K Chris McMains on identity formation
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Stacey Ishman: [00:00:00] Great. Welcome back to the Academic Medicine Strategy podcast. I am super excited to have Chris McMains with me here today. One, because he's doing amazing work around physician identity, and two, because we have been friends for more years than I'm gonna say, but since we were residents. So we worked on the resident fellow section together at the American Academy of Otolaryngology, and one of the best things I pulled out of that was a friendship with Chris.
Stacey Ishman: So thank you for being here today.
Chris McMains: Man it is a longstanding and mutual joy, so thank you so much, Stacey. It's I am a fan of the work you're doing and grateful to be able to have a small part in this, so thanks.
Stacey Ishman: Thank you so much. Now tell everybody who you are, where you work, and what we all know you for.
Stacey Ishman: Tell us how you got into professional i- physician identity. But tell us who you are.
Chris McMains: Yeah. I'm an ear, nose, and throat surgeon by training, and live in San Antonio, Texas. Have been involved in resident education for, I know we said we weren't gonna say this, but over 20 years now.
Chris McMains: And but the academic titles I hold are [00:01:00] Professor of Surgery for the Uniformed Services University as well as the Professor of Health Professions Education at Uniformed Services University. I work ... My, my day job's at the VA in San Antonio, so I'm a full-time VA employee. I'm also an Army reservist, so I serve in the country in a couple ways there.
Chris McMains: And my longstanding interest in, in, in professional identity formation led me into to PhD work. And what I studied was the career arc of professional identity a- across the, the life cycle of academic physicians. And that's really where I draw a lot of the insights for the, the work that I'm trying to get started and doing more and more of these days.
Stacey Ishman: Okay. So tell us how you got drawn into a PhD. Sorry, give us a little bit of the story, like what was the motivation to say, "I need to take this to the next step"?
Chris McMains: Yeah. One, I'm a glutton for punishment. And but two, target of opportunity in this, in, in part.
Chris McMains: So I had, I'd started doing a, a significant amount of faculty development work, and at the time was was running faculty development the main efforts at the hospital level for the, the San Antonio Military Medicine education [00:02:00] platform. And a really, most of what I had done and most of what I had published in that space was kinda self-directed, kinda autodidact stuff.
Chris McMains: And I know Donald Rumf- Rumsfeld takes a lot of stick about his unknown unknowns comment but there really is something to it and I recognize that there were probably a lot of unknown unknowns out there for me. And had the opportunity as Uniformed Services was standing up a department to begin work there and one thing led to another.
Chris McMains: I got permission from my family to convert a master's into a PhD and after many years was able to complete that work and with the results that we'll talk about some today.
Stacey Ishman: No, I love it. And clearance from the tower is always important to do all this work.
Chris McMains: Absolutely.
Stacey Ishman: So let's start off with what part of your work on physician identity would you most want an audience of chairs, deans, and faculty leaders to hear about?
Chris McMains: So there are a couple things. So number one, that there, there are some pretty characteristic identity challenges that happen at different points in the career life cycle.
Chris McMains: So when [00:03:00] somebody's a newly minted faculty person, there's a whole flood of new roles that they're trying to get to grips with. And with that, probably feeling inadequate a- about trying to figure out where their direction is, where they fit, do they fit. And so that's a, a time of real identity tension for folks.
Chris McMains: And for those who are able to get through that or resolve it successfully many will then go on mid-career and start to take on some other roles, whether they be leadership roles at their institution, whether they be larger educational roles. And some of those things start taking up enough of their time, enough of their energy en- enough of their creativity that they actually have to start releasing some of the roles that had become so important earlier in the career.
Chris McMains: And that transition or that release i- is another place of some pretty significant friction. And so some of the things that come up really strongly in the data were the importance of belonging- and how that can shape this process both early and in this mid-career.
Chris McMains: And then finally, as people can reach [00:04:00] the end of their career, this, this sort of ecosystem of identities that they may have developed within that work setting it's not just, it's not just retiring, but it's it- it's potentially disrupting all of those in a way that can be really hard on some folks.
Chris McMains: And the big idea to me that, that stands out as so powerful is this idea of belonging, and that for most of how we self-identify or how we're identified in our institutions we're appreciated for... We have a sense of belonging in, in a contingent way, in a way that's, it- it's dependent on my productivity, my, my education, my publications, my grants, what- whatever it is and that's really different from what's unlocked by allowing somebody or messaging in a deliberate way about a non-contingent or an intrinsic sense of belonging.
