institutions you are willing to consider. Find out from your mentors and program directors which institutions would be a good fit for you. These should include both sites that are advertising positions and those that are not. Often institutions will create positions for candidates they consider to be a good fit, even if they are not actively recruiting. Second, send your CV and a letter of introduction describing your interests and goals to the institutions on your list. Do not procrastinate over this step. Obtain copies of CVs and letters from former fellows and use them as templates for your own. Typically, you should address the letter to the division chief at each institution or, for advertised positions, to the contact person listed. If your division chief, program director, or mentor offers to write a letter for you, accept the offer. Endorsements increase your credibility.
After considering your CV and letter of introduction, a prospective employer may give you a personal call to find out more about you. During this conversation, it is important that you express enthusiasm and interest. First impressions are lasting. If you are busy and likely to be distracted, ask if you can call back later. After the conversation, you may be invited for an interview.
We recommend visiting any institution where you would consider accepting a position. It is best to keep an open mind early on; you may be surprised at what you find. Do not, however, visit institutions where you would not consider working under any circumstance. Doing so is a waste of everyone's time, money, and effort. If you are invited to several institutions, time constraints may require you to be selective about which ones you will visit.
Before you go to an interview, familiarize yourself with the institution and its faculty. Find out from your mentors and division chief, and from any colleagues you may have at the host institution, which faculty members you should meet. Obtain an interview agenda early and conduct medlinesearches on the faculty members with whom you will be interviewing. Visit the institution's Web site, if one is available. Finally, prepare questions for each person on your interview list, based on their areas of expertise and positions within the institution.
The goal of the first interview is to determine whether or not you are a good fit for the position, and vice versa. It is important to sell yourself, but also to be honest. Ask your hosts what they are looking for in a new faculty member and tell them how you might fulfill their needs. Also address your own needs. During your visit, which typically lasts 2 days, ask yourself: Would I be happy working here? Does the institution have the resources I need? Are there potential mentors and collaborators? Will the job as described allow me to be productive? How committed is the institution to generalism? (For example, how have generalist faculty fared in promotion and tenure?) Will my partner, children, and I be happy living here? Is the institutional environment supportive of junior faculty members? To answer the last question, it is essential to speak with junior faculty at the institution and to gauge their morale and ability to be productive. If there are no junior faculty members on your interview agenda, ask to have one added. Take notes during your interviews. You may have as many as 20 interviews in 2 days, and you may not be able to remember everything you learned during your visit.
A word of caution. Academic positions are typically described in terms of percentages of time allocated to various endeavors (e.g., 20% clinical, 80% protected for research). Beware that different institutions use different accounting to calculate these percentages. For example, an attending month on a ward service may count for 5% of your work year at one institution and 10% at another. Moreover, many institutions will define all nonclinical time as “protected” for scholarly work. An institution may offer a position with 70% clinical time and 30%“protected time,” but if they also expect you to perform administrative tasks that will occupy 1 day each week (20% of your working hours), only 10% of your time is truly protected. Thus, it is useful to find out the absolute amounts of time you will be expected to devote to various activities (number of clinic sessions, ward months, etc.), and to compare job descriptions on the basis of these numbers.
Usually you will be asked to give a formal talk during your visit. The “job talk” is one of the most important aspects of your visit; it is when you are on display, for your would-be employers to assess the product in which they are considering investing. Find out who the audience will be and tailor the talk accordingly. For example, if you are asked to speak at a housestaff conference, you should discuss your work in a broad clinical context. If the audience is mainly research faculty, you should focus largely on the methods and results of one or more fellowship projects. If you are interviewing for a clinician-educator position, you may also be asked to precept in a resident clinic or to demonstrate your teaching ability in other settings.
After your visit, review your notes and discuss with your colleagues and mentors what you learned in your interviews. Through this process you will begin to shape an image of the institution and will better understand if it is the right place for you. After you have finished your first round of visits, step back and take stock. Are you excited about any of the jobs you have looked at? Why or why not? Is it possible you are looking for the wrong type of job? Refine your goals as they become clearer throughout your job search.
If you make a favorable impression during your first visit, and a fit is deemed likely, you will be invited for a second visit. You should accept only if you are also quite interested. Try to obtain a written job offer, even a preliminary one, before your second interview. It is useful to be able to discuss the merits of the offer with your mentors and to consider the proposed details of the job before your return visit.
