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Traditional images of achievement do not capture today’s more complex career development realities. Approaching career development as a long-distance expedition can help professionals in addressing the strenuous challenges they face, in seeing that a career can be built in many ways, and in taking a long-term view of their journeys. Skills are like muscles, self-efficacy is like sturdy boots, advancement “how-to’s” are like maps, and mentors are like trail guides. Among the tasks each hiker faces are selecting destinations, navigating through rough terrain and weather, and balancing their packs. To further their hikers’ resilience, departments should pay more attention to the career development ecology, including improving access to qualified trail guides and to alternate paths.
“Each man chooses the way he walk.”—Aboriginal song
“Only those who risk going too far can possibly find out how far they can go.”—T.S. Eliot
For members of a profession, work is more than a way to earn a living; it is also an avenue of service and of growth. For academic health professionals, work is a complex combination of caring for patients, educating the next generation, expanding knowledge of health and illness, and improving health-care delivery.
The term “career” applies to the long-term expression of one’s work. For most physicians a career is at some level a quest. But a meaningful quest and a productive career are not inevitable results of the training process. And career momentum is not the force it used to be. Since educating physicians represents an enormous personal and public investment, with society depending heavily on physicians’ commitment to excellence, the successful realization of physicians’ potentials is highly consequential. Yet medical education offers trainees little preparation for taking effective responsibility for their careers.
And what are the most visible images of career success? The tenured professor, the department chair, the physician-executive – those who have “climbed the ladder,” reached the “top.” Even for those not aiming for these heights, the most common career image is linear, a steadily upward march toward more authority and income.
This model is outdated and limiting. Comparatively few junior faculty or residents have the full-time support at home necessary to support such a singular focus on work.1 Another limitation is the emphasis on achieving a top where there’s room for only a few. This hierarchical model stands in the way of developing more collaborative methods and of nurturing leadership capacities throughout organizations.2 These traditional images also do not hint at the dilemmas, impediments and excitement experienced by physicians as they mature.
Playing a significant role in determining what is real for us, the images and language we select help structure our experience. Creative metaphors can even offer new understandings of the world.3 This article offers long-distance hiking as a broadly applicable analogy of potential value to physicians as they shoulder responsibility for their careers. This framework also allows insights into why women and minorities remain less likely to reach the summit and how departments can improve the career development environment.
A professional’s career journey depends largely on how well-equipped she or he is. Consider the following parallels:
Muscles Medical education is like an indoor gym where work on basic science and clinical muscle groups proceeds with personal trainers under relatively controlled conditions. Most students eagerly anticipate the more open air of residency, but they don’t truly experience the “big sky” until their first job. They then discover many necessary but undeveloped muscles, such as personnel management skills and capacities such as maintaining optimism in the face of failure.
Cardiovascular fitness A physician’s professionalism and commitment to excellence are like cardiopulmonary power. Though all hikes require a basic level of fitness, some paths, especially service to underserved populations and leadership roles, demand a great deal of fortitude and courage (“heart”).
Compass Once a person develops guiding insights into their birthright gifts and enduring interests, these strengths and values function like a compass. Especially in poor conditions, it’s easy to lose sight of why one became a physician; remaining connected to this source of meaning is essential to staying on the chosen path.
Sturdy boots Self-efficacy is the conviction that one can competently set goals and achieve them.4 Like well-fitting boots, accurate self-confidence provides the traveler a definite advantage. However, the results will be suboptimal if one’s self-concept is either too big (i.e., arrogance) or constricting (i.e., self-limiting).
Binoculars Hikers need binoculars to gain data about what’s ahead and for pulling in views. Similarly, professionals need to sharpen their analytic focus on critical features of the organizational culture (e.g., what skills are most valued) as well as on distant horizons (e.g., funding trends).
Walking stick Supports such as family and friends are essential to maintaining equanimity, especially when crossing a swift stream (e.g., transitioning into a new role), ascending a steep cliff (e.g., adjusting to new demands), or traversing rocky terrain (e.g., competing for a job). Supports are not standard issue; hikers must discover and take care of what they need.
Maps Smart travelers seek accurate representations of the terrain. For career development purposes, promotion criteria and the organizational chart provide a basic orientation to the Academic Health Center’s (AHC) most obvious features and opportunities (though hard to interpret without the help of a guide). Career and faculty development literature and courses also offer partial maps. But critical information is always missing (e.g., how to become vice-chair, how the promotion committee determines national reputation). And trail conditions change with little warning (e.g., the chair departs, a program is closed).
