Academic hospital medicine is a young specialty, with most faculty at the rank of instructor or assistant professor.1 Traditional markers of academic success for clinical and translational investigators emphasize progressive, externally funded grants, achievements in basic science research, and prolific publication in the peer-reviewed literature.2 Promotion is often used as a proxy measure for academic success.
Conceptual models of career success derived from nonhealthcare industries and for physician-scientists include both extrinsic and intrinsic domains.3,4 Extrinsic domains of career success include financial rewards (compensation) and progression in hierarchical status (advancement).3,4 Intrinsic domains of career success include pleasure derived from daily work (job satisfaction) and satisfaction derived from aspects of the career over time (career satisfaction).3,4
Research is limited regarding hospitalist faculty beliefs about career success. A better understanding of hospitalist perspectives can inform program development to support junior faculty in academic hospital medicine. In this phenomenological, qualitative study, we explore the global concept of career success as perceived by early-career clinician-educator hospitalists.
Study Design, Setting, and Participants
We conducted interviews with hospitalists from 3 academic medical centers between May 2016 and October 2016. Purposeful sampling was used.5 Leaders within each hospital medicine group identified early-career faculty with approximately 2 to 5 years in academic medicine with a rank of instructor or assistant professor at each institution likely to self-identify as clinician-educators for targeted solicitation to enroll. Additional subjects were recruited until thematic saturation had been achieved on the personal definition of career success. Participants received disclosure and consent documents prior to enrollment. No compensation was provided to participants. This study was approved by the Colorado Multiple Institutional Review Board.
Interview Guide Development and Content
The semistructured interview format was developed and validated through an iterative process. Proposed questions were developed by study investigators on the basis of review of the literature on career success in nonhealthcare industries and academic hospitalist promotion. The questions were assessed for content validity through a review of interview domains by an academic hospitalist program director (R. P.). Cognitive interviewing with 3 representative academic hospitalists who were not part of the study cohort was done as an additional face-validation step of the question probe structure. As a result of the cognitive interviews, 1 question was eliminated, and a framework for clarifications and answer probes was derived prior to the enrollment of the first study subject. No changes were made to the interview format during the study period.
The principal investigator (E.C.) performed all interviews by using the interview tool consisting of 7 demographic questions and 11 open-ended questions and exploring aspects of the concept of career success. The initial open-ended question, “How would you personally define career success as an academic hospitalist at this stage in your career?” represented the primary question of interest. Follow-up questions were used to better understand responses to the primary question. All interviews were audio recorded, deidentified, and transcribed by the principal investigator. Transcripts were randomly audited by a second investigator (E.Y.) for accuracy and completeness.
Sample Size Determination
Interviews were continued to thematic saturation. After the first 3 interviews were transcribed, 2 members of the research team (E.C. and P.K.) reviewed the transcripts and developed a preliminary thematic codebook for the primary question. Subsequent interviews were reviewed and analyzed against these themes. Interviews were continued to thematic saturation, which was defined as more than 3 sequential interviews with no new identified themes.6
By using qualitative data analysis software (ATLAS.ti version 7; ATLAS.ti Scientific Software Development GmbH, Berlin, Germany), transcriptions were analyzed with a team-based, mixed inductive-deductive approach. An inductive approach was utilized to allow basic theme codes to emerge from the raw text, and thus remaining open to unanticipated themes. Investigators assessed each distinct quote for new themes, confirmatory themes, and challenges to previously developed concepts. Basic themes were then discussed among research team members to determine prominent themes, with basic theme codes added, removed, or combined at this stage of the analysis. Responses to each follow-up question were subsequently assessed for new themes, confirmatory themes, or challenges to previously developed concepts related to the personal definition of career success. A deductive approach was then used to map our inductively generated themes back to the organizing themes of the existing conceptual framework.
Thematic Mapping to Organizing Themes of the Conceptual Model (Table)
The single most dominant theme, “excitement about daily work” was connected to an intrinsic sense of job satisfaction. Career satisfaction emerged from interviews more frequently than extrinsic organizing themes, such as advancement or compensation. Advancement through promotion was infrequently referenced as part of success, and tenure was never raised despite being available for clinician-educators at 2 of the 3 institutions. Compensation was not referenced in any interviewee’s initial definition of career success, although in 1 interview, it came up in response to a follow-up question. The Figure visually represents the relative weighting (shown by the sizes of the boxes) of organizing themes to the early-career hospitalists’ self-concepts of career success. Relationships among organizing themes as they emerged from interviews are represented by arrows.
With regard to job satisfaction, early-career faculty often invoked words such as “excitement,” “enjoyment,” and “passionate” to describe an overall theme of “excitement about daily work.” A positive affective state created by the nature of daily work was described as integral to the personal sense of career success. It was also strongly associated with perception of sustainability in a hospitalist career.
