Harvard Cardiologist Reveals What Doctors Never Learn in Training

“In some ways, medicine is so obsessed with data — until it comes to your career. Then all of a sudden, it’s a data-free zone.”

On this episode of How I Doctor, Dr. Sanjay Divakaran, the Associate Chief of Cardiovascular Medicine at Brigham and Women’s Hospital, joins host Dr. Graham Walker to talk about the aspects of practicing medicine that no one teaches you. Like how to build a mentorship team, evaluate job offers, and make sure you understand how your employer measures success.

A Harvard-trained academic cardiologist, Sanjay shares the advice you wish you’d heard during med school and training. Whether you’re navigating your first attending role or trying to find more meaning in your work, this episode is filled with practical career insights. Here are four takeaways from Graham and Sanjay’s conversation.

1. Why Medicine Is Still an Apprenticeship

“Once you realize that medicine is still very much an apprenticeship, you begin to realize that the most important part of your days — after taking the best care of the patient possible — is to think about what things you want to emulate from the people you look up to, and what things you want to remember as things you don’t want to do.”

Medical school might teach you pathophysiology, but the culture of clinical apprenticeship teaches you how to be a doctor. And according to Sanjay, that system doesn’t stop after residency. This mindset, he says, should extend beyond medicine into career-building — learning not just from senior mentors, but from peers and personal experience as well.

2. Don’t Find Just One Mentor, Find a Board of Them

“You don’t need a 16-person board when you graduate med school, but you should know who’s in your corner for specific things. Your closest mentor may not be the best person for your next decision. That’s why you need a board — people who help you navigate different pieces of your journey.”

Mentorship is critical, but expecting one person to meet all your needs is a common mistake. Sanjay encourages physicians to be intentional about creating a diverse team of advisors, especially as career paths become less linear. He also urges young physicians not to be afraid to send that cold email or ask for a conversation. “The hit rate is higher than you’d expect,” he says.

3. Understand How You’ll Be Measured Or Risk Burning Out

“My mentor once told me, ‘You can’t meet expectations if you don’t know what you’re being measured by.’ If your department says they want a clinical star, make sure they know what that looks like. If they want a program builder or an educator, make sure you want to be that.”

Whether you’re staying in academia or going into private practice, understanding how success is measured is essential to job satisfaction. Too often, physicians walk into roles without knowing what’s expected or valued. Asking about success metrics is a critical step in avoiding misalignment. You don’t want your contributions to go unrecognized simply because your boss or institution don’t see them as priorities.

4. Medicine Loves Data Except When It’s About Your Career

“We care so much about randomized trials and outcomes, but when it comes to choosing a job? It’s a black box. No one knows what others are getting paid, what productivity benchmarks are, or how to compare offers. It’s all hushed tones and backchannel advice.”

Doctors are trained to use data in every clinical decision, but they often operate in the dark when it comes to employment contracts, compensation, and job expectations.

Sanay encourages residents and fellows to lean on peer mentorship, talk to recent hires, and embrace the idea that financial and operational literacy are more than “business skills” — they’re survival skills.

Whether you’re applying for your first attending position or figuring out what fulfillment will look like 10 years down the road, Sanjay reminds us that medicine isn’t just about mastering science. It’s about building a career that fits the life you want.

Connect further with Sanjay on LinkedIn here.

To make sure you don’t miss an episode of How I Doctor, subscribe to the show wherever you listen to podcasts. You can also read the full transcript of the episode below.

Offcall exists to help restore balance in medicine and improve the wealth and wellbeing of physicians. Sign up for Offcall here to bring about more physician compensation transparency and join our physician movement.

Transcript

Sanjay Divakaran:
I often told the interns when I was a chief resident who are now of course the best doctors in the world, not because of me, but because of who they are. I would often tell them that I have gained so much from the people I look up to that if I could give 10% of what I have gained from others back, I would have an extremely fulfilling career.

Graham Walker:

Welcome to How I Doctor, where we're bringing joy back to medicine. My guest today is Sanjay Divakaran, the associate chief and clinical director of cardiovascular medicine at Brigham and Women's Hospital, you've probably heard of that one, and an assistant professor of medicine at Harvard Medical School. You've probably heard of that one too.
Sanjay has become really a thought leader on how we can better prepare doctors for the realities of clinical medicine in 2024 and beyond. While there are many challenges that new doctors face as they transition from residency to attending-hood, today we're going to focus on the things that aren't really covered in our formal training, including financial literacy, career development, and how to be an effective employee. Welcome to the show, Sanjay. Thank you for joining us today.

