Answers to Physicians' Career Questions

II. Enhancing Satisfaction in Medical Practice

II.1. Career Past as Career Prologue

"Those who do not learn from history are condemned to repeat it." - George Santayana

If our height, health, habits and a host of other qualities of mind and body are influenced by our forbearers, is it possible that our career choices are too? What insights can we gain from examining our own working lives and those of our family of origin?

Look back on your own working life and consider:

• What influences have you knowingly assimilated from your parents and grandparents?
• Are there other more subtle influences from those same sources that may now be emerging from the shadow recesses of your being?
• What influenced your career steps when first out of residency and at 5 or 10 year intervals thereafter?
• What does a tree tops view of the career path you’ve traced on the sands of your life reveal?

Examine the careers of your family of origin.

Endless rehashing of the past will never get you focused on the future, yet some time understanding family influences especially latent ones is important. If we zero in on the obvious, what our parents and siblings or the grandparent with outsize influence did we may miss those ‘faded into the woodwork influences’ or skeletons in the family closet. A teenage son of a friend is showing prodigious talent as an artist - it was all "out of nowhere", until someone remembered a great aunt who died young from TB while an art student in Paris between the two world wars. What would exploring the family work archives teach you? Would it give you a confidence boost to discover that you were perpetuating a subtle or forgotten family trait, perhaps one where the venturer was successful?

Examine changes in your career drivers over time.

Each of us has our own motivations for the career paths we’ve chosen, some conscious, some not. These are dynamic elements and may show significant evolution over our work lives even if we remain within the same general career track. It behooves us to examine how we might have prioritized these drivers at different stages of our careers. Consider how you would rank order the elements at 5 or 10 year intervals beginning when you first completed graduate medical training. Repeat this exercise several times over at least a week and force yourself to be as honest and constructively self-critical as possible.

Primary Career Drivers

• Autonomy: To what degree are you willing to let your professional life be dependent on the reactions, behaviors and reliability of others?
• Creativity: How much freedom do you have to determine your own job description and the nature of the work you do?
• Endogenous Growth: To what degree do intrinsic development drivers motivate your career choice?
• External Recognition: To what degree do the opinions of others [parents, spouse, colleagues etc] matter?
• Financial Compensation: Salary always matters. But to what degree? Are your feelings about compensation absolute, thus driven by your need to meet expenses, or, relative and driven by your wish to outearn colleagues, siblings, friends or neighbors?
• Interpersonal contact: To what degree do you value relationships you form with colleagues at work?
• Opportunity to Mentor: How interested and committed are you to advancing the well being and careers of others?
• Security: How important is stability of your work circumstances to both your peace of mind and economic well being?
• Taste for Power: How much do you like holding some level of authority? What forms of power appeal – the purse strings, people or both?
• Technical Competency: How strong is your drive for specific expertise.
• Variety: How much novelty and change do you like in your typical day or work week? What type of change is most important – is it other people, other responsibilities, other work milieus? Do you like a highly structured work environment or one where you have a lot of freedom as to how you complete tasks?

Understand the particular career patterns you’ve made over time.

Those family traits and conscious and subconscious personal influences discussed above cause us to weave a career trail as we move through life. A pattern may emerge, one best seen from a distance that blurs the minor twists and turns but highlights our general direction and tendencies.

These career tracks emerge from 4 primary patterns discussed below which are almost never seen in pure form, but rather blended like mixed primary colors to produce careers of varying hue and saturation. A description of these blended or hybrid forms follow and are illustrated by examples within the medical profession and other walks of life. I’ve drawn on the writings of Brousseau and Driver, "CareerView Concepts. Alternative Perspectives about Career Success", in putting this material together.

