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- William W Parmley, MD, MACC, Editor-in-Chief, Journal of the American College of Cardiology
When I was a resident in internal medicine, and a fellow in cardiology, there seemed to be powerful role models to emulate. If one was considering an academic career, the role models seemed to move effortlessly between the three areas of clinical excellence, superb teaching, and creative research. At Johns Hopkins, for example, when the Chairman of Medicine, A. McGehee Harvey, came to make rounds, it was invariably a tour de force. One had to carefully examine the patients being presented just before he came so as to note every nuance of the physical examination. If you didn’t, he would. There was nothing more unnerving than for Dr. Harvey to casually ask the question as he was listening to the heart, “How long has this friction rub been present?” If you hadn’t heard it, it was a devastating moment. The prolonged discussion of the differential diagnosis on each patient, the natural history, and the approaches to therapy were inevitably a wonderful learning experience. My academic role models in cardiology, people like Dick Ross, Eugene Braunwald, Ed Sonnenblick, Dick Gorlin, Jeremy Swan, and others, also seemed to be able to do it all effortlessly. If, on the other hand, one elected to go into practice, there were also powerful role models to emulate. These were clinical faculty who were wonderful clinicians and teachers and freely donated their time to their university. They had tremendous loyalty to the school and always attended rounds and participated widely in the training programs.
Now, in the twenty-first century, as a program training director, when I discuss role models with the fellow applicants and fellows, it seems like I have moved to a new planet. There appears to be a wide variety of new role models who are mentioned. In a more traditional sense, there is the physician-scientist who spends almost all of his time in the laboratory, is successful in obtaining NIH grants, and usually has a large, active molecular biology research program. Such individuals do not usually have any clinical responsibilities but are recognized as successful basic scientists. It seems increasingly difficult to be able to do world-class basic research and still be a superb clinician. A busy academic clinician also serves as a role model because of his or her broad knowledge and skills at the bedside. Because of the requirements for generating money for the department, however, such clinicians may not have much of a research program. Clinical researchers, particularly those associated with large clinical research groups, also provide powerful role models for fellows. These are individuals who organize large trials or are part of an independent research support unit that performs trials or is the coordinating center or core lab center for echos, anglos, and the like. The plethora of large clinical trials and the publicity that such individuals get are powerful motivating forces for fellows wanting to succeed in academic medicine. The secondary gain is also very appealing.
Another popular role model is the physician-entrepreneur. This may be an interventional cardiologist or electrophysiologist, for example. They are powerful role models for the fellows because such individuals may receive considerable extra income as they develop new devices and work collaboratively with industry to bring them to market or, more often, just to sell their smaller company to a deep-pockets company, which will financially allow them to retire if they wish. These individuals greatly influence the fellows, many of whom indicate that they wish to do exactly the same thing, motivated primarily by the promise of considerable financial gain. An increasingly popular role model is the individual who goes into industry full-time. First of all, the salaries are greater than academic salaries, and in some cases individuals can still be involved in some academic activities, including clinical care, publishing, teaching, and the like. Although it was almost unheard-of in my training days to consider going directly into industry, it is now a common phenomenon among graduating fellows and junior faculty. This also has a powerful effect on fellows as they contemplate career choices. One thing is for sure: there is a much greater interest in financial gain in all of these options than seemed to be apparent when I was first looking for a job right out of fellowship.
Let’s return to the original question: “Who are the best role models for the fellows?” In the past, I thought the answer was easy and always referred to those wonderful “triple-threat” academicians or clinical faculty practitioners who seemed to remain within the triad of practice, teaching, and research. However, like many other things in life, medicine has moved to a new place, and I’m not sure what the right answer is anymore. Obviously, one can be successful in all of the above options discussed and, in some, receive far more financial reward than in traditional models. This latter fact may be the most troublesome aspect of some of the new role models. It seems to reflect other trends that say medicine is just another commodity, and we are merely employees in an industry that provides this commodity. Making medicine a business has perhaps forever altered what fellows want to do, and it is unlikely that this will ever revert to a more traditional past.
In my mind, however, there are certain elements that will always be part of the career in medicine and that I envision as essential in a role model. The first aspect is the ability to help people and the wonderful bedside interaction with patients that can be so mutually satisfying. The second aspect is to remember that the knowledge base in medicine is something that must be passed on to the next generation. Thus, the teaching of students, residents, fellows, and peers is an integral part of our obligation as physicians to pass the torch forward. Lastly, we are in a unique position to advance the frontiers of knowledge, which is one of the most satisfying aspects of an academic career. In that sense, therefore, perhaps I am still stuck with the triple-threat model that has served us so well for many generations. As important as money is in our current world, I personally believe that you cannot buy fulfillment or happiness. These are, instead, intrinsic elements of our beloved profession.
- American College of Cardiology