Advice for IM PSTP applicant

[AHDCard]

Hello all! This is my first time posting, but I've been a lurker on this forum for about a decade.

Background:
I'm an MD/PhD grad on the wrong side of 30 who just wrapped up residency interviews with IM PSTPs and categorical IM programs. I'm interested in one of the three competitive IM subspecialties. I interviewed at several excellent "Top 20" type programs (inclusive or peers of Vandy, Mayo, WashU, etc.). My PhD was moderately productive (5 first author papers in field-specific journals) and involved translationally oriented device development and computational work. (~50% of my time was coding.) I have no interest in traditional wet lab benchwork.

The normal categorical IM track involves 3 yrs of IM and 3 yrs of fellowship (the last fellowship year is often a research year at academic programs). So, total six years + any super fellowships or additional research years. PSTP programs involve two yrs of IM, two yrs of clinical fellowship, and three yrs of 80/20 research (Total seven years + any super fellowships). The benefits of a PSTP include a fellowship guarantee, protected research years, two instead of three years of IM, and a small salary bump at some institutions. You do retain the option to leave the PSTP or apply externally for fellowship just like a regular applicant. Programs like to see trainees get a K or an equivalent career-development award in the last research year leading up to a tenure-track 75/25 research/clinical position. At most programs, if you don't have external funding by the end, you are either appointed to a majority clinical position, or to a low-paid instructorship position (with a 75/25 balance) until you secure funding.

Career goals:
I'd like to have a mixed clinical/research career in academic medicine. I'm also open to working for or collaborating with industry, if the opportunity is right. Broadly speaking, my research interests involve utilizing computational techniques (ie, ML/AI) for applications relevant to patient care. However, I'm struggling on whether I want to pursue the traditional 80/20 physician scientist route (K -> RO1, etc.). Research gives me a lot of satisfaction and I would love to spend most of my time on it, but I worry that the high failure rates, grant pressure, and relatively low salary are unsustainable over the long term. A purely clinical career is not right for me either, so I wonder about whether I would be happier in a co-PI or collaborator role with closer to a 50/50 split (is that even possible?).

Questions for the forum:
1) Would you recommend that I do a PSTP? The advice I've gotten is to only do it if you're fully committed to an 80/20 career, since it's (at minimum) an extra year, and you get less robust clinical training that can limit you if you end up in a clinical career. I would love to have an 80/20 career doing research that will impact patient care, but I'm only willing to give up so much $$, time, and stress to make it happen. The idea of being in my late 30s, unfunded, and spending years struggling in the netherworld as an instructor is not appealing - I want more stability and income. Others that I have met (albeit early in GME training) seem to be all-in and do not express those insecurities, at least not openly. If my mindset is "reach for the stars, and if I fail, I land on the moon", is a PSTP worth it given the downsides?

2) On that note, what options are there to do or at least be involved with meaningful research outside of a traditional 80/20, RO1 PI path? By meaningful, I mean something beyond publishing a few case reports or small retrospective studies here and there.

3) Most of the advice that I hear is meant for those hoping to run wet labs. Logistically, what advantages or disadvantages do dry researchers have in setting up a physician-scientist career? For example, if I am unfunded at the end of a PSTP, not interested in an instructorship, and therefore am shunted to a majority clinical position, is it potentially more feasible to submit grants based on computational analyses of clinical data compared to wet-lab researchers, due to fewer infrastructure and lab upkeep requirements? What about greater opportunities for industry funding?

4) I would love advice on ranking programs, as there are so many factors (location, PSTP vs categorical, prestige of institution, research mentors). For example, how should I rank a program in a city that I would love to be at long term but is a weaker research fit, versus a similarly prestigious program that is the best research fit, but is in a city that I don't see myself long term as faculty? What about a regular categorical track in a great city, versus a PSTP with a good research fit but is in a city that I wouldn't want to live in for 7 years? The fellowship guarantee and ability to do 2 years of IM are nice, but are they worth 7 years? Obviously, I know these decisions are highly dependent on one's personal situation, but I'd love to get some insight on the relative importance of these factors, and how others navigated these situations. How much benefit does the PSTP track really add? For example, I could do 3 years of categorical IM in a location I'm happy at without a guarantee, and still likely be a competitive fellowship applicant.