Primary Career Patterns

• Primary Pattern #1: Linear.
  This is a straight climb of the pyramid with success defined by most of us by the final height of ascent. Illustrations of those who make it to the top are the entry level employee who becomes CEO, or the medical student who rises to be dean. Practically speaking it usually occurs in a hybrid fashion when combined with the expert form described below.
• Primary Pattern #2: Expert.
  Here there is acquisition of progressively greater skill often in a narrowly defined niche area. Illustrations are master craftsmen, or in its most refined form in medicine, a physician who performs procedures such as interventional neuroradiology or pediatric cardiac surgery.
• Primary Pattern #3: Spiral.
  Here, an individual looks to expand their range of knowledge and talent over time. The movement into new areas is purposeful, and their work life draws directly from blending previously acquired expertise with newly acquired skills. Examples are individuals involved in sports or the arts, who move from athlete to coach or agent, artist to arts administrator or actor to director. In healthcare examples are individuals who pursue additional (typically non-clinical) training in arenas like business, public policy, or public health. Relatively infrequent in the past, it is emerging as a growing career model for physicians.
• Primary Pattern #4: Transitory.
  In contrast to the spiral pattern, here there is a movement between fields with no apparent overlap of expertise or experience. Illustrations are individuals who hold advanced degrees, but migrate around artistic or skilled artisan fields like furniture making. The requirements of licensing and accreditation essentially eliminate this pattern being seen among physicians.

Hybrid Career Patterns

• Hybrid Pattern #1: Linear/Expert Model.
  Almost all physicians would be included in this group. Even those who pride themselves on being generalists still have their favorite areas of practice.
• Hybrid Pattern #2: Linear/Expert/Spiral Model.
  This model, an extension of #1 above, is driven by a wish for career evolution, formal advancement and recognition. It usually emerges from gaining operations experience in ancillary areas understanding the infrastructure that makes the operations of a practice or hospital or medical school function smoothly. Examples are individuals who end up as Department heads, chief medical officers or editors of a scientific journal.
• Hybrid Pattern #3: Linear/Expert/Transitory Model.
  A further variation of #1 above. Many physicians qualify by virtue of their contributions to committees in areas like credentialing, medico-legal review or IRBs. In contrast to physicians who follow the linear/expert/spiral model this work tends to be done for its sake alone, and for the good of the organization. I’ve usually seen this model in physicians with a particularly with a strong sense of commitment to their institution or practice.
• Hybrid Pattern #4: Linear/Spiral Model.
  This model is primarily applicable to non-clinical fields. Examples are those physicians who have moved relatively early in their careers into industries like pharmaceuticals, medical devices or medical insurance where rotation through different segments of the industry is commonplace.
• Hybrid Pattern #5: Linear/Spiral/Transitory Model.
  This model is a variation of #4 above and most applicable in my experience to those physicians with strong entrepreneurial streaks. Relatively rare examples that I’ve encountered include physician CEOs of small biotechnology, pharmaceutical or medical device companies.
• Hybrid Pattern #6: Expert/Spiral Model.
  This is a rare model among physicians with the best examples being physician-executives within large corporations doing development, management or consulting work. Most would claim a linear component too. Most of these individuals would have done little if any clinical work. You may find some examples on Wall St. or in large multi-faceted consulting firms.
• Hybrid Pattern #7: Expert/Transitory Model.
  This model sounds more theoretical than practical for physicians and carries the same caveat about the linear component as in #6 above. It might be represented by the more entrepreneurially minded physician doing solo or small team-based consulting.
• Hybrid Pattern #8: Spiral/Transitory Model.
  I’ve not met one yet. Theoretically this would be the highly entrepreneurially minded physician who spends their career establishing startups in diverse fields.

When considering the spectrum of hybrid career patterns it is striking that we physicians fall within a quite narrow range of the choices. Almost all of us would qualify as members of the linear/expert subset with a significantly smaller number adding additional elements making for more complex hybrids.

I propose that we’ll see this change over the next few decades as physicians pursue greater career variety. This will depend in part on our willingness to change two elements: a) surrender the dominant linear component to our career evolution, and b) accept more non-expert roles. Each will represent a breach in the dominant culture of our profession.

Conclusions

Paying attention to your family and own personal work history may illuminate much about your career doubts, increase your self knowledge and instill confidence that you can pursue a new professional direction successfully.

