Experience of A Fledgling Academic Clinician: Reflections

When I was a radiology resident (physician-in-training), I imagined my early academic life after clinical training to be smooth sailing. It was far from it. It felt more like twists and turns through a maze, unsure of where I was, what direction I was going, and unclear how to overcome hurdles. But through this exploratory process, I learned leadership lessons, met inspiring individuals who provided guidance, and became a more effective academician. The objective of this story is to describe my circuitous path and to provide insights for those pursing an academic path in clinical medicine.

My early career didn’t quite start in academics. At the end of my fellowship (nearly 10 years after I finished medical school), I accepted a private practice job close to home. I moved back to where I grew up and decided to work locally. During my 2 months off between starting my new job and finishing fellowship, I was working on a side project to create a radiology curriculum for my alma mater, University of California, Riverside, which had started a medical school. I was in the position to influence and mold a radiology curriculum for medical students. The curriculum was entirely virtual. During the effort over the next three years, I recruited 6 subspecialty radiologists, who taught radiology using Zoom video conference. I created a 1-mo remote learning curriculum adopting principles of flipped classroom and data driven effective learning strategies endorsed by Make It Stick1 to educate incoming 4th year medical students who will be continuing on to become our future generations of physicians. Nearly 170 medical students have completed the radiology clerkship to understand how to use radiology for patient care. Our methods and approaches were published in a radiology journal, JACR,2 and subsequently presented at our national society meeting, RSNA refresher course3 in education, and is being featured in RSNA News.

First lesson: I found that my side project developing a radiology clerkship curriculum and educating medical students allowed me to impact multiple generations of future physicians. Do develop secondary interests because these side gigs may provide additional sources of meaning and value.

During my 2-month hiatus before starting my new job as a private practice radiologist, my former co-fellow and colleague called me and recruited me to start an academic abdominal position in Loma Linda, California. He knew I loved teaching and research. He felt that an academic position would be a better fit than a private practice job. I was torn. I had committed to the private practice group already, but I knew it offered fewer academic opportunities. I also didn't want the group to be upset with me if I changed my mind. A mentor, who I met the following year, provided guidance which captured the essence of what I needed to do, and I paraphrase her advice: "better to deal with the minimal pain now by saying "No", then to deal with a much larger pain later by having said "Yes" to something you didn't want to do." I called the private practice group, and explained what happened. To my surprise, he was very empathetic. The medical director responded "we're sad to lose you, but you need to pursue what makes you happy". Communication is obviously very important, but few of us learn how to communicate effectively. I read an outstanding book Crucial Conversation4 a year before to learn techniques for how to deliver undesirable news, which helped me prepare for this scenario.

Second lesson: I thought my first job was going to be my last. It's not. Opportunities are random. Do learn how to transition from one role to another. Effective communication can facilitate the transition, so that all stakeholders involved are part of the discussion. In addition to Crucial Conversation, I also recommend Getting to Yes5 to improve our communication skills.

I started my job as an academic radiologist at a large tertiary medical center in Loma Linda, California and I felt lost and alone. Several months later, my former co-resident called me to ask if I could present our work on prostate cancer imaging6 at our annual Society of Abdominal Radiology meeting the following year due to her scheduling conflict. I attended the SAR meeting, feeling a little bewildered. Fortunately, SAR started hosting social networking events and I attended a happy hour event. I recognized many of the well known radiologists, but felt a little out of place. But I got over my imposter syndrome and started socializing and meeting new people. I sat down around the fire pit and started chatting with a lady. A few minutes into our conversation, I realized she was one of our newly elected SAR Board Members. Little did I imagine she would become my chair in the next couple of years. I told her I was a new faculty and I wanted to apply for an early career grant. In response, she said “you should meet AS, who is chairing the new committee for early career radiologist.” We walked over and she connected to AS, who would become a strong co-advocate of an online abdominal radiology case conference we started together.7,8 At the same meeting, I attended a research seminar and introduced myself to another well-recognized abdominal radiologist, MSD. Over the next couple of years, he helped me through several research projects9 and formatively shaped my perspective on value-based academic path and life.