Trail guides All hikers, especially the inexperienced, benefit from the individualized counsel of guides familiar with the terrain. Renowned trailblazers are in high demand and are also busy maintaining their own fitness, so establishing a relationship with such an expert can be difficult. Another challenge for guide-seekers is that some experts are so specialized they know only their own trail; others are working from out-of-date maps. Being an expert is no guarantee of listening or communication skills; some experts simply convey their version of “the path.”
As well as consulting more than one guide, savvy hikers therefore seek advisors with relationship skills and up-to-date information. They also stay in contact with hikers immediately ahead on the trail. Given breakneck performance pressures, however, some travelers may not pause long enough to share what they know; those who are racing each other are even less likely to cooperate.
Pack Physicians wear their responsibilities like a backpack. Particularly dangerous for physicians is both over-identifying with responsibilities such that the pack becomes welded to their identity and carrying chronically overloaded packs. Periodically taking the pack off and reassessing what one is carrying are necessary for resilience.
Prepared hikers are aware of the potential impediments they may encounter. These days most terrains feature crevasses of gaping clinical demands and under-staffing, boulders of immovable projects, and such false summits as the highly scored grant that was not funded. Many also discover the need to detour around the bitterness valley of manipulative or cynical colleagues. In addition to challenging terrain, sunny days of working out of their strengths and values inevitably give way to rough weather – such as a downpour of disillusionment (e.g., discovering a colleague’s duplicity) or the fog of fiscal panic when budget cuts descend. Taking every opportunity to learn from the experience of others helps prepare travelers for such exigencies.
Especially for hikers with many interests, deciding on a destination and then staying focused will not be easy. While residency sets the initial course, nothing precludes a change of direction. Though some backtracking may be necessary, physicians tend to underestimate how opportunity-granting an MD is compared to virtually any other terminal degree. Many skills and credentials are transferrable and bridge to other trails. While some routes look risky or require a “leap of faith,” individuals with regrets are usually those who fail to test themselves or to pursue their vision.
The good news for explorers and entrepreneurs is that potential destinations are expanding. Along with ever-emerging cross-disciplinary possibilities are opportunities in quality improvement, patient education, health disparities, international health, information technology, medical devices, forensics, professional associations, foundations, and journalism.
Compared to previous generations, today’s young professionals anticipate multiple career moves.5 A lack of focus, however, can waste energy, valuable daylight, and opportunities, such as a well-guided expedition to a promising uncharted area. Young hikers also err by looking only straight ahead or down, missing clues about conditions and possibilities; short- and long-term goals help hikers keep their eyes on the horizon. Also to be avoided is hiking when sleep- or nutrition-deprived. Not only do these conditions escalate the risk of injury, burn out, and poor choices, but weary travelers also shortchange their appreciation of the beauty and the perspective that increasing elevation brings.
Dante begins his epic: “Midway along the journey of life, I woke to find myself in a dark wood/where the true way was wholly lost.”6 Even well-equipped travelers at some point experience doubts — How can I recharge? Is this hill climbable? Or am I ‘over the hill’? Accustomed to mastery and control, physicians may feel lost in the face of any slowdown of their expected sense of progress. And if sustenance (e.g., the potable water of funded grants) and plateaus are scarce, setbacks take a bigger toll. Amid their thickets of responsibilities, many lose the thread or become unable to see the forest for the trees. And each person tends to feel alone in this woods, even though many peers may be struggling with similar questions. Attempting to deny their disorientation, they continue to plod on or wander in the wilderness rather than pumping their doubts for information, seeking help, exploring alternative routes, or taking a reflective “breather” to recalibrate their inner compass.7
Extrinsically motivated individuals (i.e., those oriented toward power, promotion, salary) are at greater risk of remaining “lost” than those who are more intrinsically motivated (i.e., those oriented by their values and the meaning of the work). A particular Achilles' heel of physicians is status anxiety; ironically those with the largest muscles and most performance medals may be the most susceptible. Some individuals emerge from their dark wood more intrinsically motivated; energized by a “second wind” they may turn to improving the trail, shepherding neophytes, or appreciating the flora and fauna they missed on their earlier forced march.
