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From: The Rheumatologist, November 2011

Your Career's Election Day

Voting for your future

by David S. Pisetsky, MD, PhD

David S. Pisetsky, MD, PhD

In the 1992 election, James Carville advanced an idea for President Bill Clinton’s campaign that has had enduring significance, with a statement that has entered the modern lexicon of politics—not to say almost every other realm of human activity. When asked what was on the voters’ mind, Carville said, “It’s the economy, stupid.”

Almost 20 years have passed since that memorable election, but Carville’s statement still pertains to what’s on the mind of people and how they will vote not just for candidates standing for election but for big decisions in life, including a career. “What is it, stupid, that you care about?”

For young people contemplating a career in academic medicine, these decisions are tough and can be as contested and tumultuous as the election of 2000.

The stakes are very high. Should I vote to be a basic investigator, a translational investigator, or clinical educator in the medical center sweepstakes? Or maybe I should punt this election and go into private practice?

Of course, in most elections (except those for popes), the process is ongoing. Depending on the office, ballots can be cast every two, four, or six years, and there are always options for recalls. Just as a regular person can vote in many elections, so, too, can a trainee cast many votes about his or her career, changing directions, philosophies, and leaders (i.e., mentors), and tacking with the wind, which often seems to blow dollars rather than air.

On-the-Spot Voting

Nevertheless, for a young person thinking about the future, the first vote has powerful significance and looms large. Should I submit an application for a K award or take that job in the clinic?

Career choices can be a very, very complicated business, and few people can really see far into the future and define a rational strategic plan to guide them in the decades to come. In reality, many—if not most—career choices are pretty ad-hoc affairs that reflect decisions that seemingly have little relationship to a vision for a career. I know a young rheumatologist who thought he wanted to be a clinical educator. In an unplanned development, he fell in love with a fellow in another division whose training schedule required an extra year in the medical center. Thus, the rheumatology fellow decided to extend his training and give the lab a try during the year to wait for his beloved and soon-to-be betrothed. The deus ex machina gave him the freedom to take on the challenge of hard science. This is, of course, a source of great happiness for the two divisions. Trust me, in our interviews of applicants for our fellowship program, we do not discuss the opportunities for love and romance in the Bull City.

In reality, many—if not most—career choices are pretty ad-hoc affairs that reflect decisions that seemingly have little relationship to a vision for a career.

It Comes Down to Three Words

Every year, numerous trainees have to vote on their careers, cast a ballot on their lives with a precious piece of paper, that paper likely stained with sweat as they grow anxious confronting a scary junction, stopping in a yellow wood where roads diverge, having to make choices, leaving behind a road not taken.

To these bright and nervous young people, with large debts from medical school loans, worrying about finances as they ponder buying a home or raising a family, weighing an offer in hand from a top private practice, what can I say to get them to cast their vote for the laboratory, notwithstanding 10% paylines, an uncertain future, and profit and loss statements from the chair of medicine that will be marked with red ink?

How do I fill help fill in the blank of Carville’s famous remark to help them sort out their thinking?

“It’s the _________, stupid?”

I will suggest three words from my own experience to help crystallize their thinking about research: challenge, opportunity, and excitement. Of these, I would rate challenge the highest. Although every undertaking in medicine is a great challenge, I think that the creation of important new knowledge—the kind that will transform thinking and have an impact on practice—comes with the biggest rewards and the biggest risks. The ascent to the top of research is steep and arduous and, as often as not, winds up with the person falling off the cliff, stuck in the mud, or lost in a rowboat without a paddle.

On the other hand, trying to find new knowledge also comes with wonderful rewards. Although some of these rewards are very public, like the Lasker and Nobel Prizes, most are personal and private. I do not holler, “Eureka!” I hear it in my head. Unfortunately, reviewers, editors, and study sections all too often could not recognize a eureka moment if it smacked them in the face. What do these so-called experts know, anyway?

Opportunity in science is also very bright and a reason to choose research. Opportunity, however, is a terra incognita filled with swamps, quicksand, high mountains, driving storms, and harsh wind. So, too, was the American West. Exploring new lands is never easy, but it is exciting trying to be a pioneer. It gives a jolt to the soul and makes every day truly new and invigorating.

Challenge, opportunity, and excitement. Each is a fine way to fill in Carville’s blank. It’s not nice to call anyone stupid, but it does get attention.

I will end with the words of another famous politician, Horace Greeley, who said, “Go West, young man.” Would Greeley have been remembered for saying, “Stay East, young man”? (We live in different times because the medical profession now is filled with men and women. While “Go West, young man or woman,” is not as euphonious as the original, it is more correct today.)

I know that, “Go to the laboratory, young men and women,” will never make it as a phrase, but the sentiment is as right today as it ever was.

Young people among my dear readers, think about the wisdom of our political thinkers as you vote about your careers. However you vote, your parents, teachers, and mentors will support you.

Vote wisely. Vote well. And remember, your career is like an election in Chicago. You can vote as many times as it takes to get a winner.

Dr. Pisetsky is physician editor of The Rheumatologist and professor of medicine and immunology at Duke University Medical Center in Durham, N.C.

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