IntroductionI believe that the determinants of academic success asa cl - PDF document

IntroductionI believe that the determinants of academic success asa clinician-scientist (defined in terms of principal in-vestigatorship,lead authorship,promotion,tenure,career awards,honours,power and reputation) arenot ÒacademicÓ(defined in terms of intelligence,theoretical understanding,mastery of a body ofknowledge and teaching skills). Although some acad-emics fail because they are crazy and others becausethey lack minds that are ÒpreparedÓto generate im-portant questions based on their clinical observations,the range of their intelligence is so compressed at thetop of the scale that even if it were an important determinant,attempts to correlate it with success aredoomed. Furthermore,the prevalence of academicfailure among those who understand the theory,knowthe facts,and can out-teach their colleagues,coupledto the frequency with which they are left in the acad-these attributes,are just too great to sustain that argument. While it may be that the ability to generatenovel,imaginative hypotheses plays a role in the academic success of basic researchers (a field I aban-doned 35 years ago),this rarely applies to the bur-geoning field of patient-based and clinical-practiceresearch (where the hypotheses usually are commonknowledge and often originate with patients). Finally,What,then,are the determinants of academic suc-cess? IÕve concluded that they are 3:mentoring,cre-ating periodic priority lists,and time management.Before describing them I must point out that myobservations of young academics IÕve mentored andto whom IÕve taught priority lists and time manage-ment,observations of individuals who did and didnÕtreceive mentoring or employ time management,orclearly were and were not successful,and personalexperiences of being mentored by some simply won-derful and quite awful mentors. IÕve augmentedthese personal observations with the results of aPubMed search on the MeSH terms ÒmentorsÓ(510hits) and Òtime managementÓ(901 hits),and the evi-tant evidence on the experiences and perceptions ofwomen in medicine,supports my thesis. Finally,most of the clinician-scientists IÕve mentored andobserved in the United States,Canada and theUnited Kingdom have been hospital-based internists,and IÕd encourage mentors from other health disci-essay do and do not apply to those they mentor.Effective mentoring is of 2 sorts,depending onwhether the person being mentored is a newcomer oran established academic. When the person is a grad-uate student or new faculty member,I define theirmentoring as the provision,by an already successfuland secure academic,of resources(but not obliga-(but not demands),(butDavid L. Sackett,MD SPECIAL FEATURE as a clinician-scientist ©2001 Canadian Medical Association protectionresourcesproviding the mentored tyro with space to work;productivity-enhancing equipment; free photocopy,money to go to courses and meetings; salary supple-ments if fellowships donÕt provide for simple graces;and bridge-funding of research until their first grantis awarded. In some departments,all or most ofthese resources are provided by the chair,and in others,none. In either setting,the mentor shouldÒwheel and dealÓuntil the resources are in place;spared both the time and humiliation of begging forthese resources on their own.opportunities at the beginnerÕs levelsystematic examination of everything that crosses thementorÕs desk for its potential contribution to the sci-entific development and academic advancement of theperson being mentored,and here are a few examples.cate,blind (and,of course,confidential) refereeing ofmanuscripts and grants. The comparison of these cri-tiques not only sharpens the critical appraisal skills ofjunior colleagues,it also permits them to see theirmentorÕs refereeing style* and forces them to developtheir own. When possible,they should accompanyand grant review committees to learn firsthand howthese groups function. As soon as their competencypermits,requests from prominent,refereed journals towrite editorials,commentaries or essays  should leadto collaboration in reviewing the evidence and the rele-vant literature,synthesizing it,agonizing over draft af-ter draftà of it and sharing its authorship. As soon astheir contribution warrants,the mentored individualsshould become the lead author of such pieces,with theultimate objective that they become the sole author (allthe sooner if the mentor casts a wide shadow). Simi-larly,they should be offered the chance to take overtheir mentorÕs invitations and learn how to give Òboil-erplateÓlectures (especially at nice venues and forgenerous honoraria). Their inclusion in the social aswell as academic events that comprise the visit of col-leagues from other institutions should become auto-matic. Going as a group to scientific meetings (espe-provides opportunities for them to be introduced toand hear the Òold fartsÓin the field,but also to meetand debate with other newcomers. Moreover,the op-portunities to compare the impressions and ideasgained there while they are fresh,in a relaxed and con-genial atmosphere,can be both fun and productive offuture research (but see the warning about the opportu-nity costs of meetings at the end of this essay). Finally,free books and subscriptions that are of no interest tothe mentor may be of high value to those being important that these opportunities