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II.2. Restoring Satisfaction in Clinical Practice

"Until one is committed, there is hesitancy, the chance to draw back, always ineffectiveness. Concerning all acts of initiative (and creation), there is one elementary truth the ignorance of which kills countless ideas and splendid plans: that the moment one definitely commits oneself, the providence moves too..." - W H Murray: The Scottish Himalayas Expedition 1951

Nobody’s life contract contains an exempt clause from moments of tedium, boredom, or staleness. A physician committed to achieving sustained professional satisfaction will set out to counter moments of career ennui systematically. Casual drifting without taking inventory or a sense of exaggerated entitlement-expectations should be avoided. Given the reciprocal relationship between personal and professional satisfaction a physician’s plans to enhance satisfaction in their medical practice needs to be shared with and inclusive of their family.

Consider your plan as a set of actions (couched as verbs in this piece) centered on positive steps to take and negative actions to avoid. Overarching these actions is the mindset with which you carry them out, which we’ll review first.

Adopt the right mindset.

• Moments of doubt, hesitation and unease about your clinical career are normal. Each of us has them. Thinking that we’re the odd one out is disadvantaging ourselves.
• Admit to your own vulnerabilities, a quality that is dormant in many physicians. Having the humility to admit to your doubts and talk them over with colleagues, friends and your spouse or partner can lift a sizeable weight off your shoulders.
• Words like duty and responsibility have an overly weighty valence in our professional lexicon. Lay down your tools at the end of the day knowing your in-basket is un-emptied.
• There is risk in shedding the idealistic skin of our youth for either the jaded cynicism or the creature comfort excesses of middle-age. A mid-career lifestyle or attitudes at odds with who we are at our core is a recipe for professional discontent. While I, like you, will never be the young man thrilled at the first time he donned a white coat over thirty years ago, I hope a part of the present me is still connected to that young man. The energies, enthusiasms and idealisms of our youth need not be tarnished out of all recognition, rather made more interesting by the complex patina of life itself. If latent talents may emerge in mid-life, so too may previously patent capacities go latent.

Defying Ageing

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• Plan simple fixes first. Some early success reinforces your efforts while grand plans, especially those that depend on others, are more risky.

Adopt positive actions.

• Gain both intrinsic and economic rewards from your professional life. Work to your strengths both in dealings with your patients, the administration of your practice and your interactions with colleagues. Each of us has special talents where we outperform others with an ease and grace that may surprise even ourselves. If, for instance, you have a particular ability to explain illnesses, investigations or therapies to lay people, consider writing the patient education materials for your practice rather than using handouts with some pharmaceutical company logo on the front page. Find a way to use your special abilities daily.
• Maintain work-life balance. You don’t put 90% of your investments in one stock or mutual fund, I trust. So why then would you think of doing this in other areas of your life? Work-life balance has become a tired nostrum of our times because so many of us need reminding of its importance. Stay on the positive side of your demarcation line.
• Modify your roles in the practice, department or hospital over time. Each person’s job description should remain fluid with a modest change in functions annually, and ‘term-limits’ for more sizeable roles in administration and leadership.
• Make a conscious effort to learn something new and apply it to your work. Physicians undergo intense educational experiences between the ages of 18-30 years and then too often traverse a dull plateau. Providing a new clinical service or acquiring some new procedural technique can be a fresh springtime in an established career.
• Recruit well to match your practice culture. Choose your practice colleagues, partners and support staff carefully making sure they match the prevailing culture of your practice. Incompatibility, even if not at the level of outright strife, is a drain on your psychological reserve tank. Honesty and integrity, on both sides of the negotiating table, about who you are as a practice and as an individual, allows for eyes-wide-open commitments and a far greater likelihood of a sustained collegial relationship.
• Work well with others.
  Like some cultural vestige of the era of the solo rural practitioner, physicians have a disconcerting tendency to work in isolation even when members of larger practices. This diminishes the potential rewards from sharing the highs and lows of the workplace with colleagues.
  Much of contemporary medical care involves close collaboration between groups of colleagues from inter-dependent disciplines and even within one discipline from a team of physician, nurse and other paramedical support staff. The whole team and their patients are disadvantaged when one person seeks alpha-member status.