Third lesson: Attend conferences where people like yourself convene. Imposter syndrome affects all of us, but put it on hold while you keep moving forward. When talking to people, let others know who you are and what you want. They will either directly help you or connect you with others who can help.

At the start of my second year on faculty, I started to prepare a grant for an early career award. Writing a grant was not a natural talent. Learning a new skill such as writing a grant requires time and perseverance. It was the ultimate test of Duckworth’s grit10. Just like any new skill, having a training program can help. Per recommendation of MSD, I submitted an application to RSNA Comparative Effective Research Training (CERT) program. The CERT program taught me about health services research and guided me through the grant writing process. In addition, I read Ogden Grant Writing book11 line by line to prepare the grant. I took 2 weeks of vacation time in addition to all my academic days and spare time for 3 months leading up to the two grant deadlines. I was emotionally and mentally exhausted. I waited and waited. Then, one day, I got an email “Thank you for your application but we had many great proposals and ….”. My heart dropped to the floor. I became incredibly sad, discouraged and demoralized. My friend called me because he knew how sad I would from the news and I started crying. Thereafter, I had zero interest in writing grants in the near (or far future). One month passed and I had mostly recovered, but then I heard back from the second grant agency “Congratulations!....”. I was shocked, elated and jubilant. The reviewers had a very different feedback from the first grant agency.

Fourth lesson: Writing a grant is skill like any other skills. Do enroll in a formal training or boot camp to obtain this new new skills such as grant writing (and Ogden's grant book is outstanding11). No need to do it alone. Understand that different grant committees have very disparate responses to the same proposal. In fact, research from NIH-funded study findings support that there is low agreement among reviewers evaluating the same NIH grants, which highlights the biases intrinsic in the current peer-review process.12 It may not be your proposal (and definitely not you) whether you are funded or not.

During the same year, I was interested in studying a controversial topic. The topic was polarizing. Some of the stakeholders loved the research question while others were hesitant to study the topic, stating that “the status quo is working; why change it?”. In between these opposite points of views, I didn’t know how to move forward with the research project because I wanted everyone to be on the same page. William Ury’s book Getting to Yes13 really helped. We have to understand our common shared values: why are we here? Through this shared understanding and values, everyone agreed and we proceeded with the project.  During the same year, I participated in a coaching group led by Niel Rofsky and our group critically discussed the book Coaching as Leadership Style14 and role-play scenarios to practice the ascribed techniques. I used techniques regularly to coach myself as well as others through dilemmas. In addition to the coaching group, I independently worked with a coach who I continue to work with today. Both the group and my personal coach have been tremendous in helping to understand my position, my needs, and identify solutions to resolve issues and to thrive.

Fifth lesson: Some research topics can stir controversy, and some people may not agree with the project. I was ready to fold the project because I didn't know if people would agree on the plan.  At some point, you can either succumb to the pressure or find alternatives.  Finding a team of advocates and supporters who believe in the value of work will help you find an alternate path. Learn how to negotiate, and William Ury’s book is a great start. Participate in leadership groups to develop higher-level EQ skills. Personal coaches can help clarify our needs and challenge us to strive to the next level.

Towards the end of my second year on faculty, my responsibilities and commitments started to overwhelm me. I was chairing a committee for a national society, continuing to serve as the clerkship director for the radiology clerkship, mentoring five trainees (medical students and residents) on research projects, had a couple of projects assigned to me by my department, served as a program co-chair for society, while working full time. During my third year, I was invited to give talks at four national meetings, and three of the meetings occurred over a course of 2 months. To complicate the matter, our faculty group got smaller due to a couple of leave of absence. I was losing it and not enjoying myself most days. Then at a national meeting, I bumped into a mentor. She was heading to the gym shortly after our brief meet-up and invited me to go. I joined her at the hotel gym and we worked out. It was great. I came back home and started exercising 2-3x per week. Over the next 2-3 months, I dialed down the pace of the projects, continued to exercise, and slowly my energy as well as my usual happy self re-emerged.