SD:
Graham, thanks so much for having me. Really delighted to be here.

GW:
Looking at your CV, you're a lifer at Harvard. Is that fair to say?

SD:
Fair except I went to the better institution in Cambridge, Massachusetts for undergrad.

GW:
So a Boston lifer at least?

SD:
Yeah, fair. I grew up on Long Island in New York, and I'm still an avid New York sports fan, but in all seriousness, really took to the ecosystem of Boston when it comes to the life sciences, the culture of learning, and the culture of innovation. And really just love being a physician at the Brigham and as well as in Boston.

GW:
And you direct the cardiac sarcoid program and you're also the assistant chief of the department as well. You've got a pretty full schedule already. How do you have time to also do teaching?

SD:
I often tell our fellows and our prospective fellows and residents as well that my pie chart has changed a lot, but I actually think that underscores some of the fun stuff about academic medicine. Being with our trainees is by far the most exciting part of coming to work every day. To always be surrounded by such smart and curious and talented people that really push me to be better every day and make it really fun to do whatever slice of that pie chart it is for that day.

GW:
I totally agree. I work with residents. It activates a different part of your brain to be forced to find something, to necessarily always have something to teach somebody about. When I'm working with med students, I will pull facts out of my brain that I didn't know were still there. I thought they had been gathering cobwebs, and then I'll just pull a factoid like, "Oh, it's, of course, because of the sodium potassium transporter." And I'm like, "What?" I haven't thought about that level of preclinical medicine in so long, but it is amazing that it's still there.

SD:
Absolutely. On any given day, I could have a medical student, a medicine resident, a radiology resident, a general cardiology fellow, a cardiovascular imaging fellow, could interact with all those people sometimes in the same session. And so to not only do that, as you point out Graham, but then also to be confident enough in my teaching to be able to have different levels of learners and different backgrounds and interests actually, and curiosities. And I workshop a lot. I try, I retry, particularly when things don't go as clearly as I would like to. But as you can tell by the way I'm talking about it, it's a pretty fun part of it too.

GW:
Do you find particular areas where there are still gaps that you're really finding a lot of value in helping that fourth year med student prepare to be an intern?

SD:

TEACHING AND APPRENTICESHIP IN MEDICINE

The reality is what people may or may not know outside of medicine and sometimes even medical students and residents and fellows and attendings is that I feel that medicine is still very much an apprenticeship.

GW:
Totally agree, yeah.

SD:
Once you realize that it's an apprenticeship, you begin to realize that the most important part of your days after taking the best care of the patient possible is to try to think about what things you want to emulate from the people you look up to and your peers and what things you want to remember and file away as things you may not want to do.

GW:
I love that.

SD:
And I think that is the biggest gap, and that's not just a fourth year medical student gap. I still have that gap in certain areas. And so I try to ingrain that way of thinking as soon as I can, and I often find that it's that fourth year medical student to intern transition where I spend some time on that topic.

GW:
I remember working with lots of different attendings with lots of different styles, and I always tell people, you got to pick kind of what style of attending you want to be and then steal from those attendings the way that they either work things up or talk to patients. I still have one-liners I use with patients all the time that I absolutely stole from my attendings in med school, my attendings in residency, of just how they talked with a patient about whatever it is, a patient signing out AMA, a patient being scared about a procedure. I absolutely saw how effective they were at framing a conversation and I was like, "Oh, what did that person say? I'm going to write that down. I'm stealing that because that's the exact way I would want it explained to me too."

MENTORSHIP AND CAREER DEVELOPMENT

Sanjay, you also focus not on just clinical medicine, but also the career development side of medicine as well. How did you get into that space?

SD:
At the Brigham, in the internal medicine program, you actually go onto fellowship or being an attending and then come back to be chief resident.

GW:
Wow.

SD:
And so I actually did two years of general cardiology fellowship and then came back to be a chief resident. And that was one of the most formative years of my life in many ways, really focusing on this apprenticeship aspect of things. And so I think I learned a lot from my mentors during that period, but also learned a lot about myself during that period. And I think that's really when I decided I wanted to be that triple threat. I wanted to be that clinician, educator, investigator, and now more recently, administrator, so maybe the quadruple threat.
But I just really loved that aspect of it, that mentorship aspect of it. And I often told the interns when I was a chief resident who are now of course the best doctors in the world. I would often tell them that I have gained so much from the people I look up to that if I could give 10% of what I have gained from others back, I would have an extremely fulfilling career.