Thanks for making it all the way through this! @Neuronix @dl2dp2 @SurfingDoctor

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[SurfingDoctor]

Well a couple of things. I work in the academic institutions you are talking about. Realistically, there is no such thing as 50/50 that isn't R01 funded. I'm 50/50 and have an R. 80/20 is more of a pipedream for most physician-scientists, so leave that notion at the door. If you can actually support 50% effort through grants, you've more or less made it. However, there is a caveat. For promotion in the places you mentioned, that 50% effort has to be on your grants, not someone elses typically. Like you get an R with 40% effort and are a Co-I on someone elses and have some industry to round out the 50%, you're good from a promotion standpoint. If you are 5-10% on a dozen other people grants, while your salary is covered, you are not deemed worthy of promotion. At least that is the way it is at my institution. So don't think of it as 80/20 or 50/50, think of it as doing your research versus not doing research and getting promoted for doing so. That is my opinion, and somewhat institution specific, but that will answer some of your questions.

1) I would find it questionable that any research "impacts" patient care in a meaningful way. I mean, sure that's why we all do it and because we enjoy it, but its more about laying future groundwork ("stand on the shoulders of giants") than anything tangible. That being said, if you don't want to write grants and pursue your own research, don't bother. This is my opinion, but you've already spent more time than your colleagues doing research at your own personal sacrifice. It's it not your primary goal, at this point... don't bother.

2) Well, it depends on the skill set. I don't know your field per se, but typically, PhDs can have a easier time getting two appointments. Department of Medicine and Department of X. Could your PhD skill set overlap with Biomedical Informatics or Biomedical Engineering? Those departments run on industry contacts as they aren't so much hypothesis, NIH-driven but product development driven. Again, not my field, but I have seen a good number of academic-industry partnerships that are productive. Given that the NIH is still very hypothesis driven, but that they are putting more emphasis on bigdata analysis and high-throughout analytics, I see this type of research growing exponentially in the coming years. Hard to get funding on that alone, but lots of direct costs thrown that way through subawards.

3) I can't speak specifically, maybe others can, but I will say, if you aren't really interested in running a lab and submitting grants, the instructor position is the wrong avenue to go down and a complete financial detriment to you.

4) Two points: 1) at the end of the day you want to go to a place that will give you the training you think you need and that you can tolerate living for the next couple of years. 2) don't ever put money down on the place that you will train at will be the place that you will be faculty at. Certainly, if you go to a place and go down the PSTP and are passionate about it, your likelihood that they will make a faculty spot for you increases. But even then, it's not a guarantee. It's all dependent on the needs of the hospital to fill the FTE and nothing more. Even if you are a "protected" researcher, if they need you to fill in... you do it. If they don't have need for an FTE even though they like you... tough luck, find a job elsewhere. I didn't end up being faculty anywhere close to where I trained. Some people do, but many don't. I was once told academics are nomads. I think that is more true than not.

 

[Neuronix]

Questions for the forum:
1) Would you recommend that I do a PSTP? The advice I've gotten is to only do it if you're fully committed to an 80/20 career, since it's (at minimum) an extra year, and you get less robust clinical training that can limit you if you end up in a clinical career. I would love to have an 80/20 career doing research that will impact patient care, but I'm only willing to give up so much $$, time, and stress to make it happen. The idea of being in my late 30s, unfunded, and spending years struggling in the netherworld as an instructor is not appealing - I want more stability and income. Others that I have met (albeit early in GME training) seem to be all-in and do not express those insecurities, at least not openly. If my mindset is "reach for the stars, and if I fail, I land on the moon", is a PSTP worth it given the downsides?

Only you can decide this. You can always go for it and decide later it isn't worth it if you can't gain traction. Or you can say this is too daunting and bail out now for a non-PSTP track. Also, before PSTP there were still physician-scientists, so it's not like you must do a PSTP. In my opinion, if you see yourself trying for a physician-scientist pathway, PSTP makes the most sense. You need time and mentorship to get a K grant, which a PSTP should provide. You will likely spend even more time trying to get that K grant outside of PSTP. The question here is: do you want to give a serious physician-scientist career a shot or not?

2) On that note, what options are there to do or at least be involved with meaningful research outside of a traditional 80/20, RO1 PI path? By meaningful, I mean something beyond publishing a few case reports or small retrospective studies here and there.

