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Dr. Lane has just finished her first year in a hospitalist group. Confident that her clinical skills are improving and enjoying the patient interaction, she knows she picked the right field. The Director of her hospital medicine group meets with each of the hospitalists on an annual basis to discuss performance and career planning. In preparation for the meeting, Dr. Lane has been asked to bring with her a list of one-, three-, and five-year goals. This has created quite a bit of anxiety for Dr. Lane. She knew that she wanted to continue in hospital medicine but had not really considered concrete goals beyond securing a job after residency.

Planning for a career in hospital medicine does not end with securing a hospitalist position. Rather, your professional development is an ongoing process that will lead to both anticipated and unexpected opportunities and rewards. While unexpected opportunities cannot be foreseen, the wise hospitalist plans in advance to ensure selection as the recipient of the anticipated opportunity or reward. Hard work without a goal only guarantees that you will be working hard. Without clear direction, you can toil for years without advancement in your career. With focused effort toward appropriate goals, you can use that hard work to find satisfaction in your career. After reading this chapter, you should have a basic understanding of types of goals, how to set an appropriate goal, and how to achieve that goal despite distractions.

What Are Goals: Introduction to Goal Theory

Goals are our mental representations of outcomes that we want and are committed to achieving [1]. When you think of a goal, you think of yourself in some future state like as a Chair of an important committee or partner in a hospitalist group. Though the mental image is important, the true essence in setting goals is to commit to achieving the mental state. This willingness to work toward a certain state affects how we work. Goals focus our attention toward certain activities and away from distractions. Hard work becomes directed and thus, useful. Goals also can increase motivation. By identifying a goal, the work done toward that goal becomes measurable. By seeing progression, motivation and satisfaction can increase. This motivation can also increase our persistence in working toward a goal. Studies have shown that people put in more worthwhile time working toward a goal than they otherwise would toward non-goal activities [2]. Finally, by pursuing goals we can uncover new knowledge that can make achieving future goals easier [2].

Dr. Lane thought about her 5-year goals. The practice had recently created a RVU-based bonus structure. She envisioned herself as a successful hospitalist earning bonuses because of excellent RVU productivity.

Types of Goals

There are several types of goals to consider when planning for the future. One way to define a goal is whether it approaches or avoids an outcome [1]. An approach goal is one that seeks to move toward a desired outcome. An example of an approach goal is trying to generate enough RVUs to get your maximum annual bonus. Avoidance goals try to move away from an undesired outcome. An example of an avoidance goal would be to bill just enough to avoid being fired. It is often more difficult to achieve avoidance goals because clear goals of success in avoiding the outcome are nebulous. When creating your goals in this way, be deliberate in choosing approach goals.

Considering the amount of risk is also important when planning for a goal. Risk taking may improve goal performance by inspiring higher achievement [3]. However, choosing a goal of higher risk may increase the riskiness of the strategies used to achieve that goal [3]. An example from the financial world would be using riskier stock trading strategies to improve profit. These strategies might increase profit but also may increase the chances of losing money. The balance of risk and reward must be considered when creating goals. After selecting a goal you must then create a framework for goal achievement.

Goal Setting Strategies I: The S.M.A.R.T. System

There are many types of strategies to achieve goals. One format that can be applied utilizes the S.M.A.R.T. System, which places the goals in a framework that makes attainment easier [4]. S.M.A.R.T. stands for Specific, Measurable, Achievable, Realistic, and Time related or time bound. Each goal should delineate a specific area which needs improvement. This step encompasses the what, why, and how of the S.M.A.R.T. model. Without being specific in your goals, your goals will be vague and difficult to assess if achieved. The goal should also be specific in how much that area should be improved. The goal should be measurable and progress toward the goal should be quantifiable. Goals that are not clearly measurable are impossible to assess for success or failure. The goal should be achievable, meaning you should choose a goal that you are actually capable of attaining. The goals should be realistic and relevant with a clear purpose. Finally, a goal should be time related, meaning that there should be a due date to achieve the goal. This allows for creation of a timeline to achieve the goal. The strength of this system is that it allows for goals that are readily achievable and helps gauge how much time to spend on them. These goals are also easy to communicate to others.