Lamborghini Love

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• Accept our limitations.
  We can be quick to frown on colleagues who express doubt or admit to making mistakes. In so doing, we, at a minimum, short-change ourselves and contribute to some of our colleagues feeling isolated and unhappy.

Bailed Out by Nurses

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• Celebrate successes be they in patient care, practice development or other areas. High-achieving physicians often take success for granted, an expectation met rather than an achievement to cheer about. Paid to tease out the rare and obscure, to know a major illness can seem innocent at onset, to anticipate trouble down the road, our viewing angle on the world risks being skewed to "the problem". We forget our successes, local within our own clinic or hospital, or more general in the contribution medicine has made to the improved quality and quantity of Western mans’ life in the past fifty years.
• Set healthy career goals directed to making your professional life more rewarding, not to beat yourself with, nor gain a competitive edge over another individual or practice.
• Examine the culture of your profession, discipline, or the prevailing practices of your institution. Are they consistent with your values and needs?
• Take pride in the growing diversity of physicians. A profession that cares for mankind at its most vulnerable should reflect the membership of the society it serves. The prototypic physician is no longer a white man with a wife at home. 25% of practicing physicians and 50% of medical students are women. Growth in the number of other minorities while slower also shows progress. This healthier diversity will contribute to a gradual reshaping of our professional culture such as greater attention to preventive medicine and attention to health issues in minority populations.
• Remember that many solutions and potential supporters of your initiatives are at hand. Involve others in your practice and at home to help you make any transition you propose.
• Consider scaling back your efforts. The temperament of many physicians makes them ill-suited to retirement. A physician who worked with 100% effort from 30-50 years and 70% effort from 50-70 years would put in almost the same hours as 100% effort from 30-65 years. The former choice would offer much greater opportunity for engagement in family life and the development of avocations with little down-side risk of being out of touch professionally.

Working to Seventy

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Avoid negative actions.

• Pace yourself carefully. You are engaged in a 30-year marathon by electing a life in medical practice. Emerging from the sprint like exertions of medical school and residency programs where we shift quickly from one rotation to another is not great training for long distance running.
• Regard all colleagues with equal respect. The competitive genes that served us well earlier in our careers can eventually be a millstone. Whether you serve Hollywood starlets in your Beverley Hills plastic surgery office or migrant workers in a small rural clinic in Nebraska, it’s the care of one individual for another and the quality of your work that counts.
• Stay off pedestals. Eventually you’ll fall or be pushed off. The drug company representatives may fawn over you but your colleagues, your family members and deep down you yourself know the real story. Your work is important, your contribution vital to society in general and the community where you work in particular. But if it was not you taking out Mr. Jones’s gallbladder with your usual brio while Clash is on the OR music system it would be some equally talented colleague who preferred JS Bach as she located the common bile duct.
• Temper your need for autonomy and independence. We are experiencing more collaborative models of patient care and are subject to greater degrees of accountability than before. If our primary purpose is to improve the quality of our patients lives, who would really advocate stepping backwards to say the 1960s or 1970s and hand-on-heart say "things were better then".
• Set realistic financial goals. Live well but within your means acquired during a work week that respects the importance of your family and your own need for down time. The delayed gratification and earned income that is a product of our lengthy educational process leads to a risk of splurging once the educational shackles are removed. Working on a treadmill to support expensive habits on the home front is a recipe for professional misery.
• Avoid the twin sins of procrastination and prevarication in examining and modifying your professional life.
• Ignore the negative comments of others about the challenges in the practice of contemporary medicine. There are numerous wonderful clinical and scientific advances that we should be cheering about.
• Maintain a healthy resiliency in dealing with the inevitable ebbs and troughs of our lives. Healthy resiliency is the ability to return to our natural state without distortion of the underlying fibers of our being. Any other apparent adaptability is toxic resiliency.

