Saturday, April 18, 2020

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.

1. Warren, S. L. Make It Stick: The science of successful learning. Education Review // ReseƱas 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).
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. (2017).
16. Tan, N. Short of Time? How to Help Ourselves.
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).


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