are offered withoutcoercion and accepted without resentment. Crucially,they must never involve the off-loading of odious taskswith little or no academic content from overburdenedongoing research project so that they can gainhands-on practical experience,learn how to createand function as a member of a collaborative team¤and develop skills in research management. How-ever,I think it is highly damaging to ÒgiveÓor assign(e.g.,thesis) learning focus. When this happens theindividual being mentored is denied the opportunity(and challenge) of beginning with the broadest pos-sible view of a problem in human biology or healthcare,developing the analytic and creative skills nec-essary for narrowing this overview down to the next Academic success as a clinician-scientist Clin Invest Med Vol 24, no 2, April 200195 ad hominem  Unless an invited chapter was for a very prestigious book, itsauthorship would add little or no weight to the curriculum vitae of any academic at the universities where IÕve worked. àExcept in Ireland and the United Kingdom, my junior col-leaguesÕ initial efforts at writing have been so prolix that Iasked them to prepare their second drafts using 40% fewerwords. Some of my mentoring colleagues would give them acopy of The Elements of Style(Strunk W Jr, White EB. The . 4th ed. New York: Longman; 2000). ¤Good teams are those whose membership is determined bythe question being asked (rather than by interdisciplinary fad)and whose products and publications serve the needs of bothscience (valid, useful answers) and its individual members(i.e., first-authored publications). logical research question to be asked about thisproblem and honing that question into a form thatthat will provide a valid,useful answer to it. These 3skills are central to the development of all indepen-dent investigators,and without them all they can doimportant nails to pound with the same old hammer.Mentors should provide opportunities to observe,model and discuss teaching strategies and tactics inboth clinical and classroom situations. When thementored are invited to join a clinical team they canstudy how their mentors employ different teachingstrategies and tactics as they move from the post-take/morning report to the daily review round to theclinical skills session to grand rounds. With time,those being mentored can take over these sessionsand receive feedback about their performance. TheAs junior colleagues advance toward independence,opportunities maturetional areas. The first comprises nominations to thescientific committees (e.g.,grant review committees),task forces (e.g.,for the development of methodologi-cal standards),symposia (especially those that resultin first-authored publications) and scientific organiza-tions that will increase their academic experience,net-work and recognition. The second consists of writingnominating them for the academic posts that willlaunch the next phase of their academic and career development,followed by comprehensive letters ofof negotiation and recruitment.I mean providing frequent,unhurriedmentored to think their own way through theirtion,the scientific and methodological challenges intheir individual projects,the pros and cons of em-barking on a particular program of research with aparticular set of collaborators,and their developmentacademic issues at such sessions until they havepersonal and family health,relationships,finances,and the like). This advice should take the form ofÒactive listening,Óshould focus on their developmentas independent thinkers,and should eschew com-As long as gender-based inequalities exist in run-ning households and raising children,mentors mustbe knowledgeable and effective in addressing and advising around the special problems that facewomen in academic careers. Although only 20% offemale academics in one study stated that it was im-portant to have a mentor of the same gender,imperative that all women pursuing academic careershave easy access to discussing and receiving in-formed,empathic advice about issues such as timingtheir pregnancies,parental leave,time-out,part-timeappointments,sharing and delegating householdtasks,and the like. When the principal mentor is aman,these needs are often best met by specific addi-tional mentoring around these issues from a woman. When listening to individuals being mentored sortthrough job offers,it is important for the mentor tohelp them recognize the difference between Òwant-ing to be wantedÓfor a prestigious academic post(theyÕd be crazy not to feel this way) and actuallyÒwanting to doÓthe work involved in that post(which,on reflection,the individual might recognizeas ill-matched to her or his interests,priorities,career stage,competencies or temperament). protectionI mean insulating the individual be-ing mentored from needless academic buffeting andfrom the bad behaviour of other academics. Becausescience advances though the vigorous debate ofideas,designs,data and conclusions,junior col-leagues should get used to having theirs subjected tokeen and critical scrutiny. By the same token,theyneednÕt be tossed in at the deep end. Thus,for exam-ple,they should be invited to rehearse their presenta-tions in front of their mentor so that every statementand slide can be challenged in a relaxed and support-ive setting where presentations can be revised and responses rehearsed. The objective here would be forthe toughest,most critical