GW:
It's that standing on the shoulders of giants piece of just, I think once you hit that attending level, you have a way deeper respect for what your attendings have given you. I think it's harder to see when you're in the middle of training too.

SD:
Definitely. There are times I have a teaching point or a difficult conversation and I can sometimes look at the room and remember when my attending delivered that same type of feedback, advice, et cetera. And these are my colleagues now and people I still look up to, but it's amazing how that goes.

GW:
Yeah.

THE POWER OF NETWORKING

How important do you emphasize networking when people are finishing residency, finishing fellowship and really looking for their first attending level job?

SD:
I often tell people that at every stage of training or even the first job, the most likely scenario is you're going to either stay at that institution or stay at the institution nearby. And that's just because life still happens too. It's really important because you don't know what's out there until you see it. And I will tell you that for my wife and I, we made a Venn diagram of where the next stages of our career would go at residency and at fellowship. And at the fellowship level, it was kind of the Boston area or the Bay Area, but I applied broadly in both of those areas.
And I have to tell you, I learned so much about the institutions in the same zip code or nearby zip code as I was in because I applied to all the programs. And there are still people at other programs who I still meet with on a regular basis, and I consider them my external to the Brigham advisors and coaches, and they provide me with some of the best advice I get. And so that's a small example of how crucial I think networking is and interacting with others.
I'm good about it, but not great about it, but I've done it in other ways. For example, pretty involved with the American Society of Nuclear Cardiology, which is one of our professional societies. And I give ASNC a lot of credit because I feel like they've taken me under their wing and they've really developed me into a nuclear cardiologist and an advocate for patients and a scientist. And they've invested in me and I feel that I'm going to do my part and invest my time in them.

GW:
The societies, they're not just available for clinical care, they help you network and find other people. Do you have other important areas where you can help build those meaningful connections? How do you find that people you've maintained those relationships over the years?

SD:
The most impactful ones have been the people I trained with. There is something to be said about seeing folks in their most tired state, their most beleaguered state, and just see how good of a doctor, but also how good of a person that person is. And so every year, we go through residency recruitment, fellowship recruitment, faculty recruitment, people looking to move for whatever reason. And my virtual Rolodex, the top of the list are the people who I trained with. They're personally vetted. These people have taught me so much and have taken such good care of me and my patients. That is a network I lean on the hardest, I would say. And then medical school classmates as well, because many of them did not go into cardiology or internal medicine, and so rely heavily on them for other disciplines.

GW:
I actually think that's one of the least discussed benefits of being a physician is just the network of other physicians that you have access to when you need it. I have a friend that's dealing with a colorectal cancer recurrence right now. Texted my friend that I went to med school with, haven't talked to the guy in 15 years, but he's like, "Oh, Graham, hey. Yeah, oh my God, I'd be happy to see your friend or help refer him to a colleague." It is so unrecognized by people outside of medicine of just the ability to cut through layers of bureaucracy to get somebody to the care they need.

BUILDING A BOARD OF MENTORS

Tell me a little bit about mentorship, Sanjay. Do you find that to be a key piece, especially for younger trainees, medical students, and residents?

SD:
The biggest piece of advice I have for mentorship is I tell people that physicians in general are smart. You know who you can go to when you want to hear the answer you want to get, but you have to be prepared to get an answer that you may not want to hear, but it's probably the right decision. And so I use it as an introduction to say that something that my closest mentor taught me is to have a board of mentors.
So there are some people I lean on for certain topics and there are some topics that I lean on others for. And so no one needs to have a 16 person board when they graduate medical school, but they should think about who do they have in their corner on certain topics, and that'll help them decide who to go to. But then also where they might need to network and ask for advice to develop other parts of their board of mentors. Because your closest mentor might not be the best person for the next question that comes to mind. And so to have that network of people that you might be able to reach out to is really important.

GW:
I love that, and I like to think of mentors as not just guiding you because they're more senior, but they are advisors. And like you pointed out, not just having one. Many organizations will maybe assign you a mentor if you're a new resident. We all got assigned to an attending that was our mentor. And so maybe that person isn't the perfect fit for you, but don't get rid of that person, just add a second mentor. Having multiple mentors can be helpful. Sanjay, do you give recommendations to people on how to just ask for someone to be your mentor?

