Clinician Scientist K08 Grant Number Declines Over Last Decade

[Microglia]

First- sorry for the poor image quality.

Second- I am not an expert on this subject, and I'm sure there are aspects of these funding mechanisms I'm missing or not privy to.

This is a screen grab of a graph I made on the change in percentage of K08 grants (Clinician Investigator Awards) between 2009 and 2018 by institute and in aggregate. Data source is table 110 from the NIH RePORT, linked below.

Bottom Line:
% Change in number of transitional awards between 2009 and 2018 by code:
K01: +18.23%
K08: -17.08%
K99: +46.15%
R01: +26.89%
NIH Total (All Codes- K,R, etc) Award Funding: +7.98%

I used the 2009 number as the denomenator for calculating percent change. I linked the data source below for anyone to take a look at if curious.

I was surprised by the data here- while overall in this time span NIH budget increased, funding for K01's and K99's increased, and funding for R01's increased, the number of K08's has decreased. The number of awards in 2009 was 1,001 and is currently 830.

The news is not all bad here from the data. In the past two years, K08's have increased in number, hitting an all time low for the period in 2016 at 719, and gaining awards up to the 830 that were availiable in 2018. However, when compared to the other K awards (K01, K99) and R01 grants there is a net loss only for K08 Clinician Scientist - Transitional awards.

I'm curious to get other's input on what you think of this information. Are you encouraged by the gains in the last 2 years in the K08 category and do you expect it to continue? Why do you think K08's show a unique trend of decline compared to similar funding mechanisms for the past decade? Does this difference reflect a differential value placed on clinician vs traditional PhD scientists? All input is welcome and thanks for your time.

Data Source:
K Awards: https://report.nih.gov/FileLink.aspx?rid=533
R Awards: NIH Data Book

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[dl2dp2]

To an extent there's a strong institutional push to bypass K since it has low indirect. I think what you are seeing is more phds applying for Ks (vs. just R01s as they secure institutional startup).

 

[Microglia]

To an extent there's a strong institutional push to bypass K since it has low indirect. I think what you are seeing is more phds applying for Ks (vs. just R01s as they secure institutional startup).

Very interesting- thanks for that insight. I didn’t realize that institutions would bypass K mechanisms routinely to avoid low indirects. What funding mechanisms would be used in lieu of them? Some sort of departmental or internal startup fund?

 

[dl2dp2]

Very interesting- thanks for that insight. I didn’t realize that institutions would bypass K mechanisms routinely to avoid low indirects. What funding mechanisms would be used in lieu of them? Some sort of departmental or internal startup fund?

This is correct. K08 is still useful for some segments (i.e. as a K99 backup for MDPhD basic scientists). How to move on to R01 depends a lot on the department, even within the same field. Ks are not useful for procedural specialties.

MD/PhD Ks are just a small number period, if you think about: K08+K23 subtract some PhDs (clinical psychology, clinical microbiology, etc) yield at max 1500 TOTAL, and given these are 5 year grants, each year you have 300 new awards across all of NIH. While the physician scientist pipeline is indeed defective, there are definitely more than 300 new physician scientists in the US graduating and getting academic jobs each year. How much more is unclear LOL.

 

[Neuronix]

Very interesting- thanks for that insight. I didn’t realize that institutions would bypass K mechanisms routinely to avoid low indirects. What funding mechanisms would be used in lieu of them? Some sort of departmental or internal startup fund?

Most training grants do not provide full NIH indirects and require institutional matching funds. This makes them "money losers".

If you're lucky your institution will support you for these and/or give you a startup package so that you can get preliminary data and a track record of funding to try for R01s and other large grants. In my experience, even obtaining training grants requires pretty significant preliminary data, so the ideal situation is to have a position that provides significant protected time, startup resources, and support for training grants for 3-5 years. This was the classic scenario in the 80s-90s that seems less common to me over the less decade. What I've seen some institutions say is that MD/PhDs are just too expensive--MDs need to be in clinic and PhDs can be in the lab for a fraction of the cost.

Some institutions hedge by pushing MD/PhDs straight into clinic with instructions to write R01s with minimal or no preliminary data. Or alternatively the advice will be to generate preliminary data slowly from your patients with no or very limited support and consider an R01 in 5+ years once you've "earned" your time out of clinic. When you fail, they will put the blame on your work ethic and your ideas. They will then put you in clinic 100% of the time instead of 75% of the time. Welcome to "academics"

 

[interstellar taco]

To an extent there's a strong institutional push to bypass K since it has low indirect. I think what you are seeing is more phds applying for Ks (vs. just R01s as they secure institutional startup).

Very long-time intermittent lurker here, as a non-registered guest, since the early-mid 2000's. I'm not a vocal person but I've learned a lot from reading posts by Neuronix, sluox, Fencer, Gfunk6, gbwillner, and others.

I've long had a goal of working as a surgeon-scientist, and I've finally emerged from the training pipeline (MSTP, surgical residency, clinical fellowship with lab and clinical research in my "free time"). I've been dismayed (but not dissuaded) at every juncture, and for years I've struggled with options taken by friends and colleagues along the way: private practice, management consulting, biotech, and so on. But I've stuck to what increasingly feels like a fool's errand, inspired by my own idealism, or what's left of it.

The sluox quote above really struck a chord for me.

In meeting with chairmen at top programs in my surgical specialty, every single one of them expressed a commitment to cultivating a strong research apparatus that complemented his departments' clinical enterprise. I typically approached each of these meetings with a well-prepared timeline and strategy for establishing independence and generating funding. The chairmen were enthusiastic and encouraging.

Fast forward to the final stages of ironing out my chosen position (top 5 academic program). Chair says, "It makes no sense for you to apply for a K. It pays peanuts and cuts your clinical output drastically. The department will be shouldering a huge burden. You should stay 50/50, work for an R21 then an R01 and we can figure out salary funding from there."

I've been reflecting on this for awhile now: The K08 mechanism just does not make sense for surgeon-scientists, and probably not for most procedural based physician-scientists (cardiology, GI, etc.).

Don't know how I'll be able to get to R with meager startup funds, no personnel commitment, etc. Though they keep saying, "We want you to focus on your research," it seems they really only care about how to market and increase volume for my (50%) clinical practice.

End venting.

 

[Neuronix]

Vent away my friend. This is not an uncommon experience. I found out recently that the pathologists at my institution were unable to write for K grants. Pathologists?! That's the stereotypical MD/PhD research specialty.

Everyone is going to tell you they're "supportive of" and "enthusiastic for" research. Even very clinical places want to at least pretend that they're on the leading edge to get patients in the door. The reality is that they have to put their money where their mouths are. What's the details of the support? This will make them uncomfortable if they don't plan to actually support you in any meaningful way. This will come back to you as having a "bad fit" or "personality issue". But what are you supposed to do? This has been my experience. I have to push hard for resources so I end up in very uncomfortable situations, but otherwise how do I succeed?

