This is the simple mathematics of it. If you want a salary of $250k/year and you want to be in the lab 80% of the time, you're expected to bring in 80% of $250k = $200k in salary support from grants. The more serious departments might support someone's salary for about three years to bring in that level of funding. That's not enough time, but it's out there. There are some nuances to that, but that's how the numbers roughly breakdown. Meanwhile, for $50k/year, a department can buy a post-doc and for $80k/year they can buy an assistant professor who will be in the lab 100% of the time. So that's 2-3 assistant professor PhDs vs. the department supporting a surgeon's academic salary to go do serious research.
If you can bring in a million a year in grants, of which $200k+ pays your salary, great, you can write your own ticket to most institutions. But in the current funding envrionment, that's very uncommon among anyone who graduated a MD/PhD program in the past 15 years. You could still insist on doing 80% research without that level of funding. There are a few places that will let you--for a salary more on the order of $100k/year (i.e. like a PhD only assistant professor). There are various post-doc/fellowship/instructor positions out there. But the question always is, who is willing to take on the time and risk for the uncertain future of you needing to bring in that $1M/year down the road to be more than an instructor and bring in a sustained salary comparable to your clinical peers. That level of funding is very uncommon in the current funding environment, and will require significant risk and time investment to get the protected time necessary.
The Brass 2010 data shows 27% of MD/PhD surgeons in private practice. My guess is that on the order of 70% are probably in academic practice. I disagree with the assertion that they are "100%" clinical. They are probably 80% clinical, in academic teaching positions requiring clinical research, with minimal to no funding doing work that did not require a PhD. However, that data is not reported. This is most of the research that goes on within most specialties, including surgery, as a resident and beyond. This is one of those things that the starry eyed med students and pre-meds don't get. As a resident, research allows you a few things. It gives you a break from the hellish intensity that is surgery residency. It gives the program a pool of residents to grab from if a resident has to go out for some reason like illness or pregnancy. It gives the resident time to study for exams and other things. The types of studies done during that "research" time is typically not PhD level work. However, if you worked hard and had the right mentors it's possible to pull a K08 out of it and go on to try to become a physician-scientist. It's just exceedingly rare, even among the MD/PhDs who are designed for it. If there was some degree of certainty that the research career would be worthwhile (i.e. more funding and a high chance at funding), more institutions would push their MD/PhD residents this way and give them good faculty jobs designed for research. But it just isn't there.
As always, your posts are well-reasoned and cogent Neuronix. I've been reading your posts and blog for some time now and I factored in the valuable insight you shared into my decision to pursue surgery. And it's not as ironic as it sounds. When I first started out, I was a starry-eyed med student who wanted to follow in the footsteps of my PI, likely the last batch of MSTs who got the coveted 80/20 TT job. After shadowing him a few times and listening to him occasionally complain about his few weeks of consult duties, I realized I also did not like the field as a clinical job. By the time I came back from the PhD, I was in a panic. I did not love any non-surgical specialty that had an obvious link to the kind of research I had been doing-- and it ran the gamut from IM, neurology, path, even radiology and derm. I wrote off surgery initially because I thought they're just a bunch of highly trained clinical technicians who do nothing but outcomes research. I was very very wrong. There are a great number of interesting basic to translational science projects in various surgical subspecialties. A number of MSTs I know go into something like plastics (eg nerve regeneration), transplantation (eg reperfusion injuries or immunomodulation to combat rejection), acute & critical care (eg sepsis), neurosurgery (eg tissue engineering to replace dura), optho (stem cell or gene therapy cures for blindness) or even ortho (eg cartilage renewal/repair). Sure, they're not so deep down basic as yeast cell cycle/genetics etc, but who's to say they're not worth doing? And I agree, most surgical residents likely do not use the "research years" to generate fantastic basic science post-doc work. But I've seen it done by some very motivated MD-PhD's. In short, surgery and an MD-PhD aren't necessarily incompatible.
I have not encountered any surgeon who does 80/20. In fact, a lot seem to manage it with minimal or without any protected research time, whatsoever. I've asked around and they do have neat ways of getting things done (which I won't get into). Point is, if you wanna do basic science research and you're an MD-PhD going into surgery, you can expect a great deal of hardship. Or be prepared for the outcomes others have already mentioned: give up basic science, give up your personal life or make far less money than your peers. I think we can all agree on that.
Neuronix, you made me realize that there are no 80/20 jobs available. And that made me factor in how happy I'd be doing the clinical portion of my work more heavily. I can't get away with the same decision that my PI did. He could tolerate a clinical field he did not love because he only has to do it 20% of the time. I don't have the same luxury. And since there are no 80/20 jobs available in surgery, or anywhere, it made choosing surgery easier.
When I was an undergrad, some PIs were telling me that bevacizumab would be the "cure for cancer". Fifteen years later and it has demonstrated only a modest improvement in survival in a few tumor types. Though at on the order of $100,000/year, it has made a lot of people a lot of money. This is where the funding for my med onc peers is coming from these days--trials of $120k/year+ agents that extend progression free survival or overall survival by a month or two. It's bad for society to only fund studies that are essentially all investments in future pharma company profits and not funded for the overall good of society, but it's one of the few pathways these days to bring in funding to actually do serious clinical trial work.
That's an interesting tangent. To be fair, you can hardly blame Folkman for bevacizumab. That was Roche/Genentech who developed and marketed it. I might have glossed over the story of cancer angiogenesis and assumed everyone knew everything about it. But I never meant to imply it was the "cure for cancer". I like to think of anti-angiogenesis as just another weapon-generating strategy we developed in the desperate arms race against cancer. It's a nice option to have and it was worth trying. In defense of one of my scientific idols, there are a great number of treatment ideas that came out of Folkman's lab-- including the repurposing of thalidomide (yeah, horrible old cheap drug for morning sickness that caused phocomelia in babies) for multiple myeloma.
But yeah, pharma profiteering is icky and it's sad that scientists are so strapped for funding, it's the one of the few ways to get any research going.