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II.3. Obligations of Practices to Individual Physician Satisfaction

Working within large health systems has become a more attractive model of employment for physicians over the past two decades. There is strength and safety in numbers, opportunity for a more balanced lifestyle and less need to attend to the business aspects of medical practice.

Given the national shortage of physicians, and the growth in the percentage of women physicians many of whom prefer employment in large group or academic practices, I anticipate that recruitment and retention of physicians will become highly competitive even for the nation’s most prestigious hospitals and clinics. All health systems should develop programs to actively promote professional well-being among their faculty and resident physician staff. A healthcare organization with a reputation for attentiveness to the well-being of its physician staff will advantage itself in recruitment and retention.

Physician satisfaction programs should emphasize:

• Active promotion of professional satisfaction among physicians, ensuring both intrinsic and economic rewards and opportunities for sustained professional development.
• Best practices in personnel recruitment to ensure good cultural fit of the physician with the institution or practice.
• Methods to identify early career distress in ourselves, our colleagues and those whom we mentor.
• Management strategies for career disillusionment such as the availability of counselors and mentors, goal setting techniques, pacing of career advancement given personal and professional constraints, restoring balance between professional and personal lives, and adaptation to cultural change.

Optimum programs would draw on both intramural and extramural expertise providing a balance between local knowledge and outside perspective, ensuring maximum objectivity, and assuaging the concerns of skeptical members of the physician workforce who question whether intramural or extramural expertise alone can provide the answers. ‘Buy-in’ of physician leaders is crucial for the successful implementation of such programs. Illustration of the practical aspects of such programs follows in the ensuing two essays.

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II.4. How Mission and Vision Documents Benefit Group and Individual

Years can slip like quicksilver through fingertips, while we, busy with our profession and our families, never take the time to examine how well our activities and responsibilities are meeting more fundamental needs of our own.

Should we not ask the question: "Why exactly are we in this marriage or partnership?" "What purpose does it serve?" "How do I keep tabs on how this is meeting my own needs and our mutual needs?" Mission statements and vision documents arise from such questions, and considered in this way they cease being some abstruse tool of corporate life and more intimate and immediate to our own circumstances

Here I consider how mission statements and vision documents can clarify the underlying purpose of a medical practice, monitor its progress over time, and help individual physicians determine both whether they would like working there in the first place and the ongoing goodness of fit as their careers progress.

At their heart such statements and their accompanying application tools aim to move us from the quick sand of assumptions and presumptions in our relationships with others and focused on open negotiation and honesty – they take us away from the slippery implicit and place us on the solid ground of the explicit.

What value is a mission statement to a medical practice?

Patients choose which practice to visit for emotional, logistical, economic, and other reasons. Their choice may be influenced by a succinct statement about the practice, the mission statement. A mission statement clearly and simply describes the fundamental purpose of any organization or grouping of people, as viewed from the perspective of the customer/client/patient served. It is styled to remain stable with time. It should be brief, personal in connecting the individuals in a practice to a set of patients, suggest action yet couch this in general terms, and for medical practices have a geographic or demographic dimension. In writing a mission statement for a medical practice its useful to consider it up on a highway billboard. Local or regional drivers are your target audience. The statement must be brief and catchy to be read and to register.

Examples are:

• We’re mid-Michigan’s state-of-the-art surgical practice.
• We provide you the best heart care in Okalahoma.
• We are Milwaukee’s leaders in maternal and child care

What do these three examples provide?

