You can spend the majority of your academic time executing trials (site-PI), as there are lots out there, many pharmaceutically-sponsored these days. One can debate whether or not that is wise from a career development standpoint or not, as you are essentially an on-site deputy making sure the protocol is followed at your institution. That is distinct from your clinical time taking care of patients, although you certainly can be on service and executing trials at the same time. Depending on whether or not trials are NIH-supported, you can add some salary support from these efforts, although the NIH tends to reimburse sites meagerly, once you've paid for your screening coordinators, research nurses, etc.
On the flip side, you can have a very strong academic career as a clinical trialist who designs, gets support for, and administrates multi-center trial efforts. Some of the more famous stroke neurologists out there are well-known because of their trial work.
Taking a disparaging tone for clinical trial work is not helpful. There is some basic science which is great, but much of it is nonsense: not reproducible or not worth even trying to reproduce, clinically irrelevant, so narrow as to be of no interest, or treading of well walked grounds. This academic attitude that a clinical trial doctor is "just" a deputy prevents academic sites from truly leading clinical medicine into new advances, new therapies, new areas. Even if true, so what, is being a deputy somehow a dishonorable job? Is being a small part of a large advance, like a DMT in ALS or AD, somehow less worthy of being a big part of something tiny (a new gene association, an unregulated pathway in ____, ____ cell response to ___, 98% of all fMRI studies, the list goes on)?
Especially because even these tiny advances are less probable that most every grant that promises nothing new, no innovation, little true risk, and relies on name/institution/connections mentions bench to bedside - then forgets about the bedside as soon as the money comes in, then focuses on slicing the data into a thin paper. I have no problem if academic places want to lose their positions as leaders, retreat from the needs of society, and focus on their tiny domains, only a sense of sadness. I do object to the abuses as the old
hoard their grant money at the expense of young, risk taking investigators who could make a real difference.
The fact is that a trial doctor is on the leading edge of medicine. And the people who design trials mostly work for pharm companies and their jobs are kinda boring. It takes a unique skill set, good training, and an entrepreneurial spirit to conduct clinical research: know the medicine and the models, interface with a study team, the sponsor, CROs, getting and keeping the proper subjects in a trial while keeping others out. These trials have led to real differences in care. Oncology is the best model, where trials are essentially part of the treatment plans, and never disparaged by the ivory tower. Instead, it is seems to be an ethos in the field: your fellowship entails clinical trials. Neurology has successes, DMTs in MS mostly, but has eased the suffering of millions with symptomatic medications, and we will have more. Let's all try to be part of the solutions. Seeking individual glory won't fly once all the low hanging fruit has been picked.
On a personal note, I was once being a bit churlish about a stroke study's budget, and one of your "more famous stroke neurologists out there" gently reminded me that this is a team approach, requiring sacrifice. We're a site, I guess you'd say I'm just a deputy, but I consider myself a sheriff and I'm proud of my role.
Finally, consider that your mom, friend, sibling will have early AD in 10 years. What brings you more optimism, that trials are being done or that someone is finding out, once again, that amyloid is bad for rat brains?