Heart of the problem of medicine...

[gbwillner]

Here is a link to a Medscape article I just read that discusses one half of the problem physician scientists face... namely the gradual loss of compensation over time and the lack of any ability to stop the process. This inevitably trickles down to us because there is less cash for our departments to to gamble on science. That, coupled with the depressed NIH funding rates means that our 80/20 type track is in peril of being significantly different than what we've imagined in the past.

http://www.medscape.com/viewarticle/820279?src=wnl_edit_bom_weekly

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[uniqenam]

GB, do you currently hold a TT 80/20 type position at an academic institution? It would be nice to know which of the attendings/residents on here have these sorts of positions; I always wonder what the experience of the big contributors around here (you, sluox, gutonc) is. I know Fencer is a successful PS, just wondering what everyone else's situation is if you're comfortable to give it; I think that would be useful in parsing responses.

 

[gbwillner]

I have been given both the luxury and curse of a majority research position at my institution. I am only one year out form completing all training. However, I am currently (because of the issues discussed in several previous threads) being forced to either take a majority clinical position (here or elsewhere), or leave for industry or private practice. It would be one thing had I not been successful or published or been able to acquire independent or extramural funding- this is not the case, nor am I alone. The bottom line is that my department can't afford it. I am seeing similar issues at other institutions that I am considering moving to as well.

 

[gutonc]

FWIW (since you name checked me), the best I was able to do straight out of fellowship was a 50/50 instructor level position. I did that for a year, got nowhere, said F*&$ it and now work 0.75FTE clinical making almost twice what I made working 60-70h a week while working about half the number of hours.

A very good friend of mine finished at the same time I did. He's got several 1st author Blood papers as well as a middle author NEJM. He's got a K award and multiple private/foundation grants and is still toiling as an instructor. He'll "probably" get a TT spot next year...3 years out...but no guarantee.

 

[uniqenam]

Thanks guys...this is sort of the sense I was getting, just wanted to nail down the exactitudes. As a side-note, these instructor positions are borderline-unethical (to me). It seems like basically another way to extend your post-doc, dangling the tantalizing TT-position without any promises, and extracting that much more 65-hr-per-week effort while you try to claw your way into more papers for your PI and more entry-level funding. Sort of a ridiculous purgatory to be stuck in.

 

[okemba]

I'm curious how decreased physician compensation will affect the demographics/aptitudes of newly incoming physicians, or competitiveness of medical school admissions. As much as its downplayed, a significant motivator for many people going into medicine is the guaranteed upper-middle class income.

SO...gbwillner, gutonc... frank question from an undergraduate considering applying to MD/PhD this year. Do you guys regret it?

I really feel like I am missing something. Why are all these young people throwing themselves into MD/PhD programs when:

1. The TT is a pipe dream for most people these days.
2. MD/PhD offers little advantage for most non-TT jobs.

It seems like MD/PhD applicants have either not grasped (1) (or think they are special), or are banking on large-scale remodeling of academia in the next 14 years.

 

[OCDOCDOCD]

I'm curious how decreased physician compensation will affect the demographics/aptitudes of newly incoming physicians, or competitiveness of medical school admissions. As much as its downplayed, a significant motivator for many people going into medicine is the guaranteed upper-middle class income.

SO...gbwillner, gutonc... frank question from an undergraduate considering applying to MD/PhD this year. Do you guys regret it?

I really feel like I am missing something. Why are all these young people throwing themselves into MD/PhD programs when:

1. The TT is a pipe dream for most people these days.
2. MD/PhD offers little advantage for most non-TT jobs.

It seems like MD/PhD applicants have either not grasped (1) (or think they are special), or are banking on large-scale remodeling of academia in the next 14 years.

That's exactly the reason why. TT is a pipe-dream. Research as a (half-decent) career is a pipe-dream. It's not uncommon to see life science PhDs who can't find a faculty job and who aren't yet too old throw in the towel on research and apply to medical school. These days a lot of MD/PhD applicants are people who would have applied PhD in years past but see the writing on the wall and figure they may as well cut to the chase and get that MD now so that in the very likely event they find they can't do research for a career they can fall back on the MD and still have something to show for spending half their life in school and training.

 

[mTORC]

This thread is so negative. I realize we must be realistic, but we as applicants are still young; let us have our dreams and be optimistic about the future. I think it's vital that we preserve our passion. I didn't apply MD/PhD just to "fall back on the MD".

 

[uniqenam]

This thread is so negative. I realize we must be realistic, but we as applicants are still young; let us have our dreams and be optimistic about the future. I think it's vital that we preserve our passion. I didn't apply MD/PhD just to "fall back on the MD".

Negativity and realism aren't mutually exclusive.

Granted, PhD and MD/PhD are two different beasts, but in my MS1 class alone we have multiple PhDs who were junior/senior research faculty at various institutions who dropped their professions to go back into medicine because of how awful the basic science environment is right now. I just find it hard to believe that the magic "MD" is going to make life much easier for us in 8-10 years. There are optimists, and I think rightfully so; 10 years is a long time to project out budgetary constraints, and things can/should improve. It's just that for people that have recently graduated/finished training, that's of little consolation: the window for them to be a classic physician-scientist will already be closed.

 

[gbwillner]

I'm curious how decreased physician compensation will affect the demographics/aptitudes of newly incoming physicians, or competitiveness of medical school admissions. As much as its downplayed, a significant motivator for many people going into medicine is the guaranteed upper-middle class income.

SO...gbwillner, gutonc... frank question from an undergraduate considering applying to MD/PhD this year. Do you guys regret it?

I really feel like I am missing something. Why are all these young people throwing themselves into MD/PhD programs when:

1. The TT is a pipe dream for most people these days.
2. MD/PhD offers little advantage for most non-TT jobs.

It seems like MD/PhD applicants have either not grasped (1) (or think they are special), or are banking on large-scale remodeling of academia in the next 14 years.

Do I regret it... No, because as of now I am still doing what I want to do and will still have an opportunity to do it- just not maybe in the way I had originally envisioned. 50/50 academic positions are available to me... but as with Gutonc these positions give you a very limited chance of success as a scientist. You have to work hard to buy back protected time with grants, and even then the department will be unhappy because now they need someone else to pick up your slack. But it CAN be done, especially in a specialty like Path where even if you don't have your own lab you always have access to the clinical labs for your research. Fencer is in Neuro and he's found a way to make it work. But again, I doubt its the way he always envisioned it would be. Industry also still affords you that chance at both, but in a very limited scope. I may still find that elusive 80/20, but I will have to continue on at the instructor level and secure major funding sources OR go to a non-competitive institution with poor chances at good mentorship.

Do I regret doing a post-doc and Instructor position where I learned all the novel technologies that will transform medicine??? Kinda. If I was going into industry or private practice, or even a 50/50 position I could have started 2 years ago, and really my papers, awards and grants really aren't worth that much.

Young people don't know what they are getting into. Otherwise right now MD programs wouldn't be so competitive and virtually no one would do the MSTP track or a PhD in general unless they were independently wealthy and couldn't be happy doing anything else. Look at Fencer's data... the accumulated data shows that only 15% of MD/PhD students get multiple R01's... So of the best and brightest that go into medicine, only 15% will eventually fulfil the stated goals of the program. That is FAIL.

TT is a dead pathway for 95% of MSTPers. And if you have a choice to take it OR a clinical track job with the same % research most will take the latter anyway.

As a side note, I love talking to mentors or chairmen or people in industry who describe me as a young scientist. I'm a f$%^ng middle aged man at this point. Toil for a few more years as instructor so I can get an 80/20 job by bringing in an R01? What do you think?

 

[gbwillner]

Negativity and realism aren't mutually exclusive.

Granted, PhD and MD/PhD are two different beasts, but in my MS1 class alone we have multiple PhDs who were junior/senior research faculty at various institutions who dropped their professions to go back into medicine because of how awful the basic science environment is right now. I just find it hard to believe that the magic "MD" is going to make life much easier for us in 8-10 years. There are optimists, and I think rightfully so; 10 years is a long time to project out budgetary constraints, and things can/should improve. It's just that for people that have recently graduated/finished training, that's of little consolation: the window for them to be a classic physician-scientist will already be closed.