• A one-line easily memorized statement.
• Relevance. Be you CEO, CMO, medical record clerk or a practicing physician, everybody’s mission is to provide the best center for cardiac care in the State of Okalahoma.
• The core purpose on which the dynamic elements in the vision document will be added.
• It is personal. This is who we, the providers and organization are and this is what we do for you, our patients. During my pregnancy and after delivery, my child and I will get the best clinical care in Milwaukee.
• Unequivocally states the raison d'être of the practice or organization. The merits of each decision at any level can be examined by asking - is this action serving our mission? Whether we’re recruiting a cardiac surgeon, buying new computers or re-designing the entrance lobby, will our choices advance our mission of being the best heart care service in the state?
• Ongoing editing is unnecessary, though state-of-the-art is not the same in 2007 as it was in 2000.
• It connects with specific demographic or geographic groups. I’ve got a bad heart, a family history of colon cancer, small children. Are these doctors the right ones for me?
• Sets a high but achievable bar. We’re the best, we’re the leaders, and we’re state-of-the-art. It’s straightforward and unequivocal. You’d want the same if the roles were reversed.

What are the limitations of a mission statement?

• It offers no details to support the statement. It is a hook to capture the attention of a potential patient or referring colleague. The attitudes and assertions to backup the statement lie elsewhere.
• Its brevity and factual nature exclude the precise strategy and tactics being employed to achieve the mission.
• It provides no measures by which success will be judged.

What is a vision document?

Vision is a related concept to mission, and points to the future. It indicates strategies by which a practice or organization will achieve its mission over approximately 3-5 years. It is a more inwardly directed message and tells practice members about their own goals, helping them focus on what they will show the outside world. A vision puts the flesh of details on the bones of the mission, thus is rarely reducible to a one or two sentence statement. It is, rather, a short document, considering the practice’s major functions as discrete elements.

Well constructed vision documents have direct relevance to individuals working within an organization whether that be a large conglomerate or a small private group of three individuals. To illustrate I include the vision document developed by the faculty members in the Department of Surgery at the College of Human Medicine (CHM) at Michigan State University (MSU) in 2004 below. This material was published previously in the Journal of Medical Practice Management 2006:22:84-87 by Drury I and Slomski C and has been edited to a shorter version for the purposes of this communication.

"MSU Department of Surgery will be a group of surgeons recognized for quality, evidence based, cost effective and patient oriented care. The department will be flexible, adapting to changes in technology and knowledge allowing it to bring "state of the art" care to the mid-Michigan community. Its leadership will encourage a supportive and collegial environment among the faculty.... The department will be financially viable and faculty compensation will approximate that of peer institutions in the region. Faculty compensation will reward all facets of faculty responsibilities.
The department will be a leader in surgical education...
The department will build a culture of inquisitiveness where each member will seek the answers to surgical problems.
Department surgeons will be known for the highest standard of professionalism. The department will attempt to retain the current faculty members and recruit the highest quality new faculty members available who conform to its culture and goals. Surgeons will want to work here because of an atmosphere of collegiality and stability."

Put yourself in the shoes of a member of this practice and ask: "What does this example provide?"

• It is directed to the faculty members, resident physicians and support staff within the department.
• It contains five key elements: [1]State of the Art Patient Care: [2]Leader in Surgical Education: [3]Inquisitiveness: [4]High Standards of Professionalism: [5]Financial Health.
• It is forward looking. Note the "will be" and "will build".
• It suggests action. Verbs dominate.
• It amplifies the mission statement and provides a focus for the practice’s strategies to achieve the mission.
• It challenges and inspires the faculty to pursue aligned goals within the department, the medical school and the university.
• It would help potential recruits decide if they would fit well with the practice.

How could this vision document be strengthened?

• By providing specific tactics in addition to more general strategies.
• By the addition of measurements to the tactics to judge their effectiveness, thus facilitating mid-course adjustments based on feedback.
• By providing a different structure to make the key elements more memorable to department members and thus more ingrained in the daily life of the practice.

To make this vision document tangible and embed it in the daily life of a practice I worked with the practice members and created a Vision-Tactics-Metrics table.

Using the practice’s vision document, we:

• Separated out the key elements in the vision.
• Tied several specific tactics to each element.
• Attached as precise as possible a metric to each tactic.

I’ll use one element, financial health, as an illustration –

In the six months since the V-T-M table was developed there was an improved integration of all 5 key elements of the vision into the practice’s daily operations.

