Based on the type of people that we physicians and other health care professionals tend to be – successful, disciplined, rule-following – and the formative experiences we go through in the grinder of medical or other health profession school and post-graduate training, we are apt to suffer from a certain system of beliefs about how the world works. This system of beliefs is quite adaptive and is part of what has allowed us to succeed. However, it can result in cognitive biases that can lead to a career less than it could otherwise be. 

What is this mindset I believe we are prone to? It is a belief that, because we have worked so hard for so long and have followed all the rules that society implicitly expects of us, the world now owes us something in return. This belief includes the corollary belief that we have struck a ‘bargain’ between ourselves and the people who trained us or now employ us, the very people who have the most control over our careers. 

This is what I call the “Grand Bargain” Bias and it leads us to place inordinate trust in those who control (including partially and indirectly) our careers. After all, in all the years of schooling and training, we were working under clinical tutelage and administrative oversight. For the most part, we trusted the system and the individuals who were our guides through this phase of our careers. I believe this trust was well-placed: usually, supervisors don’t benefit from undermining, misleading, or misdirecting their charges. 

But, after years of training, the terms of the bargain change: as an attending physician or independent health care professional, your bosses and administrators view you now as a “producer.” When you’re employed, you don’t pay others to train you; instead, you are now paid to do work. Those you work under are not there to nurture you but to extract work from you. They have patient and/or dollar-amount productivity expectations or firm quotas for you to meet. You and every other clinician are a means to the end of meeting those production numbers. 

Of course, I don’t imagine the person or people you work for are mean-spirited, unfair, lacking in empathy, or unfriendly. They might be but it’s not central to their job. But no matter how friendly they may be, they are not your friends! And even if they are your friends, at work they play a different role. They are the person charged with the smooth running of the operation, ensuring that productivity and quality measures are met. 

This is not news to you and most of the time this arrangement of employee and employer is acceptable to both parties. 

The problem arises when you carry the Grand Bargain mindset into the employment arena. In this mindset, you may place too much trust that your welfare is topmost in the minds of the people in charge. 

This is either not true or only partially true. Even if your current welfare is important to the powers that be – and it usually is to some degree because they don’t want you to burn out or quit – there are many aspects of your career that are completely not in their field of concern. And, perhaps, one could argue, they shouldn’t be, as I’ll explain shortly.

This Grand Bargain mentality can lead you to imagine that not only will you be treated fairly at your place of employment – and this is a completely reasonable expectation to have – but that you’ll be taken care of on an even deeper level. For example, would your boss advise you to make a decision that is better for you and worse for the institution? 

Would your boss tell you that a clinic, group, or medical center across town pays more or has better working conditions?

Would your boss tell you to slow down because you’ve accepted too many patients or too many on-calls?

Would your boss ever engage you in a conversation about your career and life trajectory? For instance, if and when you plan to get married or have kids? No, of course not! This is not appropriate or worse.

Or would your boss ever suggest ways for you to slow down or gradually retire in a way that makes financial and career sense for you? Again No. And again, that doesn’t seem appropriate. 

To stress, your boss is not a bad person. It’s simply not his or her job to manage your career for you and it would be weird and intrusive if they tried to. 

And think about this: how often do you think about similar aspects of your boss’s career? After all, that person faces those same issues regarding their potential for a better job, risk of burnout, closing window of time to start and raise a family, and ways of retiring. If you don’t bring this up with them, are you a bad person? No. It’s simply not considered your place to keep these aspects of someone with whom you have a professional relationship in mind. 

So, Step 1: become aware – place into words – your perhaps unarticulated Grand Bargain. 

Step 2: reflect on how this Grand Bargain mindset could be preventing you from taking the initiative to consider, explore, and choose what is best for your career and life path. 

Step 3: reflect on what it is you really want out of your career and your life.

Step 4: make a plan to reach your goals consistent with your values because there is no one else whose job it is to do that for you. Of course, there are many people who can help and become trusted advisors. But it’s up to you to search them out, vet them, and ask for their help. When you have found such a person or people, two good questions to ask are, “What are the most common pitfalls you’ve seen among clinicians at my stage in their careers that you can warn me about?” And, “Without getting too personal, what are some of the aspects of your career you regret most and what would you do differently if you could go back in time?

Let me know if this Grand Bargain Mindset is something you’ve come to see in yourself. If so, how has it affected your career and the choices you’ve made?

Thanks,
Dr. Jack

LanguageBrief

“If you don’t design your own life plan, chances are you’ll fall into someone else’s plan. And guess what they have planned for you? Not much.” – Jim Rohn

“The only person you are destined to become is the person you decide to be.” – Ralph Waldo Emerson

“We are our choices.” – Jean-Paul Sartre

“Responsibility to yourself means refusing to let others do your thinking, for you.” – Adrienne Rich

“No one saves us but ourselves. No one can and no one may. We ourselves must walk the path.” – Buddha