They are crazy as well taking on 250K in debt at age 30 or so, where the diminishing returns on salaries will continue and they won't be able to pay off their student loans until retirement. Here are some facts for you:

1. Most physicians feel they are not compensated properly
2. About half of physicians are NOT satisfied with their careers
3. About half of physicians would NOT choose medicine if they could go back and do it again

Why would things improve for physicians? Their salaries have decreased consistently since the 1980's. Their amount of work and expected responsibilities have only increased. The amount of knowledge they need to be competent has increased exponentially. Most physicians are NOT optimistic about the future. They tend to feel that in a few years we will all be either hospital or government employees. We cannot strike and have no leverage over our payors. We cannot refuse to provide services, even when we know they will not be paid for.

Sorry to bring such a sour note to this usually upbeat forum. But young people should be very aware of the problems in this field BEFORE they are wholly committed to it.

 

[jel34]

I hope I'm not trying to be too naive. But I feel like a lot of the people here believe that just because we go through this long and arduous training (MD/PhD, residency, so on...), that makes us all entitled to the glorious TT, 80/20, physician-scientist position that we all dream about. I think a lot of people have to realize that just because we "try our hardest", this doesn't mean we'll end up with our dream job. Absolutely no job is like that. And the success rate is probably a lot higher for us compared to a lot of "dream jobs", like becoming an astronaut, successful businessman, or professional athlete. The fact is that there are very few TT positions available, and we just have to work our asses off, and if the sun and moon line up correctly in the sky one night, maybe our dream will come true. But it very well could not, and this is why us students/applicants as well as the administration at MD/PhD programs have to really redefine what a "successful outcome" of the MD/PhD program really is. It's a fact that we're all not going to get the glorious 80/20 job that we all dream of, so why does that make a successful position in industry, or a successful 100% clinician, or a health policy official, not "successful outcomes" of MD/PhD programs? In these jobs we'll still be promoting the improvement and better understanding of human health, and isn't that what the MD/PhD program, and most of our goals in life, are all about? Remember your true goal in life, and not just the 80/20 TT goal of most MD/PhD programs.

And still, I don't deny the fact that our government and all us citizens really need to step the (expletive) up and put more money into health and science. I'm not going to go on about the changes in government, society, and academic institutions that need to happen, because that's really not the point of this thread. But maybe some of us will go into politics and help fix all these problems! And will these people still not be seen as "successful outcomes" of the MD/PhD program?

 

[uniqenam]

I hope I'm not trying to be too naive. But I feel like a lot of the people here believe that just because we go through this long and arduous training (MD/PhD, residency, so on...), that makes us all entitled to the glorious TT, 80/20, physician-scientist position that we all dream about. I think a lot of people have to realize that just because we "try our hardest", this doesn't mean we'll end up with our dream job. Absolutely no job is like that. And the success rate is probably a lot higher for us compared to a lot of "dream jobs", like becoming an astronaut, successful businessman, or professional athlete. The fact is that there are very few TT positions available, and we just have to work our asses off, and if the sun and moon line up correctly in the sky one night, maybe our dream will come true. But it very well could not, and this is why us students/applicants as well as the administration at MD/PhD programs have to really redefine what a "successful outcome" of the MD/PhD program really is. It's a fact that we're all not going to get the glorious 80/20 job that we all dream of, so why does that make a successful position in industry, or a successful 100% clinician, or a health policy official, not "successful outcomes" of MD/PhD programs? In these jobs we'll still be promoting the improvement and better understanding of human health, and isn't that what the MD/PhD program, and most of our goals in life, are all about? Remember your true goal in life, and not just the 80/20 TT goal of most MD/PhD programs.

And still, I don't deny the fact that our government and all us citizens really need to step the (expletive) up and put more money into health and science. I'm not going to go on about the changes in government, society, and academic institutions that need to happen, because that's really not the point of this thread. But maybe some of us will go into politics and help fix all these problems! And will these people still not be seen as "successful outcomes" of the MD/PhD program?

It's not just people 'trying their hardest'; a LOT of grads from top MSTPs with multiple C/N/S papers aren't getting anywhere in their careers. It's not like people are trying super hard, being unsuccessful, and then griping about it. In any other field, that level of success WOULD guarantee you a dream job. If you were a football player selected to All-American teams 3 times in college, you've got a 95%+ chance of getting your dream NFL job; if you're an MSTP grad with 3 papers of impact factor >20, you're guaranteed nothing. These people are the cream of the crop of incoming med school classes, typically excel in med school/step 1, get great scientific mentoring, publish lots of papers, and at the end of a residency/fellowship have no job prospects toward which both they and the American public have put a substantial amount of effort and capital.

The truth is that pure clinicians/health policy officials/deans of med schools are not successful outcomes of MD/PhD programs. NIH itself has this to say:

"Graduates receive the combined M.D.-Ph.D. degree, and the majority of them pursue careers in basic biomedical or clinical research."

The goal is to train investigators, and the goal is currently a failure.

 

[Fencer]

I am a 50 year-old clinician scientist, tenured professor, with 7 high impact papers (>300 citations each). I got offered the miserable "Instructor" position at a top 10 institution (big size pond but full of piranhas) as I was completing my clinical training. I declined and decided to take an Assistant Prof (AP) position with a 50/50 split in the middle of the country (medium size pond). Salary was low compared to other AP in my department (but higher than the Instructor by ~40%) because I was taking a pay cut for doing science. As I got my K award, the salary improved slightly, but I had to move again to another institution (to Texas) getting slightly better salary support and lab. I moved up thru the ranks at a 50/50 split doing research at a VA medical center. I worked 70 hour weeks, no short-cuts - some flexible time, but I also kept my commitment to my family. My research productivity has been low compared to physician-scientists doing 80 or 100% research, but I kept publishing a reasonably good paper every year. In my clinical time, I kept training clinical fellows who immediately got offered higher salaries than mine by private practices (PP) when they completed their training. I also got offered several PP/Group positions that double or even triple my salary. Did I have many doubts? Certainly, but I turned down many of those positions because I wouldn't get to do what I enjoyed the most, research and teaching during clinical service. Eventually, my salary moved up as I took over some administrative duties. In addition, I also own a little piece of a company that is in phase III studies. My trail has not been easy and has had many detours, but I have enjoyed the journey. I also been patient and lived within my means. As a single income family, there was always pressure for earning a little more. We adjusted and have lived comfortably well, after all, Texas is quite cheap and has a great quality of life. This year, I am extending a 3 day scientific meeting in Buenos Aires to a 2 week trip to Patagonia and Mendoza, but I also drive a >10 year-old vehicle. By some measures, I have succeeded - being tenured as Assoc P, promoted to Professor, reasonably well published relative to effort, made an impact in my field); by others measures, I have failed - for example, I never been 80/20 or being simultaneously supported by multiple R-01s. I have had enough research funding that allowed me to get by, now 17 years after completing fellowship. This year (2014), I will have at least one (moderate journal impact) paper in: 1) health care outcomes, 2) clinical research, and 3) basic research, while I still am taking care of patients ~50% of time. To me, that is a successful career because it fits my own personal needs regardless on how my 80/20 colleagues look at me.

Some lessons:
- If you can, leave the Ivy schools. It is easier to succeed in "mid-size ponds" than in "big ponds". You are appreciated better.
- Consider the VA medical centers because the clinical time commitment is more limited as compared to other clinical practices, and research funding still is ~25%.
- Periodically examine opportunities (every 3-5 years) in other institutions. The only significant way to increase your salary/lab goodies is by threatening to leave (a disruption in research) but they make take you on that offer.
- Be authentic as to what you want for yourself. If driving a Maserati is what you need, this path is not for you.
- Despite the challenges, if a Clinician-Scientist (CS) career is what makes you happy, stay on. Better opportunities will open up, as there is attrition of others who did not persist.
- Resilience is a critical skill for MD/PhD graduates, and it is difficult to measure up-front during the admissions process.
- You must need enough (but not too much) of an ego to persist despite the challenges.