R21 is a difficult mechanism. The grants don't pay that much and they're basically reviewed like R01s. They're not "money losers" for the department, but they put tremendous stress on the faculty since they are for two years and don't include tremendous amounts of money for projects or protected time. I've sat on these study sections and for the level of work and criticism you get back they might as well be R01s. Even if you're successful you have turn around in a very short timeframe and write another R21 or R01. So I don't understand the advice for writing R21s unless you really do have a small project that you want to accomplish.

IMO K08 mechanism makes perfect sense for all physician-scientists (surgeon or otherwise), but it's so expensive that many institutions don't support faculty to submit them. Are these places really losing money or is the issue that the profit on our clinical efforts are going to support hospital admin and C-level salaries in the "non-profit" academic medical system? I personally tried to find a research fellowship to prepare my K08 award and I couldn't even find a research fellowship (including at the NIH) so I had to move on to a non-tenure track clinical educator faculty position with no startup package. I've been fighting ever since to make something happen on the research side and it hasn't been easy.

This makes me wonder to the MSTP gurus out there and the NIH, what are we MD/PhDs supposed to be doing once we get out in the real world? The opportunities simply aren't there for a lot of us.

 

[Spacedman]

As others have said, very institution and specialty dependent. I’m in a less common destination for MSTPs (anesthesia), so my comments on this topic over the years in this forum usually get crickets. But, for the sake of the two current MSTPs that may be headed to anesthesia...

I’d consider anesthesia to be a procedural specialty, and I can say for a dead certainty the K08 is very useful... at the 5-6 institutions that have the research vision and can afford it. Chairs see it as evidence of fundability, enough to justify a few years of salary support while the candidate gets mentored* and gathers prelim data for an R level grant. The challenge, for us at least, is that it’s difficult to to tell who is doing “good” research when the specialty encompasses everything from informatics to pain biology. The K08/K23 and job offers at one of the other 5-6 places, are the surrogate measures my specialty seems to use to determine value and justify investment.

For departments and specialties that don’t have that kind of $ sitting around to invest (and I’m pretty sure that bubble won’t last), it seems much harder to argue for investing in the MD/PhD physician scientist model.

If you’re reading this and thinking of going into anesthesia... PM me for relevant details. It’s a small small world.

 

[SurfingDoctor]

Personally, I have seen departments more willing to support pursuing K08/K23 if the institution as a whole has alternative K mechanisms, KL2 or K12. This essentially allows the protected salary time for individuals at the institute, but at reduced direct costs and with a payback mechanism that if the individual on the KL2 or K12 gets an NIH-sponsored K, the institute can show evidence of success for competitive renewal.

There is also dependence on how big the institute is as each center has their own percentage of how much indirects are as a percent of directs.

That being said, I agree with above that it is highly institute dependent and also highly dependent on the medical/surgical department and lost RVU generation by not doing clinical activities. Unfortunately, many institutes at the NIH don’t offer R03 or R21s and people are just stuck pursuing R01s and competing against full time PhD who can devote more time to research at a fraction of the cost. In addition, this process has to continue indefinitely as once the R01 funds runs out, you’ve gotta keep applying against the same hurdles. I’ve seen several mid-career labs shutter from funding lapses. I think R35s are designed to address some of these issues, but I don’t know how successful they’ll be.

Personally, after seeing more and more investigators close shop, even after being in their 40s with previous R funding, I’ve become more disallusioned with the process and think it needs to fundamentally change.

 

[interstellar taco]

Does anyone really expect to be supported by NIH grants for the entirety of their career?

...

If you look at the CVs of younger faculty, you'll find that funding usually comes from many sources, including foundations, the VA/DOD, private sector/pharma, government contracts, etc.

In my post, I used NIH R01 as a surrogate for any major research grant(s). Certainly funding from NSF, DOD, VA, foundations, etc. can be a part of the calculation. The problem is the "% effort" restrictions on many of these awards -- and reconciling that with clinical FTE, or having multiple major research projects with conflicting "% effort." I am a surgeon and love to operate. But I'm also a scientist with the chops to carry out research. I understand the rationale behind "% effort" restrictions but they really hamstring me in setting up an ideal, hybrid clinical practice with translational research program. Salary caps compound the issue.

I understand that funding agencies have to look out for themselves -- i.e., not spend $500,000 on a researcher dedicating only 10-15% of his time to a project. But in today's world, I have yet to meet a physician-scientist who treats his or her career as a 40-hour-a-week, compartmentalized job. I'm thinking and "working" on my research when I'm seeing patients in clinic or and vice versa. Everything is fluid. I wish there were a way that funding agencies could recognize that.

And chairs/deans need to recognize the worth of their physician-scientists.

 

[Neuronix]

My experience is that you're either stuck at 10% - 20% effort to make the budget of the grant work OR the grant requires some amount of effort that the grant mechanism won't fund.

Both situations are not tenable unless your department is willing to support your salary.

In my case to try to make it work I sacrifice part of my own salary AND work more hours than most of my clinical colleagues. I am very conflicted about this and wonder frequently whether it's worth it in the long run.

 

[SurfingDoctor]

Does anyone really expect to be supported by NIH grants for the entirety of their career?

If I look at prominent senior faculty from my current or graduate institution in NIH Reporter, most continuously held multiple grants from the 80s/90s on. However, this clearly isn't the cases with current "rising stars" in their 30s and 40s. At best, these younger academics have one R01 at a time, and they often fail to renew them. If you look at the CVs of younger faculty, you'll find that funding usually comes from many sources, including foundations, the VA/DOD, private sector/pharma, government contracts, etc.

Of course, that means that one's research portfolio cannot be 100% basic/theoretical -- some funder has to care about the impact of your results. I think that's the new normal.

To answer your question, the answer is yes, but many people aren’t very realistic. I have noticed this in more senior investigators who started their careers in the 90s. They still have the expectation that they can fully support their career on funding. Some of this is offset by tenure and the endowments that come along with it, but yeah, I think there is at least a hope that they can reduce their clinical time to near zero. They remember the days of multiple R01s and think that is the norm, not the exception. Current investigators are far more realistic and I think most institutions are realizing that those days are gone. For instance, when I joined faculty 6 years ago, the tenure promotion track required 2 Ro1s to become an associate professor. Now, it’s any evidence of renewal funding.

While certainly there are people who are physician-scientists who have become full-time researchers, I think no one expects that as a likely outcome anymore and if they did... they are going to be sorely disappointed.

 

[SurfingDoctor]

My experience is that you're either stuck at 10% - 20% effort to make the budget of the grant work OR the grant requires some amount of effort that the grant mechanism won't fund.

Both situations are not tenable unless your department is willing to support your salary.

In my case to try to make it work I sacrifice part of my own salary AND work more hours than most of my clinical colleagues. I am very conflicted about this and wonder frequently whether it's worth it in the long run.