Sixth lesson: I forgot about self-care after I started to get overwhelmed by all the academic efforts. Do exercise, sleep a full night most nights, and make time to rest and recover. A great podcast by NPR Hidden Brain talks about how we can go into a tunnel vision when we are restricted in resources (e.g. time)15. This state of being constantly short of time starves of higher level thinking including long-term planning. To avoid tunnel vision, the key is to plan in advance and then decide early on what one can accommodate. See my blog Short of Time? How to help ourselves.16 Managing our energy levels by scheduling unstructured time, rest & recovery, exercise, and activities we find joy in doing into our calendar are critical for maintaining energy reserves needed for long-term success. The Power of Full Engagement17 and Make Time18 are outstanding books for learning techniques to maintain work-life integration.

I am coming to the end of my third year as faculty and I’m just beginning to feel comfortable with the process, understanding where I want to go, how I want to get there and the pace that I can manage. In the past 3 months, I’ve turned down more offers and opportunities than I have in my 3 years on faculty. I’m beginning to finally understand when people advise us young academic faculty to learn how to say “No”. Being mindful, introspective and thoughtful of who we are and what we can and want to do can help clarify what opportunities to accept and which to turn down. I learned this lesson only after these experiences.

To summarize, I went through several phases. In my first year, I felt completely lost. It’s okay if you don’t know what you want or where you want to go. Build your network at meetings, collaborate with veterans in the field and follow through on your promises. Into my second year, I faced challenges and had to learn how to negotiate to overcome resistance to studying controversial topics, tackle a grant and understand that sometimes, it’s not about you. Learning leadership skills through coaching can move us towards solution-focused discussion. Having a personal coach can help identify the needs and identify ways to address gaps can help achieve a more refined path forward. I rediscovered the importance of self care in my third year as faculty when I started to get overwhelmed by my commitments. Sleep, rest, and exercise power our energy reserve. Hopefully, some of my experiences will provide a perspective for what future early academic clinicians may encounter in their early years. Would love to hear your thoughts.


References:
1. Warren, S. L. Make It Stick: The science of successful learning. Education Review // Reseñas Educativas vol. 23 (2016).
2. Tan, N., Bavadian, N., Lyons, P., Lochhead, J. & Alexander, A. Flipped Classroom Approach to Teaching a Radiology Medical Student Clerkship. J. Am. Coll. Radiol. 15, 1768–1770 (2018).
3. http://archive.rsna.org/2019/Education.pdf.
4. Patterson, K., Grenny, J., McMillan, R. & Switzler, A. Crucial Conversations Tools for Talking When Stakes Are High, Second Edition. (McGraw Hill Professional, 2011).
5. Fisher, R., Ury, W. & Patton, B. Getting to Yes: Negotiating Agreement Without Giving in. (Houghton Mifflin Harcourt, 1991).
6. Tan, N. et al. Pathological and 3 Tesla Volumetric Magnetic Resonance Imaging Predictors of Biochemical Recurrence after Robotic Assisted Radical Prostatectomy: Correlation with Whole Mount Histopathology. J. Urol. 199, 1218–1223 (2018).
7. Chow, R. A., Tan, N., Henry, T. S., Kanne, J. P. & Sekhar, A. Peer Learning Through Multi-Institutional Case Conferences: Abdominal and Cardiothoracic Radiology Experience. Acad. Radiol. (2020) doi:10.1016/j.acra.2020.01.015.
8. Armstrong, V. et al. Peer Learning Through Multi-Institutional Web-based Case Conferences: Perceived Value (and Challenges) From Abdominal, Cardiothoracic, and Musculoskeletal Radiology Case Conference Participants. Acad. Radiol. (2019) doi:10.1016/j.acra.2019.11.009.
9. Tan, N. et al. Imaging of Prostate Specific Membrane Antigen Targeted Radiotracers for the Detection of Prostate Cancer Biochemical Recurrence after Definitive Therapy: A Systematic Review and Meta-Analysis. J. Urol. 202, 231–240 (2019).
10. Duckworth, A. Grit: The Power of Passion and Perseverance. (Simon and Schuster, 2016).
11. Ogden, T. E. & Goldberg, I. A. Research Proposals: A Guide to Success. Academic Emergency Medicine vol. 3 980–980 (1996).
12. Pier, E. L. et al. Low agreement among reviewers evaluating the same NIH grant applications. Proc. Natl. Acad. Sci. U. S. A. 115, 2952–2957 (2018).
13. Instaread. Getting to Yes: by Roger Fisher, William Ury, and Bruce Patton | Summary & Analysis. (Instaread, 2016).
14. Hicks, R. F. Coaching as a Leadership Style: The Art and Science of Coaching Conversations for Healthcare Professionals. (Routledge, 2013).
15. Vedantam, S. et al. The Scarcity Trap: Why We Keep Digging When We’re Stuck In A Hole. NPR.org https://www.npr.org/2017/03/20/520587241/the-scarcity-trap-why-we-keep-digging-when-were-stuck-in-a-hole (2017).
16. Tan, N. Short of Time? How to Help Ourselves. http://www.nellymd.com/2019/09/short-of-time-how-to-help-ourselves.html.
17. Loehr, J. & Schwartz, T. The Power of Full Engagement. Managing Energy, Not Time, Is the Key to High Performance and Personal Renewal. Das Summa Summarum des Erfolgs 199–216 (2006) doi:10.1007/978-3-8349-9251-2_17.
18. Knapp, J. & Zeratsky, J. Make Time: How to Focus on What Matters Every Day. (Currency, 2018).