Getting back on track to OP:
The NIH, CDC, and the R-1/CTSA institutions will need to replace their current faculty. That is a fact. As discussed in this report ( https://www.aamc.org/download/369006/data/faculty-attrition.pdf ), medical schools have had "remarkable growth of full-time faculty members from 30,000 to more than 140,000". The growth was fueled by making clinical and research revenues to support the institutions. Many of them invested heavily in buildings and other liabilities and got caught with their pants down as both of the financial foundations of these enterprises (research and clinical) are under attack. Obviously, salaries and jobs were the casualties. Academic health centers are tightening up the use of the time of their most valuable asset, their faculty. This has resulted in a greater number of disatisfied faculty: http://www.hopkinsmedicine.org/education/women_science_medicine/_pdfs/Why_Are_a_Quarter_of_Faculty_Considering_Leaving.2012 onlineproof.pdf
In my view, this is an adjustment as the 1929, 2000 or 2008/9 financial crashes. There will be attrition, primarily in the PhD fields but also some of the MDs, followed by an equilibrium with some "growth" without exuberance. MD/PhD graduates, I believe, are better situated to take advantage of these shifts. Some as described by other posts above, might shift into a 25R/75C position for a few years, but as the tide changes, they might seize a 80R/20C position. As usual, past performance is no guarantee of future returns. This is my (I believe) educated guess...

The NIH goal is to train basic AND clinical investigators. Those who are doing clinical or health care outcome research are also a success. There are many doing the latter who make contributions to translating discoveries into improved health for the community.

 

[dl2dp2]

GB, do you currently hold a TT 80/20 type position at an academic institution? It would be nice to know which of the attendings/residents on here have these sorts of positions; I always wonder what the experience of the big contributors around here (you, sluox, gutonc) is. I know Fencer is a successful PS, just wondering what everyone else's situation is if you're comfortable to give it; I think that would be useful in parsing responses.

I'm not quite done with my training. However, I'm fortunate enough to get support from a private foundation to supplement my salary so that I'm actually living kind of a fabulous lifestyle in one of the most expensive markets in the country. Not having any student debt is huge. I would say my lifestyle is significantly better than my MD-only colleagues who have loads of debt. Don't have children yet, which is also an issue. I'm also transitioning from basic to translational/human subjects work. The research fellowship I'm entering has a good track record of getting people K23s and I am getting papers out and being productive, so I can see another 5-7 years doing 80/20. The K->R transition is difficult for everyone. We'll talk when I get there.

A lot of attrition does occur, primarily because the opportunity cost is very high. I actually think anybody who wants a 80/20 career can have one after MD/PhD. It's just that the research part is very much cobbled together in a bunch of Ks, small Rs, foundations, etc. The salary is also lower, sometimes by a lot. In some specialties the department might not be very supportive of this kind of careers. So the question facing the candidate is do I struggle and do middle of the road research, or do I just focus on clinical work and make more money. Not everyone can be PI supported by R01s.

I don't think the reality is as stark as it may seem. MD/PhD is by far the best track to become a TT professor in a clinical department. Even though it's the best track, it's still not a guarantee. Having the MD/PhD gives you a lot of different options, and you can choose amongst them to suit your lifestyle as desired. The problem comes up when one is too one-track minded into thinking that TT 80/20 is the only career that can be satisfying.

Young people don't know what they are getting into. Otherwise right now MD programs wouldn't be so competitive and virtually no one would do the MSTP track or a PhD in general unless they were independently wealthy and couldn't be happy doing anything else. Look at Fencer's data... the accumulated data shows that only 15% of MD/PhD students get multiple R01's... So of the best and brightest that go into medicine, only 15% will eventually fulfil the stated goals of the program. That is FAIL.

I mean, yes and no. MD is competitive because there are few careers out there that can be high paying and secure. 15% MD/PhDs become PIs heading independent labs/groups. But the rest still have really good jobs. There is just very little alternative that's any good out there for someone who's interested in the life sciences, research, and public service.

The way I think about it, I'm gonna work hard and try for that R01 and that TT job doing the kind of research I want. But if I don't make it, then I'll go into PP and triple my salary and live a fantastic life. Won't be devastated if my R01 doesn't make that 9% cutoff. I don't really know how this could possibly suck no matter how it goes down.

 

[gbwillner]

Some lessons:
- If you can, leave the Ivy schools. It is easier to succeed in "mid-size ponds" than in "big ponds". You are appreciated better.
- Consider the VA medical centers because the clinical time commitment is more limited as compared to other clinical practices, and research funding still is ~25%.
- Periodically examine opportunities (every 3-5 years) in other institutions. The only significant way to increase your salary/lab goodies is by threatening to leave (a disruption in research) but they make take you on that offer.
- Be authentic as to what you want for yourself. If driving a Maserati is what you need, this path is not for you.
- Despite the challenges, if a Clinician-Scientist (CS) career is what makes you happy, stay on. Better opportunities will open up, as there is attrition of others who did not persist.
- Resilience is a critical skill for MD/PhD graduates, and it is difficult to measure up-front during the admissions process.
- You must need enough (but not too much) of an ego to persist despite the challenges.

I think these are good points. The only point of contention I would add is in leaving the top-tier institutions. I agree that chance for tenure and perhaps your relative value goes up in a "small pond", but your chance at NIH funding (in both K08 anr R01 where your institution and environment are scored) your chances of success go down. Plus, you are not as likely to have the same quality mentorship or pedigree. If you focus on translational projects or smaller grants this latter point may not matter as much.

 

[Fencer]

Thanks. Please notice that I said "mid-size" not small. There are over 60 CTSA institutions in the country and at least half are not "ivy-like". The CTSA has a great structure for education and mentoring of young faculty members, particularly of clinician-scientists.

 

[Patros]

I am a 50 year-old clinician scientist, tenured professor, with 7 high impact papers (>300 citations each). I got offered the miserable "Instructor" position at a top 10 institution (big size pond but full of piranhas) as I was completing my clinical training. I declined and decided to take an Assistant Prof (AP) position with a 50/50 split in the middle of the country (medium size pond). Salary was low compared to other AP in my department (but higher than the Instructor by ~40%) because I was taking a pay cut for doing science. As I got my K award, the salary improved slightly, but I had to move again to another institution (to Texas) getting slightly better salary support and lab. I moved up thru the ranks at a 50/50 split doing research at a VA medical center. I worked 70 hour weeks, no short-cuts - some flexible time, but I also kept my commitment to my family. My research productivity has been low compared to physician-scientists doing 80 or 100% research, but I kept publishing a reasonably good paper every year. In my clinical time, I kept training clinical fellows who immediately got offered higher salaries than mine by private practices (PP) when they completed their training. I also got offered several PP/Group positions that double or even triple my salary. Did I have many doubts? Certainly, but I turned down many of those positions because I wouldn't get to do what I enjoyed the most, research and teaching during clinical service. Eventually, my salary moved up as I took over some administrative duties. In addition, I also own a little piece of a company that is in phase III studies. My trail has not been easy and has had many detours, but I have enjoyed the journey. I also been patient and lived within my means. As a single income family, there was always pressure for earning a little more. We adjusted and have lived comfortably well, after all, Texas is quite cheap and has a great quality of life. This year, I am extending a 3 day scientific meeting in Buenos Aires to a 2 week trip to Patagonia and Mendoza, but I also drive a >10 year-old vehicle. By some measures, I have succeeded - being tenured as Assoc P, promoted to Professor, reasonably well published relative to effort, made an impact in my field); by others measures, I have failed - for example, I never been 80/20 or being simultaneously supported by multiple R-01s. I have had enough research funding that allowed me to get by, now 17 years after completing fellowship. This year (2014), I will have at least one (moderate journal impact) paper in: 1) health care outcomes, 2) clinical research, and 3) basic research, while I still am taking care of patients ~50% of time. To me, that is a successful career because it fits my own personal needs regardless on how my 80/20 colleagues look at me.

Thanks for typing that up. For what it's worth, it is one of the most useful things I have read on this website. Man, if I was offered a job that tripled my salary... I am not sure I would say no.

Just out of curiosity, did the physicians here go through a research-track residency (like the ABIM research pathway, or the Holman)? The thought of having to go through a 6-7 year long residency/fellowship only to get offered an instructor position fills me with dread.

 

[gutonc]

Thanks for typing that up. For what it's worth, it is one of the most useful things I have read on this website. Man, if I was offered a job that tripled my salary... I am not sure I would say no.