Some hikers pursue a leadership path — although it may feel more like climbing a vertical cliff in deep fog than a peak experience. To adjust to the thin air and to locate hand-holds, technical gear and supports are required, such as financial management training, a savvy departmental administrator, and an executive coach.
Why are women hikers less likely to reach the summit? While this is not the place to explore why women remain relatively clustered in the junior ranks, the metaphor offered here elucidates a few dimensions of this complex continuing reality.8 Not only do women carry more child- and parent-care responsibilities, they’re less likely than men to have a sherpa dedicated to helping them. Women and minorities also tend to carry more non-promotion-related responsibilities than majority male colleagues, disproportionately mentoring other women and minorities, contributing community service, and caring for especially time-consuming patients.9
Moreover, many women and minorities are hampered by limiting stereotypes that function like invisible leg weights. For instance, no matter how capably they perform, women often must chose between being respected and being liked.10 Many internalize such difficulties, which results in their underestimating their own abilities and limiting their goals, meaning they are less likely to experience the thrills possible at higher elevations or to attract a top guide.11 And so the cycle continues, even though they appear to have the “right stuff.”
Thus, women and minorities may need to take extra care to maintain contact with a community of peer-hikers for support and information exchange, to seek guides outside their institutions and muscle-building opportunities customized to their needs, to hire sherpas whenever possible, and to invest in a water-proof poncho for deflecting bias.
Many physicians experience burnout – a deterioration of body, spirit, and will; many lose momentum and fall far short of achieving their potentials. A study of faculty at four US medical schools found that 20% had significant levels of depressive symptoms, with even higher levels in younger faculty, and that over 20% were thinking often of early retirement.12 Moreover, residents are becoming less rather than more interested in a faculty appointment.13 Given likely physician shortages, facilitating their resilience is more important than ever, perhaps especially of academic generalists. Indeed, paying more attention to the interdependent factors that comprise the complex career development ecology is necessary to ensure the reproductive health of the academic physician “species.”
Expanding access to effective trail guides is critical.14 If medical schools recognized and evaluated mentoring as a core academic responsibility, its quality would likely improve. Mentoring programs can assist faculty to build these competencies and can connect guide-seekers to reliable advisors. Collaborative- and peer-mentoring programs are also emerging,15 responsive both to the guide shortage and to young professionals’ preference for exposure to a variety of styles and options, the better to see what stimulates their own development. Such efforts help create a more supportive ecology in which collegial relationships develop naturally.16
Other features of a healthy ecology are knowledge- and resource-sharing and productive collaborations17 – hard to encourage in hierarchical, siloed, competitive cultures. Leaders can strengthen resilience by paying sustained attention to everyday relational patterns18 and by promoting not only trailblazers, but also those dedicated to team-building, trail maintenance, and the assistance of junior travelers.
In addition to these supports, since young professionals bring different work/life preferences than their parents,19 it’s time to examine the assumption that the fastest route is the best. Clearly, most destinations may be reached by a variety of routes. Moreover, individuals who travel at a slower pace may have a richer journey, develop deeper (and shareable) knowledge of themselves and the trail, and ultimately enjoy a longer professional lifespan. In addition to less-than-full-time paths,20 advisable adaptations therefore include opportunities to alternate high-involvement phases with lower involvement, more off- and on-ramps,21 post-service “catch up” time, and mini-sabbaticals. While such options may incur some up-front costs, they are less expensive than re-recruiting and orienting replacements and seem likely to build loyalty in individuals who have many decades of professional life ahead.22
Looking at career development as a long-distance expedition can assist both young and mid-career professionals in preparing for the opportunities and challenges they will face. A journey of continuous learning and expanding views is possible for virtually all physicians, especially if they regularly rest and reassess what they are carrying and stay connected to a source of meaning and to trustworthy guides and fellow hikers.
However, physicians’ resilience also depends on the relational environment. Most AHCs and departments can do much more to facilitate information-sharing and teamwork and to improve access to career development supports and alternate career pathways.
The author thanks the JGIM deputy editor and reviewers and Louise Andrew, MD, Erica Frank, MD, Rebecca A. Harrison, MD, Kathryn Kaplan, PhD, Mark Linzer, MD, Delese Wear, PhD, and Penny Williamson, PhD, for their improvements to this paper.
Conflict of interest statement None disclosed.