Should You Stay or Should You Go?

(gentle upbeat music) - This is Lab Medicine Rounds, a curated podcast, for physicians, laboratory professionals and students. I'm your host, Justin Kreuter, a transfusion medicine pathologist and Assistant Professor of Laboratory Medicine and Pathology at Mayo Clinic. And today we're rounding with Dr. Rondell Graham, a Professor of Laboratory Medicine and Pathology and Anatomic Pathologist here at Mayo Clinic in Rochester, Minnesota.

We're gonna dive into Dr. Graham's journey, joining the staff at the institution where he did his training. We're grateful to have you here, Dr. Graham. - Thanks so much Justin. It's really fantastic to be with you here on the podcast. - Now we were doing a little bit of chitty chatting before we started recording. There was a line that you delivered where I was like, hold on, let's start recording. (Graham laughing) - What was that you said?

- So what I shared is that I wish when I was making my hiring decision or the decision of where I was going to stay for a job, that this podcast was available. (Justin chuckles) - All right, so for our audience to appreciate the kind of pre-planning Dr. Graham and I have for you guys today, hopefully is something that a lot of you out there will find valuable wherever you are in your journey.

And so maybe let's kick off with, Dr. Graham, why did you decide to take a job at the institution where you finished training? - I really think this is a great question Justin. And I've heard a lot of people talk about this and I've even been involved in panel discussions where this has come up before at national meetings and it's, should you stay or should you go, is really the question. I ended up staying and I've loved every minute of it.

I would say certainly collectively it has been really fantastic for me. And I would say the drivers of why to stay will probably vary by person. But for me, I think Mayo is a really fantastic institution with a great culture and a sense of teamwork, and I think that's just very attractive to be a part of. All of these people kind of are working together on this kind of singular goal. And I think that emphasis on teamwork is really attractive.

And I would say the other thing that's really attractive about Mayo Clinic is the resources provided by the institution to help teams accomplish their kind of specific mission. So they provide, I think, fantastic resources to aid clinical care, to support educating future generations and to enable research.

And I've always found that the institution's very generous about that and I found those things to be really attractive and I felt like I had a certain momentum and I felt, well, if I stay I could just keep it going. And that was pretty much the kind of the extent of my thought process at the institution level. We were very comfortable in Rochester, thought it was a great place to live and I loved the people that I trained with. Great people as co-residents and co-fellows.

Working on the stuff is a little different because you're not just having fun all the time, but residency of fellowship felt a lot like that. - Yeah, yeah, so that was how you approached it.

Like you highlighted that each person's gonna have their own different equation that they're navigating, and you have now a lot of experience. You're now a full professor. You've kind of really navigated this journey I think, very well, and so a great person for us to interview for this podcast. What are your thoughts about, what are the variables in that equation that you just wanna kind of call to mind for our audience?

I know it's not gonna be comprehensive, but what are some of those variables you think people should think about when they're considering the offers for internal or external, that should you stay or should you go conundrum you mentioned? - Yeah, I think this is a great question and I wish I had thought about it in the way that you phrased it. I appreciate your generous compliments. I think about it in kind of three levels and I'll go in the the order in which I think about it.

But I think you need to cover these three domains. I think the first is the institution culture. What's the institution like? Are people happy there? Do they tend to have a lot of turnover? What's the relationship between people in the institution? What's that like? I think that's a key question to have the answer to. I think the next comes to the level of the work unit that you will be in and the leadership of that work unit.

I wanna talk about the questions that need to be answered and you may not be in a position to ask these questions literally, but I think as you make observations, you wanna find out how your observations speak to these questions. So I think it's important to get a sense of what is the leadership like and how does the leadership relate to the people they lead? Do people feel empowered? Do they feel encouraged? Is there a sense of openness?

Is there like a fit a kind of this environment that's filled with fair or is there good communication, I think asking questions about that. What's the work environment like? What's the culture like relative to leadership and then among peers? I think a very good question to ask literally, is ask people who are in your similar situation. So people who have stayed, what it was like staying and notice what they mentioned and what they don't mention as well.

So I think if you ask people who are staying, you wanna get a sense that they felt like they were treated as an equal pair. And I think all the things that correspond to that I think will be really helpful. You really wanna sense that there's kind of mutual respect in the environment and a sense that there's equitable distribution or allocation of opportunities and resources. And so I think you wanna ask them those questions and I think that's really important at that work unit level.

At a personal level you'd wanna say, when you look out three to five years in the future, does the work environment, based on what you know of the institution, based on what you have asked people in that work unit, does it seem to support the kind of career that you envision for yourself three to five years in the future? And I think that requires that you know what that looks like.

So I think for me, I was always interested in, and still am, in an academic career at the intersection between GI and molecular pathology. I love the opportunity to collaborate with the bedside physicians and to bring teams around complex problems to solve them. And I think you wanna get a sense is that kind of career possible in the organization? Have people done it before? How do people respond to ideas like that?

I think those are kind of some of the things I would work through, if I were doing this again. And I think those are kind of key questions to answer.