Chris McMains: You belong here regardless of what you're producing. And what can come out of a person in terms of the cre- creative output and frankly, [00:05:00] their wellbeing is just radically different based on that.
Stacey Ishman: Okay. I resonate with so many of the things you just said. It's fantastic. One of the things I work on a lot, I think you know, is the career Kickstarter stuff.
Stacey Ishman: It's some of the, the workshops that we do, and it's a course that we have, and the goal is really to help people relate to what they believe so that they can start a career that actually aligns with their values, which I think we don't do a great job of. I didn't do a great job of at the beginning. But I'll also say my mid-career, I made a pivot and I went from one institution to another, and there was a junior faculty person who started asking me about my family.
Stacey Ishman: And I had this very mistaken idea that my life at home was separate from my life at work. And I didn't, actually didn't entertain the question, and I was like, "Hey, if we're out somewhere, I'm happy to talk about my family, but I'm here to work. I'm not about that."
Chris McMains: Yeah.
Stacey Ishman: And it was such a lost opportunity.
Stacey Ishman: I'm telling you, this person probably taught me the most that I ever learned, 'cause it wasn't the best relationship, but I was the problem and didn't realize it, that understanding how to bring [00:06:00] my whole self to that job and that relationship was where I got lost. And I had this identity of myself that was different than my identity at work, and that at the point at which I was able to put those together, I have been so much better in terms of happiness, in terms of belonging for sure in terms of leadership by far.
Stacey Ishman: So how do you help people reconcile those different pieces when they're coming into some of these roles, whether it's the mid-career level or the early career level?
Chris McMains: Yeah. I think there are a couple of pretty important elements of that. So one is that, Every single environment that people are gonna be listening to this podcast find themselves in aren't actually gonna be safe to bring their whole selves to work.
Chris McMains: And you know- Yeah ... I wanna just acknowledge that straight away. If somebody is not feeling like that's something that can do, that may not be their issue internally. That may be a leadership issue, and actually some of the work that I'm trying to do is lean into department chairs, division [00:07:00] chairs, and, DIOs, and, how do you work deliberately both on this idea of intrinsic belonging to message that in a deliberate way, but also- what internal work do these leaders need to do so that they don't represent an identity threat? So I think that, that's from the leadership standpoint there's some... I don't want to represent an individual, "Hey, you should be doing this. You should be able to do this in all circumstances," 'cause that is, I- Yeah
Chris McMains: I think that would be unfair, and probably we've all been in situations where leadership has not been conducive to that. So with all that, my long-winded caveat that, I want to call it a, an, an artificial separation between identities is one of the things that I think really causes people some of the most tension and sort of chips away.
Chris McMains: It's kind of the death of a thousand cuts, ... because people are always having to spend energy on self-monitoring. What's it safe for me to say? What can I say? What can I not say? What's it-- what's professional to talk about? What's not professional to talk about? And just the, the sapping of energy that takes [00:08:00] over time, it is really damaging.
Chris McMains: Sounds like it was for you, has been for me and I think we all know-- we can name dozens of other colleagues who have felt similarly. And so within this, this idea of professional identity, one of the things that's important I think to understand is that we're not talking about a singular identity.
Chris McMains: We're talking about multiple identities, multiple professional identities, clinician, educator, researcher, leader mentor, you name it. But those also then work with our personal identity. Whether those be mother, sister, daughter, whatever the identities are that you claim, wife.
Chris McMains: And similar galaxy of those things for me. And recognizing that those aren't necessarily intention. I think one of the things that gets map-misapprehended in this conversation about work-life balance is that the things that happen in work and the things that happen at home are intention and competitive.
Chris McMains: And I think that doesn't actually do justice to either. There, there's some ways, you and I have talked a, a bit about, my family dynamic and I've got a daughter with [00:09:00] special needs and how the, the I would say the tenderness and the brokenheartedness that has come with that has really enriched my ability to be a physician, a surgeon, and a, and an educator.
Chris McMains: And similarly there are some things that I do that I am able to do and be at home that get nourished by the, the work that I do you know, away from home. And that, that idea of these not necessarily being in tension and competitive but if we can find a way to integrate those identities, there, there's a lot of richness and power there.
