For several decades, I spent a large proportion of my professional life being a mentor and counselor to younger physicians, both cardiologists and noncardiologists. In addition to one-on-one meetings, I spent hours giving seminars about how to create the building blocks of a career. At the end of many talks that I give at meetings, I am surrounded by young physicians who are more interested in asking a question about themselves than the topic of my presentation. It is an unbelievable delight.
What advice do I give? My first question is: Do you think of medicine as a job or as a career?
What is the difference? A job is a position that you hold whose values and priorities are determined by your employer. A career is the sum total of your achievements and contributions, for which you are the driving force and which you carry from one position to the next. A career is your life-long professional identity and mission; a job represents a temporary financial arrangement.
The distinction is critical. If you think of medicine as a job, then your goal is to make your employer happy. It is not more complicated than that.
Satisfying your employer is your ticket to temporary stability -- but it is exceedingly fragile. A more difficult -- but far more interesting path -- is to find positions that allow you to pursue your own goals and development. If you think of medicine as a career, you select positions that allow you to keep focused on your mission.
Assuming that you are a young physician who is seeking a career, how do you go about establishing a professional identity?
If you are a surgeon, you could decide to be the best surgeon in a particular procedure or area. If you are a pediatrician, you could decide to focus on one area of clinical need that happens to be neglected by most practitioners. Being the best or being special is not the goal, but seeking to be the best or special is an important objective. It means that you are seeking to offer something unique to your patients or your discipline regardless of which institution happens to be responsible for your paycheck at any particular time.
The critical step in defining a career is to focus on something that fascinates you. Find a disease (or a procedure) that you wish to master. If you are a cardiologist, discover a part of cardiovascular medicine that puzzles you, stimulates your creative energies, causes you distress, and conquers your soul.
Read everything about it, and become the expert on it in your community. Be the resource for anyone who has a question about it. Know what people are thinking and saying about it. Immerse yourself in the pertinent literature.
Most importantly, discover what experts think they know and do not know, and above all, do not assume that what experts know is correct. If you read a paper or attend a meeting and you hear an expert say that some fact is correct, find out on your own whether there is any good evidence to support it. Often, you will find that the expert's statement sounds right or comforting, but it is based on flimsy data. Instances like these are your opportunity.
Every discipline is filled with assumptions that are based on a wobbly thought process; these are a gold mine for young investigators. Roll up your sleeves with the determination of discovering on your own whether there is any basis for a commonly-held belief. Once you have mastered the available evidence, think of an alternative way of explaining it that is contrary to current assumptions. There is a good chance that your alternative view of the universe has some truth in it.
Suppose you have found a weakness in current thinking and you have developed an alternative framework, what should you do? Some early-career investigators believe that it is too risky for them to challenge conventional wisdom; it is better (and safer) to publish work that adheres to current beliefs. They think that their lowly status relegates them to making confirmatory observations, until they build up credibility. They wrongly believe that it will be easier to challenge the status quo once they achieve some rank.
It is the single most horrific mistake that anyone can make.
The greatest opportunity and privilege of youth is to take risks. Being early in your career means having the responsibility of challenging the current state of affairs. Innovation typically does not come from those in senior positions. All too often, their status relies on maintaining the validity of current beliefs.
Amazingly, a senior person who challenges the status quo takes meaningful risks. In contrast, a junior person who challenges conventional wisdom risks nothing. The worst possible outcome is that they will be wrong.
But if they take a risk, at the very least, they will be relevant -- and even if wrong, they will have contributed importantly to their discipline.
If a junior person simply takes the "safe" path and does confirmatory work, they may turn out to be "right," but they will have made themselves inconsequential. What is their contribution if they simply reiterate what everyone already believes? A "safe" project is often a very unimportant one.
I often have the opportunity to be a co-author with junior physicians, who have been tasked with writing a review article. Too often, the first draft is a dry recitation of the existing literature, without a trace of an original idea. My response to the junior author: there is nothing new here. Their typical reply: review articles are not supposed to be novel.
My counterreply: Really? Well, they are not supposed to be boring either. As the author, you are responsible for using your own thought process to create a new synthesis. What part of this paper represents your unique contribution?
My advice to early-career physicians: do not blend into the crowd. Make yourself relevant. Ask the questions no one else is asking. Devise proposals and create ideas that drive people crazy. You may not be right, but you will be part of the conversation. And you will force senior people to do more homework -- a lot more. With some luck, you will stimulate those with resources to take a risk and invest in you. And in the not-uncommon circumstance that there is some truth in what you have to say, you will have changed the world in a good way.
Standing for a different way of doing things is the distinction between a job and a career.
Play it safe, reinforce the status quo, and you will soon be bored to tears. Your efforts will be forgotten in a millisecond. And in a short time, the world will find someone else who can repeat the same lines -- often a person who is more eloquent, personable, even younger and (almost always) less expensive.
Think unconventionally, do your homework, and make a strong and constructive case for an alternative viewpoint -- and you will never be disappointed. Your career will be full of fascinating stories and challenges that continue without end. And that is the whole point of life.
Disclosures
Packer recently consulted for Actavis, Akcea, Amgen, AstraZeneca, Boehringer Ingelheim, Cardiorentis, Daiichi Sankyo, Gilead, J&J, Novo Nordisk, Pfizer, Sanofi, Synthetic Biologics, and Takeda. He chairs the EMPEROR Executive Committee for trials of empagliflozin for the treatment of heart failure. He was previously the co-PI of the PARADIGM-HF trial and serves on the Steering Committee of the PARAGON-HF trial, but has no financial relationship with Novartis.