Transitions to Practice

The Early Career Psychiatrist: Perspectives on Academic and Personal Development

Derek Puddester, MD, FRCPC
Assistant Professor, Department of Psychiatry, and Director, Faculty Wellness Program, University of Ottawa, Ottawa, Ontario

Abstract: Early career psychiatrists (ECPs), or psychiatrists in their first five years of practice, are a unique demographic in the Canadian psychiatric workforce. This article reviews academically based ECPs’ needs and concerns, using evidence where available. By attending to these needs, universities, hospitals and professional organizations may promote this cohort’s success, well-being and contribution to clinical care.

Résumé : Le psychiatre en début de carrière : perspectives du perfectionnement universitaire et personnel

Les psychiatres en début de carrière (PDC) ou les psychiatres dans leurs cinq premières années de pratique constituent un groupe démographique unique de la population active psychiatrique au Canada. Cet article examine les besoins et préoccupations des PDC affiliés à un milieu universitaire, à l’aide des données probantes disponibles. En répondant à ces besoins, les universités, hôpitaux et organisations professionnelles peuvent favoriser le succès, le bien-être et l’apport aux soins cliniques de cette cohorte.

Key Words: faculty development, early career physician, academic medicine, mentorship, career development

In the last decade, there has been much attention to, and research in the area of, health human resources in Canada, particularly in the area of recruitment and retention of new graduates (1). Canadian medical schools produce 76 new psychiatry residents annually (2), most of whom complete training and move into clinical practice. At any one time in Canada, an estimated 380 to 400 early career psychiatrists (ECPs) fall into this category (defined as a psychiatrist who has been practising for five years or less; CPA, unpublished). It may be reasonable to hypothesize that the size of this group will increase in the next decade, owing to the 32% increase in undergraduate enrollment in medical schools. Like any other cohort, this group has particular needs and concerns that will influence their retention in a clinical and academic career. Using literature and evidence where available, this article outlines some of these unique variables, together with some strategies that may contribute to satisfaction and success. By addressing some of these issues in a proactive fashion, Canada may be better able to retain ECPs and maintain their practice in areas of high need.

A review of the Medline database from 1966 to the present, using the term “early career physician,” reveals no articles, indicating that this cohort has yet to be fully identified in the literature. However, the key term “junior faculty” identified 81 articles. Of these, 68 were both in English and abstracted. However, 19 were excluded because they were unrelated either to the practice of medicine or to the particular cohort under review. The remaining articles were clustered by theme: mentoring (n = 12), promotion and development (n = 19), women physicians (n = 3), physician health and well-being (n = 3) and research (n = 13). Only one article was directly related to psychiatry.

This paper addresses these themes, as well as others not cited in detail in the literature search, as they relate to the careers and personal development of ECPs.

Mentorship

Much has been written about the value of mentorship during any physician’s career, including the early phases of career development (3,4). Mentoring allows ECPs access to a colleague who can provide advice, direction, knowledge and opportunities that assist in career development and progression. To be successful, mentor relationships need to be clearly negotiated, frequently reviewed by all participants and routinely nurtured.

In academic centres, mentoring relationships may cross departmental boundaries, may involve multiple individuals with different areas of expertise and may require flexibility in terms of form and frequency of meetings. For example, one’s research mentor may not be the same person as one’s educational mentor, who may be different from one’s clinical mentor and so on. Further, it may also be helpful to have a mentor who is not an academic physician: such a mentor can often offer a helpful external perspective on internal career issues.

Employment Agreements

Canadian-trained specialists enjoy the benefits of contracts negotiated by professional housestaff organizations. Thus, it is often a new and unfamiliar experience for them to engage in the negotiation process as staff physicians (5). Consequently, some physicians enter into agreements that they later regret or wish to modify. It is therefore essential to obtain as much external advice as possible. Provincial medical associations, colleagues or mentors and personal lawyers can offer advice and direction in the negotiation process. Close attention should be paid to the clinical, research and educational expectations of the agreement, as well as to evaluation and promotion, career development, financial partnership agreements, administrative support and benefits.

In addition, there is evidence that more junior physicians contribute heavily to clinical service, often at the expense of contributions to research or education (6). With this in mind, it may be helpful to develop a longer-term strategy to ensure that adequate time is protected for professional development in these domains.

Financial Health

Financial security and stability has been identified as a particular issue for physicians in their early career. After many years with little or no income, ECPs often suddenly need to address a large number of financial issues for which they may have had minimal education or planning.

Taxation
Many physicians are self-employed and thus need to maintain rigorous financial records. Learning the tax implications of practice is essential, and it is critical to consult with an accountant or a financial advisor.

Debt Reduction and Retirement Planning
Recent graduates are entering practice with debt loads of over $100 000 (7), and careful planning to reduce debt will be required. Debt reduction also needs to be balanced with retirement investment, and contributions to registered retirement savings plans need to be co-ordinated.

Insurance
Several products can be considered, depending on individual needs and wants, all of which become increasingly important in the early phases of a psychiatrists career.

Disability insurance is essential and should be obtained as early in life as possible. Insurance plans can vary significantly and should be carefully reviewed with an expert consultant. Life insurance in its various forms may also be helpful to those with partners or families. “Critical incident” insurance is a recent product that offers protection in the event of a catastrophic health event. These products, along with overhead insurance, automobile insurance and office insurance, all warrant consideration and evaluation.