There are always opportunities for research within academics. The question is how hard you will push for it vs. settling into a more clinical pathway.

3) Most of the advice that I hear is meant for those hoping to run wet labs. Logistically, what advantages or disadvantages do dry researchers have in setting up a physician-scientist career? For example, if I am unfunded at the end of a PSTP, not interested in an instructorship, and therefore am shunted to a majority clinical position, is it potentially more feasible to submit grants based on computational analyses of clinical data compared to wet-lab researchers, due to fewer infrastructure and lab upkeep requirements?

In theory you need less resources if you do not have a wet lab. This is a blessing and a curse. The blessing is that you can potentially do a lot with a little. The curse is that people may expect you to pull rabbits out of your hat with little to no support. You can very easily end up in a mostly or 100% clinical position still trying to get data for and write grants. This is how I did it, though I don't recommend it.

What about greater opportunities for industry funding?

I have never had much luck with industry funding. The grant sizes have been small, and they limit indirects significantly. Maybe that's not true in all industries.

4) I would love advice on ranking programs, as there are so many factors (location, PSTP vs categorical, prestige of institution, research mentors). For example, how should I rank a program in a city that I would love to be at long term but is a weaker research fit, versus a similarly prestigious program that is the best research fit, but is in a city that I don't see myself long term as faculty? What about a regular categorical track in a great city, versus a PSTP with a good research fit but is in a city that I wouldn't want to live in for 7 years? The fellowship guarantee and ability to do 2 years of IM are nice, but are they worth 7 years? Obviously, I know these decisions are highly dependent on one's personal situation, but I'd love to get some insight on the relative importance of these factors, and how others navigated these situations. How much benefit does the PSTP track really add? For example, I could do 3 years of categorical IM in a location I'm happy at without a guarantee, and still likely be a competitive fellowship applicant.

Thanks for making it all the way through this! @Neuronix @dl2dp2 @SurfingDoctor

Only you can decide these things. You need to decide how much you want to try to be a physician-scientist. If it's really important to try for that, then you should heavily weight the best research opportunities within PSTP. If not, why even do PSTP and location can take over.

I navigated this by necessity. I never felt like I had much choice of institution. I didn't get the interviews I expected when I applied for residency, didn't match where I expected, research fellowship positions rejected me, and I was largely ignored for faculty positions. I had one faculty position when I finished my training where I could try to pursue my research (with a full clinical load and shared resources only), so I took it. I looked for a new job for years as junior faculty and came up empty handed. So here I sit.

 

[dl2dp2]

Hello all! This is my first time posting, but I've been a lurker on this forum for about a decade.


Career goals:
I'd like to have a mixed clinical/research career in academic medicine. I'm also open to working for or collaborating with industry, if the opportunity is right. Broadly speaking, my research interests involve utilizing computational techniques (ie, ML/AI) for applications relevant to patient care. However, I'm struggling on whether I want to pursue the traditional 80/20 physician scientist route (K -> RO1, etc.). Research gives me a lot of satisfaction and I would love to spend most of my time on it, but I worry that the high failure rates, grant pressure, and relatively low salary are unsustainable over the long term. A purely clinical career is not right for me either, so I wonder about whether I would be happier in a co-PI or collaborator role with closer to a 50/50 split (is that even possible?).

Agree with @SurfingDoctor you can be put on people's grants to the point of having administratively 50/50, but in order to be promoted beyond assistant prof you typically need your own PI-ship grants. Often this is explicitly in the milestone plans when you discuss with your boss. This is variable depending on departments--sometimes procedurally oriented departments will promote you if you meet clinical performance metrics.

That having been said, there's no "struggling" here. If you want to do it, you can always AIM for 80/20, then drop out if you find the gestalt not "sustainable'. I'm not sure what the "struggle" is exactly. Do you mean you want to quit and do pure clinical now? Struggle less. Work more. If you don't like the work, quit. Or, if you want to change the proportion, mix it up and try it out. You don't know if you'll like something and whether that time is worth the money you get paid or give up until you try it.

