I was recently asked to give a speech to the graduating residents in my department, and while preparing my talk, I reflected upon what I wish I had known when I had first embarked on a career in academic medicine — and what nobody was willing to tell me.   So what follows are a few thoughts that I learned on the job, often without warning, sometimes too late.  I should emphasize that I could not ask for a better employer than the medical school where I currently work; these musings are not laments or gripes, and certainly not directed at my home institution, but rather general pearls of wisdom that might help recently-minted attendings navigate their new roles.

1. Everyone is expendable. When the Pope dies, it takes a week to anoint a new Pope.  When the British monarch shuffles off a mortal coil, they manage to find a new king or queen.  If they can do that, replacing you won’t be much of a challenge.  There is nothing inherently wrong with this:  The problem arises when people forget that they are expendable.  So feel free to serve up ultimatums or bluffs, but do not be surprised when your bosses take you up your offers.  Of course, there are different ways to be expended.   Everyone will foul things up royally at some point during their careers, and many will face consequences as a result.  However, if you go through your workdays displaying kindness and generating goodwill, the powers-that-be will often find a relatively gentle place for you to land after your fall.  Maybe you will run a minor institute or become dean of a summer school.   In contrast, if you build your career making the lives of your colleagues and supervisors difficult, when you fail, they will kick you to the curbside with as much force as they can muster.

2. Nothing lasts forever — not Greece, not Rome, not even administrators. Most problems in medicine can be solved by watchful waiting:  Wait long enough and whoever created the problem with eventually work someplace else.   Unfortunately, a corollary to this principle is that the evil that you know is frequently preferable to the evil that you don’t know; often enough, a new administrator will come along to institute a new policy far less workable — and often directly opposed to — the previous one.

3.  The boss is never your friend.  It doesn’t matter whether she’s your aunt; it doesn’t matter whether you’re sleeping with him.  The boss may be a lovely human being, Hospital Digest’s “Mensch of the Year,” the sort of person you would want to marry your sister.  None of that matters.  You are certainly welcome to like or admire your boss, just do not forget who is boss.  At some point, the boss’s interests and yours will diverge.   Such is the nature of employment.  But if you are unprepared for that divergence, you will unnecessary transform a professional conflict into a personal one.

4.  You can’t fight city hall. As an employee, you have lots of rights … only, not really.  Sure, the hospital probably cannot chain you to an operating table for a seventy-two-hour shift or pay you in wooden nickels, but for most less egregious issues, you are at the mercy of the institution.  You work at the pleasure of the chair, who works at the pleasure of the dean, whom the Board of Trustees can send packing with a loot bag at a moment’s notice. Needless to say, you can always litigate the matter — insignificant you against the legal team of a major medical institution.  Good luck with that!  As a result, your bargaining power is rather limited:  Much like you can shop around for the best deal, but you can’t haggle over the price of lawn chairs at Walmart, your options are usually to work on the hospital’s terms or to work elsewhere. Unless you have a Nobel Prize or two under your belt.

5. Shave with Hanlon’s razor: Never assume malice when incompetence offers a plausible explanation.   Most people are too busy messing things up to be vindictive.  What cannot be explained by incompetence can usually be attributed to self-interest. Theirs, not yours.  Usually, you just aren’t important enough for anybody to squander their time spiting.  See #1 above.

6. Your grievance is someone else’s nuisance.  When tempted to speak at committee meetings, apply the WAIT principle: “Why am I talking?” Count from 1,000 to 0 backwards in Norwegian before answering any group email.  If you hit reply all, promptly resign.

7. If you are asked to speak for one hour and you speak brilliantly for 61 minutes, all people will recall is that you stole their minute.  If you are asked to speak for one hour, and you muddle along for 59 minutes, people will say, “He wasn’t that bad, and he got us out on time.”

8. Nobody’s tombstone has ever read: “I wish I had spent more time charting.”

9.  The hospital or medical school may pay your bills, but you work for your patients and students, or if you happen to be a researcher, the future patients, and students who will benefit from the knowledge that you discover.  They are your true bosses, not the suits who evaluate your performance with meaningless metrics.  The day you lose sight of that is the day you should hang up your stethoscope and tear down your shingle.

Jacob M. Appel is a psychiatrist.

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