I’ve had to do more clinical work without increases in my clinical FTE salary to cover research support staff. I struggle with it too, but I feel it kinda is my burden to bare to keep the lab open, the personnel available and stretch the funding. Thus far, I’ve been willing to deal with it.

My wife on the other hand... tells me to make more money and screw research... ha.

 

[Neuronix]

To answer your question, the answer is yes, but many people aren’t very realistic. I have noticed this in more senior investigators who started their careers in the 90s. They still have the expectation that they can fully support their career on funding. Some of this is offset by tenure and the endowments that come along with it, but yeah, I think there is at least a hope that they can reduce their clinical time to near zero. They remember the days of multiple R01s and think that is the norm, not the exception. Current investigators are far more realistic and I think most institutions are realizing that those days are gone.

I still see a lot of people today who trained in the 80s and 90s who seem to think it's the norm to have multiple R01s. Those who can't manage to sustain that are basically looked at as a failure. Certainly the model of my training program was to produce 80% researchers. I don't see how it's even possible to get there anymore.

For instance, when I joined faculty 6 years ago, the tenure promotion track required 2 Ro1s to become an associate professor. Now, it’s any evidence of renewal funding.

How low can you go? After a national search I couldn't find a research fellowship or tenure track job, so I am and have always been non-tenure "clinical educator" track.

 

[SurfingDoctor]

I still see a lot of people today who trained in the 80s and 90s who seem to think it's the norm to have multiple R01s. Those who can't manage to sustain that are basically looked at as a failure. Certainly the model of my training program was to produce 80% researchers. I don't see how it's even possible to get there anymore.



How low can you go? After a national search I couldn't find a research fellowship or tenure track job, so I am and have always been non-tenure "clinical educator" track.

I’m not sure there is a dollar or coverage amount, literally they said “renewable funding”. The benchmark for that is an R01 or R35, but I have seen people get by on DoD, foundation grants and P awards. The rub of all of that of course is just because the award mechanism is “renewable”, it doesn’t mean it will actually be renewed.

Tenure is mostly a dog and pony show anyway and typically comes with an up or out clock, so I’m not sure clinician-educator tracks are really that much of a downside. Personally, if I could keep doing what I’m doing and get off the tenure track... I probably would. But I’m too far along at this point to jump tracks so I’m told. I get a reminder every year of my up or out date. I have no idea how serious they are about it though.

 

[interstellar taco]

In my case to try to make it work I sacrifice part of my own salary AND work more hours than most of my clinical colleagues. I am very conflicted about this and wonder frequently whether it's worth it in the long run.

This sucks!

I’ve had to do more clinical work without increases in my clinical FTE salary to cover research support staff. I struggle with it too, but I feel it kinda is my burden to bare to keep the lab open, the personnel available and stretch the funding. Thus far, I’ve been willing to deal with it.

My wife on the other hand... tells me to make more money and screw research... ha.

This also sucks.

We should all just make more money and screw research...

My appointment is still sort of up in the air with respect to Clinician-Educator vs. Tenure Track. There are pros and cons to both. Right now I'm tentatively earmarked for Clinician-Educator unless the stars align from a chair/dean/faculty senate standpoint to conjure a tenure track position. I have a (non-governmental) career development award in my pocket that gives me some bargaining power, but not much.

 

[SurfingDoctor]

This sucks!



This also sucks.

We should all just make more money and screw research...

My appointment is still sort of up in the air with respect to Clinician-Educator vs. Tenure Track. There are pros and cons to both. Right now I'm tentatively earmarked for Clinician-Educator unless the stars align from a chair/dean/faculty senate standpoint to conjure a tenure track position. I have a (non-governmental) career development award in my pocket that gives me some bargaining power, but not much.

I don’t know what tenure used to be, but nowadays it gets you nothing except higher expectations at a lower salary up front. If you do make tenure, all it means is that they can’t fire you but if you climb the ranks high enough, you can get an endowed chair position. That being said, even though they can’t fire you, they can reduce your salary to essentially nothing and put you in the basement with Milton and his red stapler if you don’t continue to fund your salary with funding.

 

[dl2dp2]

In my post, I used NIH R01 as a surrogate for any major research grant(s). Certainly funding from NSF, DOD, VA, foundations, etc. can be a part of the calculation. The problem is the "% effort" restrictions on many of these awards -- and reconciling that with clinical FTE, or having multiple major research projects with conflicting "% effort." I am a surgeon and love to operate. But I'm also a scientist with the chops to carry out research. I understand the rationale behind "% effort" restrictions but they really hamstring me in setting up an ideal, hybrid clinical practice with translational research program. Salary caps compound the issue.

I understand that funding agencies have to look out for themselves -- i.e., not spend $500,000 on a researcher dedicating only 10-15% of his time to a project. But in today's world, I have yet to meet a physician-scientist who treats his or her career as a 40-hour-a-week, compartmentalized job. I'm thinking and "working" on my research when I'm seeing patients in clinic or and vice versa. Everything is fluid. I wish there were a way that funding agencies could recognize that.

And chairs/deans need to recognize the worth of their physician-scientists.

Your comments are very useful, as there are few surgeon scientists--most people at the K level or beyond are in cognitive specialties. Unfortunately, even in cognitive specialties, issues of this type are coming up, as the salary differential between clinician and scientist components going up dramatically, institutions are finding themselves having to square a circle of paying a very low salary on paper and meeting at least marginally close to market salary for an fully trained MD.

There are various way to overcome these issues. For example, frequently universities/medical centers set up a separate non-profit to accept federal funding, and your hospital FTE is therefore segregated from your reported research FTE to the feds, and can add up to > 1.0. Whether this is kosher at audit is unclear, but this overcomes the hard federal salary cap and is done all the time, and is generally in a legal gray zone (i.e. there's no reason to not allow for "overtime"), since fed salary cap is stipulated on a 38.5 hour work week or whatever. (This by the way applies to senior researchers too. Endowment money is supposed to be allocated for 1.0 FTE salary support, so that you can save salary support off grants, but typically senior researchers still draw full 1.0FTE off federal soft money in addition to their endowment, pushing their salary way up, if they have that many grants. How the budget is written typically only depends on private negotiation between the senior researcher and the dept admin--i.e. is a comparable rainmaker bringing $X indirect paid $Y at peer institutions? If so we'll allow him to draw $Z from his 5 grants plus that named chair, which is now only paying for 1% FTE). Suffice it is to say, if your department chair's answer to your requesting higher salary is that it's not possible due to fed FTE restrictions, something's up. It's an excuse.