Questions for the forum:
1) Would you recommend that I do a PSTP? The advice I've gotten is to only do it if you're fully committed to an 80/20 career, since it's (at minimum) an extra year, and you get less robust clinical training that can limit you if you end up in a clinical career. I would love to have an 80/20 career doing research that will impact patient care, but I'm only willing to give up so much $$, time, and stress to make it happen. The idea of being in my late 30s, unfunded, and spending years struggling in the netherworld as an instructor is not appealing - I want more stability and income. Others that I have met (albeit early in GME training) seem to be all-in and do not express those insecurities, at least not openly. If my mindset is "reach for the stars, and if I fail, I land on the moon", is a PSTP worth it given the downsides?

LOL. This depends on too many variables. Generally though in academia if you follow a track things are easier and more laid out for you, which is why tracks are competitive and paid less.

If you want to be paid in excess of what you might think of as what people on the track typically get paid, you'd have to think outside of the box. Speaking on behalf of both @Neuronix and me, while we were sort of technically "on track" for a long time, neither of us followed the usual academic model as enumerated by our boss and boss's boss, at least since the end of residency. So the answer to your questions is that it may or may not be worth it, and there are possibilities that you don't even know existed, but there's no set way to find them within the "track", as nobody on these tracks knows about them, or if they did they would never talk about them with trainees.

It's sort of magical and woo-woo, but unfortunately, this is the way it is given the reality of the NIH-driven funding environment. People who "make it" end up getting "lucky" in very case-specific ways. The only general advice I have for you is to talk to as many "successful" people as possible in your field, and don't restrict your solicitation of advice from only academic types.

2) On that note, what options are there to do or at least be involved with meaningful research outside of a traditional 80/20, RO1 PI path? By meaningful, I mean something beyond publishing a few case reports or small retrospective studies here and there.

There's industry research, for one. In academia, there's generally none, though in some departments (proceduralist) they can cough up a budget for you to do research without external grant support. But even then it's tough to get more than a few hundred thousand a year to run a "lab".

Industry research is also highly variable. Some companies like to write lots of papers. Others forbid you from writing papers. OTOH, I would say if you pushed some device through phase I or II it's "meaningful". So you kind of have to deliminate what is the metric for your definition of "meaningful research".

3) Most of the advice that I hear is meant for those hoping to run wet labs. Logistically, what advantages or disadvantages do dry researchers have in setting up a physician-scientist career? For example, if I am unfunded at the end of a PSTP, not interested in an instructorship, and therefore am shunted to a majority clinical position, is it potentially more feasible to submit grants based on computational analyses of clinical data compared to wet-lab researchers, due to fewer infrastructure and lab upkeep requirements? What about greater opportunities for industry funding?

Wet lab is generally more annoying and less feasible for being 80/20, but people who do wet lab usually can't do dry lab, especially into their mid to late 30s and vice versa. You can submit grants for whatever you want, and the process is similar.

Industry prefers people who have clinical research or other more industry-relevant experience (i.e. regulatory), and this can be dry or wet. You could in theory go for a pre-clinical job, but they paid very badly. You want the medical director series of jobs in the industry. But what really makes you marketable for industry is previous industry experience. So ideally you just get whatever job you can get in industry and move from there.

Unfortunately, even though by the end of PhD you might have as much skill as an entry level engineer in R&D, by the time you are done with your residency/fellowship, the value in your PhD has decreased comparatively. I was talking with several colleagues recently about this. Very few MD-PhDs going into industry end up doing a job fitted for their PhD training rather than their MD-residency-fellowship training, as the latter typically start at a salary that's 2-3x the former. In terms of actual skills/knowledge-base, PhDs are useless, even for the PhDs that are very useful in general (i.e. computational). You could think of your residency-fellowship as industry experience. A senior engineer with 5-7 years of experience might have a salary comparable to a specialty physician, but you can't jump directly from entry-level to senior without relevant experience.

4) I would love advice on ranking programs, as there are so many factors (location, PSTP vs categorical, prestige of institution, research mentors). For example, how should I rank a program in a city that I would love to be at long term but is a weaker research fit, versus a similarly prestigious program that is the best research fit, but is in a city that I don't see myself long term as faculty? What about a regular categorical track in a great city, versus a PSTP with a good research fit but is in a city that I wouldn't want to live in for 7 years? The fellowship guarantee and ability to do 2 years of IM are nice, but are they worth 7 years? Obviously, I know these decisions are highly dependent on one's personal situation, but I'd love to get some insight on the relative importance of these factors, and how others navigated these situations. How much benefit does the PSTP track really add? For example, I could do 3 years of categorical IM in a location I'm happy at without a guarantee, and still likely be a competitive fellowship applicant.

