I was asked to briefly outline my career pathway as an example of one way in which what might be considered a successful and fulfilling career can be achieved. I will say at the outset that I could never have planned it this way. So here it is. This is Shelley Hsu. When I applied for my first faculty position with him, he was at the top of the neurosurgery world. If I had told him that I wanted to combine a career in skull-based surgery, pediatric neurosurgery, and study the application of sophisticated clinical research techniques to neurosurgery, I might have spent my career in private practice in Schenectady, New York, where I grew up. He wanted some of what I had to offer, good training, good references, and the Van Wagenen, but not everything that I wanted. He could offer most of what I was looking for, a real job in an outstanding department, prominent colleagues who could help my career, but not everything, a strong clinical research environment or subspecialty practice. We both assessed the risk-benefit ratio and took a chance. It worked, but it wasn't a straight line. Seven years into my time at Minnesota, Dr. Hsu stepped down as chair. I did not have tenure at the time. It was more important then than it is now. And although I had a pretty good general neurosurgical practice with some emphasis on pediatric neurosurgery and trigeminal neuralgia, I had failed to develop the animal research laboratory that Dr. Hsu wanted. During the search for his successor, I was nervous. I looked about for other possible academic and private practice positions, even thought about Schenectady, New York again. But I got lucky. The search committee chose Roberto Haros and he chose Minnesota. Roberto had been a junior faculty member during my residency at Pittsburgh. I knew him well in that role and knew we could work together. It worked very well. He promoted the transition to subspecialty practice, making me head of pediatric neurosurgery and sponsored an educational tour of major skull-based centers to help me build this department's skull-based program. He let me pursue my clinical research methodology interests and I was awarded a large NIH clinical trial grant. And he got me started on my career in the Congress of Neurological Surgeons, ending as president in 1996. Sometimes you get lucky and find an environment that helps you succeed. My luck changed a few years later. Managed care hit Minnesota as hard as anywhere in the country. A scandal in surgery hit the papers. Changes in leadership at the university were not favorable to surgical specialties, especially neurosurgery. My chairman, mentor, and guardian angel decided to leave. His reasons for leaving were also good reasons for considering a personal move. It was clear that under the administration of the time, maintaining the momentum of my career would be difficult. It was time to investigate the possibility that I could find a better environment in which to continue my focused practice in skull-based surgery, pediatric neurosurgery, and trigeminal neuralgia. This would require either a very special professorship or possibly taking a department chair. Although I had never specifically targeted chairmanship as a goal, this turned out to be the best solution to the problem. Fortunately, there were about seven open chairs at the time. After a year of careful investigation, the best alternative was at the Medical University of South Carolina. So in the middle of the summer of 1997, I moved to Charleston to assume a new set of challenges. My new medical school was inviting, the staff excellent, and the dean supportive. There was a history with Julian Yeomans and Fanner Perot as prior chairs. They even provided me a little snow during my first winter there. They had an excellent skull base surgeon, also skull base trained at Pittsburgh, but needed a pediatric neurosurgeon. So much of my practice there was pediatric. However, it became very difficult to reassemble my clinical trial research team, and without them, and with my new responsibilities, my active clinical trials research program faded. Charleston is a beautiful city, but not an easy place for a true Yankee, I was born in Vermont, to live. Eventually, when the growth of the department threatened the practice of the chair of the board of trustees, who happened to be an orthopedic spine surgeon, and I was told to stop growing, it was clear that my time in Charleston was limited. I looked again at several department chairs. Minnesota beckoned. Recovery from the problems of the 90s had begun, but there was much to do. And so, in the dead of winter, I headed north. Coming home was clinically easy. The old practice was there as well as known colleagues in neurotology and pediatrics. However, the faculty was down to three surgeons. The residency was in trouble and research had come nearly to a halt. The thing that was clearest is that the job was no longer about my career, but about the department and the success of my faculty and residents. We hired, we fired faculty and residents. We acquired clinical skills missing from the program and research programs that fit the institution. I deliberately hired people to grow into my clinical practice. If you hire and nurture successful people, you will be considered successful. And in the end, in retirement, there's great comfort and reassurance in leaving a department that is larger, better, and more successful than when you entered it. What have I learned and what advice can I give? You start with a vision of the career you think you want. Reality intervenes and reshapes it. Your skills and desires interact with the environment in which you work. The decisions you make will determine if that interaction leads to a full, successful, and fulfilling career. The institution in which you work changes. Sometimes these changes are good, sometimes not. Change is sometimes necessary, but it is very disruptive to a career that depends on a referral practice and a carefully developed research team. Change when necessary, but carefully assess the costs. The job of department chair has changed dramatically over the time of my career. In most institutions, there is far less control of resources and far more bureaucracy to deal with. Doing a good job will take time away from your own practice, research, and time spent with trainees. The best chairs I know took the job reluctantly and understand the personal sacrifices it requires. The failures often come from those who saw the chair as the next step in their career. It's a wonderful and challenging journey. The outcome will be different from what you expected at the start. Choose carefully and adapt to the strengths of the environment in which you work. It will reward you in the end.

career pathway

strategic decisions

faculty position

subspecialty practice

mentor support