Just out of curiosity, did the physicians here go through a research-track residency (like the ABIM research pathway, or the Holman)? The thought of having to go through a 6-7 year long residency/fellowship only to get offered an instructor position fills me with dread.

I did. 6 years, 3 of them 90% research. To be clear, there were lots of factors at play in my situation but to say the playing field hasn't changed dramatically in the last 5-10 years is patently false. I watched people who graduated just 2 or 3 years ahead of me in my program, with almost no research experience or pubs get offered TT positions (at least 50/50) straight out of fellowship. 3 years later, a true star coming from the program (not me) spends 3 years as an instructor.

 

[gbwillner]

Thanks for typing that up. For what it's worth, it is one of the most useful things I have read on this website. Man, if I was offered a job that tripled my salary... I am not sure I would say no.

Just out of curiosity, did the physicians here go through a research-track residency (like the ABIM research pathway, or the Holman)? The thought of having to go through a 6-7 year long residency/fellowship only to get offered an instructor position fills me with dread.

FYI I did a PSTP program.

Re: the instructorship... It's not all bad and is only at certain institutions. "top" programs do it because they can, but in reality it's not all a bad thing. The advantage to the instructorship is that, as a "favor" to you, you are afforded a decent wage (>Post-doc, >resident, >fellow) to do almost or exclusively research. The point is to get established before the tenure clock starts ticking. You have 5-7 years to land at a minimum 2 R01s and probably >3 nature/cell/science papers at some of these institutions to get tenure, and in theory this extra year or so allows you a chance to get data and start writing papers and grants before the clock starts ticking down. Once promoted you start your clinical work but are already rolling in lab. So that's good. In theory. In practice now, some top places starts everyone off this way, and won't let them advance to Asst. Prof in a TT position until they land a major grant (sometimes K08 is not enough!) like a K99 or maybe even an R01. At this stage it is ridiculous, but that is the current state of affairs.

"Lesser" institutions would never hire anyone like this because who in their right mind would do it? So they have to offer up Asst. prof off the bat. Maybe they can steal some good faculty from the "top" places who are tired of being stuck at the bottom of the pole.

 

[Underarchiever]

I think these are good points. The only point of contention I would add is in leaving the top-tier institutions. I agree that chance for tenure and perhaps your relative value goes up in a "small pond", but your chance at NIH funding (in both K08 anr R01 where your institution and environment are scored) your chances of success go down. Plus, you are not as likely to have the same quality mentorship or pedigree. If you focus on translational projects or smaller grants this latter point may not matter as much.

I have some doubt in that contention. I sat in a couple of study sections. Maybe reputation of an institute has significant impact on KO8 award. The reputation of institute has almost no impact on NIH RO1 award or DOD idea development award. It is the innovation and the potential impact of the work that matters the most. The next in the line is the productivity and "reputation"of the PI. A well connected PI usually gets some edge. I have to point out that most reviewers sitting in the study sections are not IVY league graduates or from IVY league. They just wouldn't care that much about the label. It is lean time right now. But funding situation is cyclical. It is so every 10-15 years. It may be good for science such that it drives some non-scientists away from science, while allows the die-hard and (good) scientists to stay on. If you survive this period and get a RO1, you should be fine. Top institutes may demand publications in top journals for tenured position. But you don't need publication in top journal to get a RO1. I have seen people getting 5-6 RO1 without publishing an article in any top journal.

 

[gbwillner]

I have some doubt in that contention. I sat in a couple of study sections. Maybe reputation of an institute has significant impact on KO8 award. The reputation of institute has almost no impact on NIH RO1 award or DOD idea development award. It is the innovation and the potential impact of the work that matters the most. The next in the line is the productivity and "reputation"of the PI. A well connected PI usually gets some edge. I have to point out that most reviewers sitting in the study sections are not IVY league graduates or from IVY league. They just wouldn't care that much about the label. It is lean time right now. But funding situation is cyclical. It is so every 10-15 years. It may be good for science such that it drives some non-scientists away from science, while allows the die-hard and (good) scientists to stay on. If you survive this period and get a RO1, you should be fine. Top institutes may demand publications in top journals for tenured position. But you don't need publication in top journal to get a RO1. I have seen people getting 5-6 RO1 without publishing an article in any top journal.

My experience has just been in K08, where you are scored, your institution is scored, your mentors are scored, and your environment is scored. Sure, opinions are like a-holes, so how someone views your institution will affect your score in study section. I could be wrong on the R01 since I have not applied, but that was my impression.

I understand the reasoning about surviving the lean times to be successful during the booms. That's how I've convinced myself to stay in the game as long as I have. I just think the older folks out there are naive to the current conditions because they are not going through them and are somewhat insulated from them. It is far easier for a department to save/support a struggling existing lab and try to restore their investment than to bring a new person on and recommit more resources. The "cyclical" talk reminds me of the stock market. In reality, past performance is no predictor of future events. Does anyone see the political will in place to restore funding? This trough started roughly 12 years ago- shouldn't we be getting set for a peak? I think it's foolish to bet on it.

For the older folks who have been awarded R01s and had successful careers and don't see what the fuss is about, I would ask:
1. How many years were you a post-doc after completing residency and fellowship?
2. How many years were you instructor before being promoted to asst. prof?
3. How much funding was required before you were promoted to a Jr position (asst prof)?
4. How much of the above would you have tolerated for the chance at continuing your TT aspirations?

Look, I'm not saying TT has evaporated and all jobs are gone. I'm saying it is going this way, and in the past 5 years I have seen the criteria for hiring at my and other institutions get rapidly and steadily insane. Almost all my friends in the field have fled to clinical (even private) jobs. And they were not the chaff. They saw the writing on the wall.

 

[Fencer]

I see the problems. I have been fortunate because I am insulated by working at the VA in an area related to TBI, where there is now good funding. I did 2 years of Instructor (public Ivy-like) prior to getting back into 5 years of residency/fellowship (private Ivy-like). After my residency, I ended up doing 9 years of Assistant divided into 2 institutions (non-Ivy - I had a 2 year break due to a frivolous lawsuit for firing a fraudulent lab tech; this almost broke my career but I was proven right). I brought almost 2 Million of grant support during those 9 years. No tier one papers but solid specialty contributions every year with 3.5 year gap due to above (I couldn't trust any data, had to repeat experiments). After being promoted to Associate Professor with tenure, I had 3 years as Associate bringing about 0.75 Million, I was then promoted to Professor.

As an administrator (Assistant Dean), I see the squeeze described by our younger faculty contributors. At my institution (which has adequate financial reserves), we have used several mechanisms to keep them engaged because we don't want to lose a generation of clinician scientists. Some other institutions might not have those resources or leadership.

 

[Neuronix]

Look, I'm not saying TT has evaporated and all jobs are gone.

I agree. This is what the naive pre-meds at age 22 (including my former self...) don't understand. When you're in your mid-30s your priorities might change when you're looking at several more years of 80+ hours a week for sub-100k salary, with little location flexibility, still for no guaranteed job and still being treated like an underling despite 16+ years of post-high school education. If you're board eligible or board certified, you can often easily double, triple, quadruple your salary (or more!) by giving up basic science but staying in academics or by giving up the research component altogether. By trading for a clinical job, all of a sudden the job market opens up and your stress level goes way down.

However, if you want to keep trying, keep fighting for grants, keep fighting to stay in academics, those positions are still there. They exist. You can spend your whole career in a post-doc/instructor position if you never get serious funding. You may never top 100k/year. You may never have your own lab space. You may have to move multiple times to <insert undesirable locations here>. But you could likely do it. The question is, who would? The only people I could see are those who are really die hard, or more realistically, those who are board/license ineligible.

There are a lot of things that force people's hands, even if they do want to keep pursuing a physician-scientist pathway. If you have a wife and kids, you may need more money. You may want to see your family more. You may decide that there are things you enjoy instead of being in a clinic or lab all the time. You may decide the stress and uncertainty are not worth it. Your priorities change. When I was 22 I thought I would have no problem working 80+ hours a week for the rest of my life. I grew up poor--I figured 100k/year would be more than enough money for me forever. I had no hobbies when I was younger outside of video games because I had no money and no experience in the real world. I've changed. I was offered a research residency position and I turned it down for a clinical pathway. While I haven't finished residency yet, I have absolutely no qualms about going into private practice. When I look back on what I've truly enjoyed in my past 10 years of life, little of it has to do with this grueling MD/PhD training pathway. I've suffered major setbacks despite incredibly hard work. I don't see it getting any better by staying in academics.