Prior to applying for insurance, physicians should be well aware of their own health status, particularly in regard to communicable diseases and mental health. In addition, physicians should be aware of what information may be entered into insurance databases and how their health information may affect their ability to be insured or obtain a licence to practise. Provincial and national medical associations may offer excellent insurance products at reduced rates, so it is wise to investigate options thoroughly.

Estate Planning
Finally, each physician should have a will. This is often not considered by young and healthy graduates, but should be, given that a will can ensure that wishes are fully respected and an estate fully protected. Legal counsel should be sought for the development of a will, and “do-it-yourself” kits avoided.

Academic Development

ECPs can and should develop their own career plans for academic development and should begin that process before applying for, or accepting, any particular position. Once employed, they should review that plan in collaboration with their department leaders and their mentors. Part of their academic development strategy may be heavily influenced by the type and location of their practice: some practice settings have been identified as having unique challenges and opportunities for academic development in psychiatry (8). In addition, depending on the institution, new or alternative opportunities may arise that will promote revision.

The literature suggests that there are four core domains of academic concern for the early career physician: mentorship, scholarship, research and career planning and development (9). There are resources particular to psychiatry, such as Jerald Kay’s Handbook of Psychiatric Education and Faculty Development, which outlines approaches to these themes and many others that ECPs may face (10).

Research development may be enhanced by joining site-specific research groups or institutes, and mentorship relationships should be established as soon as possible. Issues such as protected time, authorship, staff support, lab time, grant review, seed money and so on should also be negotiated before embarking on research activities. New data indicate that daily efforts at research-oriented writing may help ECPs develop their publication potential (11).

Educational development also requires careful consideration. Canada’s medical schools are enjoying increased rates of admission, and the need for clinical teachers is high. Thus, there are ample opportunities to become involved in pedagogical activity. However, ECPs should seek out an educational mentor before assuming a teaching role and should review site-specific resources that will assist them in their teaching duties. Some universities may have particular training programs or workshops to assist in the development of teaching and evaluation skills. A well-maintained and well-organized teaching portfolio will support efforts to successfully apply for academic promotion.

Finally, ECPs should meet at least annually with their department leaders to review their performance and to discuss their progression toward academic promotion.

Health and Well-Being

Canadian physicians have increasingly become more open and aware of the need to attend to their own health and well-being, as is evident from position papers (12,13), national and provincial centres of research and intervention (14) and specific university-based programs (15).

These various bodies emphasize the need for all physicians to monitor and advocate for their own health. They are advised to have their own family physician, to have a periodic health review, to avoid self-prescribing, and to enjoy adequate rest, recreation and nutrition. In general, these preventive behaviours are best established early in life; however, physicians are more likely than the general population not to attend to them. ECPs can use the life event of entering practice as an opportunity to review their health and health management.

The demographics of the ECP population suggest that they will have significant personal responsibilities to partners or spouses and families. It appears that newer physicians are more focused on these relationships than in the past and that they will be less tolerant of potentially damaging or threatening career-related expectations. The particular effect of these cultural changes on the practice of psychiatry is unclear and may require change on a systemic level. Regardless of whether change is needed, future study of this area will be required.

Leadership Development and Networking

A sense of belonging has already been identified as one of the most important factors in early career physician satisfaction. However, there is little published on the role of ECPs within their professional associations or on how their involvement may foster such a sense of belonging and promote resiliency to stress in practice.

There are many organizations that ECPs can join, each with its own mission, activities, opportunities and dues. New psychiatrists need to assess these options with care and determine how best to invest their membership dollars. It may help, at a minimum, to decide on which organization(s) will best promote their clinical development, educational development and research development and to carefully review ongoing membership annually.

Professional organizations also frequently offer leadership training and opportunities. These opportunities can benefit ECPs wishing to become more proficient in administration, management or leadership. Time-management skills will be essential, particularly as additional duties (paid or volunteer) are assumed.

Continuing Medical Education

ECPs are also expected to quickly become familiar with their obligations to participate in continuing medical education. The Royal College of Physicians and Surgeons of Canada (RCPSC) has clear guidelines and expectations in this regard (see http://rcpsc.medical.org/english/maintenance), and Fellows are required to submit their activities annually. The RCPSC maintains a right to audit submissions and reviews three per cent of records each year. Fellows are therefore encouraged to maintain meticulous records and be prepared to submit them to the RCPSC for verification.

CME opportunities vary and can cater to the individual needs of adult learners. Some learners attend events that provide education and training on highly focused topics, while others attend annual general reviews. The ability to assess and acknowledge knowledge gaps and learning needs is an important skill for physicians, and mentors can help fine tune skills in this area. CME costs can vary, and membership associations often offer premium events at a reduced cost to members. In addition, many self-employed physicians can combine the travel required for CME with vacation or holiday time and thus benefit from the tax implications of business-related travel.

Conclusion

The ECP population in Canada is an important one, particularly as the psychiatrist population ages and retires. To ensure that Canada gets maximum benefit from this cohort, it will be essential for universities, hospitals and professional organizations to take a proactive and collaborative approach to meeting their particular needs. ECPs can also be proactive in their own career development by identifying and collaborating with their own “career support team” (as outlined in the box, above left).

In partnership, physicians and health systems can promote success, well-being, and excellent clinical care.

References

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14. Canadian Medical Association. Fact Sheet—Centre for Physician Health and Well-Being. Ottawa (ON): CMA Publications; 2003.

15. MacDonald NE, Davidson S. The wellness program for medical faculty at the University of Ottawa. CMAJ 2000;163:735–8.