The burden of judgment.

Retention of faculty in academic medicine is a growing challenge. It has been suggested that inattention to the humanistic values of the faculty is contributing to this problem. Professional development should consider faculty members’ search for meaning, purpose, and professional fulfillment and should support the development of an ability to reflect on these issues. Ensuring the alignment of academic physicians’ inner direction with their outer context is critical to professional fulfillment and effectiveness. Personal reflection on the synergy of one’s strengths, passions, and values can help faculty members define meaningful work so as to enable clearer career decision making. The premise of this article is that an awareness of and the pursuit of meaningful work and its alignment with the academic context are important considerations in the professional fulfillment and retention of academic faculty. A conceptual framework for understanding meaningful work and alignment and ways in which that framework can be applied and taught in development programs are presented and discussed. Acad Med. 2009; 84:1383–1388. Retention of faculty in academic medicine is a “grand challenge.”1 Although there is normal attrition throughout the years, loss of new faculty is of particular significance in the current context of medical education.2 The increasing numbers of vacant academic positions and an aging faculty further complicate the issue.3 According to some in academic medicine, inattention to the humanistic values of faculty is contributing to this problem.4 Professional development should consider faculty members’ search for meaning, purpose, and professional fulfillment and should support the development of an ability to reflect on these issues.5,6 Such self-awareness is the first step in effective career decision making. The process of leadership involves engaging people toward goals that are shared.7,8 Academic physicians enact leadership when they engage with others in pursuit of the realization of a shared academic mission of education, research, and service. They lead, directly, by significantly affecting the thoughts, feelings, and/or behaviors of others, or, indirectly, by exerting an impact through the works that they create.9 Souba10 has asserted that ensuring alignment of the inner direction of these individuals with the context and mission of the academic health science center is critical to their professional fulfillment and effectiveness. Reflection on the directions, strengths, and values of one’s academic environment can inform decisions about how to enable an authentic fit. The premise of this article is that awareness of and the pursuit of meaningful work and its alignment with the academic context are key to the professional fulfillment and retention of academic faculty. A description of a conceptual framework for understanding meaningful work and alignment and how that framework can be applied is provided. Such awareness can inform faculty members’ career planning and action. This paradigm has been successfully used in a number of leadership and career development programs for faculty and residents in the Faculty of Medicine at the University of Toronto. Retention and Recruitment Is a Problem in Academic Medicine In a recent analysis, the Association of American Medical Colleges reported that, during a 10-year period, only 52% of faculty remained at their original medical schools; 10% switched medical schools, and 38% left academic medicine altogether.2 The attrition rate during the seven-year study period was 38% overall and 43% for faculty in their first appointment. In 2003, recruitment and retention were of sufficient international concern that a working party with global geographic representation, the International Campaign to Revitalize Academic Medicine, was formed to study and address the issues.11 Whereas this group has advised of the need to develop structures to support and retain faculty, what form those structures should take is not clear. Addressing faculty members’ needs for professional fulfillment is an important strategy to consider.6 The Need to Address Professional Fulfillment Brown and Gunderman6 have described professional fulfillment as a sense of professional engagement and reward that implies feeling completed—the thorough realization of one’s potential. When physicians feel professionally fulfilled, patients are more likely to feel satisfied, to comply with treatment, and to have greater trust and confidence in their physicians.12,13 Physician dissatisfaction is associated with increased turnover and departures.14 Herzberg’s theory of workplace motivation proposes that the Dr. Lieff is director, Academic Leadership Development, Center for Faculty Development, St. Michael’s Hospital, and Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; associate professor, Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada; and staff psychiatrist, Baycrest Geriatric Health Care System, Toronto, Ontario, Canada. Correspondence should be addressed to Dr. Lieff, Center for Faculty Development, St. Michael’s Hospital, 2 Queen Street East, Suite 908, PO Box 15, Toronto, ON M5C 3G7, Canada; telephone: (416) 864-6060 (ext. 6977); fax: (416) 864-5929; e-mail: ([email protected]). Academic Medicine, Vol. 84, No. 10 / October 2009 1383 nature of the work has the capacity to motivate and satisfy by gratifying the need for gaining status, assuming responsibility, and achieving self-realization.15 Similarly, Maslow, in his hierarchy of individual needs, has proposed that once an individual’s physiological, safety, social, and esteem needs have been met, that person develops a desire to realize all of his or her potential for being an effective, learning, and creative human being.16 The ability to feel effective and creative, to lead a life of purpose that is balanced with one’s value system, and to realize one’s potential is an attribute of emotional and spiritual health.17 Keyes and colleagues18 and McGregor and Little19 affirmed that psychological well-being is associated with the realization of one’s true potential and with commitment to a