But do I regret anything? No way! Having no debt during/after the MD/PhD program and having a stipend during the MD/PhD program gave me a quality of life I couldn't have otherwise. It sure beat living on a couch covered in fleas or in a tiny room in a house with one bathroom shared with 7 other people like I did for 6 years.

 

[solitude]

I agree. This is what the naive pre-meds at age 22 (including my former self...) don't understand. When you're in your mid-30s your priorities might change when you're looking at several more years of 80+ hours a week for sub-100k salary, with little location flexibility, still for no guaranteed job and still being treated like an underling despite 16+ years of post-high school education. If you're board eligible or board certified, you can often easily double, triple, quadruple your salary (or more!) by giving up basic science but staying in academics or by giving up the research component altogether. By trading for a clinical job, all of a sudden the job market opens up and your stress level goes way down.

However, if you want to keep trying, keep fighting for grants, keep fighting to stay in academics, those positions are still there. They exist. You can spend your whole career in a post-doc/instructor position if you never get serious funding. You may never top 100k/year. You may never have your own lab space. You may have to move multiple times to <insert undesirable locations here>. But you could likely do it. The question is, who would? The only people I could see are those who are really die hard, or more realistically, those who are board/license ineligible.

There are a lot of things that force people's hands, even if they do want to keep pursuing a physician-scientist pathway. If you have a wife and kids, you may need more money. You may want to see your family more. You may decide that there are things you enjoy instead of being in a clinic or lab all the time. You may decide the stress and uncertainty are not worth it. Your priorities change. When I was 22 I thought I would have no problem working 80+ hours a week for the rest of my life. I grew up poor--I figured 100k/year would be more than enough money for me forever. I had no hobbies when I was younger outside of video games because I had no money and no experience in the real world. I've changed. I was offered a research residency position and I turned it down for a clinical pathway. While I haven't finished residency yet, I have absolutely no qualms about going into private practice. When I look back on what I've truly enjoyed in my past 10 years of life, little of it has to do with this grueling MD/PhD training pathway. I've suffered major setbacks despite incredibly hard work. I don't see it getting any better by staying in academics.

But do I regret anything? No way! Having no debt during/after the MD/PhD program and having a stipend during the MD/PhD program gave me a quality of life I couldn't have otherwise. It sure beat living on a couch covered in fleas or in a tiny room in a house with one bathroom shared with 7 other people like I did for 6 years.

This is a very nice description of the transformation that many of us go through as we move through this arduous training path. I still like research, and if I could do research for a similar salary but at the cost of substantially more stress and uncertainty, I would do research. If I could do research for less money, but reasonable work hours, I would do research. If I could do research and have a reasonable shot at running an independent lab, not having to kowtow to the NIH every year for funding, I would do research. But the combination of all these things - a huge paycut, massive uncertainty, 12 hour days in perpetuity, an average 1st R01 in the mid-40s - it's just not going to happen.

Frankly, I am amazed that ANYONE finds a way to make it work nowadays. Actually, I'm skeptical that anybody really is. Over the course of my clinical years in medical school, I haven't met a single physician-scientist on the wards or in clinic. Not one, even in IM, Peds, Neuro, etc. Met plenty of MD-PhDs, all clinical track, or MD-PhD housestaff who had already given up on basic science. All of the research folks must be 100% research. That is a hell of a lot of clinical training, MD+residency+fellowship used to inform one's Western blotting. The physician-scientist track isn't just an endangered species...it's basically moribund.

 

[gutonc]

This is a very nice description of the transformation that many of us go through as we move through this arduous training path. I still like research, and if I could do research for a similar salary but at the cost of substantially more stress and uncertainty, I would do research. If I could do research for less money, but reasonable work hours, I would do research. If I could do research and have a reasonable shot at running an independent lab, not having to kowtow to the NIH every year for funding, I would do research. But the combination of all these things - a huge paycut, massive uncertainty, 12 hour days in perpetuity, an average 1st R01 in the mid-40s - it's just not going to happen.

Agreed.

I was willing to make a sacrifice or two (hours, salary, stress, independence, stress)...but not 12. Once I realized that what was keeping me awake at night wasn't thinking about what I could do better for my dying metastatic pancreatic cancer patients, but rather that, if the QPCR I ran in the morning didn't work then I wouldn't have a good slide to put in my lab meeting presentation, it all kind of came together for me. And I called it a day.

I now spend 3 days a week in clinic and still go to lab meeting because I f*%(&ing love science, but don't love what it's done to me and my colleagues.

 

[tortuga87]

So... if TT is unlikely, but you don't want to do purely clinical or just dabble in some clinical trials, what are the other options?

What about industry? I know grad students talk about industry as a nebulous thing that you go into if you don't make it in academia, but what are the jobs that are really out there? I hear it's not as free as academia, but it's not completely monotonous either. I personally wouldnt mind working in something like cancer therapy discovery

I feel like nowadays we should be realistically shooting for alternatives to academia and only go into academia if we are really lucky, as opposed to planning that we are going to be professors from the start

 

[gbwillner]

Thank you all for the stimulating conversation and personal and accurate reflection on the current state of affairs for physician-scientists.

Re: industry- it's not something that is talked about much in academia. 3/5 past graduating grad students in my lab are going into or have gone into industry. It is harder to break into for sure. But it can be MUCH more lucrative. One recent grad is getting >>$100K out the gate without a post-doc (or an MD). Academic post-docs are easy to get. These positions are different. What are your skills? How can you contribute to the team and help make the company money? Publication record is of secondary importance, as is your mentor unless they have direct ties with or reputation in industry.

Back to TT... the jobs are thinning for sure but are still there. The more relevant question to ask nowadays, I think, is why you should even take one. TT jobs can be tied to NIH salary limits for grant support. You also have to pay for yourself primarily from your grant support, which is rather thin as we all know. The solution most smart people who decide to stay in academics I have come across lately is to take a clinical track position with negotiated protected research time and start-up. That gives you far more flexibility.

After my tribulations I just want to add that I have been offered a TT position at an "IVY" place... so they ARE there, just MUCH harder to get. In the end I turned down this offer to consider a clinical-track position (with start-up and protected time) at the same place. This will increase my clinical service time but would also be a much more stable position.

 

[solitude]

Thank you all for the stimulating conversation and personal and accurate reflection on the current state of affairs for physician-scientists.

Re: industry- it's not something that is talked about much in academia. 3/5 past graduating grad students in my lab are going into or have gone into industry. It is harder to break into for sure. But it can be MUCH more lucrative. One recent grad is getting >>$100K out the gate without a post-doc (or an MD). Academic post-docs are easy to get. These positions are different. What are your skills? How can you contribute to the team and help make the company money? Publication record is of secondary importance, as is your mentor unless they have direct ties with or reputation in industry.

Back to TT... the jobs are thinning for sure but are still there. The more relevant question to ask nowadays, I think, is why you should even take one. TT jobs can be tied to NIH salary limits for grant support. You also have to pay for yourself primarily from your grant support, which is rather thin as we all know. The solution most smart people who decide to stay in academics I have come across lately is to take a clinical track position with negotiated protected research time and start-up. That gives you far more flexibility.

After my tribulations I just want to add that I have been offered a TT position at an "IVY" place... so they ARE there, just MUCH harder to get. In the end I turned down this offer to consider a clinical-track position (with start-up and protected time) at the same place. This will increase my clinical service time but would also be a much more stable position.

Thanks for starting the thread and for your perspective. I am confused on what you mean by TT vs. clinical track with protected research time and startup. I know that some people are on the TT in terms of their academic appointment, vs. Assistant Clinical Professor which is technically not TT. But I have never met anybody on the Clinical track who is doing basic science research in a sustained, dedicated way (i.e., having their own lab, writing their own R01s). Most of them do research with human subjects, chart review, or collaborate with basic scientists. Granted, I am not familiar with pathology. But is this becoming a thing now? Clinical track jobs where people get 2-3 days a week to do basic science? Or when you say you are getting start up and protected time, are we talking more about translational/clinical trial stuff?

