Managing career transitions in the profession of acute care surgery

Finding your first job

Selecting your first job is one of the most important career decisions not only to make as a surgeon, as the first few years of one’s surgical career are critical to ensuring clinical proficiency, but also to setting of professional development goals. Therefore, it is imperative to find the place where you ‘fit’ the best. Finding the right fit is important as it can help promote faculty engagement, which ultimately leads to more commitment to patient care, research, teaching, and promoting the mission of the institution.1–4 Research has also shown that one of the main causes of surgeon dissatisfaction in their jobs is related to personal and professional interactions with their colleagues.5 6

To find the right fit, doing some background research prior to starting the interview process is a key first step. First, it is helpful to define what type of job you are looking for. Within the field of trauma and acute care surgery, there are many different types of jobs including academic practices, private practices, community practices or a hybrid of these, each with their own unique pros and cons.7 Once you have determined what type of job environment you are searching for, the next step includes defining your personal, clinical and academic priorities; determining the non-negotiables, or specific aspects of the practice that you do not anticipate being happy without. These may vary based on each individual but can include things such as the opportunity for an elective practice, the presence of robotics, various laboratory resources, etc. Geographic location also plays an important role in the job search process and should be thoughtfully considered as well. Once you have identified specific characteristics of a job that you absolutely must have, design your ideal practice without any limitations. When designing this practice, it is helpful to include all desired features regardless of the likelihood of achieving everything you are seeking. It is not only important to have a good understanding of what an ideal practice is to you but also to be able to communicate this when interviewing. Although it is unlikely that a position will be able to offer you every element of your ideal practice, having a clear sense of what you are looking for will assist you in negotiations and help to get you as close to your goal as possible.

During the interview process, ask pointed and meaningful questions. This is your opportunity to learn about each institution and what they have to offer. Various topics to consider include how each program defines a 1.0 FTE (full-time equivalent), pay structure, benefits, recent turnover in the department, faculty background and education, mentoring, opportunity for advancement, the expectations of various services, satellite campus needs, research support, organizational priorities and mission and the overall health and viability of the organization. While asking these questions, pay attention to how closely the answers mirror your ideal practice characteristics that you determined for yourself. Throughout the interview process, enlist the help of the resources available to you at your current institution to continue to learn more about each program prior to signing a contract.

Once interviews are over, it is important to consider fit again. Have pointed and direct conversations with your partner and/or family as they will be experiencing this transition with you and their needs also need to be met. Ultimately, the institution where you sign your contract should be extremely interested in fostering your career as a junior surgeon and should be somewhere where you feel like you would be successful. Additionally, you should be able to work towards obtaining most of your ideal practice without compromising on any of the non-negotiable characteristics that you previously defined. Finally, it is important to ensure that you feel comfortable with your future partners as these individuals will serve as your work-based support system; they will be who you will call for assistance or advice when needed.

Navigating a job change

Once you have established yourself in your career, you may notice that certain changes occur that affect your career path. Typically, these begin to appear around 5–6 years into practice or as you are beginning to consider moving into an associate professor role. Some examples of this type of change can include a promotion, an interview at another institution, feelings of outgrowing your current position, new leadership within the department or even a direct conflict within your division. Regardless of the type of change, anticipate that there will be an emotional response associated with it that can range from excitement and elation to sadness and despair. As you begin to process this change, recognize that the emotions are normal but should not be the sole driver behind your decision. Instead, the goal is to end up in a better situation than the one that you currently find yourself in. The time to look for a new job is when you want growth opportunities; leaving a job because of dissatisfaction may not result in a better position.

Once you recognize that a specific change in your career is inevitable, reflect on what your goals are within this change and determine what your ideal outcome is. Introspection is of key importance when navigating a job change. External problems that are evident in one job may be similar in a new position. Furthermore, if there is an internal, personal issue that is not taken into account and resolved, this may also result in similar feelings in a new position. Realize that there is no perfect job and every new job offer has potential financial constraints, varying politics, and different clinical stress points than what you are used to navigating. These stressors are also not always obvious during the interview process and thus it is important to ask pertinent and pointed questions. If you are considering leaving your current position for a new one, assess whether the departmental leadership at the new institution seems committed to furthering your specific interests and promoting your academic needs.8 Furthermore, recognize that the processes of moving and transition are stressors and thus do not take a new position if there is only going to be minimal career improvement. Just as considering your partner and family was important when picking your first job, they are just as important in a career transition and should be included in all discussions about the best course of action to take.