Research fit in general is worthless. This is a weird insight that would not be available to me until recently. If you are interested in someone else's research, the best way is to build a collaboration. Research fit people talk about at trainee level typically entails some senior person being an expert in a field of interest. This CAN be helpful, but in general, if you pester enough between your own boss and this person, it doesn't matter if this person is at your site or not, especially if you can write a paper/grant on your own without too much of their involvement.

If all you really care about is success in research, the real key to me is to match as high prestige as you can get in the field. That's pretty much it. Operationally this can be defined as NIH dollars, but there are field specific variations. However, in general at this stage personal reasons for location >>> "all you care about is research". PTSP as I said above, is mostly window-dressing.

 

[Neuronix]

Agree with @SurfingDoctor you can be put on people's grants to the point of having administratively 50/50, but in order to be promoted beyond assistant prof you typically need your own PI-ship grants. Often this is explicitly in the milestone plans when you discuss with your boss. This is variable depending on departments--sometimes procedurally oriented departments will promote you if you meet clinical performance metrics.

This depends on track. This sounds like a more research/tenure track.

If you want to be paid in excess of what you might think of as what people on the track typically get paid, you'd have to think outside of the box. Speaking on behalf of both @Neuronix and me, while we were sort of technically "on track" for a long time, neither of us followed the usual academic model as enumerated by our boss and boss's boss, at least since the end of residency. So the answer to your questions is that it may or may not be worth it, and there are possibilities that you don't even know existed, but there's no set way to find them within the "track", as nobody on these tracks knows about them, or if they did they would never talk about them with trainees.

What track was I on? I'm still clinical-instructor track and associate professor of clinical title. Grants were not expected or required to be promoted, and most people in my department will go from assistant through full professor without grants or with small grants only. I know another place in my state that requires assistant faculty to submit a grant to be considered for associate, and of course most of these will never be funded.

It's sort of magical and woo-woo, but unfortunately, this is the way it is given the reality of the NIH-driven funding environment. People who "make it" end up getting "lucky" in very case-specific ways. The only general advice I have for you is to talk to as many "successful" people as possible in your field, and don't restrict your solicitation of advice from only academic types.

Agree luck has a lot to do with it. However, luck is just one element. You don't just stumble into running a good lab. You put your all into it and hope it works out.

If all you really care about is success in research, the real key to me is to match as high prestige as you can get in the field. That's pretty much it. Operationally this can be defined as NIH dollars, but there are field specific variations. However, in general at this stage personal reasons for location >>> "all you care about is research". PTSP as I said above, is mostly window-dressing.

I don't think prestige is everything. Some high prestige places are not committed to supporting junior faculty. If you have multiple opportunities you should evaluate what each institution brings to the table as far as committed resources and strength in your area of interest.

 

[AHDCard]

Thank you all for the insight! A couple points I wanted to follow up on:

For promotion in the places you mentioned, that 50% effort has to be on your grants, not someone elses typically. Like you get an R with 40% effort and are a Co-I on someone elses and have some industry to round out the 50%, you're good from a promotion standpoint. If you are 5-10% on a dozen other people grants, while your salary is covered, you are not deemed worthy of promotion. At least that is the way it is at my institution. So don't think of it as 80/20 or 50/50, think of it as doing your research versus not doing research and getting promoted for doing so. That is my opinion, and somewhat institution specific, but that will answer some of your questions.

Like @Neuronix said, are you referring to promotions if one is in a tenure track position? This is one thing I've never understood - what is the advantage of being a tenure track position? My understanding is that both the clinical and tenure track positions at academic medical centers are soft money positions where you "buy" your nonclinical time by bringing in external funding or perform administrative duties. So why does the tenure track even exist? In fact, it seems like the tenure track is perhaps even less flexible, given that you need to hit certain funding / publication benchmarks for promotion, which clinical track faculty don't need to worry about. I've actually asked a few PSTP directors this question and all have said "there is no benefit" or gave me a vague answer; in fact, some were even on the clinical track themselves. Despite this, most still talked about a tenure-track appointment as the ideal outcome for a trainee - is this just a way for their outcome metrics to look good?