Stacey Ishman: So tell me a little bit about the work you're doing with leaders. Like, how do you help them? First of all, how often do you come into a situation where they need to recognize that they need to do the work? And then let's say they understand they need to do the work, do you have a program that does that?
Stacey Ishman: Or how do you bring them through it?
Chris McMains: The, a lot of my work over the last six months has been building a suite of instruments and also workshop material aimed at addressing these [00:10:00] characteristic identity challenges. And I guess for one what I'd say is that, I have all compliment and honor for the chairs that actually choose to do this work.
Chris McMains: Because, in some ways that's a recognition of my department, my, whatever my unit that I'm responsible for that I can bring a better me to that as well. On the one hand there's a lot of leaning into, and we've got some instruments around belonging and where people are with respect to their sense of belonging and how that is either nourishing or inhibiting their trajectory of identity growth.
Chris McMains: And then there's actually an ask to do some internal work there too. Let's look at, what programs for success have led you to where you are, and where the limitations of those are, and how that, those things might be e- even in, in a subconscious level be creating conditions that are difficult for the people under, under your wing, under your care to actually feel like they belong and feel like they can thrive.
Stacey Ishman: And one of the things you have written about is the [00:11:00] controlled burn, and it's about, have we, as we change these professional identities, whether it's managed well or managed badly. So what does managing it look like, and, where do departments make it harder without realizing it?
Chris McMains: Yeah so the, the metaphor of the controlled burn it's taken from forestry and, and so for the longest time people thought, "Oh, we can't let anything burn because, forest fires are bad." As I'm in a geography today where, it's been, subsumed by Canadian smoke in the last week or so. This I think is on a lot of people's mind. But, the way that, that forests are renourished is actually and kept from having these super destructive super fires are by routine burns to clear out the underbrush.
Chris McMains: And the, the metaphor sort of leans into as we go through our careers, it, th- there are these identities that we take on sometimes without deliberate exploration. And, that particular paper was looking at end of career and as people are thinking about transitioning away from full-time clinical practice.
Chris McMains: W- what are the things that [00:12:00] need to be identified, need to be examined, perhaps need to be put the flame to a little bit to allow that transition to happen in, in, in a healthy way? And so really being deliberate about what are the, what is the ecosystem of identities that have come together to give me a sense of belonging, to give me a sense of mattering?
Chris McMains: And to get out ahead of that conversation. Say, what changes can I make? What things actually do I need to release, and what things do I want to try to preserve in some way? And I have to say, one of the things that was really powerful as we were doing this work, Stacey, was that- it occurred to me that we've got language that ennobles, this task of being a physician, this task of being a surgeon.
Chris McMains: We've got this special contract with society, and this idea of obligation to patients above self in some cases, and this sort of self-sacrificial work life that we have. And there's no language that ennobles leaving that. There's no rituals that have any kind of emotional [00:13:00] valence that, help people to lay down that mantle.
Chris McMains: And so a lot of the thinking and work that I've been doing recently, and again, some of the work that I'm trying to do with leaders as well, is to let's think about, one, how rituals work and how, two, how we can employ rituals to help people through these transition times to give it some emotional freight.
Chris McMains: I guess the way to say it is we've got a white coat ceremony that works in a ritual way to bring people within the fold, but we don't have anything that works similarly for people to lay it down.
Stacey Ishman: No, I love that conversation. When I left the last academic department I was in, I actually really had a hard time for the fact that there was no fanfare for it.
Stacey Ishman: There was no goodbye party. There was no announcement. I didn't get to wave the flag and thank the people and it was a style choice that was chosen by a, a d- a different person than myself. But I felt like just that would've helped me retain more of a sense of belonging with that group than I had by just leaving and [00:14:00] going to the next job in the institution that I went to.
Stacey Ishman: I moved into a medical director of utilization management, and it felt bad. So it makes a lot of sense to think, whether it's retirement or shifting into administration or whatever you end up doing the ceremonies mean something. And I love the idea of creating something more universal for you to leave a position.
Stacey Ishman: 'Cause I did have a lot of identity stuff going on right around then, and it took me a while to figure out. And of course, the beauty of having a lot of teenagers is my teenage son then would poke the bear all the time and say, "Remember when you used to be a doctor?" And I was like, "I am still a doctor."
Stacey Ishman: But, he turns 17 tomorrow, and it's still something he likes to... Luckily, it doesn't hurt anymore, but it hurt for a while
Chris McMains: Yeah, for sure. And what you highlight, Stacey, is like and this is-- there's a fellow named Bridges that writes about this, and it's the psychological process of change.