life of purpose and meaning beyond oneself that is also meaningfully connected to being oneself. Seligman20 described the meaningful life as “knowing your highest strengths and using them in service of something larger than [yourself].” He noted that the pursuit of meaning has the strongest correlation with life satisfaction. This need for self-realization in the form of contribution to a greater purpose or good is a foundation of professional fulfillment in academic medicine.6 It parallels the primary commitment of physicians to service and recognizes medicine as a vocation.21 Work that is experienced as a vocation has social meaning and value and provides a sense of meaning, fulfillment, and identity to the individual. Such work presumes an inner desire to engage the world in a substantive way—“a calling.” As important as is the need for self-realization through meaningful work, however, that need is rarely considered by faculties of medicine in supporting the academic career planning of their members. Current Recommendations to Support Career Planning and Leadership Development in Academic Medicine Bickel22 suggested that visionary leaders in academic medicine understand that nurturing the development of individuals is a smart business strategy, because employee productivity is dependent on employee satisfaction and creativity. The development of individual faculty members should begin with the faculty members’ identification of their most important personal values.23 These values become an internal guideline that should inform career decision making and goal setting. Because they can be difficult to articulate, activities such as examining daydreams, writing one’s own 80th-birthday tribute, or examining the satisfaction that one obtains from day-today activities can be useful. Identification of strengths should be encouraged, as a way to energize and situate one’s aspirations. In addition, deficits should be recognized so that one can attend to their mitigation. Periodic feedback from trusted colleagues or impartial individuals on one’s self-assessment and planning is critical to this reflective process, as it provides a reality check and also renews one’s energy and interest.24 A regular commitment to such reflection enables faculty members to stay in touch with their career trajectory while recognizing that this commitment is a nonlinear process that will undulate over time. Academic physicians function in many formal and informal leadership roles in the complex academic environment of teaching, research, and clinical settings. Souba10 has reminded us that their journey of leadership begins on the inside, with the asking of fundamental questions such as “Where does my leadership come from, and what is my purpose?” How academic physicians lead will depend substantially on how they express who they are and how they derive meaning from their work.5 Effective leaders invest in developing a deep understanding of themselves.25 They develop this insight by committing to active observation of and continuous learning from their life stories and experiences in service of developing an awareness of who they are, what they care about, and why they care. They lead through the stories they tell and the lives that they live.26 They embody their values and passions in their choice of day-to-day activities and their decisions.27,28 Palmer29 has described this process as leading an undivided life. Similarly, academic medical leaders identified integrity, the need to be aware of and to act according to one’s beliefs and values at all times, as the most essential value.30 Effective leaders also focus on developing their gifts and leveraging their natural strengths.31 They recognize that their limitations must be managed and that leveraging their special talents and skills begets excellence. Specifically focusing on the development of self-awareness about their life stories, strengths, and values enables academic physicians to identify the work that they find meaningful in their formal or informal leadership roles.25 This evolving awareness of meaningful work can inform the individual’s reflections and actions on his or her career direction. To achieve professional fulfillment, however, a person’s career choices must be aligned with his or her environment. Meaningful Work and Alignment: An Integrating Framework and Its Application Meaningful work can be described as the realization of one’s potential and purpose—the point at which a person’s passions, strengths, and core values interact synergistically in his or her work. Buechner32 defined this point as “the place where your own deep gladness meets the world’s deep needs.” Reflecting on one’s past, current, or aspired-to activities can yield information about the occasions when one’s passions, values, and strengths connected in a synchronous way. Such occasions are opportunities for recognizing and reflecting on what is personally meaningful work and what are one’s core beliefs about meaning and purpose in work life. For professional fulfillment, meaningful work and one’s core purpose must be aligned with the interests, strengths, and cultural context of work (Figure 1). The multiple contexts of academic medicine can include the university, faculty of medicine, academic departments and programs, and the variety of clinical settings, programs, and departments. Exercises to Identify Core Elements of Meaningful Work and One’s Core Purpose A number of sequential exercises can be used in professional development programs to assist faculty and trainees in teasing out the elements of meaningful work and in reflecting on the connection of the elements with each other and on their alignment with their academic setting. Faculty members should be advised that the focus of these exercises does not address the equally important personal and family roles that they Career Development Academic Medicine, Vol. 84, No. 10 / October 2009 1384 occupy. They need to reflect on their personal and family goals on other occasions and consider the compatibility of these goals with their career direction. Such alignment may ultimately require trade-offs or revision of their goals.