The question here is: do you want to give a serious physician-scientist career a shot or not?


In theory you need less resources if you do not have a wet lab. This is a blessing and a curse. The blessing is that you can potentially do a lot with a little. The curse is that people may expect you to pull rabbits out of your hat with little to no support. You can very easily end up in a mostly or 100% clinical position still trying to get data for and write grants. This is how I did it, though I don't recommend it.

Framed like that, I would like to give a serious physician-scientist career at least a shot.

Do you mind expanding on how others' overinflated expectations can hurt you? For example, do you mean your chief may not give you a sufficient start-up package? Or won't give you enough research time (that you haven't brought in the grants to support) to be successful?

Agree with @SurfingDoctor you can be put on people's grants to the point of having administratively 50/50, but in order to be promoted beyond assistant prof you typically need your own PI-ship grants. Often this is explicitly in the milestone plans when you discuss with your boss. This is variable depending on departments--sometimes procedurally oriented departments will promote you if you meet clinical performance metrics.

LOL. This depends on too many variables. Generally though in academia if you follow a track things are easier and more laid out for you, which is why tracks are competitive and paid less.

If you want to be paid in excess of what you might think of as what people on the track typically get paid, you'd have to think outside of the box. Speaking on behalf of both @Neuronix and me, while we were sort of technically "on track" for a long time, neither of us followed the usual academic model as enumerated by our boss and boss's boss, at least since the end of residency. So the answer to your questions is that it may or may not be worth it, and there are possibilities that you don't even know existed, but there's no set way to find them within the "track", as nobody on these tracks knows about them, or if they did they would never talk about them with trainees.

By track, are you referring to tenure-track positions? See my above question - what is the benefit of being a tenure track position if it's soft money anyways?

Unfortunately, even though by the end of PhD you might have as much skill as an entry level engineer in R&D, by the time you are done with your residency/fellowship, the value in your PhD has decreased comparatively. I was talking with several colleagues recently about this. Very few MD-PhDs going into industry end up doing a job fitted for their PhD training rather than their MD-residency-fellowship training, as the latter typically start at a salary that's 2-3x the former. In terms of actual skills/knowledge-base, PhDs are useless, even for the PhDs that are very useful in general (i.e. computational). You could think of your residency-fellowship as industry experience. A senior engineer with 5-7 years of experience might have a salary comparable to a specialty physician, but you can't jump directly from entry-level to senior without relevant experience.

This makes sense and has generally been consistent with my observations. Once an MD/PhD has completed residency/fellowship, the fact that they can treat patients grossly distorts their value in a good way - they always have full-time clinician as a high salary career option, have knowledge of patient care, are legally able to recruit patients for trials, and have a network of clinicians they know. I feel MD/PhDs who do residency/fellowship are MDs with research skills, and MD/PhDs who don't do residency/fellowship are PhDs who can talk to doctors.

Research fit in general is worthless. This is a weird insight that would not be available to me until recently. If you are interested in someone else's research, the best way is to build a collaboration. Research fit people talk about at trainee level typically entails some senior person being an expert in a field of interest. This CAN be helpful, but in general, if you pester enough between your own boss and this person, it doesn't matter if this person is at your site or not, especially if you can write a paper/grant on your own without too much of their involvement.

If all you really care about is success in research, the real key to me is to match as high prestige as you can get in the field. That's pretty much it. Operationally this can be defined as NIH dollars, but there are field specific variations. However, in general at this stage personal reasons for location >>> "all you care about is research". PTSP as I said above, is mostly window-dressing.

I don't think prestige is everything. Some high prestige places are not committed to supporting junior faculty. If you have multiple opportunities you should evaluate what each institution brings to the table as far as committed resources and strength in your area of interest.

Do you mind expanding on this @dl2dp2 ? I can understand going to an institution that is less strong in your field as a junior faculty: less entrenched competition within the institution, you are seen as novel, etc.. However, as a PSTP/postdoc I would still be a semi-trainee, and it seems intuitively advantageous to go to an institution with better mentors, infrastructure, and institutional support for my area of interest, even at the expense of some prestige as @Neuronix said.