question about the work tohave been raised for the first time during its rehearsal,not after its final presentation. Similarly,critical let-ters to the editor following their first publication canbe recognized for what they almost always are:an at-tempt to show off and win at rhetoric rather than to Sackett how to protect themselves by generating responsesthat re-summarize their key conclusions,answersubstantive questions (if any),and remain aloof fromthe tawdry slurs that their detractors attempt to passoff as harmless wit. Finally,disputes between seniorinvestigators often are fought over the corpses oftheir graduate students,and mentors need to inter-vene swiftly and decisively whenever they detectsuch attacks on their junior colleagues,especiallythose related to gender,race or sexual orientation.The intention of rapid retaliation is not so much tochange the attackerÕs point of view but to make therepercussions of picking on young investigators sounpleasant that he (or she) never tries it again. If notalready introduced,the classic on Òhow to swim withsharksÓcan be integrated with the foregoing.I donÕt believe that academics ever outgrow theirneed for mentoring. As they become established in-vestigators,they require gentle confrontation aboutwhether they are becoming recognized ÒexpertsÓandtaking on the bad habits that inevitably accompanyAnd,given the huge number of highlyprestigious but simply awful chairs and deanshipsthat are pressed upon even unsuccessful academics,these offers need the dispassionate (even cynical)eye of a colleague who can help distinguish thegolden opportunities from the black holes. Finally,mentors can help senior academics find the courageto seize opportunities for radical but fulfilling andeven useful changes in the directions of their careers.For example,I am ever indebted to my then-mentorBill Spaulding,who helped me confirm the senseand then find the courage to repeat my internal medicine residency shortly before my 50th birthday.What are the prerequisites for a good mentor fornewcomers to the field? I think there are 5. First,mentors have to be competent clinician-scientists.Second,they must not only have achieved their ownacademic success but also must act like it towardtheir junior colleagues. That is,mentors must feel se-cure enough that they are not only comfortable withof authorship and recognition but actively pursuethis secondary role; everything fails when mentorscompete with individuals they are mentoring forrecognition. Third,mentors should not directly con-the individuals they are mentoring,lest this interferewith the free and open exchange of ideas,priorities,aspirations and criticisms. Fourth,mentors must likementoring and be willing to devote the time and energy required to explore and solve both the routineand the extraordinary scientific and personal chal-lenges that arise when they take on this responsibil-ity. Finally,mentors must periodically seek feedbackso that they can evaluate their own performance,decide whether they remain the best person to con-tinue to mentor their junior colleague,and identifyways to improve their mentoring skills. The periodic priority listsmallest degree of control over their day-to-day activ-ities and destiny (say,the day of their first faculty defence),they should be reminded (at least every 6months,and more often if needed) that itÕs time forthem to generate and present their periodic prioritylist to their mentor. Updating and discussing this listrest of anyoneÕs career. For established academics thelonger be a senior colleague; indeed,the most effec-tive mentoring IÕm receiving in the twilight of my The priority list is trivially simple in format butdreadfully difficult in execution. It has 4 elements:¥List 1:Things IÕm doing that I want to List 1a:Things IÕve just been asked to do that IdonÕt want to do.¥List 2:Things IÕm not doing that I want to ¥List 3:Things I want to keep doing¥List 4:How I plan to shorten List 1 andlengthen List 2 over the next 6 months.Note that the entries on this list are about (things like research,clinical practice,teaching,writ-ing,and the like) not about (things like space,titles,rank or income). Note,too,that there are noÒcop-outÓentries for Òthings I to doÓ(theymust be thought through until they can be allocatedeither to List 1 of things I want to quit or List 3 ofthings I want to keep doing).Generating Lists 1 and 3 can benefit from review- Academic success as a clinician-scientist Clin Invest Med Vol 24, no 2, April 200197 ing oneÕs schedule for the past weeks or months andList 1a from recalled messages and conversationswith bosses or colleagues who were attempting tomake their problems your problems. List 2 is derivedfrom multiple sources:the logical next research ques-that pop up in patient encounters,while reading orduring conversations or trips to meetings and otherresearch centres; long-held aspirations that are nowrelationships,etc. Reviewing the length and contentof List 3 enables self-diagnosis and insight. If long,isit comfortable but complacent,stifling furthergrowth? Worse yet,is it the list of an expert,compris-ing the tasks required to protect and extend personalÒturfÓin ways that lead to the Òsins of expertness?