SD:
I got advice from George Ruiz on this when I was an undergraduate, and George is a graduate of the internal medicine program at the Brigham, and I was introduced to him by a very close friend and mentor, Jay Bradner, who's also a graduate of the Brigham medicine program. He told me that you should email anyone you want. What's the worst that could happen? They don't email you back and that's it. But that mentality was really important.
I was at a summer internship at the time in D.C., I was like, "Huh, I guess I should do this." And I did, and my hit rate was extremely high of people that were more than happy to meet, to talk about their career, advice, et cetera. You should never hesitate to reach out to folks. The cold email sometimes is a pleasant surprise for people.

GW:
I think that's really true. Because it's an apprenticeship, I think all of us or most of us have a sense that at some point we're going to retire and we're going to need healthcare too. And so there is a sense that other people have done this for us, it's now my turn. I'm now an attending. It's my turn to do it for the next generation too. I have people messaging me constantly on LinkedIn, "Hey, can we grab a coffee?" And if it's a medical student or a resident, I actually will pretty much always say yes just because I think it's really important. I think it's critical that we train the next generation and support them because we all know it's not easy to go through medical training.

SD:
I joke and I often tell pre-medical students or medical students that the most formative week of my medical school training was my week of ophthalmology because I realized that I did not want to be an ophthalmologist. And I have close friends who are ophthalmologists and are really good ophthalmologists and I'm glad they are. You got to see stuff, and so if someone's reaching out to me that wants to know what it's like to be me or at least just see what it's like to be in clinic with me or someone like my phenotype, I owe it to that person before they sign up for this and not know what they're getting into.

GW:
My dad's a doctor. I remember when I was a pre-med, he asked one of his friends who's an ER doctor, "Hey, can my son come shadow you?" And now I'm thinking back like, "Oh God, I'm sure I was so cringey." But just like two months ago, a colleague reached out to me, said, "Hey, my friend's son is interested in emergency medicine. He's a pre-med. Can you do it?" And I'm like, "Oh." But then I'm like, "You know what? Somebody did this for me." I think it's an important part of passing on the tradition, the profession.

WORK-LIFE BALANCE AND NONCLINICAL INTERESTS

The younger generation I think is more and more interested in work-life balance. I think they're more likely to see medicine as a job, less as a calling, I think still a career, but less as a calling. When you interact with pre-meds and medical students and younger residents, do you get a sense that they want to do something outside of medicine?

SD:
100%. My wife is an early stage tech investor, and I often joke with my colleagues that it's not rare that a trainee actually wants to meet with my wife and not meet with me.

GW:
They're trying to meet with you to get to your wife.

SD:
Exactly. I'm still flattered by it and I would do the same thing, but people are interested in being a physician, but also using that clinical knowledge and clinical training to make impact in different ways. When I applied for medical school, I considered myself kind of a vanilla applicant. I was a senior in college. I applied to medical school. And I was going on the interview trail, and everyone I met had taken a year or two of gap years. And in fact, almost all of my friends from medical school are a year or two older than me.
When I went back home, back to college and I kept saying, "I think I'm the non-traditional one. I'm the one that actually is going straight through." And so I feel that way now too. I'm this academic cardiologist that's stayed at the same place and done the same thing and I love it. I think at every step of the way when someone is thinking about a role here at the Brigham or asking for advice, the number one thing I tell them is to be an excellent clinician.

GW:
Could not agree with you more.

SD:
Right. Even if you're late [inaudible 00:17:14] yeah, just be an excellent clinician. And I often tell people, when I came on faculty, I was floored that people who trained me would ask my opinion on an imaging study or clinical care, this and that. I was like, "Wow, this is completely unexpected." But then I realized they trained me. They saw me in my darkest days and the 3:30 in the morning, seeing patients when I was on consults and this and that. And so they saw the way I went about clinical medicine and felt that they could trust me because they saw that. At the end of the day, I feel that the biggest value I add is my clinical approach and clinical care. And so I spend the most time every day honing in on that and being better in that every day.

GW:

KNOWING HOW YOU’RE MEASURED

Sanjay, let me transition a little bit to talking about being an employee. As we talked a lot about at Offcall in the past decade, our profession has drastically changed, right? We've mostly become employees of somebody else. Do you talk about that piece of things with trainees as well?