 

[gbwillner]

Thanks for starting the thread and for your perspective. I am confused on what you mean by TT vs. clinical track with protected research time and startup. I know that some people are on the TT in terms of their academic appointment, vs. Assistant Clinical Professor which is technically not TT. But I have never met anybody on the Clinical track who is doing basic science research in a sustained, dedicated way (i.e., having their own lab, writing their own R01s). Most of them do research with human subjects, chart review, or collaborate with basic scientists. Granted, I am not familiar with pathology. But is this becoming a thing now? Clinical track jobs where people get 2-3 days a week to do basic science? Or when you say you are getting start up and protected time, are we talking more about translational/clinical trial stuff?

In my field, this is definitely becoming the norm for physician scientists, as TT is going to purely PhDs or people without any (or virtually no) clinical responsibilities. The details of the differences probably change between institutions, but in general you have protected time and can continue to keep it with extramural funding. But your clinical job keeps you paid at a physician level. You are primarily hired for clinical skills, but have the time and resources to attempt a research career. Start-up and space will of course be different at different institutions, and are generally less than TT.

 

[dl2dp2]

I am confused on what you mean by TT vs. clinical track with protected research time and startup. I know that some people are on the TT in terms of their academic appointment, vs. Assistant Clinical Professor which is technically not TT. But I have never met anybody on the Clinical track who is doing basic science research in a sustained, dedicated way (i.e., having their own lab, writing their own R01s). Most of them do research with human subjects, chart review, or collaborate with basic scientists.

In my field, there are several ways of doing it. Suppose after postdoc/K you are able to get an R01. The department has funding for a clinical position. It cuts that clinical position into pieces and give you some clinical work (say 10-20% = 40k). The R01 funds the rest of the 80%, which is often a full salary for a basic scientist (perhaps 95k as an assistant professor), but really a low salary for a physician scientist, but the R01s say you need a minimum of 75% effort, or something like that. This still gives a lowish salary in a cognitive specialty (135k ~10-20% lower than a similar level private physician), but good benefits. This is considered "tenure track". As you get more R01s and start to leverage outside offers, the department can decide to give you a raise and find more "hard money", so that less and less of your salary comes out of the R01s. Eventually, if you are a baller, you can find a private donor/endowment funds to endow a chair so that your entire "hard" salary comes out of the endowment revenue. This is how you get "tenured". This is the classic pathway.

You can see why this pathway is not particularly practicable for procedural specialties, because that lowish "tenure-track" salary is 50% or more lower than a private physician position. No one will endow a basic science position that pays a procedural specialty salary. Furthermore, even people who successfully get on the tenure track probably need to supplement their income with outside clinical work such as part time private practice or moonlighting in expensive markets. But the advantage here is that you are the PI on your R01s. The department loves you and wants to keep you because of your ability to attract extramural funding (though will never raise your salary unless you have a competing offer). You can become Brown and Goldstein in the end if you are truly a rock star.

If you are not as gun-ho about "tenure track", you can elect to work 2-3 days on research, or less, so long as a PI is able to hire you for some reason (i.e. analysis of data, study physician, etc.) For clinical research the R01s often have a budget to hire study physicians, and use Medicare physician pay scale. So this is more or less practicable. One then applies for smaller awards (R21s, etc.) and if things align in the right way R01s, and perhaps move into the tenure track later on. Various other mechanisms can be used to supplement salary for this kind of positions. The title is usually "assistant clinical professor". Many MD/PhDs in the end get into these types of positions. The advantage is that you still get to do some research, you have stability and higher salary compared to other "life long postdocs" jobs (i.e. associate scientist, etc.). Some, such as gbwillner I'm guess, can get Ks and R01s, but elect for this kind of jobs for exactly that reason. The disadvantage is that unless you are the PI on a project grant, you never get to be your own boss. Using internal medicine as an example for estimating salary for this kind of a job. Assuming that you are very good with your hands, and a successful PI wants to retain you for your skills in microscopy/molecular biology and work on some projects. He has enough funds for a full time "associate scientist" for 60k. You negotiate successfully to work 4 days a week. You squeeze 4 days into 3, then work 2 more days as a hospital consultant/outpatient subspecialist for another 70k. Your total salary = 130k. Meanwhile, a full time academic clinical subspecialist makes about 70k*/2*5 = 175k. A private subspecialist make maybe 235k. Not a huge difference, right? This is how the math works.

But you can see how the pipeline starts to get leaky. The smart woman who works 3 days a week in research suddenly realizes that she will never get the credit for the work she did because she's not the PI--even if her gels had that HMG-CoA reductase, she will never be Brown and Goldstein. Furthermore, she has no competitive leverage and her now fancy basic science PI may easily lose his third R01 next year. Her interest in science and using her hands wanes, and she leaves for the much more lucrative private job.

Picking the right specialty is probably one of the most important factors in "doing basic science research in a sustained, dedicated way" as a physician scientist.

 

[dl2dp2]

You can see from my post that this kind of stuff is entirely on my mind constantly every day. Things might look sort of grim and bitter at first glance, but consider the alternative: suppose you only have a PhD, and the clinical duty is off limits to you.

Now you are applying for a position where the start-up and salary are funded entirely through the endowment, with the catch that the department expects you to get an R01 within 3-5 years. Guess what your salary is? 95k. Guess where your job is? Middle of nowhere. Guess how many equally competitive applicants are there? Thousands. Best case scenario, you get your R01 or two, and you get tenured. Guess what your salary is now? 135k. It really goes far where you live, doesn't it. Congratulations Dr. full professor.

That desirable "doing basic science research in a sustained, dedicated way" job doesn't look so desirable now does it. "Doing basic science research in a sustained, dedicated way" isn't necessarily just something to pursue--to a large degree it is a form of sacrifice that you decide to make.

 

[solitude]

Picking the right specialty is probably one of the most important factors in "doing basic science research in a sustained, dedicated way" as a physician scientist.

This is a very interesting point. Paradoxically, it almost seems that picking a higher-paying specialty that doesn't ostensibly value research highly is the right call, because then the paycut that you take, while similar on a relatively scale, results in a higher absolute value for salary. Also these departments tend to have more cash lying around and willing to spend on bolstering research careers. I have heard this argument made by people in Anesthesia, Ophtho, etc. Of course, there is the lure of big money if you jump the academic ship, which is pulling in the other direction. But from a personal perspective, it seems like it is certainly better to have lots of options.

 

[Fencer]

This is a very interesting point. Paradoxically, it almost seems that picking a higher-paying specialty that doesn't ostensibly value research highly is the right call ... results in a higher absolute value for salary. Also these departments tend to have more cash lying around and willing to spend on bolstering research careers. ... Of course, there is the lure of big money if you jump the academic ship, which is pulling in the other direction. But from a personal perspective, it seems like it is certainly better to have lots of options.

See my highlighting of solitude's quote. I have seen this phenomenon among recent MD/PhD graduates. Another issue to consider is the lack of a community within the department that understands and values what you do increases the pressure to share on the clinical responsibilities, particularly when the clinical track faculty jump the ship as they realize that they do the same as those private practitioners.

 

[Spacedman]

Paradoxically, it almost seems that picking a higher-paying specialty that doesn't ostensibly value research highly is the right call, because then the paycut that you take, while similar on a relatively scale, results in a higher absolute value for salary. Also these departments tend to have more cash lying around and willing to spend on bolstering research careers. I have heard this argument made by people in Anesthesia, Ophtho, etc.

