[00:00:00] Dr. Cifu: On today's episode of The Clinical Excellence Podcast and the final one of our third season, we have Dr. Michelle Josephson talking about the last third of a career in academic medicine.
[00:00:16] Dr. Josephson: One of the issues to think about is that at this point, I've got a lot of experience. I've got a lot of cumulative knowledge, but I'm also in a different place and I'm thinking about what to do with it.
And let me just start with the elephant in the room because I don't think I'm alone in saying this. I think that a number of us struggle with at this point in our career is with the issue of relevance.
[00:00:45] Dr. Cifu: Welcome to The Clinical Excellence Podcast, sponsored by the Bucksbaum-Siegler Institute for Clinical Excellence. On this podcast, we speak to patients and doctors about all aspects of excellence in clinical medicine. I am Adam Cifu, and today I am joined by Dr. Michelle Josephson. Michelle is a transplant nephrologist who provides care to renal transplant recipients and potential donors.
She manages transplant recipients before and after surgery. She's a nationally known expert on BK virus nephropathy. Dr. Josephson is also recognized for her work on pregnancy in kidney transplant recipients. An active educator and researcher, Dr. Josephson focuses on complications in transplant patients, including infection and bone disorders, as well as gender-specific concerns.
She's also a senior faculty scholar in the Bucksbaum-Siegler Institute for Clinical Excellence. Michelle, thank you so much for joining me today.
[00:01:43] Dr. Josephson: Well, Adam, thank you for inviting me. It's really a wonderful opportunity to talk to you about this issue, which has been front and center as I'm sort of navigating this period. I didn't know it was thought of as a third phase, but I guess that's a... Or a third part of whatever you said but I think that's a good way of thinking about it.
[00:02:05] Dr. Cifu: I'm organizing it like that. Let me start with just a, I don't know, fairly straightforward question. I feel a little bit bad 'cause I listed all your kind of specializations and accomplishments, but I'm going to put them aside and just, you know, focus on this like timeframe.
After you, we, whatever, have kind of checked all the boxes that define success in academics, you know, rank, leadership positions, publications, are there things that you find kind of challenging about this later stage of career?
[00:02:35] Dr. Josephson: Yeah. I'd like to reframe it a little bit, if possible. I don't think it's just later stage of career. I think one has to recognize this is also a later stage in your life. So... And because of that, they kind of, in a way, go hand in hand together. And there are considerations on both ends. So I think, you know, it's a transition point in my life or a lot of people's lives.
And I think one of the issues to think about is that at this point I've got a lot of experience. I've got a lot of cumulative knowledge but I'm also in a different place. And I'm thinking about what to do with it. And let me just start with the elephant in the room because I don't think I'm alone in saying this. I think that a number of us struggle with at this point in our career is with the issue of relevance.
[00:03:24] Dr. Cifu: Yeah. Yeah.
[00:03:25] Dr. Josephson: And I mean that in some ways. So part of this career is you are a little bit on the sidelines in certain areas, and as you step into the side... And some of that is intentional. You may step away from a position you had or give someone else an opportunity.
You do struggle a little bit with that issue of relevance. So I think that I don't want... And that's hard and I don't want to understate that because I think that's one of the challenges of this period.
[00:03:57] Dr. Cifu: And that is a change from the rest of the career where I think for so long, you know, you are working to be sort of front and center of multiple different things. And some people in the, you know, later stages of career just sort of stick with that. And other people do say, you know, I need to step away. I need to explore other things. I need to, as you mentioned, open the door for other people, you know, who kind of need a chance. There are only so many positions at most places but it does then change your... You know, both your job and your kind of goal, right? Because you're looking at achieving different things actually at work.
[00:04:40] Dr. Josephson: Right. And I think that's actually a nice transition to what I was just going to say which is that, or a segue, which is that I think you really have to define what you want to do, and that's also a challenge.
You know, we've been... In medicine, a lot of times we're told along the way, what we want to do. Now we really have to define it. Someone suggested that I listen to or think about some things that someone by the name of Mary Catherine Bateson, who's Margaret Mead's daughter, wrote, and she apparently wrote about composing a life. And so this is, I guess, in a sense one of those phases, you know, where we have to really, I think, look inside and compose that life. And that's a bit of a challenge. I think you have to really focus on moving forward. It's very easy to focus on looking backwards. And I think you have to be extraordinarily honest with yourself about what you value and what you want to do. You sort of have to accept, you have to sort of accept yourself. I mean, it's always helpful to accept yourself at any point along the way but I think this is a period that is particularly helpful to accept yourself and also accept that you can't do it all. And so define what you want to do. I think there are some other challenges too. I just would like to mention, you know, I'm losing a cohort.
[00:06:10] Dr. Cifu: Mm-hmm. Right, right.