Are you saying that I should go to the most prestigious institution, regardless of whether there is expertise in my field, then develop informal, email-based mentorship arrangements with the experts at other institutions? It seems like there would be so many things missing - infrastructure ie, computational/cloud hardware, existing datasets, ability to discuss research questions with peers on a day to day basis, networking in your field, etc. Also, why would those experts at other institutions even agree to help you? I imagine some would see you as competition and/or not care about supporting you. Unless you're prolific and willing to put their names on papers/grants.

 

[SurfingDoctor]

Thank you all for the insight! A couple points I wanted to follow up on:



Like @Neuronix said, are you referring to promotions if one is in a tenure track position? This is one thing I've never understood - what is the advantage of being a tenure track position? My understanding is that both the clinical and tenure track positions at academic medical centers are soft money positions where you "buy" your nonclinical time by bringing in external funding or perform administrative duties. So why does the tenure track even exist? In fact, it seems like the tenure track is perhaps even less flexible, given that you need to hit certain funding / publication benchmarks for promotion, which clinical track faculty don't need to worry about. I've actually asked a few PSTP directors this question and all have said "there is no benefit" or gave me a vague answer; in fact, some were even on the clinical track themselves. Despite this, most still talked about a tenure-track appointment as the ideal outcome for a trainee - is this just a way for their outcome metrics to look good?

Yes, this is a good question. The real answer is probably as unsatisfactory as you can imagine... self-worth. Tenure in the old days, meant protection of time for other scholarly pursuits... namely sabbaticals, where you could mingle amongst colleagues, learn some new technique to bring back, expand your science. But those days are gone. Medicine and academia are far more business oriented than they used to be and no institution is going to pay you to go fart around on their dime. It's just not going to happen. So, with that gone, what are you left with? Well, at the assistant professor stage, you are generally required to be placed on a tenure-track if you are going to receive start up funds. The institution considers this an investment in the hopes that you make good use of the money so that you can get a RPG and they can finally recoup the loss in the form of indirects. In most institutions, and this is really less important for MDs-MD/PhDs as it is PhDs, if you don't make that hurdle, you get fired. Then they can drop the dead weight so to speak and reinvest whatever money into someone else to get those indirect costs. Realizing that one RPG will net indirects on the order of close to 1 million dollars, it's viewed as a win-win scenario for the investigator and institution, realizing that that point of view is relative. In the associate professor time, tenure nets you nothing. Nothing really except, as I said, sense of self-worth. You are differentiated amongst your colleagues because you achieved something they could not. But it really doesn't go beyond that at that stage. At the professor level, tenure nets you endowments and the ability to climb up with academia food chain. It clearly depends on the institution and department, but you typically can't be a leader if you haven't been selected for tenure. Again, not a hard and fast rule, but most chiefs, chairs, etc are tenured professors. It's the reward for paying back the institution in money all those years. In turn, those positions usually come with endowments. This is soft money that can be used to fund pet projects and personnel. It essentially helps fund the science even if you don't have grants to support the science. It doesn't provide a lot, but enough typically that if you wanted to float by for the rest of your career, you probably could. Granted, most tenured professors would prefer to keep getting grants to get more staff (and many do), but it's a reward more or less.

So for most of ones career, tenure doesn't net you anything except pride I guess, but toward the end of one's career, is the gateway to climbing the academia ladder. It also tends to just be the metric the institution uses to guide it's own prestige (realizing that the bar of "tenure" varies wildly between institutions where an R-funded assistant professor at Hopkins could be a tenure full professor at Appalachian State).

But the question of is that worth it? Generally speaking... probably not, which is why you get those vague answers.

Of course, you can also be a full professor in a clinical track. It's usually harder to get because you don't necessarily get rewarded from an institutional standpoint by not bringing in indirects (unless of course, you are on a clinical track bringing in indirects). So it does happen. But if you are not bringing in indirect, you need to be generating a good amount of RVUs to generate money for the system. That being said, if you don't generate indirect and generate modest RVUs based on your specialty, most institutions are just as content to leave you at assistant professor till the day you retire. At some institutions, because the percent increase in salary doesn't make up for the extra RVU and indirects needed to be promoted, some people intentionally never even bother. I know a couple institutions like that.