I've been lurking on this thread for a while without much to add since i'm in one of those oddball specialties (anesthesia). however, it seems I'm in a similar to situation to many of you- recently finished residency, instructor level attending 20%, basic science postdoc 80%, doing a bit of math on how long i can keep this show going-- i had a wtf moment recently as i was handling mice at 3am on a saturday night, in moderate disbelief that this was my life after 13 years of post college training....

for what it's worth (and this is probably more pertinent for soon-to-be MSTP grads), I strongly agree with what's been said in that your specialty choice and department chair will make or break your ability to do science. My department has an outstanding revenue stream, and a strong interest in advancing its reputation as a "cutting edge" department in basic and translational science within our specialty. So, the clear upside for me is that a day a week in the OR + T32/etc support come out to ~150. (which is about half of a starting clinical academic attending salary). on top of that, anesthesia has slowly been emerging from an academic wasteland, and there simply aren't that many folks competing for foundation grants within the specialty (compared to, say, neurology/psychiatry/oncology). The downside of this situation -- very few people to talk to, very few senior labs, and a lot of glazed eyeballs when basic science is presented in grand rounds. So, the few of us doing the 80/20 bit end up going to labs outside the department, which may come back to bite me in the a$$ when none of my clinical colleagues even know who I'm working with, let alone what i'm working on.

Maybe two years of majority research with a decent salary is as good as it gets? Two years to get a K99, and if not... back to the saltmines.

I'd encourage MSTP students to take a serious look anesthesia-- I'd like to hear if this is the situation for other nonsurgical procedural specialties. based on my colleagues' experiences, ophthalmologists and dermatologists are much smarter than us gas-passers, so the competition for research time and department $ is a lot more intense.

 

[Fencer]

One of my MS-4 is going into Anesthesia. As I indicated, there is the "the lack of a community within the department that understands and values what you do increases the pressure to share on the clinical responsibilities". You might find that larger community within your professional society.

 

[dl2dp2]

So, the clear upside for me is that a day a week in the OR + T32/etc support come out to ~150.

In a non procedural specialty if you can practice some medicine, you can end up making maybe 120-130k a year as a T32. This makes sense because the $ generated by research is approximately the same, and there's only so much subsidizing a department is willing to do even if they are oh so committed to "be the cutting edge department." The upside is that in a non procedure specialty a graduating resident in pure clinical career make about ~200-250k rather than 250-300k, and an academic graduating resident make significantly less...perhaps 150-200k. So your red eyed beating the Jones psychological dissatisfaction is not as acute, especially when they have a lot more debt than you.

You have to look horizontally though at your basic science colleagues, not vertically at your clinician colleagues. Suppose someone is doing basic bench work as a POST-DOC. How much money do you think they make? 150k is the salary of a FULL TENURED PhD-only PROFESSOR in a basic science department. It's all very relative.

 

[Mad Jack]

This thread is so negative. I realize we must be realistic, but we as applicants are still young; let us have our dreams and be optimistic about the future. I think it's vital that we preserve our passion. I didn't apply MD/PhD just to "fall back on the MD".

Going in blind and idealistic is just ridiculous. You should be well aware of the job market you are facing and assess whether you can handle the reality, rather than the fantasy, of that market. If you just keep to your idealism without a dose of realism mixed in, you're going to end up seriously disillusioned when you complete your training. This applies to any field, within or outside of medicine. Idealism without a hefty dose of reality is often a one-way ticket to burnout city.

 

[Spacedman]

One of my MS-4 is going into Anesthesia. As I indicated, there is the "the lack of a community within the department that understands and values what you do increases the pressure to share on the clinical responsibilities". You might find that larger community within your professional society.

absolutely true, and one of my biggest concerns when i applied to the specialty--

Fencer, perhaps you have some insight: when I applied, I looked for departments that had some evidence of commitment to developing physician scientists, and part of that "commitment" included subsidizing the salaries of 80/20 types to be on par with pure clinical colleagues, since R01s would never make up that difference. Not surprisingly, the few departments fitting these criteria were at "top tier" hospitals. What I could not figure out, though, was what possible incentive a department would have to spend so much money developing research at the cost of clinical productivity -- clearly they weren't making up for it in indirects from the NIH, and it's hard to imagine how they could monetize whatever prestige being "cutting edge" brings.

My best guess- when i imagine department chairs sitting with the dean of the medical school (in my imagination they're all in tuxedos and fine evening wear, seated at an enormous oval lacquered redwood table nibbling caviar and foie gras), their influence is a combination of the clinical revenue they bring in, and their NIH funding rank within their specialty. So within the top tier of NIH funding for, say, OB/GYN, the difference between 4th and 13th is $3.5M. A couple more R01s, and now, hey look Dean! we're a top-5 department, we need more lab space to maintain our status as a leading OB/GYN center, suck on that Emergency Medicine!

I may have a few details wrong.

Anyway, this is the only justification I can imagine for a department to pay double or triple for each NIH dollar they bring in. Thoughts?

 

[Solarium90]

Thank you all for this sobering discussion... it's a good reminder of the future realities that many of us just starting out will have to face.

 

[Fencer]

Sorry but no tuxedos, caviar or foie gras. However, negotiations do occur like that, but prior to this, the main issue is let me see your departmental dashboard (or balanced scorecard) and your budget projections. All discussions are in first name, after all the chairs serve at the pleasure of the dean. Now, the power chairs are those who bring the most revenue (i.e.: surgery and medicine). NIH funding ranking is not as powerful. The tale is that research doesn't pay, i.e.: the institution actually subsidizes at least 20-30 cents on the total dollar (indirect+direct). Teaching also doesn't pay either. Teaching and Research are what we do at Academic Medical Centers, and are often subsidized from clinical revenue. There is a ripple effect of reputation (due to Teaching and Research) that leads to a minor enhancement in the clinical revenue.

 

[Spacedman]

The tale is that research doesn't pay, i.e.: the institution actually subsidizes at least 20-30 cents on the total dollar (indirect+direct). Teaching also doesn't pay either. Teaching and Research are what we do at Academic Medical Centers, and are often subsidized from clinical revenue. There is a ripple effect of reputation (due to Teaching and Research) that leads to a minor enhancement in the clinical revenue.

Hmmm. So, I guess I return to my question- what incentive does a department chair have to subsidize research other than a personal vision? I mean, it would seem that at the level of Dean, one would want to ensure that your departments are fulfilling the "teaching and research" mission, and that one would be more inclined to support individual departments that have broken into "top 10 in the US" status (ie it's much more significant to go from #12 to #4 than to go from being #27 to #19)....

seriously, if i were the dean of the med school and I wanted a cost-effective medical research machine, i'd redistribute the revenue from lucrative but academically weaker departments (say, anesthesia, ER) and subsidize departments which could attract higher profile physician scientists and put out higher impact science (eg heme-onc, psychiatry etc). even a top ranked ER department pulls in significantly less NIH funding than a middling psychiatry department.

at the department chair level, to fulfill the research mission, i'd be much more likely to fund clinical research and "translational" projects rather than take expensive risks on slow-to-mature basic science.

this, perhaps, is why i will never be an administrator, but i'm still struggling to understand what's keeping science alive in clinical departments... more specifically, if one day in the distant future i win an R01, there's every incentive for my chair to increase my clinical commitment from 20% to 50% to maintain my salary. yet, in a number of "top tier" departments within my specialty this still hasn't happened. just a matter of time?

 

[gutonc]

Many clinical departments don't have primary research appointments. For instance, at my institution, in the Dept of Medicine, all of the research faculty have 0.X FTE clinical appointments in their primary clinical division and 1-0.X FTE appointments in a basic science division. The Division of Nephrology and Hypertension will of course lay public claim to the research actually done in the Department of Physiology and Pharmacology (for example) but the Dept of Medicine and it's Divisions don't actually employ basic scientists.

This is obviously not true across institutions or even across departments at a single institution (both Anesthesia and Surgery have primary basic science faculty and clinician/basic scientists on faculty for instance), but it's certainly one way around the issue you bring up.

 

[dl2dp2]

seriously, if i were the dean of the med school and I wanted a cost-effective medical research machine, i'd redistribute the revenue from lucrative but academically weaker departments (say, anesthesia, ER) and subsidize departments which could attract higher profile physician scientists and put out higher impact science (eg heme-onc, psychiatry etc). even a top ranked ER department pulls in significantly less NIH funding than a middling psychiatry department.

This happens. It's called a "dean's tax". This is why academic ER department physicians get paid less than a private ER physician. Dean's taxes are used to often subsidize "campus-wide" initiatives, such as small amount of money for junior faculty and core facilities.

