By Arthur L. Kellermann, MD, MPH, Professor and Chairman, Department of Emergency Medicine, Director, Center for Injury Control, Emory University
Positions in academic Emergency Medicine rarely pay as well as private practice. The overhead involved in running an academic group is simply too great to allow it to match most private practice salaries, but most academic positions offer better benefits and job security. Moreover, the non-monetary rewards of academic practice compensate for even sizeable differences in salary. One of the biggest rewards is the pleasure of teaching – whether it involves medical students, EM residents, rotating residents from other specialties, paramedics, or professional colleagues through continuing medical education. Another reward is the opportunity to travel (both nationally and internationally) and interact with visionary Emergency Physicians who share your values and ideals. Finally, academic Emergency Medicine allows you to make a difference – locally, regionally, or nationally. In short, academics offers a pathway to a long and satisfying career in Emergency Medicine.
After twenty years of recruiting Emergency Physicians to academic practice, I have learned that those who succeed share three characteristics:
- Excellent clinical skills – you won't be respected if you aren't a good doctor.
- A love of teaching – if you are a gifted clinician, but don't care about teaching, you will eventually switch to private practice.
- A burning desire to make a difference – how is up to you. You can make your mark in the classroom, in the ED, in a laboratory, or in the community.
As you ponder the prospects of am academic career, what questions should you consider?
1. "Should I do a fellowship first, or jump right in?"
It depends on what you want to do – research, EMS, toxicology, ultrasound or teaching? If you are clearly interested in research or subspecialty practice, I strongly recommend the fellowship route. You will not be able to successfully compete for federal research rants without formal training and/or extensive experience in research. There are several excellent research fellowships within EM, and a few exceptional ones outside it (like the Robert Wood Johnson Foundation Clinical Scholars Program). Look into them.
Most EM fellowships are "bootstrap" affairs. This means they are largely funded by the fellow's clinical activity. In effect, the EM fellow is hired as a part-time faculty member, paid an equally part-time faculty salary, and pursues his/her fellowship experience with the unfunded balance of their time. When considering a fellowship, examine the expected clinical time, the value of your training , your level of access to mentors, and the value of experience. Be realistic. Unless your fellowship is funded by a major foundation (e.g., Kaiser, RWJ), a training grant (e.g., NIH, EMF), or a federal agency (e.g., NIH or the CDC) you will have to earn your salary by working some sort of clinical schedule. However, the long-term rewards of a high-quality fellowship are well worth the short-term sacrifice.
If you are primarily interested in a career as an educator, the need for fellowship training is less clear-cut. However, if you choose to skip this option, look for a department that tales a formal, structured, multi- year, approach to developing its faculty members, including internal, intra-institutional, and external training opportunities. You also want one that can offer you concrete opportunities to apply what you've learned.
2. "Should I limit my search to programs with an established Emergency Medicine residency?"
In weighing a career in academic EM, you may be offered positions at teaching hospitals that lack an AM residency (and have no plans to start one), teaching hospitals that want an EM residency (but do not yet have one), or teaching hospitals that already gave an EM residency or are directly affiliated with one. If the programs are equivalent in other respects, my advice is to choose a hospital with an existing EM residency. It is generally easier to strengthen a troubled residency then to start a new one from scratch (I learned this the hard way at UT Memphis). Beware promises of glory, even what they are sincere. If you are being recruited to help someone establish a residency program, take a hard look at that individual – does she or he have what it takes to pull it off? Also, consider the clinical and political environment of the institution, and its history. Otherwise, you may end up very frustrated.
3. "Is there a difference between a Section, a Division, or an academic Department?"
Having run two different divisions and later an autonomous academic department, I can tell you that departmental status offers numerous advantages. These include greater academic standing, better access to resources, political autonomy, and programmatic flexibility. However, departmental status is not a guarantee of success Some EM departments struggle, and some EM sections or divisions prosper, especially if the are part of a sponsoring department rich and enlightened. If the program interviewing you was recently elevated to an autonomous department, try to find out if this was simply a name change, or was accompanied by substantial financial and political commitments.
4. Do I want to "warm the bench", or "start?"
Beware of programs that promise to appoint you to a major leadership position straight out of residency. Sometimes these opportunities work out, but more often he lead to burnout. Be equally careful of taking a job at a program that has no leadership opportunities and few prospects of advancement. The best institution is one that has a senior and/or mid-career mentors willing to help you learn, but plenty of opportunities as well.