[00:06:11] Dr. Josephson: Or cohorts. And I'm going to say that in several ways. I'm losing colleagues to retirement. And that's the better way of losing them.
I'll get to the other part. And I would say that Covid in a way, also accelerated that because I think there are people who retired who might not have otherwise retired had it not been for Covid. And then, you know, I've lost colleagues to death, which is obviously very painful. And I've lost patients. I've lost patients who have died, and in my work, I've taken care of patients over many, many years. And many of them are very sick. And so, you know, it's not a surprise, but many of them died, and it's very hard 'cause these are people that I cared for, worked with, and care for, for so many years.
And then I've lost friends. So it's a different phase. Look, loss is part of life. It's expected, but at this point, there's a larger cumulative loss, and you might sort of understand it. You might get a little bit used to it, but I don't think it gets any easier.
[00:07:14] Dr. Cifu: Right. I think it's interesting when I listen to you speak, and I'm going to be less impressive. Rather than quoting from Margaret Mead's daughter, I'm going to quote from Jane Fonda. So I have listened to this podcast, which I may have mentioned to you in the past, this podcast that Julie Louis Dreyfus does.
[00:07:37] Dr. Josephson: I heard of that. No, no. Someone recommended it to me. Actually, Wendy Stock recommended it highly.
[00:07:42] Dr. Cifu: So the podcast is called Wiser Than Me. The shtick is that she interviews women who are older and wiser than her, and they're all over 70. The first one on the podcast was Jane Fonda. And she talked about life as sort of going into thirds. The first third is kind of when you develop. The second third is when you achieve, and then the last third is, who knows? You kind of figure that out, but as you talk about the career, you know, the career almost becomes, you know, a microcosm of the life, right? Where at the beginning of your career, you're working to sort of grow, find who you are, find what you do.
The second part is, you know, all the achievements, checking all the boxes and stuff. And then it is the later part of the career where it's okay, you can a little bit figure out, you know, what's important, what you want to do, but it's marked with some of the same things that, you know, the last third of life is, you know. And yes, most of the loss of colleagues is to retirement and not death, fortunately, but you know, it kind of presages that a little bit.
[00:08:49] Dr. Josephson: It does. And I would also say that medicine is a team sport. And at least in academic medicine, our cohorts are really important. You know, we work with groups of people. So I think when you lose people, you sort of feel a little bit... There's a loss, you know, you're out of balance a little bit.
The group that you're maybe, you know, talking to or sort of working things through, it's different. You have to redefine yourself a little bit. And I do think medicine in some ways, academic medicine, I mean, it is... You know, it is a life, it's not just a job. And so it is, in a sense, we do, I think, maybe not everybody, but I think, you know, many of us do sink a lot of ourselves, our identity into it. And so consequently, there are these parallels. And also, consequently, this third phase where you... You're right, you're kind of... It's like you're building the plane while you're flying it. I think that, you know, all of that is true.
[00:09:56] Dr. Cifu: I thought less, I have to say, about the colleague perspective than you've talked about. And it's funny because it is something that I am aware of daily, about having to sort of make an effort to drop by the offices and visit, you know, the newer faculty members who I don't have 15, 20, 25 years of history with.
And as, you know, the cohort, sort of my age and older, you know, disappear, I'm sort of left with "Okay, you know, there aren't that many people right at my level. If I'm going to have sort of a rich collegial crowd, I got to work on that a little bit more."
[00:10:39] Dr. Josephson: Absolutely. No, I think that's a really good point, and I think it's worth working on. You know, because you absolutely learn things from people at different stages, but it's still different. And they view you differently.
And so, you know, I've been at U of C forever. I mean, I spent my career here, so I grew up with these folks. I mean, I was a resident here.
And so, you know, some of the people that were here, you know, we knew each other in the trenches, so to speak. And it's very different. There's a certain level of trust. There's a certain level of, you know, I could call them for anything, for any reason.
And all of a sudden, people are now looking up to you for advice, and you're like, "I still need advice, I still need that mentor, but oh gosh, I'm the mentor," but anyway. I mean, I think there's one other part to this I just want to mention, which gets back to that life part, which is that, I mean, I still feel very physically active and whatnot, but I'm older.
You know? So I am not perhaps as quick, I'm not as good... I'm certainly not as good on computers as my younger colleagues are. You know, maybe I'm not quite as energetic as I once was. You know, there are different strengths, which, you know, hopefully, we'll talk about, but I think that these are real things that people... You know, staying up night after night after night is not something I could do anymore. Maybe I could never do it, but I did it, you know.