Dr. Lane considered many goals for her overall 5-year plan. However, she also knew that she had pressing day-to-day matters. Her state licensure needed to be renewed in 9 months, and she had not performed any of the CME in order to renew it. She needed to complete 50 h of CME in the next 9 months or be unable to renew her license. Using the SMART method she planned this goal.

  • Specific: To achieve 50 h of CME in the next 8 months.

  • Measurable: Plan to go to grand rounds (1 h) 2 times a month and do 1.5 h of CME every week or 6 h a month. Total time 8 h every month.

  • Achievable: Will plan time in schedule to go to grand rounds and move schedule to open time to attend. Have already joined two professional societies so will use CME in those societies and one journal as a basis for fulfilling requirement.

  • Realistic/Relevant: Goal is necessary to renew license to continue practicing medicine.

  • Time related: Will plan to achieve goal in 7 months. Will review total CMEs at end of each month. If deficient in 1 h will add to next month if deficient in 2 h will add 1 h to next 2 months if deficient in more reassess goal strategy. Will set aside time on first day off each week to spend on CME time. If not halfway point in 4 months will reassess strategy. Will leave month 8 for catch up.

The weakness of the S.M.A.R.T. System is that goals that are distant or aspirational do not fit neatly into this system. If one has all the skills, then the SMART system allows for time planning toward a goal. However, the truly transformational goals often have large gaps and do not fit well into this system. The question is “How to achieve a dream goal?”

Goal Setting Strategies II: The B.H.A.G

The answer is through a system called the Big Hairy Audacious Goal or BHAG [5]. The purpose of this system is to help navigate a goal that is transformative and often daunting. These goals are very difficult to achieve because the skills needed, timeframe, and measurement of progress can be unknown. The BHAG system first looks not at the objective to achieve the goal but the obstacles standing in the way. Each obstacle blocking access to the goal is outlined and ordered chronologically. An intermediate objective to solve each obstacle is then put in place. This directs work toward solving each objective. As each objective is conquered the overall goal is closer to achievement. Once all objectives are achieved then so will the overall goal. The strength of this system is that a larger problem can be broken into smaller achievable goals [5].

After much consideration of his career plans, Dr. Lane realized she would very much like to be involved in resident education and set a 5-year goal of becoming an associate program director. However, she had no idea how to achieve this goal. Using the BHAG method she tried to come up with a plan to become an associate program director.

  • Overall Goal: To become an associate program directory for the Internal Medicine residency program at my new institution (Table 5.1).

    Table 5.1 Pathway to associate program director
    Full size table

Goal Striving : Tips for Improving Goal Success

Goal Striving I: Planning

Once a goal has been set, the process of goal striving can begin. This is the process taken to achieve a goal. One important aspect to recognize when striving for a goal is that there are multiple paths to achievement. If intermediate objectives or specific goals seem very difficult using one avenue, they may become significantly easier using a different path. This mental exercise demonstrates one of the first steps toward goal striving, or mental planning [1]. In the process of planning for the goal, you may also have the ability to anticipate challenges before they occur. These challenges may then be added to list of obstacles and goals set to overcome them. An important part of planning is timing and chronologically arranging goals. This will allow you to decide which goals to work toward first. It will allow you to push goals that seem distant or more difficult to achieve until later, and will give you time to learn strategies that allow easier completion of the goal.

Dr. Lane knew that some goals, like becoming more involved in the residency would take time, so she started working on becoming more involved as a teaching attending. She knew that she wanted to become a better instructor so she began to plan presentations for the students. In addition, she planned to go to morning report. She emailed the residency program director and asked to help with resident activities. She planned to use the time getting CMEs to find those pertinent to medical education.