 

[dl2dp2]

Do you mind expanding on this @dl2dp2 ? I can understand going to an institution that is less strong in your field as a junior faculty: less entrenched competition within the institution, you are seen as novel, etc.. However, as a PSTP/postdoc I would still be a semi-trainee, and it seems intuitively advantageous to go to an institution with better mentors, infrastructure, and institutional support for my area of interest, even at the expense of some prestige as @Neuronix said.

Are you saying that I should go to the most prestigious institution, regardless of whether there is expertise in my field, then develop informal, email-based mentorship arrangements with the experts at other institutions? It seems like there would be so many things missing - infrastructure ie, computational/cloud hardware, existing datasets, ability to discuss research questions with peers on a day to day basis, networking in your field, etc. Also, why would those experts at other institutions even agree to help you? I imagine some would see you as competition and/or not care about supporting you. Unless you're prolific and willing to put their names on papers/grants.

You are obsessed with shell games and I think very often these “tracks” considerations make things unnecessarily complicated. Your job as a PI is to write lots and lots of grants. Fundamentally if you don’t like writing grants it almost doesn’t matter what tracks you are sitting in. It’s like ok you want to be a chef, do you like cooking? If don’t like cooking it’s really hard to be like oh actually if I only cook at a fancy restaurant that gives me tenure I’ll like it.

Write grants. Write papers. Hire people write papers for you, etc. If you don't know how to write grants, figure it out. Like, if I tell you you will LOSE your health insurance AND salary in 10 months if you don't submit a grant in 3 months, what would you do? Btw, this scenario is so common now it's not even a theoretical exercise. It's basically constant in academia AFTER you get a job. Do whatever it takes to hustle to get the grants written. And if you don't have enough salary support get a side job or beg your department chair or wealthy parents for handouts (all true stories, happen all the time).

The bigger problem is you don’t know if you like the grant writing process until you start doing it, and whether you like it changes depending on your success. This is why I think they should just filter graduate students by grant writing abilities. Which they sort of do— by using prestige journal as a proxy, as typically prestige journal requires more hustling. You are asking me specific questions on *how* to hustle, which is really beyond the scope of internet advice, which I think of as more strategic. Do you see how all of this works now? Lol

 

[gbwillner]

I did a PSTP and never regretted it, even though I left academia.

Also- did you know about the informatics fellowship through clinical pathology? That is another fast-track and may be more fulfilling given your research goals.

 

[Neuronix]

Framed like that, I would like to give a serious physician-scientist career at least a shot.

Do you mind expanding on how others' overinflated expectations can hurt you? For example, do you mean your chief may not give you a sufficient start-up package? Or won't give you enough research time (that you haven't brought in the grants to support) to be successful?

Yes. It's not uncommon that chairs or directors like the idea of hiring a dry lab MD or MD/PhD with no/minimal startup resources with the idea that the junior faculty will just fiddle with some computers in their free time and make papers and grants happen. They will be more than happy to take credit for your success when you are successful, but if you're not just blame you and move on to the next new grad.

By track, are you referring to tenure-track positions? See my above question - what is the benefit of being a tenure track position if it's soft money anyways?

Tenure track is preferred because there's at least an idea that you are on a track to tenure and people should be supporting you to be successful in the classic sense of grants, high impact papers, presentations, committees, long-term commitments between the faculty and University, etc. How that actually plays out in support and mentorship is very institution dependent, though there's still at least a notion that tenure track is intended to produce successful physician-scientists and someone who falls off the track is a "failure" that maybe the institution could have supported better.

For clinical track people there often is no support. They may not actually care if you get grants, papers, and you may be treated as a dime a dozen interchangeable faculty with all the other clinical faculty since most MDs are clinical people and the hiring pool is much larger. Again, this depends on the University and department.

 

[AHDCard]

I did a PSTP and never regretted it, even though I left academia.

Also- did you know about the informatics fellowship through clinical pathology? That is another fast-track and may be more fulfilling given your research goals.

I have heard of informatics fellowships (and I believe you can do one after completing any residency, not just after or in conjunction with pathology).

However, my impression is that they are geared towards training someone to be a health-systems administrator that manages and improve the way that EMR is used, rather than an academic researcher.

Do you agree with that impression or am I wrong? Or does it depend on the program?

 

[gbwillner]

Like any fellowship it is going to be geared to a clinical end- that said I am sure depending on the program there will be good opportunity for research. This is a pretty hot field.