Another (and I would argue at times superior) way to do this is where you would operate at a private hospital or moonlight for surgery calls separately from the university. While technically this is double dipping, given that research time is flexible, you can make an argument that you are simply setting flexible hours for yourself. If your department is purely performance driven (i.e. paying you only on soft money), they might look the other way. But typically your department generally doesn't want this because likely they are paying you a very low combined "salary" and make money off of you [doing clinical work], but if you know the numbers it's possible to make an argument to your chair that goes in the right way (i.e. for him to support a K application). Or, more frequently is where some departments don't have a subspecialty niche service that's especially lucrative, in which case they don't care if the faculty is working elsewhere because they often wouldn't even know where to start looking to check if this is happening or not. To make this more explicit: the reason your department is telling you we'll pay you $X to do 50/50 is that the 50% clinical work they make you do is making $X+profit margin. You could tell them that I'll apply for a K, and if i get the K, I want $X + K salary, but I'll agree to cover exactly the same amount the clinical work. The department makes the same profit margin (which is likely way bigger than K indirect) + K indirect. Maybe that'll work. Maybe it won't because that profit margin is WAY too large and they think you'll balk on doing the same amount of clinical work. But you don't know unless you ask. I'm getting a feeling that you are not in the "inner circle" yet and are not privy to the guts. It's helpful to get a trusted mentor who's familiar with departmental politics and has a track record of this type of career to show you how it's done.

 

[tr]

Fast forward to the final stages of ironing out my chosen position (top 5 academic program). Chair says, "It makes no sense for you to apply for a K. It pays peanuts and cuts your clinical output drastically. The department will be shouldering a huge burden. You should stay 50/50, work for an R21 then an R01 and we can figure out salary funding from there."

Nooooo! Don't waste your time applying for R21s. They have like <10% funding rates and it's a total lie that they don't require preliminary data, and even if you get it they're only good for two years so it's like a mad dash to get your project done and prove your worth. Plus you will have trouble wringing a few droplets of protected time out of the limited funding they bring. Ks have like 30+% funding rates, explicitly cover your salary, and last 4-5 years.

Don't know how I'll be able to get to R with meager startup funds, no personnel commitment, etc. Though they keep saying, "We want you to focus on your research," it seems they really only care about how to market and increase volume for my (50%) clinical practice.

Correct

 

[tr]

I don’t know what tenure used to be, but nowadays it gets you nothing except higher expectations at a lower salary up front. If you do make tenure, all it means is that they can’t fire you but if you climb the ranks high enough, you can get an endowed chair position. That being said, even though they can’t fire you, they can reduce your salary to essentially nothing and put you in the basement with Milton and his red stapler if you don’t continue to fund your salary with funding.

Yeah I was surprised to find that my buddies on the tenure line are *still* expected to make their salaries out of soft money. Any shortfall and they make it up with clinical work, just like those of us on the clinician-educator line. There doesn't seem to be any practical advantage to the tenure line, other than it being more prestigious.

 

[SurfingDoctor]

Yeah I was surprised to find that my buddies on the tenure line are *still* expected to make their salaries out of soft money. Any shortfall and they make it up with clinical work, just like those of us on the clinician-educator line. There doesn't seem to be any practical advantage to the tenure line, other than it being more prestigious.

I mean, most endowed chair positions are tenured positions. If one is able to obtain one, they help offset the cost of 1, maybe 2, support staff and provide some minimal money toward projects. But it’s not really that much. I do think prestige is what it’s function mostly is... but prestige and a feeling of self-accomplishment don’t really pay bills.

 

[tr]

Personally, if I could keep doing what I’m doing and get off the tenure track... I probably would. But I’m too far along at this point to jump tracks so I’m told. I get a reminder every year of my up or out date. I have no idea how serious they are about it though.

They won't let you off the tenure track? At my institution you can switch from tenure to C/E anytime. It looks like most people who start off as assistant prof with Ks, then switch to clinician-educator track after that. There is a minority who make it through the funding gauntlet and go to associate on the tenure line. I haven't seen anybody with a research interest actually leave to go to another research institution. (Of course we bleed clinicians to the incomparably better pay outside of academia.) It's not supposed to be possible to go the other way (from C/E to tenure line) but I have seen one prof do it so that's obviously not a hard and fast.

 

[SurfingDoctor]

They won't let you off the tenure track? At my institution you can switch from tenure to C/E anytime. It looks like most people who start off as assistant prof with Ks, then switch to clinician-educator track after that. There is a minority who make it through the funding gauntlet and go to associate on the tenure line. I haven't seen anybody with a research interest actually leave to go to another research institution. (Of course we bleed clinicians to the incomparably better pay outside of academia.) It's not supposed to be possible to go the other way (from C/E to tenure line) but I have seen one prof do it so that's obviously not a hard and fast.

It depends. You can switch tracks up to a certain point, then there is no turning back. Now that being said, they know the cost of recruiting new faculty isn’t small and if you’re willing to just see patients and generate RVUs I think they’re relatively lenient. But I’ve seen a hand full of people let go.

I’ve tried to position myself within other administrative tasks and committees as well as university wide volunteer functions to provide service so that if I can’t get sustainable funding, I’ve made myself somewhat worthwhile. Plus I talked to my chair early and laid out my alternative strategies to the point where they said “if the clock runs out, I’ll just fire you and then hire you back the next day”. Of course that’s assuming, he’s still there when the clock runs out.

 

[dl2dp2]

What?? It sounds like you're advocating for federal fraud in both of your examples. Which is obviously a TERRIBLE idea if you've paid attention to what happens to physicians who try to scam Medicare. Hint: you go to prison, lose your medical license, and live the rest of your life as a felon.

There is only one way to legally make more than the salary cap: have your institution commit to paying you an inflated salary, and then adhere to the salary cap for the proportion of your time dedicated to NIH-sponsored research. By the way, there is no "overtime" or "second jobs" to the NIH -- you divide all your work activities among all your employers as a part of your 100% level of effort.

A sample salary calculation is here: NOT-OD-15-049: Notice of Salary Limitation on Grants, Cooperative Agreements, and Contracts

A FAQ about joint University/VA appointments clarifies that each position only contributes to overall effort: Frequently Asked Questions Regarding the Usage of Person Months

You have no idea what you are talking about. Have you ever written a federal grant budget? Neither is fraud to the feds. It may be "fraud" to (one of) your hiring institutions (that might audit the other), but that's neither here nor there. You should read the NIH notice more carefully. The NIH salary cap means that your institution (i.e. the recipient of the grant, which may be the non-profit research institute or the hospital, rather than the university) cannot pay you more from the federal grant itself for a certain percent effort of your employment at the said institution. How exactly is your percent effort tabulated at the institution is determined by institutional policy only, not by federal regulations. Imagine this surgeon investigator who works 75% effort on his K and 25% on his clinical work. That 25% clinical work may constitute 20 hours a week, since most of his clinical colleagues work 80 hours a week on average. However, his research work is only 75% effort, and can therefore be tabulated as taking 30 hours, for a total of 50 hours. He can DRAW up to the salary cap from the federal grant for the 75% effort on the documentation to the feds, but nowhere does the federal regulation says that the institution must pay the remaining 25% at cap/0.75*0.25--this makes ZERO sense! That number as of 2019 is ALWAYS 133k or something because K cap is 100k. What physician scientist gets paid 133k (except hilariously, in a few non-lucrative subspecialties at a few centers?). The institution could pay him more or less, depending on their willingness to do so. It would constitute fraud to your other employer (i.e. the university), however, if you sign an agreement with the university saying that you will work entirely as a university faculty and not receive any other form of compensation (i.e. non-compete). This is typically not an issue, because usually universities only care about compensated CLINICAL activities. It may become an issue if part of your research percent effort pays for clinical activity (i.e. as a study physician on some other grant, but not on a K award), in which case more complicated things happen (does the university draw a deans tax? is it a subcontract to the university?). But rest assured, all of this can be worked out by the grants admin.