Goal Striving II: Goal Habits

The next strategy to improve goal attainment is to make the behavior involved in goal striving automatic. Making behaviors that lead toward goals automatic affords several benefits. First, you can work toward goals without putting in significant mental effort each time. Choosing when to begin any task is difficult. Automating this cue allows us to start to develop habits that improve goal attainment [1]. For example, doing CME for one and half hours each week on the first day off. Though it is not enjoyable to work on CME, it is difficult to procrastinate when the time is set. Automating goal striving allows good habits to form. These habits help propel one to goal achievement.

One of the most difficult things for Dr. Lane was finding time to read journals for her CME. She wanted to read them as soon as she awoke on his days off, but she was too tired. In addition, she had numerous errands to run and procrastinated reading. As a result, she consistently fell behind on her weekly reading goal. She decided that the easiest way to carve out time was to do it at night. When her day off arrived, she would finish her errands. Instead of watching TV at night, she read the literature. This improved her ability to complete CMEs and soon was hitting her goal for both reading and preparing teaching material for the team.

Goal Striving III: Maintaining Motivation

Setting a goal has been shown to increase motivation. However, motivation is often difficult to continue during the long process of goal striving . As the distance toward the goal remains great, fatigue and disappointment can set in. Keeping motivation high when the goals are distant can be difficult. Research has shown that setting proximal goals can improve goal striving and motivation [6]. Goals that are almost achievable elicit effort on our part to achieve them above what we would normally contribute [6]. When goals are distant, our natural tendency toward procrastination increases. Proximal goals create a sense of urgency and keep motivation and persistence high. This is the benefit of setting deadlines for yourself. Deadlines create a sense of urgency and motivation to complete goals. By creating deadlines for yourself, goal achievement increases.

Knowing what motivates us and our tendencies toward putting off distant goals can help us plan and strive toward goals more effectively [6]. This is even more important because research has shown that motivation itself is not infinite [1]. Our motivation depletes as we seek to remain focused on our primary goal. Since motivation is the driver for goal achievement, it must be preserved. Planning for a goal allows you to focus your motivation on areas that will lead to goal achievement. Setting up goal achievement habits allows you to automate and decrease the conscious motivation in goal striving . Finally, setting proximal goals can give the extra burst of motivation to achieve a goal. Using the goal striving strategies can improve your chances of achieving your goal, but how do you keep motivation high when you did not choose the goal?

Dr. Lane was meeting her deadlines for her CME as well as preparing presentations for the residents. She was able to make it to grand rounds and felt confident that she was progressing toward her goal. Recognizing Dr. Lane’s high aptitude for teaching, Dr. Lane’s hospitalist director assigned Dr. Lane the task of creating a new hospitalist curriculum for physician assistants (P.A.’s) in the group. Dr. Lane would be monetarily incentivized for her work; however, Dr. Lane recognized this assignment would require a significant amount of effort and time on her part. Unsure of how she would work this into her already busy schedule, Dr. Lane began to plan for this goal as well.

Goal Striving IV: Goal Conflict

Your personal goals and those attributed to you by others may not align. This problem is known as goal conflict. Goal conflict can undermine performance on our primary goals if it motivates movement toward contrary goals [2]. This can be difficult, especially if the contrary goals are important as would be the case if your hospitalist director assigned you a new task. The fact that both goals are important and competing for time can make choosing which goal to pursue more difficult. Though mentally it is difficult to work on two goals at once, research has shown that when the motivation to work toward goals is self-determined, goal conflict is lessened [7]. That is to say, when we choose which goals motivate us and focus on those goals, our motivation remains high in the face of contrary goals. Using the goal striving strategies above can also help increase motivation. If you realize that, then both goals can exist together and can be achieved through planning, habits, and setting proximal goals. Though you may not be able to strive toward both goals simultaneously, organizing them so that there is protected time may improve attainment. If you feel as though you are progressing toward both goals, the sense of conflict decreases. Though you have little choice in goals assigned by superiors, it is important to avoid choosing too many goals. Therefore, before taking on additional responsibilities or goals, it is important to judge if they will come into conflict. If there is a chance of conflict, careful planning should be used to minimize it; otherwise, you run the risk of feeling overwhelmed. In Dr. Lane’s situation, she believed she could indeed meet the expectations of her hospitalist director without sacrificing progress on her own goals.