Some examples included:

• Greater individual participation at practice meetings.
• Easier integration of two new staff members into the multifaceted operations of the practice.
• Availability of written materials with which the Chair can discuss the evolving department culture with physicians considering joining the practice.

Further details of the VTM table are available in:
Drury I, Slomski C. Making a vision document tangible using vision-tactics-metrics tables. J Medical Practice Management 2006; 22: 180-182.

A successful vision document for a medical practice will address the following questions:

• Can the physician staff and the support staff identify the main elements in the vision?
• Does the vision help focus the practice’s strategic direction and tactics?
• Does the vision reflect the unique strengths of the practice?
• Does the vision provide benchmarks to judge performance?
• Will implementation of the vision enhance productivity & efficiency?
• Will the vision force practice members to do more than the same thing a little better?
• Will the vision facilitate change implementation?
• Can the vision withstand some perturbation such as physician staff turnover?
• Does the vision meet our human needs of being inspired, challenged, and feeling connected?
• Will the vision help potential recruits decide if they will fit well with the practice?
• If the practice is part of a larger organization, is the vision consonant with that organization’s vision?

The rate and scale of changes impacting physicians practicing medicine in the US today is unprecedented. A well conceived vision document offers significant opportunities to remodel a practice culture to ensure sustained success in the face of change.

For the individual physician already established in a practice, vision documents provide measures of goals and accomplishments to evolve over time, a clear roadmap of their responsibilities and expectations, greater likelihood of professional success and diminished likelihood of professional disillusionment because of unclear expectations.

Potential recruits to a medical practice can use a VTM table to help them determine how well they would fit into that practice’s culture.

An additional refinement, is the creation of a Mutual Expectation Compact discussed in the next essay in this section.

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II.5. How Expectation Compacts Benefit Group and Individual

We often create difficulties for ourselves both at home and at work by presuming we know what our spouse, partner, offspring and colleagues want, need or value. Commonly, our presumptions are invalid. We become aware of subtle cracks in the foundations, but unsure how to address them are more likely to allow them expand into communication chasms. Problems like this are common in all parts of our lives and can be best avoided by frank exchange of our mutual expectations with spouse, partner, colleague or supervisor

A compact defines the interconnection between a person and the greater whole that is their nation, their profession, their hospital, corporation, or university. A healthy compact exists when the mutual expectations are aligned and articulated. In physician practices healthy compacts should be explicit, consistent with the mission and vision of the practice and revisited regularly.

A mutual expectation compact (MEC) is an explicit written document created between an employing organization, department or practice and a cohort of its staff members which delineates the reciprocal and overarching "give" and "get" that exists between them. Its purpose is to obviate the distrust or disillusionment that can arise when different parties have reached different implicit understandings of the nature of the relationship.

Overarching implies that the principles described in this document relate to the overall vision of the practice and its guiding philosophy. The MEC is not a substitute for an individual-specific employment agreement or contract dealing with such issues as compensation, physical resources, and provision of support staff.

What are the functions of a Mutual Expectation Compact?

• Its preparation requires existing physician leaders and physician staff to think deeply about their respective goals, their reciprocal responsibilities, and the cultural qualities they wish to sustain or develop.
• It serves as a written document of the guiding philosophies and aspirations of the practice, thus further clarifying its mission statement and vision document.
• It serves as a written document to share with potential recruits to the practice to assist both parties in decisions regarding ‘goodness-of-cultural-fit’.
• It serves as a touchstone for practice members to debate ongoing issues helping keep such discussions focused and productive.
• It diminishes the potential for the conflicts and difficulties seen when we presume we know what our superior or colleagues want or value, only to find that our presumptions are invalid, incomplete, or outdated.
• It enhances professional satisfaction by providing clarity of vision, reinforcement of practice culture, and reduced likelihood of misunderstandings

Using the same model as in the previous essay, here is a segment of a MEC table focused on financial health within a surgical practice, and discussed fully in Drury I, Slomski C. Mutual expectation compacts - a means to link practice culture and vision. J Medical Practice Management 2007; 22: 227-229.

