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"10 Things Your Mom Forgot to Tell You About the Real World" — Academic Practice

Thursday, January 12, 2012

10 things you might not know about starting out in academic cardiac surgery, but definitely should

Caveat: The guy who wrote this (me) is barely into his third year out of training, so trust me when I say this is not a guide on how to be a wildly successful, world famous clinician-scientist. It’s just a list of things that were not obvious to me that I hope you find helpful. Good luck!

10. The most important part of the job is the people with whom you work.

When I started looking for an academic job, I asked my chairman for the most important thing I didn't already know about the process, and this was the second thing he told me. The first was, "You have no leverage." (It was an uplifting day.) No matter how well you think you are trained, no matter how awesome a researcher you are, you are still an unproven commodity with a remarkably high chance of failure. The program that hires you is taking a chance on you, and you have no independent track record as a surgeon or an investigator.Don't focus on negotiating salary, OR time, lab space, etc. If you don't have the support of your partners or don't get along with them, none of that will matter. You don't all have to go bowling together (why would you want to?), but you need to get a sense that they are committed to your success, and they will dedicate the necessary resources (the most valuable of which are their time and mentorship) to helping you. The same should be said about your research colleagues. Let's face it, you are not going to do this by yourself. No matter who you are, everyone needs advice, feedback on specific aims, space in the minus eighty freezer, someone to split your cells while you are putting an aorta back together, etc. Without support on the research end, a cardiac surgeon is too busy to be a successful investigator.

9. Know what research you want to do. When you interview at a place, make sure you will have the necessary resources to do it.

Going in with a plan helps with number 8, writing a grant, which you should start doing before you start working, or whenever now is. It helps if you can continue work you have done already (see number 5, preliminary data), and if it is related to your clinical interest. When you visit a prospective program, or are negotiating your contract, it goes without saying that you should make sure you will have the ability to do the research intended. This includes shared resources, collaborations, technical support, the whole nine yards. If you don't know what you plan to do, there is no way to know what kind of start-up package or assistance you will need to get up and running. This may all seem too obvious to even mention, except that I did absolutely none of the above.

8. Your operative skills will not determine your success (although they may determine your failure).

Don't get me wrong, you absolutely need to be able to operate, and your outcomes need to be good, but on some level, it is expected that you can do this. This is the part of the job you spent the last eleven years learning, and you are probably pretty good at it. What you spent a lot less time learning is how to communicate with referring physicians, help your office and other staff make you more efficient, prioritize tasks now that you have three jobs instead of one, secure funding, get an IACUC or IRB protocol approved, document so that you get credit (in RVUs or billing) for what you did, and a host of other things that will affect your career progress just as much (gasp!) as your surgical chops.

7. Deciding when to operate is almost as important as deciding on whom to operate.

Not to burst your bubble, but the new recruit doesn't necessarily get the cherry elective referrals from the local cardiologists. More likely, you will get called because some cirrhotic with end-stage psoriasis had an asystolic arrest in the middle of his radical neck and is crashing in the cath lab with a balloon pump after a failed angioplasty. Some of these people will benefit from an operation, some will not. If you are not sure, talk to one of your partners. Even if you are sure, it can make the conversation with the cardiologists easier if you can tell them you ran the case by somebody they already know and trust, at least until that somebody is you. Your partners will also appreciate your asking for their input before you embark on such a disaster in the making, rather than hours later when you are putting in the LVAD. A somewhat more subtle, but just as critical, judgement is when to take someone to the OR, especially after a cardiac arrest or episode of decompensated heart failure. Again, don't be afraid to benefit from the experience of your senior partners when trying to separate who won't get better until surgery from who needs to get better before surgery. The referring who is upset you are not operating immediately will be even more upset if the patient does poorly.

6. There is more to teaching than letting the resident do the case.

Operating with residents and watching them progress may be one of the most rewarding aspects of academics. That doesn't mean you should feel pressured into a situation that you feel is unsafe. Maybe the senior fellow is doing a case with the chief, and you are operating with the medical student. Or maybe you just don't feel ready to take the resident through a mitral yet. Whatever. It's OK. Your comfort level will increase with time. Remember, you will be learning a lot too in the beginning. Establish expectations early, so the resident isn't surprised when you show up wearing a headlight. Personally, I like the "graduated responsibility" approach. Let them do more as time goes on, and both of you will feel like you are making progress. No matter who is operating, you can (and should) teach by talking about the reasons you do things, other ways of doing them, and when you might do it that way. This is an excellent opportunity to tell stories about your crazy attendings, not that I have ever done that.

5. Preliminary data should be published, preferably in a high-impact (read: basic science) journal.

No matter what kind of startup package you got, you will need to think about getting grants for more money. The purpose of the startup package is to get preliminary data for those grants. These days, especially for the NIH, reviewers want preliminary data to be published. Keep in mind that most NIH reviewers are not surgeons, they do not read surgical journals, and they expect preliminary data to published in higher-impact (basic science) journals. Since most everything I have ever published is in surgery journals, I found this out the hard way. You will want to present your findings to colleagues at meetings of organizations that support surgical research, but to improve your chances with reviewers, you have to send some of your work to basic science journals.

4. Get help with your finances.

Everyone’s financial situation is different, in terms of contract, housing, debt, family, etc, so there is no “one size fits all” strategy. But if you are anything like me (or most of my friends), once you have a job, you will find yourself in economic unknown territory, with little understanding of how all this “money” stuff works, and the financial wherewithal to do incredible damage to your future (and credit). Talk to someone (financial planner, consultant, sister-in-law who is an accountant, whatever) who can help get you sorted.

3. Start working on a grant right now.

No matter when "now" is. Even if you don't have a job yet. Even if you have a sweet start-up package. Even if you already have a grant. Stop reading this right now and write a(nother) grant, then come back and finish. The National Institute of Allergy and Infectious Disease has a great website for new investigators ( that I found very helpful. Obviously, it’s not geared toward heart surgeons, but the information is applicable to anyone writing a grant or getting a lab started.

2. There is no such thing as protected time.

Sorry, not in this business. In other fields, you can be "off-service" for weeks or months at a time with no clinical responsibility. If you have referring cardiologists, cases to do, and patients in house or in the clinic (and I hope you will, don't you?), you are going to be pulled in two directions most of the time. It's going to be up to you to decide when to say no, when to say you are unavailable, when ask one of your partners to pinch hit for you. In other words, you protect your own time. A couple of tips: First, be predictable by doing as much as you can one particular day per week, and try to be consistently busy that day. Eventually, some of them will catch on and stop looking. Second, the best way to protect your time is to do efficient operations and avoid complications. Nothing sucks up a day faster than bleeding in the ICU.

1. Cultivate your life outside the hospital and lab.

It is very easy to get buried in patient care, and just as easy to stay late doing research. Take time with your family and friends. Exercise. Do something else to blow off steam. Anything else. I should not have to give you a reason to do this, but nurturing your support network, staying healthy, preserving your mental health - all require energy and commitment, and all are crucial not only to your success, but your survival in this crazy business.


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