Dr. Lane reviewed her presentations for the P.A.’s prior to giving them. However, she noticed that the P.A.’s asked questions that suggested they did not understand the presentations. She reviewed her presentations and went online to look at P.A. textbooks to try to find appropriate topics. However, nothing worked, and she was unsure how to tailor the presentations to improve understanding. She decided to ask one of the lead P.A.’s to sit in on the presentations so she could offer advice on how to change the presentations. In addition, Dr. Lane developed a short survey for the P.A.’s to complete after presentations in order to gauge the effectiveness of the presentations.

Eliciting Feedback I: Feedback Sources

Feedback is vital to goal striving . An important aspect of working toward a goal is judging the progress toward goal completion. Both internal and external feedback help assure that we remain on track and effective in pursuit of our goals. When you review your goal progress weekly, you are eliciting internal feedback. Internal feedback helps ensure that the idea of the goal has not changed and progress is being made [2]. However, for objective evidence of progress external feedback is vital. This feedback can be given by several people including your direct supervisor, colleagues, and mentors. Physicians crave feedback and research has shown that even interns have this need [8]. Feedback-seeking behaviors should continue even after residency. This provides an opportunity for hospitalists to gain insight into performance and perceptions of performance by hospitalist directors. Other sources of feedback are also helpful as feedback from a single supervisor may not provide adequate information to a junior physician. Incorporating the use of 360° evaluations, or multisource feedback, can be a powerful approach to gain additional feedback. These questionnaires can be given to colleagues, patients, and other healthcare providers. They generally cover the five areas of professionalism, clinical competence, communication, managerial relationships, and interpersonal skills. These evaluations can help fill the gaps in feedback and offer different insights than that of a single manager [9]. By using multiple sources of feedback , quite a bit can be learned and your progress toward improving clinically and educationally can be ascertained.

Dr. Lane was concerned. Though she received a good review at her annual meeting, she still felt like she was having trouble progressing toward the goal of Associate Program Director. She approached a senior hospitalist, Dr. Matthews, who previously worked in the education program. He offered to meet with Dr. Lane to discuss her goals and strategies to achieve them. After the meeting, Dr. Lane felt like she had her questions answered and had new ideas for reaching her goals. She wanted to meet with Dr. Matthews regularly for advice and he agreed to be her mentor.

Eliciting Feedback II: Mentorship

Mentorship is invaluable in a hospitalist’s career development . Mentorship brings with it the benefits of career satisfaction, protection against burnout, sufficient opportunity for promotion, and a more productive career [10]. Unfortunately, given the relative infancy of hospital medicine a plethora of seasoned mentors may not be readily available at your institution. In order to find a mentor there are several options consider. If seasoned hospitalist mentors are not available, look for physicians with similar interests. For instance, a veteran surgeon who is intimately involved with decreasing central line associated blood stream infections (CLABSI) may be a good mentor if you have a similar interest in CLABSI. Alternatively, you can seek out a mentor who has served you well in the past even if they are in a different institution. An additional way to find an appropriate mentor is through hospitalist societies like the Society of Hospital Medicine. In order to get the most out of the mentor–mentee relationship, the mentee should keep several points in mind. They should be clear in expressing what goals they have and what they need from the mentor to achieve them. They should be prepared and come to each meeting with a list of questions and take adequate notes. In addition, the mentee should update the mentor on the progress toward goals since the previous meeting. This will allow information to flow smoothly and the relationship to remain positive. The mentee should also elicit feedback and advice from the mentor as this makes the process easier and more productive [11]. Finding and building a strong relationship with a mentor is a critical piece in providing feedback when striving toward a goal.

Conclusion

Goals are essential to turn a job in hospital medicine into a career. Goals can be simple or complex, but with the proper planning and goal striving strategies, any goal is achievable. However, the journey does not end when a goal has been achieved. Goal setting is a cycle. Once one set of goals is complete another should already be planned. Just as your dreams change with time, your goals will evolve as you achieve them. This can allow your career to grow in the way that you choose and bring you much satisfaction through the years.