[00:12:06] Dr. Cifu: One night is about all I can handle these days. So I think I'm sort of sorry, maybe I shouldn't have started with challenges. And I think we've touched on a lot of these things 'cause it seems like this phase of a career does offer a lot of opportunities. Are there specific things that you've found that you're like, "Huh! I am sort of free to do X, Y, and Z," or things that you could never have kind of imagined doing, you know, 10, 15, 20 years ago?
[00:12:36] Dr. Josephson: Yeah. No, I think that's true. That's the exciting part and the good part. And, you know, just a couple of things I'll touch on is I think I mentor better. I see the big picture. I sort of have a better perspective on things. I don't sweat some of the small stuff. You know, I would never have done this podcast, you know, in the past 'cause I would've been too scared.
This is going to sound funny 'cause you think, what could you do better, but I'm also finding it easier to not say yes to things, which is important. And so I guess what I'm finding easier is to say no to things and understand that either other opportunities will come along or no opportunity. Is that earth-shattering?
And so there is a bit of a liberation from these obligations again, to figure out, you know, to pursue what you want to do. I love working with my trainees and my former trainees. I love continuing to help them, my daughter, I love to do that. I think the other thing that I did in this part is that I took on a very big national leadership role, which I knew was time-limited. And I became president of the American Society of Nephrology two years ago, which to me was...
You know, people were just like, "Oh, weren't you so busy?" It was the best year. It was the best time because it allowed me to do things that I'd never done before, to work with new people. In this, they gave me the opportunity to write some perspectives, which was just a wonderful thing to do because it really challenged me to think and to use my right brain more than my left brain. So I guess, you know, maybe in a way, this is a period of right brain. I would say, it's important to keep a sense of excitement and wonder. And if you can do that, you know, you will find other things but you do need to do that.
You know, there's this joke that when does life begin? Right? There's the joke that the rabbi says, life begins when the kids leave the house and the dog dies. So my dog is still alive. I have a wonderful golden retriever who's still with me, but my daughter is out of the house.
And so there is a little bit more freedom to do something like... You know, I just decided to work with an international group where we're going to be exploring some issues in green nephrology, which is very exciting to me because I feel like it's nice to see, you know, the ability to move a field forward in a way, at a global level. So there are very exciting things one can do.
[00:15:18] Dr. Cifu: Yeah. And I often recommend that people earlier in their career sort of say yes to everything, right? And then you figure out what you're good at, what you like, and then you can start saying no to things. I really feel like for myself, a couple of years ago, I said, I am really only going to do the things that I really enjoy now. And I found that hugely liberating. Right? Because it sort of gives you the power to say no. Right? You're like, nope, not something for me. You know, something for someone else.
[00:15:51] Dr. Josephson: And you can give it to someone else. You could actually say but so-and-so is right.
[00:15:55] Dr. Cifu: And you seem very generous.
You're just protecting yourself.
[00:15:58] Dr. Josephson: It's both generous and self-serving at the same time.
[00:16:00] Dr. Cifu: Right. And it's good then because then you can sort of use the time for things that, okay, I want to spend time doing X, Y, or Z.
[00:16:08] Dr. Josephson: I think that point of time is critical because, you know, time is the most valuable thing we have in our lives. It always is, but it becomes that much more clear as you get older. And you really do realize this. You know, one more thing I want to mention is there may be some gender differences here. And I think for some women they may have felt, "I spent so much time taking care of my kids earlier. This is the time that I want to do some things that maybe others did earlier." So I think it depends. I think everyone finds a different focus at this point and it may really vary.
[00:16:45] Dr. Cifu: So I'll ask one off-topic question before I get to my final question for you.
[00:16:50] Dr. Josephson: Okay, sure.
[00:16:51] Dr. Cifu: I have taken care of many physicians as they transition from their career to retirement. My observation is that women physicians seem to succeed better in retirement than men physicians. Do you think that that's somewhat related? Is that because of, you know, the caregiving stuff and what's sort of pushed into later times? Women, therefore, either find their careers richer or have more to dedicate themselves to, while maybe men are defining themselves more completely by their career?
[00:17:30] Dr. Josephson: That's a fascinating question, and I probably don't have the answer, but I would say...
[00:17:35] Dr. Cifu: It's incredibly stereotyping.
[00:17:36] Dr. Josephson: No, no, no, no, but yeah, I mean, obviously, individuals are individuals, and there are men who probably thrive during retirement and some who don't, but I think that what you pointed out is absolutely an element. I also think that, and again, I'm going... This is a total stereotype, so, you know, but I think sometimes women are better at making connections and having sort of friend connections and so they're not quite as isolated maybe when they go out into retirement.
[00:18:09] Dr. Cifu: And lose the sort of forced relationships which come, you know, in a career, working every day.