The purpose of the second visit is to discuss the details of the position, to address concerns that you identified during your first visit, to speak with potential mentors and collaborators, and to allow your spouse or partner to see your potential future home. If you have not yet met with the department chair or others to whom you would be accountable, ask to meet with them. If you are interviewing for a clinician-educator position, ask to meet with the program directors, clerkship directors, and clinic directors with whom you might expect to work. During this visit you should try to clarify details of the position that will to varying degrees determine your happiness and productivity (Table 4) Meet with your mentors beforehand to find out what you can reasonably ask for and expect.
Negotiation begins soon after the first visit and does not end until you have officially accepted a position. Many fellows have never had to negotiate for a job before. It is a skill worth learning, as you will be doing it throughout your career. Certain principles of negotiation are universal.11,12 For fellows negotiating for junior faculty positions, we emphasize the following:
Do not be intimidated. As a fellow accustomed to the academic hierarchy, you may feel powerless when sitting across the table from a division chief or department chair. If you have demonstrated that you will be an outstanding addition to their faculty, however, you are in a good bargaining position. Do not underestimate your worth. Be reasonable, but ask for what you want. If you do not get it now, you may never get it.
Generate offers from more than one institution. Your ability to negotiate is substantially greater if you have a competing offer. This is true, however, only if you are truly willing to refuse an offer and go to another institution if the offer does not meet your needs.
Get it in writing. Agreements may be reached in an effort to satisfy your needs. Agreements, however, are not always remembered. Unless specifically addressed in a written offer, you should not assume that you will get what you agreed upon verbally. Items that should be addressed in an offer letter are shown in Table 4.
Be willing to compromise. The purpose of negotiation is not to get everything you want but to reach a mutually satisfying agreement. Prioritize your demands, and be willing to sacrifice those at the bottom of your list. Your prospective employers are not salespeople, from whom you are trying to get the best deal possible. They are your future colleagues and mentors, with whom you will have ongoing relationships.
Be honest. Despite popular conception, negotiation need not be like a poker game, rife with trickery and deception. Good negotiation results from mutual knowledge and efforts to satisfy each party's needs. These are people with whom you may soon be working. The relationship should begin with trust and cooperation.
Being in a position to decide between offers can be uplifting but also challenging. Some fellows use complex decision-making strategies to help them with difficult choices. We believe, however, that your “gut instinct” is the best decision aid. Discuss relevant issues with your colleagues and mentors. In the end, however, the decision will rest on where you and your partner or spouse think you will be happiest.
Once you have made a decision, let everyone know at the same time. Call all the people awaiting your decision, as well as those who gave you advice along the way, with the good and bad news. As an academic generalist, you will be part of a growing but still relatively small community. No matter where you end up, your relationships with those whose paths you crossed during your job search will last for years to come.
Successful transition from general medicine fellowship to junior faculty requires careful, strategic planning. Fellows should present their work at meetings and write manuscripts as early as possible, in order to demonstrate productivity. Mentors should help fellows decide whether or not to apply for grants during the training period. Finally, although securing a junior faculty position is an exciting process, it is also time-consuming; fellows should begin thinking about what type of job they want and searching for that job early during the final year of their program. We hope that a better understanding of these issues will aid fellows as they pursue their goals in academic general medicine.
The authors thank Mary A. Whooley, MD, Robert H. Fletcher, MD, MSc, Frederick P. Rivara, MD, MPH, Gordon L. Noel, MD, Martha S. Gerrity, MD, MPH, PhD, Judith L. Bowen, MD, William A. Kormos, MD, Mari Kai, MD, and Associate Editor Michael Berkwits, MD, for their review of and helpful comments on earlier versions of this manuscript. We thank our colleagues, advisors, and mentors, whose experience and advice helped shape this manuscript.
Dr. Saha was a fellow in the Robert Wood Johnson Clinical Scholars Program, University of Washington, and Health Services Research and Development, VA Puget Sound Health Care System. Drs. Saint and Christakis were fellows in the Robert Wood Johnson Clinical Scholars Program, University of Washington. Dr. Simon was a fellow in the Harvard General Internal Medicine Fellowship and Faculty Development Program, and the Thomas O. Pyle Fellowship in Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim Health Care. Dr. Fihn is director of the VA Ambulatory Care and Health Services Research and Development Fellowship Programs, VA Puget Sound Health Care System.