Now there are OTHER regulatory issues if your department just loves you so much and wants to pay you lotsa extra for that 25%. Several department chairs have mentioned to me that moving people arbitrarily out of salary bands can result in reviews that might trigger Federal Equal Pay Act. Personally I *still* think this is a BS excuse: why is it this is only brought up at junior level and never brought up at senior level? Because the more rain you can make you'd deserve more lawyer hours to structure your salary plan to be complying with any of the laws you want. Ultimately market pressure is what matters.

Frankly what's more frightening is how all of these things are explicitly LEGAL--in fact they are encouraged--everything I've said here are the directives FROM TOP DOWN, in attempt to make you work more and pay you much less! Massive numbers of trainees are being exploited institutionally that grossly violate federal labor laws, and nobody seems to care one iota. But that's a different conversation for a different time.

 

[interstellar taco]

I'm trying to understand the salary cap in light of the discussion points raised in this thread. Can someone tell me if the calculation below is correct or incorrect?

Suppose I get an NIH grant. Let's say the NIH salary cap is 180,000 (for ease of calculation). Let's also say that I'm 50% effort on the grant.

0.5 * 180,000 = 90,000 for salary and benefits. Let's say the salary part of that is 60,000, benefits 30,000.

So the grant will pay 60,000 towards my salary, and 30,000 towards my benefits, right?

So for the clinical 50% of my appointment, I can get paid whatever the academic market says I'm worth, right? Example:
- Typical 100% clinical surgeon starting salary is 275,000-325,000. Let's call it 300,000.
- 0.5 * 300,000 = 150,000.
- So the institution "should" pay me at least 150,000 salary.
- Therefore my total salary "floor" is 150,000 clinical + 60,000 research = 210,000.

I hope academic institutions understand that this could be perceived as a low-ball to a physician-scientist. They should see that there's some cognitive or reputation value-added to recruiting and retaining a physician-scientist. So perhaps they pay me equivalent to my clinical peers -- 300,000 -- which therefore means they must be "subsidizing" 90,000 of my salary.

Is this an accurate representation of how caps/effort/salaries work? Keep in mind I'm new at this game.

If this is indeed how things work, then the "subsidy" part of things makes me feel emotionally guilty for getting "free" money, even though I know intellectually I am worth at least that much, or more, for what I bring to the institution... Plus there's something to be said for the federal or foundation money that I conjured for the institution that would not exist without my presence, right? Or am I totally out of my depth?

Sluox? Neuronix? tr?

 

[dl2dp2]

Good thing you're a physician, rather than a lawyer, because you're really all over the place here. In your previous post, you talk about "FTE" which has no relation to level of effort (LOE), and also advocate illegally moonlighting (working unreported activity over one's full LOE). Then you take an entire paragraph to re-explain the information I linked from NOT-OD-15-049. This notice clearly explains that salaries can be any amount at the institutional level, but the NIH funded portion of the salary is subject to the cap. Also, yes, equal pay laws make it difficult to negotiate outside of salary bands. I'm not sure what duty hour violations have to do with anything.

Look, government grants are were never supposed to be that lucrative. Americans won't stand for academics to get rich off of performing "frivolous" research with taxpayer money. Now, if you really want to make money hand over fist with the taxpayer's blessing, get into contracting.

It's worse than this. First of all, you can make up to the salary cap, and then get fringe benefits and institutional indirects on top of that, but those rates are negotiated by your specific institution.

So, to your point, if you wanted to make $300,000 with the current salary cap of $189,600, your "official" salary with a 50% LOE on a R01 would have to be $410,400.

$300,000 = $410,400*.5 + $189,600*.5

BUT, then you'd have to actually earn $205,200 clinically at a 50% LOE, but that would probably take about a 66% LOE, so, in practice, your department would have to eat that 16% difference in salary (~$48,000).

A "normal" salary here would probably be $244,800 ($300,000*0.5 + $189,600*0.5), if $300,000 were a full time clinical salary. So, in this example, an unsubsidized professor would be making 19% less than a pure clinician. This disparity would, of course, get worse if the academic had greater LOE (like the vaunted 80/20 split) devoted to NIH-sponsored research.

You are not entirely wrong, but you are also not entirely right. What you are wrong about is the enforcement of the regulation gray zone (e.g. reporting of your outside employment, as an example), is very institutionally dependent. There are hospitals (Mayo Clinic approximately 10 years ago when I talked to someone there) that are the same entity as the university and therefore your entire paycheck comes from the same pot, in which case what you describe is exactly right, and people end up writing grants with weird budgets. More commonly though, the university (which receives the money) and the hospital (that gives you the clinical revenue) are not the same entity. I know very well three major academic hospital systems on the east coast all have that model. Let me give you a hypothetical example (I don't work there). You are a budding academic researcher in anesthesia who trained at MGH. After your fellowship, you decide to apply for a K award. Your department head directs you to apply through the department of anesthesiology at MGH -- so his indirect number will look more glowing when he reports to the Dean of HMS, who counts all the beans -- and also tell you there's no way he will pay you a cent more than 100k at MGH. However, when you nicely point out how it's unaffordable to live in Boston with 2 small children on 100k, he directs you to his friend, who's the chair at Beth Israel, a separate but affiliated legal entity. That person says, oh if you cover the ORs on Friday/Sat/Sun every other week, I'll pay you 250k. You sign separate contracts to MGH and Beth Israel (or, if you are talking about the Harvard system, no contract at all only a handshake), and these contracts are carefully vetted to be in compliant with "LOE" requirements (which yes lol not a lawyer the **** to this day I still don't know what the difference is between 1.0 FTE and 100% LOE). Viola you are now paid 250k as an attending anesthesiologist. Technically, if your Beth Israel contracts says you must report all outside activities, this would get vetted. But of course it gets vetted. By your own damn boss who created this arrangement in the first place! The feds think you are paid 100k doing research. And to a certain extent you are. But they have no idea how much you are ACTUALLY getting paid (unless they audit your income tax returns). And don't tell me this is "rare". Around where I am this is basically universally how the math works out.