Chris McMains: And the thing that's counterintuitive and is universal is that any change, even one that we're looking forward to, even like... So let's say this utilization management was a dream for you. ... Like even something you're looking forward [00:15:00] to, any change begins with a loss. And then what follows after that loss is what they call a, what he calls a liminal space or like this transition time, and so there's this time of you don't yet have the energy of the new thing or the sense of belonging in the new thing, but the old thing's gone. So it is this prolonged time of discomfort that honestly people don't talk about this. All you... When people talk about change it's, it almost...
Chris McMains: I don't know your experience, but my experience is it's almost universally a rah-rah, let's have a pep rally, and let's get behind this thing, without actually acknowledging the loss that people are feeling that are preparatory to being able to move into that change, and I think that's an, an important part and part of why and how rituals can be so important and so valuable in these transition times.
Stacey Ishman: I love that you just brought that up. I literally just used that whole framework to work with a department whose division chief was leaving, and they were trying to figure out what did that mean for the group, and what did the vision look like? And we [00:16:00] started with that. So everybody felt comfortable in the uncomfortable space that's in between, so you don't rush through it.
Stacey Ishman: 'Cause I think it's the natural inclination is nobody wants that discomfort, but you need to sit in it for a little while in order to actually healthily move through it.
Chris McMains: Yeah, and it doesn't happen at the pace of a Hallmark movie, it's not like at the end of an hour and a half, you're like, you get the soft glow and the whole thing.
Chris McMains: I'm like, sometimes that's a months-long process- Yeah ... of searching and that discomfort really is, as unwelcome as it is and as bad as it feels, can be really generative in terms of sharpening our sense of what we're going to and what we need to go to.
Stacey Ishman: Yeah. No, I love that. I know we're running towards the end of our time.
Stacey Ishman: I am really passionate about faculty retention. I think part of it's by setting up people at the beginning in a way that they feel that sense that they're doing what they love and that they're moving towards their own goals and not somebody else's. And I think your sense of belonging conversation is really important for people to feel like they wanna stay, even when things are a little bit hard, or the RVUs are all [00:17:00] we're talking about, or the trainee isn't your favorite one to work with, whatever it might be.
Stacey Ishman: But for a chair or a dean who's listening, what's one structural thing that we could put in place that supports identity and retention before somebody's already in crisis?
Chris McMains: Yeah. So the thing that occurs to me is just this recognition that this professional identity arc is happening, becoming is happening.
Chris McMains: And the question really is how deliberate do you wanna be about that trajectory? Do you want that to happen passively or do you wanna engage with it? And so the question is what deliberate architecture are you working to put in place, whether cultural signaling of belonging, whether it be rituals that you're developing around these transitions?
Chris McMains: What deliberate actions are you taking that are gonna help your faculty thrive, both in that liminal space, but also to supercharge their growth as they come out of that liminal space [00:18:00] into the next phase of their identity growth?
Stacey Ishman: When you talk about that, it sounds really great, but if I'm the chair, is that we have a welcome party when you walk in the door so you feel like you know everybody?
Stacey Ishman: Is it I assign you to a mentor so you have a space to belong? Is it that we create affinity groups in our hospital so you can find people who have similar thoughts? What is it? Give me some concrete things people could do.
Chris McMains: Yeah. So this is one of those things about which the the, the car manufacturers will say actual mileage may vary.
Chris McMains: ... But by which I mean, I think that the things that are gonna be meaningful to different individuals, individuals are individual. And so this is not gonna be a one-size-fits-all solution, but I think putting this in the conversation, making the... any of those I think would be efforts that could potentially resonate with folks, but getting a sense from people.
Chris McMains: So here's one of the things is that I hear a lot is that people say early on in your career you just need to say yes to everything. And that feels to me like, it's, it pretty potentially damaging [00:19:00] advice, and and I know you've written about this some, even recently.
Chris McMains: And what can the individual leader do is actually get to know their faculty member enough so that they can have a sense of what's gonna feel meaningful to this person. Where are the friction points where they're not feeling like they belong, where they're feeling like an imposter?
Chris McMains: Is that a conversation, and again, I know your director of education has just, published a book on imposter syndrome and and I'm a big fan. Imposter syndrome to me feels like a, it's like a resource, right? Like- Yeah ... one, it tells me that somebody has enough insight to know that they're not yet the fully fledged professional they hope to be, and also they care enough about that, that it bugs them.
