A Funny Thing Happened On The Way To The Ivory Tower

Back in training, my fellow residents and I gulped ladles full of Kool-Aid from tenured professors who ruled an impressively pedigreed land of job security and underlings to perform scut.

For readers outside of medicine, scut refers to the small and annoying tasks involved in routine patient care. Examples might include drawing blood at specific time to test levels of the hormone ACTH at distinct intervals; phoning a specialist to request a consult; or placing a foley catheter into a patient's bladder.

I recall one attending physician during training who was a brilliant researcher but demonstrated room for improvement with his interpersonal skills.

The residents in our program completely ignored his repeated pleas to perform anoscopy in the ED on patients who presented with bloody stool, insisting, "That's a perfectly good billable procedure you are losing revenue on."

The butt biller was an exception to the rule of otherwise deeply humane and engaged mentors who wanted nothing more than to see us succeed. Our professors never meant us harm. They'd led charmed lives, and it was natural for them to mentor others to do the same.

Our faculty encouraged us to follow in their footsteps, that we might someday occupy a corner office in the ivory tower and work our clinical shifts in tertiary centers with an army of trainees to do most of our heavy lifting (which is a variant of a favorite saying of my brother-in-law's: Work is for suckers).

But a funny thing happened on the way to the Ivory Tower.

I relished the intellectual curiosity and the constant interaction with enthusiastic residents, but it turned out that the attributes I brought to the table and the aspects of the role I loved were not likely to be rewarded with advancement or to offset my clinical responsibilities.

I have classmates who pursued academic careers successfully, and I give them the enormous credit they are due - obtaining grant funding, publishing scholarly articles and research, and serially relocating to potentially undesirable geographic locations for the best opportunity to advance one's career involves discipline and sacrifice.

But the harsh reality is that of those who pursued academic careers, the numerator of successes is small relative to the denominator of those who flamed out or found themselves on a stuck on a treadmill without hope for advancing.

I realized I was chasing a shiny brass ring I'd been taught to chase because my faculty valued academic prestige. I course-corrected, experiencing anguish in the process - especially in the first few years, I felt like the black sheep among extremely accomplished peers whose rise through the ranks rankled during insomniac where-are-they-now google searches.

Once I accepted that my personal goals diverged irreconcilably from the academic career I'd entertained, designing a life based on my internal scorecard made for a refreshing pivot. It helped to fall goofy in love with someone who had arrived at the same conclusions, but even with the support of my wife it was a blow to my self-esteem that took time to heal.

I've spent the past fifteen years in "academic sobriety" - creating a life that did not place climbing the ladder of university appointments at the center of all our family's decision-making.

It's been interesting to observe friends from training who'd stuck with academics during the same period of time reaching out to test the less prestigious waters I swim in. They uniformly express surprise that there happens to be far less pee in my pool than their own.

Having experienced that the trade offs of pursuing an academic career did not match their values, did not support their family needs, or proved detrimental to their relationships, many are preparing to transition to community practice positions.

When you start the hard work of building your ideal life, and it diverges from the cookie-cutter medical career path that your peers took, you'll go through stages of grief over the loss of what you thought you wanted. Eventually you make peace with that loss, and after triple-checking that your process is sound, you chart your own path.

Like any investment, you need to give that path a sufficiently long horizon to draw a meaningful conclusion as to whether your strategy was successful.

In the case of abandoning my initial academic trajectory and building a community medical career, it was hard to take the less prestigious job after a fellowship that might have served as a stepping stone to academia.

The experience of doing the hard and unexpected thing served me well years later, when it was equally hard to recalibrate my community job to fit my life when a majority of my colleagues felt fine with the status quo.

But over a long period of time, with a lot of false starts and continuous course-corrections, I built a life in medicine that fit my needs.

And if you build it, eventually, they will come.