Although changing institutions is a way to move forward in your career, another consideration is to make your current job into your ideal, dream job. If you have another job offer, use this as a starting point of discussion to determine whether similar opportunities for growth can be cultivated within your institution. In select circumstances, one can gently negotiate for a retention package, focusing specifically on things that you may be missing in your current job. However, do not overuse this technique as it may cause you to be perceived as malcontent. Prior to entering into negotiations, it would be prudent to discuss your wants and ‘asks’ with a trusted mentor in order to ensure that you are pursuing this in a diplomatic and professional manner.

While many changes do promote feelings of excitement, some may promote feelings of sadness or anger, which can be much more problematic. A transition does not necessarily have to be thought of as something negative. Be introspective and determine what about the change is the most anxiety provoking. Change is a time to critically evaluate yourself in the form of multisource feedback, or a 360° evaluation.9 10 This type of evaluation has long been used to direct professional development. By obtaining feedback from multiple sources within your work environment, you are better able to learn about any ‘blind spots’ that you may have, so that you do not repeat the same mistakes at your new institution.9–12

If you recognize that you have done everything you can to optimize your contributions to your current institution with no success, it is time to cultivate an exit strategy. A successful exit strategy involves a continued positive attitude throughout the process. It is important to continue to do your job to the best of your ability. Do not ruin relationships in the process of transition as the goal is to run towards a job, not to run away from a job. Finally, once you are starting at a new institution, listen and be curious but do not be judgmental. Just as you are going through a transition, you represent a transition or change at your new institution. While your new institution is going to be enthusiastic about the new perspectives that you are bringing with you, remember that strategies you employed in your old position may not be as effective or as welcome in your new one. Ultimately, challenges are meant to assist and promote your personal and professional growth, use this time of transition to your advantage and as a period of self-discovery.

Knowing when you are ready to lead

As your career progresses, leadership opportunities may become more available to you and it is important that you know when you are ready to lead. Serving as a leader is not necessarily a ‘senior’ phenomenon as leadership can take on many different forms. Furthermore, while definitions of what a leader is and what it means to lead may vary, leadership is not defined by the position, or by power, but is ultimately defined by influence and your ability to support and grow those who work for you.

When considering leadership, there are differences between the military and civilian worlds. In the military, leadership is gained as you rise through the ranks. However, someone’s seniority and position for a long tenure do not necessarily translate into being ready to lead.13 In the civilian world, promotion is not as clearly delineated and mentorship is of critical importance to assist and guide you during the transition into a leadership role. Leadership also takes on different forms in academic versus clinical career tracks and it is important to identify metrics for promotion and leadership opportunities specific to your chosen path. Formal leadership courses tailored to surgeons can also offer insights into which types of leadership pathways to pursue and aid in development of key skillsets (eg, the American Association for the Surgery of Trauma Leadership Academy, box 1). Be mindful that just because you obtain an advanced degree or complete a leadership course, this does not mean that you will directly ascend into a leadership position. These courses are merely designed to act as a framework and provide guidance for a successful transition into a leadership position but do not guarantee success.

In the quest to become a leader, there are different ramifications between saying ‘yes’ and saying ‘no’ to various opportunities, and both answers can be appropriate at times. Oftentimes, the motivation behind saying ‘yes’ to an opportunity is simply because you do not want to miss out on the specific opportunity. In these instances, do not shy away from working hard. Conversely, it is imperative to know what is the right opportunity for you at that time and saying ‘no’ to opportunities that are not aligned with your mission or goal is necessary. Remember that doing everything but accomplishing nothing is not a sustainable goal and that at times, this balance is difficult to achieve. Ultimately, it is up to you to understand your purpose and to know your ‘why.’ Understanding your underlying motivation is crucial as it helps to avoid burnout and overwhelming fatigue.