- I love you're throwing out gems and I think I'll put a pin in that one where you're talking about, knowing what kind of a career that you want to have, 'cause I think that's something that we can probably revisit in the future, to dive into, 'cause I feel like that's a whole conversation in and of itself. I wanted to ask you one follow-up question though, right?

I think you're so insightful, Of highlighting it's not just the questions that you ask, some questions you can't literally ask, I think you put it, but also what are you seeing and is there one or two things that when you go for your onsite interview at a place that you're kind of eyes wide open and noticing when you're in that environment, I imagine for a lot of people it's kind of very wide eye, all new spaces and you're just kind of taking a lot in, but what might somebody focus on?

- This is a great question, Justin. When going on an interview or being offered an interview at a place, I think it's really important to pay attention to the trajectory of people. So separate and apart from what they're saying, are people in that practice being promoted, if it's an academic practice, being promoted in academic rank? And what is the timeline like for promotion? Is there a high turnover? Do a lot of people start there for a year and then they leave the practice?

Certainly you want want an environment where people are being promoted, that's a feature of productivity and a kind of a constructive environment. You will be concerned if that timeline seems unusually long or different from other places that you may be looking at. And of course if there's a lot of turnover that's usually a sign that something's not quite right, at least one thing is not quite right. I would say pay attention to the people that you are invited to meet or set up to meet with.

If you are a, a GI pathologist, as a for instance, and you are only gonna meet with two or three of the GI pathologists, but they're really six, I will be curious why you're meeting with some and not all of that. And that, I think a fair question to ask. So you wanna know who you're meeting. Are you only meeting people not in your peer group?

So people who are very senior, well established and not people in your peer group or obviously if you are the reverse scenario, you're meeting people not in your specialty and no one in your specialty. Those are things that I think you would wanna pay attention to and certainly be curious about because you really ought to be meeting the people you'll be working with. I think it is important to observe kinda what are the interpersonal dynamics.

In particular, I would say pay attention for smiles and laughter. When people are comfortable together, have a good relationship, it's easy to laugh. But a relationship that is fraught or really tense, laughter is very unusual. So if you see spontaneous laughter, that's usually a feature of good relationship and smiles, even if they're not highly extroverted people. You'll see people who enjoy each other and who have great respect for each other laugh.

The other thing I'll say to is that if you see people speaking positively of their peers, so if you were to interview at a place and they talk a lot about the institution, I think that's great, but it's normal and I think healthy to see people having respect, appreciation, admiration for their peers, regardless of their specialty. So I think that's something that comes out in healthy environments.

For example, we appreciate what you do here, Justin, with this podcast, educating people and there are many other things that we could appreciate about the Mayo Clinic practice. And so that's something that you ought to be hearing about colleagues and I think that speaks to a healthy work environment. And why I think those things are so crucial is there's so many intelligent people in healthcare and in pathology right now at various levels of training.

It's really encouraging to see that. And what I think probably holds people back or will be limitations or barriers that people will recognize is usually an environment where they don't feel quite supported or they don't have access to the resources they need. So where I'm going with this is that the gap or the barrier for most people is not one of intelligence or certainly not one of intellect. It's usually the other thing, so it is important to pay attention to those other things.

- So on that mark, I wanna kind of pivot us, and I don't wanna belittle, I think there's so many gems you just laid out for our listeners, whatever stage they are as far as what are some interesting things to pay attention to. You mentioned a lot of things like laughter, I hadn't really reflected and thought about, but I wanted to kind of pivot to this last point you were making about what are the barriers for our successes in our careers.

And I want to kind of take us forward and let's just kind of run the hypothetical of okay, we have now accepted the job at the place where we did training, right? And kind of those first couple of years in practice establishing your career, what's important to be really kind of hypervigilant about? - Wow, super great question. I would say at the beginning, one of the things that is perhaps the most important is time management. So time management I think is top of mind is a key thing early.

I learned a lot about this from one of my mentors, Dr. Laura Lamb, she's at the University of Michigan and I've had other mentors, including John Goble at the Cleveland Clinic, and other mentors here like Dr. Amina Jatoi. super fantastic in many ways, but each of them would emphasize and Laura's particularly expert at this, the importance of knowing where your time is going, not where you intend it to go but where it's actually going.

And so one of the things that we did as a level set was we started looking first at my calendar, where was I going? Did I need to be there? How did those things fit in the priorities? And then adjusting accordingly. I found that that was usually helpful for me because what I realized was my energy was going in places that I didn't intend, and certain places that it didn't need to. That helped me to recover a lot of time.

I'm talking about of the order of a quarter to a third of my time, I was able to redirect into academics. So time management and energy management, super crucial. I think one of the common things is going to meetings where you are needed, where you are engaged. I think understanding where you work best, when you work best. So for me, I work best in the mornings. So arriving early with a clear list of the most important things first and working through that list, very important.

So it is the total amount of time, but also knowing when you work best, so that will be my top of mind thing. - Wow, and just to highlight for everybody, I deal with a lot of change management things. A lot of pathologists, physicians, laboratory professionals will talk about just the time, "I don't have the time," and to hear you say being thoughtful about your time management. And I love the fact that you're highlighting not where you intended it to go.