SD:
As an academic, it was kind of a foregone conclusion that was going to be the case for me. I never considered having my own practice. The way I talk about this with trainees, particularly those who are going for clinical jobs, is that you just had to have a firm grasp on what are your expectations. My mentor, Marcelo Di Carli gave this advice to me, which is, you always want to know what you're being measured by because how can you perform to expectations if you don't know the measurement?
And so the first thing that came to mind when you thought about being an employee is someone who takes a clinical job or is looking at primarily a clinical job, what are your benchmarks? What are your goals? For example, are you going to build out a cardiac PET program or are you going to try to be the clinical star at a place and you're going to be measured by excellent quality care, you take care of predominantly outpatients? Thinking about how you're going to be measured because that'll enable you to figure out where do you want to spend time, where do you want to grow, and also if it's the right fit.

GW:
If you want to be the outpatient star and just you're banging through patients all day long, you want your boss, supervisor, chief, whatever it is, to recognize that that's an important thing that you're doing. If you're an interventionalist and you're doing caths all day or you're EP or you're running a cardiac sarcoid program or doing cardiac imaging, you also want your chief to acknowledge that that is also valued too. I think that that could be the place where people get into trouble, where you're contributing in a way that your chief has not acknowledged is valued by him or her or the organization at large. Sanjay, do you think that a new doctor needs to understand the basics of the system in order to be an effective employee?

SD:
I was telling someone recently that I've been at the Brigham since 2012, and now I interact with people on a daily basis who are really good and who are really bright and really motivated, who have never interacted before February of this year.

GW:
And they've probably existed in your system for many years-

SD:
Exactly.

GW:
... and you just never came across them.

SD:
Because it's a completely different side of things, whether it be operations, data, logistics. And so I'm a good example of, I actually wasn't aware of a lot of these things. But I feel I have a much better grasp of it, and I feel like I can transmit that kind of knowledge to the next generation, not to the level I know now, but to the level that I think is important for that person.
I think it's really important for physicians just to know where they fit in and what the expectations are for them as a unit, because I think that in my opinion, my hypothesis is that tracks really well with quality of life and happiness. So I don't know if you need to know globally, for example, what are the X, Y, and Z initiative and operations at the system level. I don't think everyone needs to know that, but I think understanding how you fit in for your role I think is really important.

GW:

NAVIGATING SYSTEMS AND NEW RELATIONSHIPS

Let's talk a little bit about how you have navigated these new relationships that you've had to build, these new people that you didn't know existed before. How have you found navigating these relationships with these new people, introducing yourself, understanding what their values are, what their needs are, how have you approached that?

SD:
The patient always comes first, and I think that helps tremendously in every interaction I've had. Marcelo's really ingrained this into me as well, whether it be in the imaging lab, in clinic, in meetings, when we think about a bunch of stuff, the patient comes first, and that has really been a north star. That's really, really important. And I actually tell patients this. I tell patients that healthcare is a service industry. In clinic I'll tell them, you could see a Harvard cardiologist across the street, literally, you could cross the street and there'll be three Harvard cardiologists right there. You don't have to see me, but I owe it to you to be prepared for the visit to show you your images, not just talk about them, show you that I know what's going on, or at least I think I know what's going on and tell you when I don't know what's going on and what I'm going to do next because there are options and there should be options.
So that service industry mentality, I actually think that's a positive, but I take that into these interactions as well, so what do I bring to the table? So I bring to the table, one, I'm a clinician. Two, I am trying to be that quadruple threat. And then most importantly is that you have to listen. The worst meetings are you start a meeting and you realize this is going to go nowhere really quick, right?

GW:
I mean, no, I've never been to a meeting like that. I don't know what you're talking about, do not know what you're referring to.

SD:
And I'm in very few of those meetings, thankfully because of our organization and because of the people I work with. But those types of meetings, it makes you appreciate being at a place where people listen and people are motivated to listen to others' expertise and ideas.

GW:
It's interesting, your advice that you just gave is actually perfect advice for all of medicine and being a good doctor, listen and keep it about the patient. I think anytime you're stuck or frazzled or something is challenging, if you just continue to listen to the other people and always bring it back to the patient and how is this impacting the patient, you're probably going to be moving in the right direction.