COVID19 Pandemic Sparks the Heart of Humanity: Observations of Resilience & Adapatability

COVID19 pandemic has caused a global havoc and started a financial crisis. Despite the awful effects on humanity, people have rose to the challenge and evolved in creative and innovative ways.

Pre-COVID19, our economy was booming, and people were pursuing big plans with stable, strong incomes/returns. Then COVID19 came like a lightening strike and very quickly, everything came to a standstill. Busy streets were empty. Schools closed. Hospitals stopped outpatient services. "Stay at Home" orders went into full effect. Worst of all, many have or are actively dying, and many more are loosing our jobs or having work hours slashed. We are forced to stop and think about the bare essentials and cut out anything extraneous.

But, I am a hopeful optimist and I predict that COVID19 will identify effective new processes, and insights. Over the next decade, these new discoveries will make up and increase the returns many folds beyond the pre-COVID19 state.

Reed Omary's tweet "Constraints spark creativity" succinctly summarizes some of the observations I've made. COVID19 has forced us to step outside of our myopic views and consider alternatives. Technology tools have powered many of these alternatives.

Fig 1: Elementary school issued new rules for online learning.😂

For example, COVID19 transformed education.

Schools moved to e-learning. During COVID19, parents and children together went online to learn. Teachers adapted. Our elementary school teachers used Google Classroom to host assignments, Zoom videoconference for instructions, virtual office hours to answer parents' questions. We got daily briefings about the status of the school and COVID19. In addition, I gained new insights. Being in the background while my daughter's 2nd grade teacher gave instructions on Zoom shed new light. We love our elementary teachers, but watching/listening to her & the other kids during the online instructions made me acutely aware of how grateful I became to the school and the staff. The teachers treated the students with kindness and compassion, while being stern with inappropriate behaviors and imparting life lessons along the way for the students. In addition, new issues arose the school issued new rules for online learning including "Don't take your laptop to the bathroom" 😂 (Figure 1).

Learning became easier and more accessible:

• National societies released or extended free access to incredible online content free-of-charge
• Lecturers went online and hosted their lectures for a global audience. 
• Virtual grand rounds became the new standard for departments. One colleague commented that he had more turnout for the virtual grand rounds than any of the prior in-person grand rounds.
• Educators taught our trainees using Skype / Zoom to give lectures during rotations and read out studies in radiology.
• Our own abdominal radiology case conference (@AbdominalCase) went to twice weekly from monthly to serve the need for growing desire by trainees for learning opportunities. Inadvertently, the common desire to learn from each other allowed educators to connect online during virtual case conference.