'cause at the start of the day, we maybe intended to knock out a lot, but just at the end of the day, right, where did it actually go? And that you are saying that you took steps and you recovered a quarter to one third of your time that you were able to redirect into your academic practice, right? Which has allowed you to rise to the ranks, in really an expeditious way. - This is really helpful. I think you, you've captured it.

I think that was a big game changer for me and I think there's a real opportunity there for all of us. The ability to manage that time and part of the time management includes delegation, I wanna mention this because a lot of learners are developing skills to do, which is fantastic. And once you finish your training, one of these skills that you need to use, which you probably don't emphasize, is to delegate and not to do.

And so learning how to work with my assistant and to delegate tasks related to the calendar management, related to meetings and for us in anatomic pathology, related to materials and planning, this would be pathology materials, specimens, paperwork, et cetera, was a game changer because it gave me flexibility to do more working in partnership with her. So yeah, total game changer, time management, really important. And I would say one last thing about it.

I would say all of the highly effective people that I've met at Mayo Clinic and there are many and at academic medical centers across the country and even in other fields, they manage their time really well. - If I could just draw it, let me paraphrase something, you could tell me if this is hitting it or if I'm off the mark. As I'm reflecting, you're talking about delegation. I think that a lot of times I think when I finished my training and got into practice,

I thought of myself, like you were point out, we wanna be equals. I thought of myself as a fully trained board certified pathologist. But to your point exactly, like this was the first time I had an administrative assistant to work with. There are a lot of new things and I probably failed to appreciate that was a skill that I had not practiced, that I had not honed.

And so I think one of the ways to paraphrase this, is just that we can fully train through, but there are additional skills that we might want to kind of be front of mind and to be aware of. I have not had administrative assistant before, how can I best use this person? Or maybe we find ourselves several years into practicing, I don't know, maybe for listeners to sit back and think, are you using your administrative assistants, people that you can delegate to the maximum benefit?

Does that kind of capture you think? - Yeah, you nailed it, nailed it. - All right, let me close with one question that Rondell, I'm really curious for your answer. So as listeners may know, I recently finished teaching a course for first year medical students and as we're always knowing medicine is constantly evolving, right? And I had a first year medical student who was wonderful in the course asked me in class, who teaches me the updates in medicine? - That's an awesome question.

- Rondelle, I'm curious how would you answer that question? Who teaches you the updates in medicine? - This is a great question and I would say for me it's informal and formal. I would say in terms of the formal of this, this will be participation in CME meetings and activities organized by subspecialty societies of which I'm a part. So that's a big part of my kind of formal education and staying up to date in medicine.

I will say, I think the meetings are super fantastic, not quite enough because that's why I do subscribe to a number of journals and I'm sure many of us do and I will kind of stay in tune with those. Because I have kind of like a cadence by which they come to me in email and I will kind of like always read the table of contents and based on the table of contents pick up which abstracts and based on the abstracts, which full papers to read.

I think many of those journals though and resources that I have found to be helpful will have sometimes updates. There'll be an article or a title or review updates and those are usually something that I'll pay a lot of attention to. So those are kind of the two formal things that immediately jump out to me along with the institutional cadence of grand rounds, and updates, emerging technologies, these kinds of things.

In terms of the informal, I would say informally, a lot of this comes to people who are considered to be thought leaders in various areas. Asking them what's going on, how things are going, what are the new things. I found that to be really valuable. I will say my approach in general is actually to ask people not in my specialty. So in particular, I will ask people who are looking at it from a different perspective or working in a slightly different area

because I find that to be really academically engaging and stimulating, to kind of see what's going on in the world from their vantage point. And then one that might surprise you, I surprise some of the listeners. I look at what I consider to be some really trusted curators of what's going on in the world. So there's some thought leaders like that and I will check out kind of what they think are important perspectives and sometimes it's really helpful.

One of them is there's a group, there's a company called Wellington Investment Management. And the reason I became aware of them is because they put out an article talking about change in healthcare and I noticed they have researchers doing research in healthcare. They don't have a lot of direct medical expertise, but they are like, "What are the key themes?" And I've found that to be really helpful in having a, I would say a macro view, of what is moving the contours in medicine.

So it's not CME, but it gives me a sense, or at least their view of what's going on in healthcare that's a top priority. And to their credit, what they mentioned, dementia, obesity and is related consequences, and precision medicine related to cancer therapy. So it just gives you a sense, okay, these are some topics I need to keep my eye on. So I hope that's a helpful answer for that student. - That is a phenomenal answer. We've been rounding with the amazing Dr. Rondell Graham.

Thanks for being here with us today. - Thanks so much. I've really enjoyed it. - And to all of our listeners, thank you for joining us today. We invite you to share your thoughts and suggestions by email to [email protected]. If you've enjoyed this podcast, please subscribe and until our next rounds together, we encourage you to continue to connect to lab medicine and the clinical practice through educational conversations. (gentle upbeat music)