JOBS, DATA, AND TRANSPARENCY

We are focused a lot on employee contracts and transparency with Offcall. Do you advise a group of people about pitfalls in either contracts or employment or how to compare jobs when they're starting that very first attending job? Because they will likely, like you said earlier, likely spend at least three, five, maybe their entire career at that job.

SD:
When a job position opens up or an advertisement is placed, there is a need. There's a kind of need. It's not set in stone that you need this many weeks of this and this many days of this. But in general, an institution, a practice, they're looking for something and we think about that when we put an ad out. We want a clinician educator. If it's not our institution, but somewhere else, we're looking to establish perfusion PET. And so understand the need and understand if that's something you're interested in. In some ways, medicine is so interesting because we care so much about data, clinical trials, randomization, what are the data for this? What are the data for that? Then when it comes to getting a job, all of a sudden we're in a data-free zone.

GW:
I never thought of it that way. That's such a great point.

SD:
Right? We don't know what people's clinical makeup is. We don't know what their salaries are. We don't know what their benchmarks are for clinical productivity. We really rely on that apprenticeship model again. And so I've benefited greatly from mentors and colleagues who have told me, "Hey, this is how this works." So you rely on your network. So again, again, not to sound cliche, but going back to our prior conversations, all these things we talked about are really important for that job search and thinking about opportunities as well. And understanding, I'm a great example how things can change.

GW:
That's such a great point. It'd be like if I was calling you for a consult and I have a patient with whatever, CHF, and I say, "Oh, hi. Yeah, I've got this guy with CHF, but I don't know his ejection fraction. I haven't done an EKG, I haven't gotten a BNP, I haven't done a chest X-ray." And I'm like, "Oh, yeah, can you give me some recommendations?" I would appropriately get chastised for not being able to provide you any data on a decision that you need to make about this patient. And we as physicians are often making very large decisions about our employment without that same level of scrutiny and data that we use every single day for every single one of our patients.

SD:
Totally.

GW:
That's such a great point. I love that. How do you advise people try to get that information? Obviously, we're trying to address that at Offcall, but right now, I think it is kind of an unspoken, like hushed tones, talk to your mentors, ask them if they'll tell you what's going on. Any other ways that you've seen people get access to that information?

SD:
I often tell people to look at recent hires or recent graduates.

GW:
Oh, that's great.

SD:
And so if you're looking at a program and someone was recently hired, it might not be in the same space, maybe for example, interventional versus imager. But just to get an idea of what their makeup is, how did the contract stuff go, what were the expectations? And then others that go to other institutions. And then I see our fellows bouncing ideas off of each other about what they've learned and that kind of thing.
So peer mentorship I think at this stage is incredibly important. Or near peer mentorship, recent hires, recent graduates, people who you know interviewed at places that didn't take that opportunity. I feel like they're the most willing to give advice and help others because they also know how much of a black box it was for them.

GW:
Yeah, it's a great point. I want to go back to one of the points you said earlier about knowing that the hospital has a need by the time they've posted something. I was assistant chief and my department spent a lot of time hiring and finding people, and you're absolutely right. By the time it's gotten to a job posting and gone through the hospital's HR system, that often takes a long time, there's probably been a need for a while. I mean, there's so many different ways that a job posting can appear the same on the outside. And it's really not until you talk to the hiring chief or assistant chief that you often find out what they really want, and then you need to decide if that's a good fit for you as well.

SD:
And it also will guide expectations also. For example, if you're being recruited to a place where there's a job posting to build a new lab, obviously your clinical productivity is not going to be as high as you'd like it to be in the first X number of years because you're working with a technologist, building protocols. And so understanding if that's a need, then you know that their expectations for your productivity should be lower to start with. And so that can help guide those conversations about what you're going to be measured by.
In that case as a specific example, maybe you want to be measured by what's the date of the first patient you scan? What's the volume look like? That kind of thing, as opposed to joining an established program where maybe you say, "Hey, I actually want to be an educator in this program." This clinical program is awesome, but we haven't been able to keep our residents and fellows and they go to other places, so can we build out recruitment? Can we build out our educational mission here? And if that's in the job posting, then you realize, okay, this is something. One, am I interested in this? And two, again, my clinical productivity is great, but will I be measured by resident retention, fellow retention, that kind of thing?