“I think [career success] would be job satisfaction. …So, for me, that would be happiness with my job. I like coming to work. I like doing what I do and at the end of the day going home and saying that was a good day. I like to think that would be success at work…is how I would define it.”
This theme was also related to a negative aspect often referred to as burnout, which many identified as antithetical to career success. More often, they described success as a heightened state of enthusiasm for the daily work experience.
“I am staying engaged and excited. So, I am not just taking care of patients; I am not just teaching. Having enough excitement from my work to come home and talk about it at dinner. To enjoy my days off but at the same time being excited to get back to work.”
This description of passion toward the work of being a hospitalist was often linked to a sense of deeper purpose found through the delivery of clinical care and education of learners.
“I really feel that we have the opportunity to very meaningfully and powerfully impact people’s lives, and that to me is meaningful. …That’s value. ...That’s coming home at the end of the day and thinking that you have had a positive impact.”
The interviews reflected that core to meaningful work was a sense of personal efficacy as a clinician, which was reflected in the themes of clinical proficiency and practicing high-quality care.
“I think developing clinical expertise, both through experience and studying. Getting to the point to where you can take really excellent care of your patient through expertise would be a sense of success that a lot of academic hospitalists would strive for.”
Within career satisfaction, participants described that “being respected and recognized” and “dissemination of work” were important contributors to career success. Reputation was frequently referenced as a measure of career success. Reputation was defined by some in a local context of having the respect of learners, peers, and others as a national renown. As a prerequisite for developing a reputation beyond the local academic environment, dissemination of work was often referenced as an important component of satisfaction in the career. This dissemination extended beyond peer-reviewed publications and included other forms of scholarship, presentations at conferences, and sharing clinical innovations between hospitals.
“For me personally, I have less of an emphasis on research and some of the more, I don’t want to say ‘academic’ because I think education is academic, but maybe some of the more scholarly practice of medicine, doing research and the writing of papers and things like that, although I certainly view some of that as a part of career success.”
Within career satisfaction, participants also described a diverse set of themes, including progressive improvement in skills, developing a self-perception of excellence in 1 or more arenas of academic medicine, leadership, work–life integration, innovation, and relationships. The concept of developing a niche, or becoming an expert in a particular domain of hospital medicine, was frequently referenced.
“I think part of [success] is ‘Have they identified a niche?’ Because I think if you want to be in an academic center, as much as I value teaching and taking care of patients, I think 1 of the advantages is the opportunity to potentially identify an area of expertise.”
Participants frequently alluded to the idea that the most important aspects of career satisfaction are not static phenomena but rather values that could evolve over the course of a career. For instance, in the early-career, making a difference with individual learners or patients could have greater valence, but as the career progressed, finding a niche, disseminating work, and building a national reputation would gain importance to a personal sense of career satisfaction.
Promotion was typically referenced when discussing career success, but it was not uniformly valued by early career hospitalists. Some expressed significant ambivalence about its effect on their personal sense of career success. Academic hospitalists identified a number of organizations with definitions of success that influence them. Definitions of success for the university were more relevant to interviewees compared to those of the hospital or professional societies. Interviewees were able to describe a variety of criteria by which their universities define or recognize career success. These commonly included promotion, publications and/or scholarship, and research. The list of factors perceived as success by the hospital were often distinct from those of the university and included cost-effective care, patient safety, and clinical leadership roles.
Participants described a sense of internal conflict when external-stakeholder definitions of success diverged from internal motivators. This was particularly true when this divergence led academic hospitalists to engage in activities for advancement that they did not find personally fulfilling. Academic hospitalists recognized that advancement was central to the concept of career success for organizations even if this was not identified as being core to their personal definitions of success.
“I think that for me, the idea of being promoted and being a leader in the field is less important to me than...for the organization.”
Hospitalists expressed that objective markers, such as promotion and publications, were perceived as more important at higher levels of the academic organization, whereas more subjective aspects of success, aligned with intrinsic personal definitions, were more valued within the hospital medicine group.
Compensation was notable for its absence in participants’ discussion of career success. When asked about their definitions of career success, academic hospitalists did not spontaneously raise the topic of compensation. The only mention of compensation was in response to a question about how personal and external definitions of career success differ.
While it was almost universally recognized by participants as important, ambivalence toward the “academic value of clinical work,” “scholarship,” and especially “promotion” represented an unexpected thematic family.
“I can’t quite get excited about a title attached to my name or the number of times my name pops up when I enter it into PubMed. My personal definition is more…where do I have something that I am interested [in] that someone else values. And that value is not shown as an associate professorship or an assistant professorship next to my name. …When you push me on it, you could call me clinical instructor forever, and I don’t think I would care too much.”