5. "Should I try to develop a research focus, or stick with teaching?"
Most EM faculty members are appointed on the "clinical" track, which stresses excellence in patient care and teaching over productivity. However, in order to secure promotion you will probably have to develop a modest but meaningful publication record and present several invited lectureships at other institutions or regional & national meetings. Some will want you to secure one or more grants. Combined with the levels of teaching and service characteristics of career-committed EM faculty members, this should be enough to insure promotion in all but the prissiest institutions.
This doesn't mean that you have to sequence DNA or clone sheep to get ahead. A lot of valuable EM research focuses on patient care, innovative approaches to teaching, clinical informatics , and ethics. Remember, anything worth doing is worth doing well. And if it's worth doing well, it is worth evaluating and sharing your findings with your peers. If it's worth sharing with your peers, it is worth presenting at a national meeting and publishing in a specialty journal. If you follow this chain of logic, you will automatically conduct research.
Few EM residency programs can prepare graduates for a successful research career, regardless of weather it is a three or four-year program, It's simply not their job. If you want to be successful and compete for federal grants, you must either do a well-developed research fellowship, or join an academic program willing to invest several years in formally helping you acquire the skills you need to succeed.
6. Find a program that fits your philosophy.
There are two dominant organizational models for academic faculties of EM – the "egalitarian" model, and the "specialization" model.
The egalitarian model, commonly employed by smaller programs, treats everyone more or less the same. Regardless of individual talents or interests, all faculty members work a similar number of shifts, teach a proportionate share of lectures, and carry a proportionate load of administrative tasks and duties, such as departmental CQI and interviewing residency candidates. This approach is consistent with the egalitarian spirit of EM, but rarely produces excellence. In practice, inequities quickly develop, because not everyone is willing, or able, to do all of these things well.
The specialization model, adopts a "team" approach to individual and program development. Everyone does clinical shifts, but specialization allows a department to tailor its career development efforts to match a faculty member's innate strengths and interests. At Emory, we have clinician-educators, clinician-administrators, and clinician-researchers. We also have four non-clinician researchers. The number of shifts a faculty member works depends on his or her role, and the individual's success at securing grants, contracts, gifts or other sources of revenue.
Hit the ground running. It is difficult to get recognized beyond your institution unless you get involved on a regional or national level. A key criterion for promotion to Associate Professor and subsequently full Professor is achievement of "national prominence". It is not only rewarding, but fun. In the second part of this two-part series, I'll describe how to achieve national prominence in academic Emergency Medicine.
Academic EM is still a small club. All of the majoring EM organizations (ACEP, SAEM, ABEM, CORD, NAEMSP, etc...) have ample opportunities for those who are willing to get involved. If you have talent, energy and commitment, you can quickly gain visibility on the national scene. All you have to do is follow these simple rules:
Show up – Given the crazy schedules that most Emergency Physicians work, it takes effort to cluster your free days together in order to attend a state, regional or national meeting. Do it. You won't get known outside your institution if you don't make the effort to meet professional colleagues at regional and national meetings.
Speak up – If you have something to say at a regional or national meeting, say it! If you have a special interest or expertise that an EM organization can use, offer it. At academic meetings like SAEM and ACEP, making periodic trips to the microphone to ask cogent questions or offer useful insights is a good way to increase your visibility and become engaged in the intellectual discourse of the meeting. Just be careful not to overdo it.
Volunteer – Committee assignments are a mixed blessing. Service on an ACEP or SAEM national committee or task force is a great way to meet colleagues from around the country and become better known. If you aren't careful, however, committee work can become a drain on your time and energy. Beware becoming overextended by volunteering for multiple committees, by taking on too many assignments, or by getting drawn into long complex projects that have little hope of success. If you are unsure of what to do, consult a senior colleague, mentor, or your Chair for advice.
Network – It is fairly easy to get placed on a committee or task force. Generally, all you have to do is respond with a written expression of interest within the time frame requested by the organization. You can enhance your chances by asking your chair, chief, state chapter president or a key faculty colleague to lobby on your behalf. Emergency Medicine is a remarkably egalitarian organization. Those fortunate enough to reach positions of leadership within an organized EM haven't forgotten what it was like to be a resident, a junior faculty member, or an organizational newcomer. Everyone in EM, regardless of age or achievement is very approachable. If you don't know colleagues who are active on a national level, odds are that your chair, mentor, or senior colleague does – ask him or her to introduce you, and work through them to secure invitations you need.