The whole subsidy math is nonsense also. Beth Israel is not "subsidizing". It's a different pot of money, you are paid exactly the same as the other moonlighter rates. The kind of BS that gets into these interviews is just unbelievable. Why would any department ever "subsidize" something that loses money in the long run? The answer is they won't. Junior faculty salary bumps are not subsidies, they are investments. If the differential is too out of control, nobody (well, except the well off) will stay on. They only do this because the indirects. The indirects. The indirects.

I've heard your line "oh tax payers don't want to pay for frivolous research and hence you deserve nothing" used too many times when rainmakers get paid a ton, that this line has no salience for me. If you want the actual god honest truth, academia is just as corporate as corporate. They just hide it better and use more excuses. If you bring in 30M with a P50 or U54, you bet your ass your starting negotiation number will be at 350k+, regardless of that damn "federal salary cap". Let's get real.

 

[dl2dp2]

I hope academic institutions understand that this could be perceived as a low-ball to a physician-scientist. They should see that there's some cognitive or reputation value-added to recruiting and retaining a physician-scientist. So perhaps they pay me equivalent to my clinical peers -- 300,000 -- which therefore means they must be "subsidizing" 90,000 of my salary.

This is highly dependent on field/institution. They'll offer 210k (maybe, but the reason you give is a post hoc justification, rather than an actual reason. The actual reason is market math). The only way to find out is to go on the job market and shop around. Or you could just moonlight and forget about negotiating. Generally speaking though yes, you'll get paid less. In specific cases as I outlined above, you might get paid more. For example, a nationally known breast reconstruction expert who gets a carve out for a very high clinical reimbursement could get paid MORE for his service than his clinical colleagues, even though he only works 20% of the time and the rest of the time he works on his grants. THIS kind of thing by the way happens WAY MORE than you think, which is why you need mentorship for backdoor arrangements if you want to win the game. Many many many of the senior subspecialists who maintain a practice have that type of thing going on. Also keep in mind that the procedural based specialties, academic salary is typically at 50-60% "overhead". This means that admin has a lot of wiggle room for "subsidizing"--or rather, make somewhat less money off your head than a rank-and-file staff physician.

 

[dl2dp2]

Okay, so this is all fraud. See here for more examples: http://www.hcca-info.org/Portals/0/...ce_Handouts/Compliance_Institute/2006/208.pdf

On the plus side, the False Claims Act allows qui tam settlements, so whistleblowers are explicitly allocated a cut of the penalties imposed by the DOJ. Report your competitors!

On a more serious note, engaging in blatant fraud like this is a very poor idea in an era when NIH funding and physicians in general are already under a microscope. Trump (or Bernie) would love to gloat about busting "fat cat" physician researchers on national television.

You are wrong. We also had a tutorial of this type at our "shoot for R01" workshop series. And you are still wrong.

1) Slide material 19-20 explicitly states that base salary definition is based on a level of effort of your role at the organization that is in receipt of the grant. In fact, my sense is that this incentivizes umbrella institutions to have a more formal Chinese wall between their grants organization and clinical organization. MGH prefer to just have you 100% on K than figure out some "arrangement" for you in-house that might trigger compliance review. NIH has NO authority in regulating your life outside of your duty at the organization. That's patently absurd. I'd rather work as a rock star on weekends, and I just so happen to be very good at it and make 1M a week. Does that trigger issues with my LOA? Hells no. And who is a judge of whether my duty is in conflict with my job at the receiving institution? The institution. Hence neither of the cases that I talked about are fraud. It may be a contract violation if I signed an agreement re: "outside activities", but that's none of the feds business.

2) The settlement numbers are PEANUTS. It's shameful that the fines are so low when some of the actual frauds are so egregious. Putting non-citizens on Ks, for example. Clearly neither the feds nor the university care about this kind of "paperwork error". And I would say none of the fines are worth the whistleblowing. Sadly. If they increase the fines to 20M a pop, I'd whistleblow in a split second. It's bright as daylight that this is all insider games. I’m not wasting my nuclear option on this.

3) I'd love Trump (Bernie) to bust this system wide open, and expose how entrenched the academic medical centers are to the establishment. Academic medical systems and universities are some of the most change-resistant lobbying groups in America. And radically unequal. How about paying postdoc more than minimal wage? How about limiting the number of R01s rainmakers are elegible for? The academic medical system is hugely and systematically corrupt, but paying a K awardee a reasonable salary by manipulating the meaning of outside activity is not where the corruption occurs.

 

[Spacedman]

You are a budding academic researcher in anesthesia who trained at MGH. After your fellowship, you decide to apply for a K award. Your department head directs you to apply through the department of anesthesiology at MGH -- so his indirect number will look more glowing when he reports to the Dean of HMS, who counts all the beans -- and also tell you there's no way he will pay you a cent more than 100k at MGH. However, when you nicely point out how it's unaffordable to live in Boston with 2 small children on 100k, he directs you to his friend, who's the chair at Beth Israel, a separate but affiliated legal entity. That person says, oh if you cover the ORs on Friday/Sat/Sun every other week, I'll pay you 250k. You sign separate contracts to MGH and Beth Israel (or, if you are talking about the Harvard system, no contract at all only a handshake), and these contracts are carefully vetted to be in compliant with "LOE" requirements (which yes lol not a lawyer the **** to this day I still don't know what the difference is between 1.0 FTE and 100% LOE). Viola you are now paid 250k as an attending anesthesiologist. Technically, if your Beth Israel contracts says you must report all outside activities, this would get vetted. But of course it gets vetted. By your own damn boss who created this arrangement in the first place! The feds think you are paid 100k doing research. And to a certain extent you are. But they have no idea how much you are ACTUALLY getting paid (unless they audit your income tax returns). And don't tell me this is "rare". Around where I am this is basically universally how the math works out.

PSA for anyone actually thinking of going into anesthesia.... this is not normal. Maybe this is specific to MGH/BI, but not the way salary is derived at several other comparable anesthesia departments. I've never heard of this kind of side deal moonlighting scenario for academic anesthesiologists (I'm sure the Harvard system is very special though). Maybe anesthesia was a bad example to illustrate the point. I've interviewed for several academic anesthesia faculty positions. The broad strokes are true - the chair hiring in each case has offered a salary commensurate with 100% clinical colleagues while the actual pro rata clinical effort + grant support does not add up to that salary....I don't think there's any accounting magic involved or necessary. No argument that this is a money losing proposition until the recruit generates indirects... you can call it a subsidy or an investment, the calculus depends on the department, institution, specialty, how important NIH funding rankings are to said entities. And a K grant does not automatically mean that a candidate will get that subsidy, especially fresh out of training.

 

[dl2dp2]

You are advocating for a "conflict of commitment," detailed here: COI: Conflicts of Commitment

MGH also specifically prohibits this: MGH Institute of Health Professions - Outside Professional Activities

Finally, clinical activities with other institutions that result in over $5000 in compensation (FAQ here: Frequently Asked Questions - Responsibility of Applicants for Promoting Objectivity in Research (2011 Revised Regulation)) must be disclosed to the NIH as a financial conflict of interest.