People connect online given Social Distancing constraints. Late adopters of videoconferencing came onboard and realized videoconferencing allows more people to connect and share.

• Staff meetings went virtual and more people were able to join. A colleague, who is a chair of a department, shared with me that he viewed faculty meetings as an opportunity for people to connect. But, when faculty meetings went online, he had more turn out and interactions than the in-person meeting. He concluded that maybe faculty meetings do not necessarily to be a social function, and instead social events (e.g. holiday parties) can serve that purpose. More importantly, online meetings serves a forum to distribute information to a wider audience than previously allowable with in-person meetings. 
• Virtual Happy Hours with our friends and new people popped up. Work-life integration was one click away. I had meet-ups with my friends online. Some hosted virtual dinner dates. The physician mom group (PMG) of Phoenix/Scottsdale hosted Saturday 5pm happy hours for us to connect with other PMGs in the area.



Fig 2: Generation alpha leverage technology to connect and collaborate.

• Virtual Playdates allowed children to spend more time with each other. My daughter met her classmates everyday for several hours during Spring Break and regular schooldays to play online Animal Jam together (Fig 2). She works together on multi player game with her classmates during virtual playdate. Generation alpha are digital natives, who are growing up leveraging technology in a new way and COVID19 has highlighted their resilience and adaptability.

Fig 3: Our leaders reveal their superpowers during COVID19.
  Image Credit PicsArt

Leaders rose to the challenge.  I was on a virtual meet up with a coaching group recently and we went around sharing our perspective on COVID19 at our respective institutions. The responses were mostly of struggle or adaptation, but then, one of the individuals, who is a Vice Chair of Operations, commented and I summarize what he said: "it's fantastic. This is what we were trained for and it's great to be able to serve and do what we have been preparing to do all our lives".  Leaders are the superman/superwoman. When the time calls for them, they remove their daily professional clothes and reveal themselves to rest of us (Fig. 3). In the hospitals, our clinical volumes dramatically dropped, in the range of 70-80% depending on site. This has caused a major financial struggle for hospitals to maintain daily needs.  Our administrators have taken the brunt of the workload behind the scenes to carry us through. They meet daily, 7-days a week, strategize as new information flows in, organize, re-organize and plan accordingly real-time to adapt to the crisis and the impact it has had on the health system. Our leaders help us balance both the new clinical needs imposed by COVID19 and spread out the financial strain to the collective. I became ever more grateful for incredible leadership in my department to provide transparency, as well as hope, while emphasizing flexibility and adaptability for all of us. Given the uncertainty and without knowing the gravity of the financial crisis, leaders inspired us and provided realistic hope and optimism encourage us to stay calm and ride the storm.

Fig 4: Service to others during crisis helps us all.
Image Credit: pomocnadlonwschowa

People serve others in need during COVID19. Working parents (including me) were scrambling with childcare because our children were home full-time. Parents had to find new childcare coverage, which became harder because fewer childcare providers were willing to give care due to social distancing. Childcare centers closed. Babysitters stopped babysitting. During these times, the medical students organized themselves to provide childcare services to serve the healthcare workers. Several medical student volunteered to babysit my daughter.  But then, when Arizona issued Stay at Home order at the end of March, I followed up with a student who was scheduled to babysit to let her know I'll figure an alternative. In response, she wrote to me "[medical students] have found that caring for the children of healthcare workers is classified as essential, so I would be comfortable providing that if you need it". Peoples' values surfaced and behaviors became driven by intrinsic motivations (e.g. to serve others) rather than extrinsic motivation (e.g money) (Fig 4). Medical students have been at the heart of these intrinsically motivated behaviors and actions, which makes me so proud to be an educator contributing to developing our future generations of physicians.

In conclusion, COVID19 will leave its mark on humanity and I believe 10 years from now, we will look back and realize COVID19 will have been the strike that sparked the fire of human ingenuity, creativity, innovation and brought out the best in us.