Listen – Sometimes the best thing you can do is shut up and listen. Study leadership styles. What makes a leader effective? What turns people off? Accept constructive criticism graciously and incorporate good ideas into your repertoire. If your chair or research director chews up your idea, don't sulk. Consider their feedback, revise, and try again.
Produce – It is not enough to volunteer. You must produce. If you undertake a research project, generate high quality work. If you accept appointment to a national committee, meet your responsibilities. If you don't hold up your end, you'll be labeled a "slacker". In that case, it is unlikely that you will be tapped again. Committee chairs are generally picked from the ranks of committee members who met their deadlines, followed through on assignments and demonstrated initiative.
Focus – Although Emergency Medicine is broad, most of the leading figures in academic EM are respected for the expertise in a fairly narrow area of knowledge. Figure out what you want to be "known" for, and develop expertise in that topic or endeavor. Once you have done this, publish on or more high-quality case reports or review articles on the topic and prepare a national-quality lecture you can present at other programs or national venue. You should also explore opportunities to conduct research.
Present your work – It is not enough to become na expert on a topic, you must also share your expertise. Producing a competitive abstract or an interesting didactic session for SAEM or ACEP is a great way to boost your visibility and add a "national talk" to your CV. Don't overlook opportunities to present at international meetings as well. They carry mystique and often impress promotion and tenure committees. Interestingly, it is often easier to get a paper accepted to an international meeting than a top-tier national meeting like SAEM. Because most international meetings rely on registration fees to fund their event, they accept a high percentage of submitted abstracts to encourage attendance.
Publish your work – Presenting papers and posters at national meetings is fun, but the effect is transient. The only way you will make a lasting contribution to EM is to publish your work in a peer-reviewed journal. The same can be said for the objectives of your committee is to produce a report, position paper, or other document, make sure you made enough of a contribution to the product to warrant inclusion as a co-author, if not the first author. At many institutions, publishing is essential to gain promotion.
Document your achievements – In addition to building your CV, learn how to compile and update a personal "teaching portfolio" that summarizes your teaching, compiles evaluations and awards, and includes examples of lectures and other evidence of your academic achievements. A growing number of institutions are requiring submission of a teaching portfolio to establish excellence in teaching.
Persist – Don't be discouraged if your first manuscript is rejected, if you are passed over for membership on a committee or task force, or if you lose an election (all of us have). Be gracious in defeat, and learn what you can from the experience. Then, try again.
Maintain balance – If you want to succeed in academics, you have to stay in it for the long haul. High quality research can take years to produce. Leadership roles in EM organizations can take even longer. If you try to take on too many projects, or push too hard too soon, you will get frustrated or burn out and abandon your quest.
Help others along the way – As you begin to climb the ladder of academic success, don't overlook opportunities to mentor or help others. Remember all of the favors done for you and extend the same courtesy for those who come behind you. Seek to advance the careers of your EM colleagues, whether they work at your institution or at another program. By helping others freely and willingly, you advance the interests of our specialty and your fellow specialists. You will make countless friends.
Don't forget your colleagues back home – Once you achieve a measure of recognition, don't be surprised if this stirs resentment among your colleagues back home. To minimize the risk of this happening, freely acknowledge their role in your success, make sure you carry your share of the load, and use your newly won recognition for the good of the program. If you are a "name" that applicants to your program recognize, make sure you show up on interview days. If you get time off to attend a top national EM meeting, make a point of repaying your colleagues when they need time off for a special trip or a family vacation. If you are rewarded with a reduced clinical schedule in exchange for time to conduct your research or teach, make sure that you do your fair share of nights, evenings and weekend shifts.
Don't forget your family – Travel is fun, and service to a national organization can be a real ego trip. There is a great danger, however, in letting success go to your head. Count the number of nights and weekends that you spend away from home, and add them to your annual total of night and weekend shifts. Too many EM organizations expect their leaders to sacrifice their families and personal relationships to the glory of a short-term title. Don't do it. It is up to us to redefine what is required to succeed, so future leaders can contribute to the specialty and achieve national prominence without sacrificing their families and themselves along the way.
Academic EM is a wonderful career. On a good day, I am amazed that people pay me to do it. On a bad day, I remind myself that it still beats working for a living. In academic EM, the good days vastly out number the bad ones.