Why are you trying to skirt the salary cap so brazenly? Just get out of research if you don't like the pay. It's not worth fraud.

I can tell you what business office justifies this with regard to FCOI. These are actually two different issues (FCOI vs. salary cap). This explanation might not satisfy you, but whatever...

"Under the 2011 FCOI regulation, Significant Financial Interests that are subject to disclosure by an Investigator to an Institution are those that reasonably appear to be related to the Investigator’s ‘‘Institutional responsibilities,” as defined by the Institution."

The clinical revenue generated outside of the institutional responsibilities (which are research and research related commercial activities, if you are 100% LOA research on grants) are not subject to disclosure. The MGH policy is very similar. It's essentially a non-compete, but non-competes are very specific about conflict of the institutional missions. It means you can't be employed simultaneously at a different institute for a similar role. It doesn't mean you can't brush toilets on weekends. Also, not everyone who works for MGH signed a contract with MGH that makes them subject to regulations of the faculty handbook--an interesting but important detail. Many staff physicians at MGH are not "faculty" in that way. Certain things you say show that you haven't been around the block too much.

You don't have to be on your moral high horse about money. I frankly find it kind of evil, actually--I know of instances where women and ethnic minorities were cheated out of MILLIONS of salary dollars basically because of how these policies are differentially enforced and spun. I'm just posting some specific comments for our surgeon colleague to consider. You are just another stranger on the internet. Your opinion is just valid as mine. It's pretty clear that everyone here at least admits that places like MGH does this kind of thing all the time (at minimum, play around with salary numbers on budgets). Whether that's "fraud" and whether it's "worth doing", and whether he/she should just "get out of research" is not up to you to decide.

 

[dl2dp2]

Wrong again! 42 CFR Sec. 50.603 (here: 42 CFR § 50.603 - Definitions.) clearly states that "institutional responsibilities" include "professional practice" (i.e. clinical work), and that a "significant financial interest" includes any financial interest reasonably related to an investigator's institutional responsibilities.

I'm not going to argue with you anymore, because you keep citing unverifiable institutional standard operating procedures that seem fraudulent. I've never worked for a place that engaged in such behavior and I'd be happy to report anyone who does to the NIH OIG. If you don't want to follow federal law, then don't take federal funds. America is awash in unregulated private money.

Here is the actual definition:
“Institutional responsibilities means an Investigator's professional responsibilities on behalf of the Institution, and as defined by the Institution in its policy on financial conflicts of interest, which may include for example: activities such as research, research consultation, teaching, professional practice, institutional committee memberships, and service on panels such as Institutional Review Boards or Data and Safety Monitoring Boards.”

Institutional responsibilities are always defined by the institution in its policy. If your institutional responsibility does not involve engaging in clinical practice, then it’s not a conflict of interest. Also, again, just to be clear to everyone: FCOI is unrelated to LOE reporting. FCOI can be “managed”-- even if outside activities presents a COI, it's possible to still do it if it’s disclosed and vetted. Salary cap is fixed and doesn't matter whether what you do is in conflict or not you can't draw more than the cap on federal funds.

Feel free to whistleblow on Harvard (or anyone) to the OIG. Many have. Many will. Nothing particularly significant has happened to Harvard. I have no idea if you worked for a place who did this or not. I actually don’t believe that you haven’t—because what I outlined is a universal phenomenon. It's more likely that you are just unaware of how the sausage is made because it's beyond your pay grade. Still, don't believe me, it doesn't matter. You shouldn't believe me. Ask your own boss and your compliance office.

The broad strokes are true - the chair hiring in each case has offered a salary commensurate with 100% clinical colleagues while the actual pro rata clinical effort + grant support does not add up to that salary....I don't think there's any accounting magic involved or necessary. No argument that this is a money losing proposition until the recruit generates indirects...

I would make it very clear that it's not "losing money" as opposed to "making less money". If something's truly constantly losing money, the system cannot perpetuate itself. Yes, if the chair hired a straight clinician he'd generate more revenue per head. But this is not what the bean counters up above care about. The bean counters (i.e. Dean) only care about indirects. Even if you are being "subsidized", it's always to a degree that your clinical revenue fully covers your salary and then some. This is not a private practice where left over profit gets shared. One obvious corollary is that full time clinicians working at an academic center gets exploited even more, because likely their salary is arbitrarily clamped to a low level so the profit margin is high so such "subsidies" can occur in perpetuity.

 

[Spacedman]

I would make it very clear that it's not "losing money" as opposed to "making less money". If something's truly constantly losing money, the system cannot perpetuate itself. Yes, if the chair hired a straight clinician he'd generate more revenue per head. But this is not what the bean counters up above care about. The bean counters (i.e. Dean) only care about indirects. Even if you are being "subsidized", it's always to a degree that your clinical revenue fully covers your salary and then some. This is not a private practice where left over profit gets shared. One obvious corollary is that full time clinicians working at an academic center gets exploited even more, because likely their salary is arbitrarily clamped to a low level so the profit margin is high so such "subsidies" can occur in perpetuity.

I don't want to start a flame war - again, PSA for any MD/PhDs actually interested in going into anesthesia: this is not how my department works, and not consistent with physician scientist jobs in other major anesthesia departments. I'm sure there are places (Harvard, I guess) where the department's only goal is to have a positive cash flow from your clincal work + grants from day 1. I'm happy to discuss details, but not in an open forum. This is just a fact: our department hires physician scientist faculty whose clinical revenue + grant covered salary do not cover their actual salary. It's a gamble. Salary difference is made up by the department, or the medical school, or the university. This setup is possible because I am fortunate to have a chair with the vision and resources to invest in the future of our specialty. Sometimes the investment pays off with faculty becoming successful and generating indirects. Sometimes faculty become a financial liability for the department and are moved to higher clinical commitments. I think, over years, it's a net positive. I could not currently generate my salary if I worked the same clinical hours at a private practice and had 100% of my effort on NIH grants with salary caps noted above.

This is a wonderful arrangement, no doubt about it, and I am thankful for it. It won't last if I don't get additional funding. I think this situation may be unique to anesthesia where, at a handful of institutions, the demand for physician scientists outstrips supply, and the specialty as a whole generates high clinical revenue. This situation comes with significant caveats, and I certainly whine a lot my colleagues, but it is one reason among several why I chose anesthesiology. If you are an MD/PhD and considering anesthesiology, I'd be happy to discuss the opportunities in the specialty by PM.