The interaction between work and personal activities as representing complementary aspects of a global sense of success was also unexpected and ran contrary to a simplistic conception of work and life in conflict. Academic hospitalists referenced that the ability to participate in aspects of life external to the workplace was important to their sense of career success. Participants frequently used phrases such as “work–life balance” to encompass a larger sense that work and nonwork life needed to merge to form a holistic sense of having a positive impact.
“Personal success is becoming what I have termed a ‘man of worth.’ I think [that is] someone who feels as though they make a positive impact in the world. Through both my career, but I guess the things that I do that are external to my career. Those would be defined by being a good husband, a good son, a philanthropist out in the community…sometimes, these are not things that can necessarily go on a [curriculum vitae].”
Conflict Among Organizing Themes
At times, academic hospitalists described a tension between day-to-day job satisfaction and what would be necessary to accomplish longer-term career success in the other organizing themes. This was reflected by a sense of trade-off. For instance, activities that lead to some aspects of career satisfaction or advancement would take time away from the direct exposure to learners and clinical care that currently drive job satisfaction.
“If the institution wanted me to be more productive from a research standpoint or…advocate that I receive funding so I could buy down clinical time and interactions I have with my students and my patients, then I can see my satisfaction going down.”
Many described a sense of engaging in activities they did not find personally fulfilling because of a sense of expectation that those activities were considered successful by others. Some described a state in which the drive toward advancement as an extrinsic incentive could come at the expense of the intrinsic rewards of being an academic hospitalist.
Career success has been defined as “the positive psychological or work-related outcomes or achievements one accumulates as a result of work experiences.”4,7,8 Academic career success for hospitalist faculty isn’t as well defined and has not been examined from the perspectives of early-career clinician-educator hospitalist faculty themselves.
The themes that emerged in this study describe a definition of success anchored in the daily work of striving to become an exceptional clinician and teacher. The major themes included (1) having excitement about daily work, (2) having meaningful impact, (3) development of a niche (4) a sense of respect within the sphere of academic medicine, and (5) disseminating work.
Success was very much internally defined as having a positive, meaningful impact on patients, learners, and the systems in which they practice. The faculty had a conception of what promotion committees value and often internalized aspects of this, such as developing a national reputation and giving talks at national meetings. Participants typically self-identified as clinician-educators, and yet dissemination of work remained an important component of personal success. While promotion was clearly identified as a marker of success, academic hospitalists often rejected the supposition of promotion itself as a professional goal. They expressed hope, and some skepticism, that external recognition of career success would follow the pursuit of internally meaningful goals.
While promotion and peer-reviewed publications represent easily measured markers often used as proxies for individual career and programmatic success, our research demonstrates that there is a deep well of externally imperceptible influences on an individual’s sense of success as an academic hospitalist. In our analysis, intrinsic elements of career success received far greater weight with early-career academic hospitalists. Our findings are supported by a prior survey of academic physicians that similarly found that faculty with >50% of their time devoted to clinical care placed greater career value in patient care, relationships with patients, and recognition by patients and residents compared to national reputation.9 Similar to our own findings, highly clinical faculty in that study were also less likely to value promotion and tenure as indicators of career success.9
The main focus of our questions was how early-career faculty define success at this point in their careers. When asked to extrapolate to a future state of career success, the concept of progression was repeatedly raised. This included successive promotions to higher academic ranks, increasing responsibility, titles, leadership, and achieving competitive roles or awards. It also included a progressively increasing impact of scholarship, growing national reputation, and becoming part of a network of accomplished academic hospitalists across the country. Looking forward, our early-career hospitalists felt that long-term career success would represent accomplishing these things and still being able to be focused on being excellent clinicians to patients, having a work–life balance, and keeping joy and excitement in daily activities.
Our work has limitations, including a focus on early-career clinician-educator hospitalists. The perception of career success may evolve over time, and future work to examine perceptions in more advanced academic hospitalists would be of interest. Our work used purposeful sampling to capture individuals who were likely to self-identify as academic clinician-educators, and results may not generalize to hospitalist physician-scientists or hospitalists in community practices.
Our analysis suggests that external organizations influence internal perceptions of career success. However, success is ultimately defined by the individual and not the institution. Efforts to measure and improve academic hospitalists’ attainment of career success should attend to intrinsic aspects of satisfaction in addition to objective measures, such as publications and promotion. This may provide a mechanism to address burnout and improve retention. As important as commonality in themes is the variation in self-definitions of career success among individuals. This suggests the value of inquiry by academic leadership in exploring and understanding what success is from the individual faculty perspective. This may enhance the alignment among personal definitions, organizational values, and, ultimately, sustainable, successful careers.
Disclosure: The authors have nothing to disclose.