[00:18:14] Dr. Josephson: Right, which, you know, are very valuable. I mean, I have a friend and a colleague. So then she says that we're frolleagues, and that's how she defines it. It's a little different. You know, you're more than a colleague. You're not absolutely a hundred percent like a friend. I'm not going to go over her house, but we're  frolleagues.
[00:18:34] Dr. Cifu: Right. I love that. So given all these opportunities that, you know, this is potentially an amazing part of a career, what do you think gets in the way of people kind of making the most of it? You know, enjoying it, being productive, you know, being able to look back and say, "Huh, you know, these, I don't know, last 10 years that I worked was sort of better than any other 10 years."
[00:18:59] Dr. Josephson: Yeah, no, I think that's really a critical question. I would sort of go back to part of answer one which is not everyone... It's sometimes very hard to define what you want to do. And so unless you can really define what you want to do, you're not going to... You know, [unintelligible] say is failure to plan is a plan to fail or fail to plan, you know, whatever that statement is but I think, you know, it is really important. And you really have to, I think, let go of the external validation. You have to let go of everything that we've lived in for decades and sort of look inwards and say, "What do I care about? What is important to me?" Not, you know, what's important to anyone else. And that can be hard because of who we are and what have been the field that we've been in. I think the other thing is that you have to be firm about saying... Even though it's easier to say no, you have to be very firm about saying no 'cause otherwise you're pulled into so many things.
And I think that the other thing which makes it hard has to do with our world as it is right now and our medical system as it is right now, there's so much noise. We have Epic, we have emails, we have... You know, everything's coming at you continuously. And so it's just, we live in a world of distraction and it makes it really easy to just do what you're being distracted by and to avoid really putting the effort into what you want to do. You have to be intentional.
[00:20:40] Dr. Cifu: I think that's really well said. I was going to say, it makes it really easy to do nothing, and you're not doing nothing, but you can sit at your desk and sort of answer Epic notes sort of as they come in one after another. And if you do that, you know, by definition, then you are not, you know, accomplishing anything else. You're accomplishing good patient care or maybe somewhat more rapid patient care, but there is a cost to that.
[00:21:05] Dr. Josephson: A hundred percent. And it's hard. So I happened to chat with a friend who was a resident here many years ago. And we were talking a little bit about this transition, 'cause I think, you know, it is an issue that a number of people in my age bracket, whatever, are thinking about and facing. And what he said I thought was interesting. He said, "You have to be able to distinguish between urgent and important." And there's just so much urgent in our lives but you have to really be able to focus on what's important. Not that you can't get to the urgent stuff, but you got to really prioritize the important.
[00:21:41] Dr. Cifu: I'm working on a piece for our Substack, which I think gets to a less interesting but maybe more concrete issue. It's sort of the issue of funding at this time, you know, in our careers because a lot of times when you give up things that you don't want to do, you give up, you know, the salary support for that. Right? And you're left with a possibility of like, well, also, if my salary support gets made up by just seeing more and more patients, then you certainly don't have the space for these other things. And I wonder if there should be more of an investment in people at this stage of their career to be, you know, senior researchers, senior educators, senior administrators. You know, because a lot of these people actually have an incredible amount to offer. And if that's, you know, for a half day a week, you sort of go from office to office and brainstorm with people, that may be more impactful than a lot of the things we've done in our careers.
[00:22:46] Dr. Josephson: Yeah. I love that idea. I think you're a hundred percent right. I think there is for sure an understandable emphasis on protecting time for junior faculty to allow them to develop but I do think that there is something that we're losing when we're taking our senior faculty, whose strengths may be other than a business model strength of just cranking them out, seeing more patients, and thinking about what strengths do these individuals have to offer. And I think there are a great number of strengths but maybe it doesn't work so well in the business model of medicine these days.
[00:23:25] Dr. Cifu: Maybe we'll make an argument that some portion of the shrinking indirects will go to support late-career faculty members.
[00:23:33] Dr. Josephson: Great idea. Never happened, but great idea.
[00:23:36] Dr. Cifu: We'll see how far that goes.
[00:23:37] Dr. Josephson: Not very, but I love it.
[00:23:39] Dr. Cifu: So, Michelle, I just wanted to thank you so much for sitting and talking with me. I think this was both a great conversation and a great way to sort of finish our season with an injection of wisdom out there into the world.
[00:23:51] Dr. Josephson: Maybe a little humor too.
[00:23:53] Dr. Cifu: Yeah. So, thanks for joining us for this episode of The Clinical Excellence Podcast. We are sponsored by the Bucksbaum-Siegler Institute for Clinical Excellence at the University of Chicago. Please feel free to reach out to us with your thoughts and ideas via the Institute webpage at bucksbauminstitute.uchicago.edu.
The music for The Clinical Excellence Podcast is courtesy of Dr. Maylyn Martinez.