GW:

FINANCIAL LITERACY AND EXPECTATIONS

It's okay to ask those data-rich questions like, "Hey, what are my expectations here?" I do get the sense, Sanjay, that the younger generation is way more attuned to the financial piece of medicine. I think probably part of that is from student loans, and part of that is from the changing way that student loans are paid. Do you get a sense that they're also more financially literate than say millennial doctors like myself?

SD:
I have a few theories on this. One of them is that my wife and I, our closest friends from college, many of them are not in medicine. But now I've seen for almost two decades now what they do. And so opportunity costs might not be the right word or right phrase for it, but that's sometimes how I feel. We can be working less hard for more money doing other things, and I think some of the literacy goes to what's the opportunity cost? What else could I be doing with my skills, with my knowledge, with my work ethic? The loans for sure, but I feel like everyone has friends who are really happy professionally and personally doing something different. And I think many people realize that, hey, you could actually do that too or get better at it and do that too.

GW:
You often hear politicians and laypeople criticize the American high school system for not teaching people about taxes and personal finance. Should that be part of medical training or residency training, like the business side of medicine, whether it's going into what's an RVU or how physicians are paid? Should that be part of the curriculum?

SD:
You should be able to access that knowledge in a learnable way if you're interested in it. We're doing a podcast right now. And so I think asynchronous learning is something that I think a lot about. I feel like we should have better access to the Khan Academy type thing. This is what an RVU is, this is what this is, this is what that is. Part of the curriculum is tricky for me because I feel that we're already not teaching enough. We're not already doing enough. There's just not enough time, and you want to get people into the clinic. And I actually think preclinical education is getting shorter and shorter. But having access to these things I think is really, really important.

GW:
The idea of understanding an RVU and then tying that back to why it's important or why you might want to know what's an RVU, it almost is the connection between preclinical medicine and clinical medicine. It's like you want to know that Lasix acts in the loop of Henle or whatever, so that you can then understand what's going on with the kidney and why Lasix works or why it might not work in somebody with X, Y, Z condition.

SD:
I like your medical analogies. It's totally the same thing. Have the knowledge and then decide how you're going to apply that, whether it be the job interview or being an administrator or whatever it might be.

GW:
Sanjay, do you give advice to residents and medical students about just how to be financially literate or how to make smart decisions as whether it's a resident or a fellow or once they become an attending?

SD:
It's not an area that I have a deep fund of knowledge in. In my household, no one relies on me for this decision making, thankfully. I often joke that I'm the CMO of our household and our kids and my wife are the president and CEO depending on the decision at hand. However, I still make sure people know there are options for a given opportunity or a given interest. Sitting down with a fellow and say, "Hey, this is how grants work. This is how buying back your time works. These are the type of grants that can offer salary support and those that cannot. These are educational roles that come with FTE and those that don't."
These are things that in the grand scheme of things are so tiny, but in my world actually are really, really important and for trainees to understand that. As an example, we have so many trainees that would be great program directors, but there's only a certain number of those jobs. And just a understanding about how those work, how they're compensated, what those roles are, that type of education is what I do in terms of literacy when it comes to finances. I'm not as good when it comes to loans, investing, things like that.

GW:
No, I think that piece of it is, I think critical because it's way less explained.

SD:
Absolutely.

GW:
That's a key learning because it also helps you understand and set your expectations appropriately for where your career path may take you.

SD:
Yeah.

GW:

Well, Sanjay, I know we're reaching time. I just wanted to thank you. This has been an incredibly wonderful conversation. It's been great to meet you. Sanjay, where can listeners find you and support the work that you do?

SD:
You can look at the stuff we're doing in both our investigation and educational space at a few different places. Our cardiovascular imaging program at the Brigham has a nice website where we highlight our faculty. Of course, Mass General Brigham, we're building out a heart and vascular institute, so you can Google that and read about that. And then if you just search for me and Harvard Catalyst, you'll get a little description of recent publications and interests about the work we're doing.

GW:
Amazing. Well, thank you again for taking the time. Really appreciate it. Thanks for joining me today. For interviews with physicians creating meaningful change, check out offcall.com/podcast. Make an account on Offcall to confidentially share your details about your work, and sign up for our newsletter where you can hear more about the latest trends we're seeing in physician pay. You can find How I Doctor on Apple, Spotify, or wherever you listen to podcasts. We'll have new episodes weekly. This has been and continues to be Dr. Graham Walker. Stay well, stay inspired, and practice with purpose.