The question remains, how do you know when you are ready to lead? There are a few things to pay attention to as your career progresses. First, you may notice that colleagues and mentors are encouraging you to move into a leadership role. When considering this position, be thoughtful about your motives. Leadership roles supporting a mission and junior colleagues are likely to be more rewarding than those that prioritize career advancement. Next, you are likely ready to take on a leadership position if you embrace being a good communicator, you are compassionate, are receptive to feedback, don’t shy away from difficult conversations and see obstacles as worthwhile challenges. Buchler et al characterized core traits of successful leaders and included the characteristics of high energy, intuitiveness, maturity, team orientation, empathy, charisma, and open-mindedness.14 15

Ultimately, when you step into a leadership role, do not be afraid to color outside the lines to affect change. Be willing to take risks for your colleagues. Be disciplined and have high expectations of your team but make sure to foster a culture of compassion and respect. Similar to clinical practice, setting clear expectations in your leadership role is more likely to yield consistent results from those you lead and is also more likely to lead to consistent responses from those whom you report to. Most importantly, continue to do what you think is right, even when it is challenging to do so. Remember, leadership is found in teamwork, no one can successfully lead alone.

When is it enough? Navigating scaling back and retirement

Eventually, you will reach a point in your career where you will start to consider scaling back clinically and retirement. Currently, the average age of retirement for surgeons is around 64 years.15 While there are no formal guidelines or mandates around when or even if a surgeon should retire, some things to consider include physical stamina, cognition, and fine motor skills. Perhaps most importantly is to be aware that your self-perception is not always accurate and that others may perceive you differently.

Despite a lack of formal guidelines, there are various reasons to consider retirement. These reasons can include your desire to retire, physical health constraints including underlying comorbidities, ergonomic injuries, worsening eyesight, various neurologic disorders, progressive cognitive impairments, and family reasons. As the discussion of retirement progresses, there are also many stakeholders to consider. These include patients, colleagues, payors, hospital administrators, attorneys, and society at large. Although some institutions are moving towards more formal cognitive testing of their senior surgeons including a physical assessment, cognitive screening, and peer assessment of clinical performance, this is not the norm (figure 1).

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If you are considering retirement, there are ways to stay engaged without continuing a full clinical practice. Many surgeons continue to assist their colleagues in the operating room on an as needed basis. Others choose to transition to a more office-based practice or perform certain lower risk procedures. In academic settings, senior surgeons often staff resident-led clinics and round on hospitalized patients to offload some of the work within the rest of the group. Taking on more teaching or mentorship-based roles allows you to continue to be involved without the burden of full clinical schedule. Do note that your salary may be affected by scaling back clinically. These are important conversations to have with your departmental leadership as you are entering into this transition.

As you design your path towards retirement, anticipate and work toward a more gradual path rather than an abrupt transition. For most surgeons, it is unrealistic to implement an abrupt change from a busy surgical practice to a few hours of a hobby a week. Pick up interests and hobbies outside of medicine as your career progresses. When surveying 2153 retired surgeons, Kristo et al discovered that more than half of these surgeons wished they would have done something different in their careers. The most common answer being having a healthier work–life balance.15 It is important to begin to develop a healthier work–life balance now rather than waiting until retirement to do so.

There are some mistakes to avoid when planning your retirement. It is imperative to have a well thought out plan in place, especially in regards to finances and retirement funds. Typically, you should plan to save enough to maintain approximately 70%–80% of your preretirement annual income after retirement per year, realizing that some will accrue as your assets continue to grow overtime. In a similar fashion, consider investing in a good financial planner to ensure that you are maximizing your retirement dollars. Remember to plan for various tax implications, long-term health costs and to be strategic about estate planning and outside investments. Ultimately, retirement is not a sign of weakness and phased retirement is a good strategy to employ to allow for ongoing engagement.

Conclusion

Transitions are inevitable events across every trauma and acute care surgeon’s career. Navigating these transitions can be complex and challenging as they can often be associated with emotional stress and anxiety. It is important to continue to focus on individual goals and what you hope to achieve out of each change. Do not hesitate to enlist the assistance and advice of previously identified mentors as you move through each phase of your career. Finally, a combination of continued self-awareness along with peer support and assessment is important as the way you are perceived outwardly may be different than what you perceive to be true about yourself.