After the development and early experience of use of an MEC in a surgical practice, the practice leaders observed the following particular merits.

• It forced a discipline around implementing the department’s vision document. Practice members had to think concretely about their goals and reciprocal responsibilities, and the cultural qualities they wish to sustain or develop.
• It documented the guiding philosophies and aspirations of the practice, thus reinforcing the mission statement and vision document.
• It signaled to potential recruits and new practice members the purposeful way in which a new vision and a modified culture were being pursued in the practice.
• It kept debate at practice meetings focused and productive.
• It contributed to improved physician career satisfaction.

The final point above is of particular importance. At a time where disillusionment with a career in medicine affects one in five physicians in the US, all efforts to improve physician work satisfaction are critical. One contributor to career burnout among physicians is a sense of poor management and resources provided by the hospital or healthcare organization where they practice. Psychological contracts emphasizing reciprocity between employer and employee have eroded in healthcare as in most other industries. Maslach believes that violation of the psychological contract contributes to burnout because it erodes professional well-being.

MECs can be powerful tools to reinforce a vision document and promote cultural adaptation with broad application to many medical practices. MECs also serve to clarify the reciprocal roles and responsibilities of physicians in a practice and obviate the breakdowns in psychological contracts that may contribute to burnout.

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II.6. Physician Career Satisfaction Summary Talking Points

Practicing medicine while keeping balance in your life is as challenging as performing a tightrope act in the dark. It’s a wonder that as many physicians pull the feat off as do. As an extension of the material in the earlier essays in this section I’ve included some critical talking points below.

I’ve identified five dimensions to meeting the challenge of physician career satisfaction successfully. Each dimension has a number of subsidiary elements which can be viewed as take off discussion or thinking points for individuals, families or groups. Taken together they will help you develop your own practical solutions to restore professional satisfaction, deepen important personal relationships, and help you plan for your future.

Taking Charge of Change

No profession has experienced as much change in the past two decades as medical practitioners have. The satisfaction derived from improvements in patient care has been diminished by bureaucratic oversight and lost autonomy. If change is inevitable, we must learn how to deal with it. Key points to consider therefore are:

• Enhancing our own tolerance for change
• Managing those unanticipated but inevitable transitions that we all meet
• Preserving a sense of autonomy amidst growing bureaucratic oversight
• Turning scientific and technological advances to your advantage
• Building a culture of ongoing change into your practice
• Maintaining a competitive advantage for your practice

Pacing Your Career

Many physicians spend their whole careers still moving at the sprint-like pace of rotations in medical school and residency, rather than adapting to the fast-paced marathon that represents a long career in medical practice. Issues to consider include:

• Acceptance of the never-empty-in-box
• Avoiding career tedium and burnout
• Keeping new challenges in the career mix
• Approaches to scaling back
• How healthy family relationships enhance your career

Building Strong Teams

Strong working relationships with colleagues, administrators and support staff can make a night or day difference in the physician’s world. We would do well to have consistently healthy teams in all areas of our lives. Some important talking points are:

• Applying lessons from successful sports teams and industry
• Focusing on retention rather than recruitment
• Delegation without double-checking
• Rotating responsibilities among colleagues
• Collegial relationships with physician and non-physician administrators

Strengthening Marriage & Family Life

One or more doctors at home can raise extra challenges for marriage and family life. A strong marriage can be a terrific advantage to a physician and allow them handle the stresses of medical practice with confidence. Major considerations include:

• Maintaining friendship and love over time
• Being a good doctor and a good parent
• Making work-life balance more than an overplayed jingle
• Keeping work pressures at work
• Building empathy in our personal lives

Planning for the Long Term

Many of us can expect to have years of good health and material comfort after we stop practicing medicine. Getting to live those years in a meaningful, personally satisfying way includes but goes well beyond meeting some target on a spreadsheet. Rather than just meeting with your financial planner twice a year, think over:

• When is "enough" enough?
• Developing financial peace of mind
• Developing avocations
• Scaling back, not shutting down
• Contributions as a physician after retirement

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