ÓIt then becomes necessary to titrate Lists 2 and 3versus List 1. The failure to stop doing enough oldthings in order to free up time for doing new things isa recipe for both academic and personal disaster. Noting the deadly label of a Ònon-finisher,Óclinician-scientists experience increasing dissatisfaction withboth their professional and personal lives. The ultimateobjective here is to construct lists that,if realized,would lead to a set of research,teaching and clinicalactivities that would make it fun to go to work.All the foregoing leads to List 4,identifying thestrategies and tactics for achieving the next phase incareer development. It adds greatly to oneÕs academicreputation when this list promotes change throughevolution (giving 6-monthsÕnotice and helping find asuccessor) rather than revolution (resigning and run-ning away). Furthermore,one can gain administrativeskills by sorting out which tasks can be delegated toassistants,with what degrees of supervision.Just as troubled families are said to achieve 80% ofthe benefits of family therapy (acknowledging prob-lems,becoming ready to explore and adopt solutions,and the like) before they sit down with a therapist,themajority of the benefit derived from the periodic pri-with oneÕs mentor. Nonetheless,additional insightscome with presenting these lists to someone else,andsuggestions of additional strategies for change (e.g.,learning how to say ÒnoÓnicely) usually arise follow-ing this presentation. As before,the ability to discussgender-specific issues in balancing priorities with aninformed,empathic mentor is essential. Moreover,because the period of greatest academic dependencyfor many aspiring clinician-scientists coincides withdency of their children and partners,the discussion ofthe latter. The suggestions that emerge from thesediscussions often focus on the effective and efficientuse of time,which leads us to the third determinantof academic success:time management. Time management. IÕveencountered several successful academics whoseonly control over their schedule has been protectedwriting time. Conversely,IÕve met very few acade-time,regardless of how well they controlled theother elements of their schedules. For some acade-malÓworking hours,but the price of such nocturnaland weekend toil is often paid for by family,friendsaside 1 day a week (except during periods of inten-sive clinical responsibilities; vide infraactivity,and clearly mean it by telling everyone thatthey arenÕt available for chats,phone calls,commit-tees,classes or departmental meetings that day. IÕve never admired the publications of any acade-mic who told me writing was easy for her or him;those whose work I admire tell me they find it verydifficult to write (although many find it nonethelessenormously enjoyable and gratifying). Given the dif-ficulty of writing well,no wonder so many acade-mics find other things to do when they should bewriting for publication. The great enemy here is pro-crastination,and rigorous self-imposed rules areneeded for this protected writing time:it is not forwriting grants,not for refereeing manuscripts fromother academics (arenÕt they already ahead of youwith their writing?),not for answering electronic orsnail mail,not for keeping up with the literature,notfor responding to non-emergencies that can wait Sackett until dayÕs end,not for making lists of what shouldbe written about in the future,not for merely outlin-ing a paper,and not for coffee-breaks with col-leagues. Early on,self-imposed daily quotas of intel-ligible prose may be necessary,and these should beset at realistic and achievable levels (as small as 300coherent words for beginners).It is imperative that no interruptions occur on writ-ing days. Unless protected by a ruthless secretary andrespected by garrulous colleagues,this often can bestbe achieved by creating a Òwriting roomÓaway fromthe office; whether this is elsewhere in the building orat home depends on distractions (including familyobligations) at these other sites (for a time I simplytraded offices with a colleague who wrote the sameday as I). Writing in a separate,designated room notonly permits the creation of stacks of drafts,refer-ences and the other organized litter that accompanieswriting for publication,it also avoids the unansweredmail,the unrefereed manuscripts,the undictated patient charts and the other distracting,disorganizedlitter of a principal office. Moreover,if email is disabled in the computer in the writing office,a major cause for procrastination is avoided.Mondays hold 3 distinct advantages as writingdays. First,the things that ÒcanÕt waitÓare muchmore likely to arise on Fridays,and very few thingsthat arise over the week-end canÕt wait until Mondaynight or Tuesday. Second,a draft that gets off to abrief bits of free time over the next 4 days and sentout for comments by weekÕs end. Third,the comfort-ing knowledge on a Sunday night that Monday willbe protected for writing can go far to improving andmaintaining the mental health,family function andsatisfaction of aspiring academics. And,of course,week,the greater the opportunity for trading officesThe second important element of time managementrequires scheduling clinical activities so that the acad-emics maximize the delivery of high-quality care and(through provoking research questions to be askedand providing patients who might be willing to helpanswer them),or at least minimizing conflicts with,the other elements of an academic career. I reckon thisis best accomplished in inpatient disciplines by devot-ing specific blocks (of,say,1 month) of Òon-serviceÓtime