Chris McMains: Yeah. And so that's an actual resource. And so figuring out, w- what messages are they receiving and how can you shape that narrative in ways and so that, that... And so again, that may c- take the form of affinity groups. It may take the form of a specific mentor that that, that leader knows.
Chris McMains: There are any number of things there. It may be that there, there, [00:20:00] there are rituals that have some emotional valance either on the onboarding side or the transition side, the leaving side that just help communicate that, each of these people who's under my care, who's in my charge is valuable and valued, and that isn't in a contingent way, that's an intrinsic value that they belong here with us, and I'm just trying to help them to thrive and become the richest professional, the richest educator, the richest clinician that they can be.
Chris McMains: And I don't mean that in financial terms, though hallelujah if that happens for all of us. But I mean that in terms of life experience
Stacey Ishman: Nope. Thank you so much for that. For those of you who don't know, Kirsten Bombdiggity is my director of education and she wrote a book called Imposter Syndrome is a Growth Spurt which I couldn't agree with more.
Stacey Ishman: I really think that sitting in the discomfort is one of the things we are not taught. Although for me, when I'm uncomfortable, I've always known that I'm learning something and it's good, but it starts off feeling really hard. And I love the idea that there are some important yeses that are not things that you necessarily would [00:21:00] naturally want to do.
Stacey Ishman: Like there are some service things that we say yes to, but saying yes to everything is terrible advice, and I am the poster child for somebody who did it, and I give this story a lot. I was on five editorial boards at one point. You do not need to be on five in order to get promoted or show you have natural recognition.
Stacey Ishman: And I didn't like any of them. I didn't get any personal satisfaction out of them. I actively disliked it. And one of the best days of my entire life, I became chair of the Board of Governors for the American Academy of Otolaryngology, and I was gonna be on the board of directors, and I was sitting on the executive committee.
Stacey Ishman: And I finally felt like I could say, "No, thank you." And I resigned from all five of them in one day. And found a way to get rid of my associate editor position to somebody else who I sponsored and was excited about it. But it was absolutely an offshoot and like for a couple years of me feeling like I had to say yes to everything.
Stacey Ishman: And it was terrible advice for me. And I was glad that I could figure out, Eventually [00:22:00] that you didn't have to do that, and also not give that advice to people, because it was absolutely the advice I was given at the beginning of my career.
Chris McMains: Yeah. A- and I think many of us have heard it. And frankly, again, like there are some opportun- like there's some work we just have to do.
Chris McMains: There's some work that we're all gonna have to do that, that isn't gonna thrill our hearts. Fair enough. That's part of being on a team. That's part of pitching in, right? But it can't all be that. And again a, a, a leader who's interested in the development of the people under their care I think will look and listen carefully for those opportunities that actually they know really resonate or potentially could resonate.
Chris McMains: And the other thing that, that, that really strikes me about the story you tell Stacey is that there was something that gave you permission to be able to release that. And again, so as we think about, what things can people put in place let's listen carefully for what's gonna give our faculty permission-
Chris McMains: Yeah ... to set aside the things that are currently weighing them down, and where the job is getting in the way of their work the work that, the work of their heart, the work that they're meant to be doing, the work that they're gonna bring the most energy and effort to to the department, to, to your [00:23:00] section, to, to whatever the organization is.
Stacey Ishman: Yeah, and if you do listen, I think you can oftentimes find ways that people can serve in an area that really lights their fire and fits their passion. And so I love the idea that if you just know enough, you can actually even put the service pieces in the right alley. So I know we're out of time.
Stacey Ishman: I would love for you to tell us how people can find you in case they wanna work with you or learn more about how they can use the identity work that you've done in order to improve their own departments or theirselves.
Chris McMains: Sure. So the, the website is attendingtoself.com. And I'm just at [email protected].
Stacey Ishman: Awesome. Thank you so much for joining me. I hope we get to have another conversation again in the future. I'm excited to read whatever comes out next. And everybody'll be looking for the website. We'll put it in the show notes. Thank you very much for joining us at the Academic Medicine Strategy Group.
Stacey Ishman: Please share this with anybody who might find this useful, and we look forward to talking to you next week.
Chris McMains: Yeah. Thanks so [00:24:00] much, Stacey. It's a, I'm a big fan of your work and a pleasure to be with you