However, to conduct "higher impact science", you need much much much more than what ER depts can subsidize you. Unless you plan to hire 1000 cardiologists and tax their 50% of their salary or more (and to a certain extent they are already taxed 20-30%), you can't subsidize the millions of dollars of research that's going on. And if you do hire 1000 cardiologists, you can't get enough patients for them all to cath non-stop. And even if you can get these patients, they often have horrible insurance/Medicaid. In major metropolitan areas, large tertiary medical centers often LOSE money in terms of clinical revenue OVERALL, because of the poor payer mix. Clinical departments are not nearly as flush with cash as you think, and often are subsidized by the local government through various mechanisms.

I can give you an example of the major academic center that I work at, and pull a slide from an administrative meeting that the employees went to. out of the ~ 1.2 billion total revenue, about 30% comes from clinical practice. 30% comes from sponsored research, 9% from university endowment, 5% tuition, and then various other things. I think this is fairly typical distribution for major centers.

You can see that the daily business of an academic medical center depends heavily heavily on federal funding, and that's why your dean loves you if you can get more R01s. There's literally no money left over from clinical revenue to subsidize the hundreds of millions needed to do all the research. This is also why the higher ups get super nervous when NIH funding is threatened. If the 30 billion NIH money gets cut, academic medical centers shut down. Think of academic medical centers as a shopping mall. Individual labs (and for that matter, clinical services) are vendors renting the space. Your dean runs the shopping mall and charges a rental fee. If you can make money by getting grants, your dean gets a cut from "indirect cost" and pay for phone, internet, maintenance, janitors, etc.. That's why the more the merrier. If you run a really successful and profitable clinical service, your dean would love you too. If you run something that's necessary but loses money (community clinic, say), your dean would have to put up with you and subsidize you rather unwillingly, and constantly try to shut you down. Same if you are a researcher who can't fund his own work.

at the department chair level, to fulfill the research mission, i'd be much more likely to fund clinical research and "translational" projects rather than take expensive risks on slow-to-mature basic science.

Clinical departments generally do not sponsor basic science ANYWAY these days. Basic science at medical centers are done in basic science departments, and clinical revenue really never goes over except through dean's tax. Basic science faculties get their own R01s in order to stay in business.

Remember in the end it's all about money. Academic medical centers can't survive if any one of its endeavors are constantly bleeding money. It doesn't matter how much Nature papers you publish if you can't get enough money somehow to fund your job you won't have a job. On the other hand, if you can get a lot of money, whether you publish in Nature is somewhat negotiable. THAT's the main reason "clinical/translational research" is preferred, even though often they don't publish in Nature. In high end basic science places, there's an added problem especially during tenure review that even when people do get money, they want to additionally make sure you publish in Nature, due to the fact that there's "hard money" (i.e. from endowment) commitment in basic science departments and these spots are extremely scarce. If they think you are not good enough they can always kick you out and bring someone better in on the same hard money pay line, because of the extreme imbalance in supply and demand. You can take your R01 somewhere less prestigious and they don't care. In clinical depts, everyone's on soft money to begin with, so the system is set up such that the dept doesn't care how good you are as long as you get extramural money, because they always take a cut. The department just grows larger and larger with more and more grants and shrinks when grants are gone. There are no "fixed" spots. Doctors who fail to get grants either easily find a job within the clinical portion or easily go somewhere else. Doctors don't need tenure for exactly this reason.

This game is super complex. I'm just barely scratching the surface. This is why department chairs have full time jobs.

 

[strangeglove]

Here's my experience: I graduated from an MSTP, completed a residency in psychiatry at a "top ten" institution in a big city, where I subsequently completed a research/clinical fellowship, obtained a K award, and am now an Assistant Professor in the same department. My research is translational, combining clinical trials with brain imaging. I also teach clinical psychiatry/supervise residents for a couple of hours a week. My K award pays 90K of my salary, and the department caps the Assistant Professor institutional salary at around 120K. I am free to make up the difference using any non-NIH source, such as clinical work within the Department, or non-NIH grants (this is stipulated by the NIH). I am considering a one day per week clinical position at the University outpatient clinic for this purpose. All of my salary and research funding is through "soft money." The University provides me nothing that I am not generating myself. Rather, they are making money off of me. Thankfully, I am allowed to have a private practice on the side, and keep all of the income from this (this is quite unusual for academic psychiatry departments). I work about 10 hours per week in the private practice, which is all private pay/non-insurance and, as a result, I am free to practice the kind of psychiatry that I really enjoy while earning an extra 150K per year. No call. No weekends. I happen to be clinically specialized in the same disorders/treatments that I research in the lab, so the private practice also provides a lot of inspiration for the science. It's also kind-of fun to own a small business. I have 3 kids. I take them to all of their music lessons, sports practices and doctors' appointments, and am home for dinner every night. I work a lot on my computer at night, after they are asleep. I am looking forward to a 5-year stretch where I can maintain this lifestyle, hopefully publish 7-8 decent papers, and then try to get a couple of R01's. If I can do this without a huge struggle or without giving up a significant amount of time for my family, I will keep going. If not, I always have my private practice to fall back on, along with a salaried clinical job somewhere if I desire. I have been extremely fortunate in being able to publish a couple of papers that changed the direction of my field just a little bit. This also allows me to tell myself that I've accomplished what I set out to do as a scientist, and that science is now primarily for my enjoyment, so that if doing science starts to make me or my family suffer, I can leave it easily because my kids and my happiness are more important than any narcissistic gratification that science provides. Despite this seemingly detached attitude (possibly because of it), I consider myself quite productive. As far as I can tell, I'm living the dream. However, I also see how my situation is quite unique, especially my ability to have a private practice that is financially viable in this current economic environment.

My sense is that translational research is considerably more likely to get funded than pure lab research in the current climate. In other words, MD/PhD's who are combining clinical trials with analysis of tissue/blood/brain imaging data, etc., from patients in these trials have a distinct advantage over MD/PhD's who do not have any interface with clinical research. As MD/PhD's, we are ideally suited to do translational research, although my experience has been that the basic science training I received in the MSTP was worthless for doing clinical research, apart from some statistical methods that I learned. I suspect many MD/PhDs see clinical research as beneath us, too easy, or somehow less scientific than our elegant and highly controlled laboratory experiments. I speculate this is due to the culture of MSTP's, where students have to constantly worry about proving their scientific chops to their supervisors, who are usually basic scientists who seem to be disdainful of clinical medicine and clinical research (this itself is tied to envy that basic scientists feel about clinician pay and the relative ease of obtaining funding for clinical research). However, these folks will need to wake up and smell the coffee once they start applying for R01's. In any case, it's a good idea to take full advantage of your clinical training so that you can always be a doctor if you need to pay the rent. That de-pressurizes the situation considerably, such that the very real problems with funding/academic stability are no longer a matter of life/death/feeding your family. This is the true advantage of having an MD/PhD, above the PhD-only.

 

[gutonc]

Here's my experience: I am looking forward to a 5-year stretch where I can maintain this lifestyle, hopefully publish 7-8 decent papers, and then try to get a couple of R01's. If I can do this without a huge struggle or without giving up a significant amount of time for my family, I will keep going. If not, I always have my private practice to fall back on, along with a salaried clinical job somewhere if I desire. I have been extremely fortunate in being able to publish a couple of papers that changed the direction of my field just a little bit. This also allows me to tell myself that I've accomplished what I set out to do as a scientist, and that science is now primarily for my enjoyment, so that if doing science starts to make me or my family suffer, I can leave it easily because my kids and my happiness are more important than any narcissistic gratification that science provides. Despite this seemingly detached attitude (possibly because of it), I consider myself quite productive. As far as I can tell, I'm living the dream. However, I also see how my situation is quite unique, especially my ability to have a private practice that is financially viable in this current economic environment.

Thanks for this post. I will say that your options for supplementing your income are quite unique as you point out...but really nice if you can do it. For me, the only option was moonlighting and that meant even more time away from my family which wasn't acceptable to me or them.

And the bolded part above is the reason that I called it when I did. I just couldn't see myself going another 5 years in the hope of maybe being able to make a go of it long term.

 

[dl2dp2]

my happiness are more important than any narcissistic gratification that science provides

Excellent points and thanks for sharing your experiences. I can especially identify with the above sentiment.