to nothing but clinical service and teaching.When on-service,total attention is paid to the needs ofpatients and clinical learners,and no time is spentwriting,travelling,attending meetings or teachingnonclinical topics. This total devotion to clinical activ-ber of patients and clinical learners (on my medicalinpatient service at Oxford I was on call every thirdday,my clinical team of up to 16 learners and visitorsadmitted 230 patients per month,and in addition toour individual daily bedside rounds my Fellows and Iprovided 13 hours of clinical teaching each week).When off-serviceÓoneÕs time and attention shifts ascompletely as possible to research and nonclinicalteaching. Ideally there is no time spent Òon-callÓwhenoff-service,nor should off-service time be devoted topost-hospital outpatient follow-up unless itÕs trulyclinically indicated (again on my service,post-admission and pre-discharge telephone conversa-follow-up to less than 5% of admissions). Academicclinicians who fear getting rusty or out of date be-shadowing a colleague for a week or so prior to reas-care and intensive care units for my Òwarm-upÓweeks). Like so many other elements of academicsuccess,time management is fostered by the devel-opment of a team of like-minded individuals whospell one another in providing excellent clinical care.Clinicians in other fields (e.g.,intensive care andmany of the surgical specialties) sometimes find itsearch in units of 1 week. Another variant of this whose current incomes are derived solely from pri-vate practice. They devote 3 weeks each month to in-tensive clinical practice in order to free up the fourthThis still leaves the outpatient dilemma. Academicclinicians usually accept ambulatory referrals to theirgeneral or subspecialty clinics 1 or 2 half-days everysession itself,several hours are spent during the fol- Academic success as a clinician-scientist Clin Invest Med Vol 24, no 2, April 200199 lowing 2 to 3 days chasing down ÒlabÓresults,talkingthat this pattern of practice by academic clinicianswho are (and should be) frequently out of town as vis-iting professors,presenters and grant reviewers riskslowering the quality of their outpatient care; whathappens when they are 1000 km away from one oftheir outpatients who gets sick during a work-up orhas an adverse reaction after starting a new treatmentregimen? Moreover,the aforementioned interruptionsof other academic activities in the 2 to 3 days follow-ing an outpatient session threaten both research pro-ductivity and peace of mind. A solution worth consid-ering is to stop holding outpatient sessions every weekics just once a month. By staying in town for the fewdays following this outpatient Òblitz,Óa month of clin-icsÕloose ends get tied up all at once (especially ifchasing down lab results can be delegated) and the remainder of the month is free for academic activities.My final remarks concern spending time going toannual scientific and clinical meetings. Such meet-ings usually are fun and relaxing,often are educa-tional (especially,as noted above,when attended in agroup of mentors and mentored) and sometimes offerthe chance to meet or at least observe the ephemeralexperts in the field. But the opportunity costs of at-tending meetings are measured in time away fromteaching,patients and especially writing,and I knowwho seldom or never go to meetings (which shows usthat attending them is not a prerequisite for academicsuccess). As with the other elements of time manage-ment,self-discipline is required,and the adoption ofrules such as the following may be useful:1. Never go to an annual meeting for the first timeunless you have submitted an abstract that willget published in a journal (thus inaugurating2. Never go to that meeting a second time until youhave a full paper based on that abstract in print orin press (thus making a major contribution to3. Thereafter,only go to that meeting if this yearÕs abstract hasbeen selected for oral presentation (or you havebeen invited to give the keynote lecture). References1.Sackett DL. The fall of Òclinical researchÓ and the rise2.Verrier ED. Getting started in academic cardiothoracic3.Morzinski JA, Diehr S, Bower DJ, Simpson DE. A de-4.Goldman L. Blueprint for a research career in general5.Rogers JC, Holloway RL, Miller SM. Academic men-6.Applegate WB. Career development in academic med-7.Stange KC, Heckelman FP. Mentoring needs and fam-8.Williams R, Blackburn RT. Mentoring and junior fac-9.Eisenberg JM. Cultivating a new field: development of10.Bland CJ, Schmitz CC. Characteristics of the success-11.Palepu A, Friedman RH, Barnett RC, Carr PL, Ash12.Levinson W, Kaufman K, Clark B, Tolle SW. Mentors13.Johns RJ. How to swim with sharks: the advanced14.Sackett DL. The sins of expertness and a proposal for Sackett Correspondence (no reprints) to:Dr. David L.Sackett,Director,Trout Research & Education Cen-tre at Irish Lake,R.R. 1,Markdale ON N0C 1H0;sackett@bmts.com Many thanks to Paul Armstrong, NormCampbell, Iain Chalmers, Heather Clark, Deborah Cook, AlanDetsky, PJ Devereaux, Suzanne Fletcher, Gordon Guyatt,Mary Hannah, Anne Holbrook, Dianne Jackowski, RomanJaeschke, Agnes Lee, Hui Lee, Rosemary Martino, FinlayMcAlister, Heather Murray, Dick Oepkes, Scott Richardson,Jolie Ringash, Carlos Rizo, Joseph Sapira, Sharon Straus,George Sweeney, Juan Carlos Villar and Deborah Zimmermanfor their very helpful feedback on drafts of this essay.