 

[interstellar taco]

I'm bumping this thread in light of the salary discussion on a separate thread. Now that I'm happily ensconced in (what turned out to be) a fantastic academic surgeon-scientist job, I have to say that Spacedman's comments above regarding his anesthesiology physician-scientist position are 100% applicable to my situation as an MD/PhD surgical subspecialist. Specifically:

This is just a fact: our department hires physician scientist faculty whose clinical revenue + grant covered salary do not cover their actual salary. It's a gamble. Salary difference is made up by the department, or the medical school, or the university. This setup is possible because I am fortunate to have a chair with the vision and resources to invest in the future of our specialty. Sometimes the investment pays off with faculty becoming successful and generating indirects. Sometimes faculty become a financial liability for the department and are moved to higher clinical commitments. I think, over years, it's a net positive. I could not currently generate my salary if I worked the same clinical hours at a private practice and had 100% of my effort on NIH grants with salary caps noted above.

I feel like I could speak those same words about my position, my department, and my chair. I'm fortunate to be in a department that has an unequivocal commitment to recruiting and developing a core of physician-scientists at early, mid, and seasoned career levels.

Once they are past the 2-3 year "guarantee" phase ($250-325k), surgeons in my department who are "100% clinical" generally have state-reported income in the $400-650k range (mostly in the lower part of that range, with a few exceptionally high volume senior faculty in excess of that range). To achieve salary parity, the physician-scientists benefit from departmental investment, philanthropic funds, dean support, and grants.

Consulting can be a helpful adjunct for faculty who have the interest, time, and relationships. Some departments and specialties frown on this, but pharma/device consulting seems to be encouraged in surgical fields, at least from my vantage point as a junior faculty.

More education about the "finances" of physician-scientist life would have been super helpful to me along the way. I wish it had been a part of training during my MSTP -- not just personal finance or "get grants," but a true enumeration of faculty salary structure, protected time, revenue flow in departments (and the difference between older systems and newer systems, like "funds flow"), grants, directs/indirects, startup packages, etc. It seems to me that many of our PhD-only colleagues get this education during bona fide postdoctoral fellowships, but physician-scientists often skip over the traditional multi-year laboratory postdoctoral fellowships and thus miss that part of education.

 

[dl2dp2]

Once they are past the 2-3 year "guarantee" phase ($250-325k), surgeons in my department who are "100% clinical" generally have state-reported income in the $400-650k range (mostly in the lower part of that range, with a few exceptionally high volume senior faculty in excess of that range). To achieve salary parity, the physician-scientists benefit from departmental investment, philanthropic funds, dean support, and grants.

So your chair says, look, I pay my 100% surgeons $400k. I pay you $375k. Your grant only generates $100k, and your are 25% clinical, so you generate another $100k salary for yourself. So instead of $200k I'm paying you $375, I'm losing $175. Count your lucky stars!

Right? That's the math?

Little did he tell you, that 25% of clinical effort on your part generates > $300k of indirect revenue for the medical center and over 100k of net profit for the department. And that's not counting that 50k indirect your 100k salary generates. This is what I mean by "making less money" rather than "losing money".

 

[Spacedman]

So your chair says, look, I pay my 100% surgeons $400k. I pay you $375k. Your grant only generates $100k, and your are 25% clinical, so you generate another $100k salary for yourself. So instead of $200k I'm paying you $375, I'm losing $175. Count your lucky stars!

Right? That's the math?

Little did he tell you, that 25% of clinical effort on your part generates > $300k of indirect revenue for the medical center and over 100k of net profit for the department. And that's not counting that 50k indirect your 100k salary generates. This is what I mean by "making less money" rather than "losing money".

How many different ways are there to say this... my department is supporting several junior faculty MD/PhDs with 25% clinical time and a K. There is literally NO WAY the clinical billing and grant add up to the salary paid.

Perhaps you could concede that not every interaction in academic medicine is a scam. A lot of times, yes, it is predatory. But sometimes, research has value to a department that cannot be immediately monetized. For the students out there, find those departments.

 

[interstellar taco]

I keep track of my RVUs and look at my monthly clinical revenue reports, account receivables by payor, etc. At 50% clinical, I am "meeting my nut" so to speak. Even in year 1 as faculty, working to set up my practice and my research program, I am meeting a general RVU target for 0.5 FTE clinical. And the revenue from that RVU is bonkers high (I had no idea, and now I understand how my private practice colleagues are doing so well) -- especially from the "good insurances." So I do lean more toward sluox's spin on the numbers.

Are there physician-scientists in our department who are less clinically productive? Sure. But they still bring in a fair chunk of revenue to help keep the lights on, the nurses paid, the equipment in functioning order, etc. But their clinical billing and grants may not add up to their individual salaries. Mine probably does (right now) but if I reduce my clinical load as I'm thinking of doing, then probably not -- then Spacedman is 100% right.

 

[Spacedman]

Agree- At 50% FTE, I'd probably be breaking even for the department. For my 100% clinical counterparts, they are clearly generating more revenue for the hospital than they're seeing in their paycheck, but that's the price you pay to work at a fancy academic center. PP in our area does pay more, but plenty of pure clinicians are evidently willing to take that deal.

 

[dl2dp2]

How many different ways are there to say this... my department is supporting several junior faculty MD/PhDs with 25% clinical time and a K. There is literally NO WAY the clinical billing and grant add up to the salary paid.

Perhaps you could concede that not every interaction in academic medicine is a scam. A lot of times, yes, it is predatory. But sometimes, research has value to a department that cannot be immediately monetized. For the students out there, find those departments.

Did you count the grant indirects and facility fees in your math? You do realize that MDs don't just bill for professional service, right?

It's not a "scam". Our department leadership is very transparent that unless the rain you make covers the salary and then some, you don't need to exist. I also don't think it's "predatory", in the sense that (unlike people who buy into socialist etiologies, as an example) I don't think of large organizations in general as predatory, if they derive some amount of margin in the long run to maintain sustainability--they are only predatory if the ways with which the margin is derived violate some other ethics (i.e. anti-trust, malignant labor market competition, etc) What *would* be a scam is the way in which department chairs manipulate junior faculty by making them feel beholden to their largesse in shamelessly making an impossible argument that they are *so* special that they deserve the department's generous "investment". I'm just not as delusional as all that. Maybe it's true that your department chair is uniquely generous, and perhaps trainees would be able to find them if they looked really hard, but my point is it would be smarter if baseline assumption that there's no free lunch and work from there.

In the short run, yes, perhaps sometimes things are not monetizable *immediately*. In the long run, it's not really possible to just "lose money" on staff in a generalized way if you want to grow your institution. This part should be obvious.

 

[Spacedman]

Did you count the grant indirects and facility fees in your math? You do realize that MDs don't just bill for professional service, right?

Can I just be right about this one? In my specialty, my department, my own paycheck, out of the mouth of my chair? Give it a rest. I'm getting serious "wake up sheeple!" vibes dude (or dudette).

Maybe it's true that your department chair is uniquely generous, and perhaps trainees would be able to find them if they looked really hard, but my point is it would be smarter if baseline assumption that there's no free lunch and work from there.

In the short run, yes, perhaps sometimes things are not monetizable *immediately*. In the long run, it's not really possible to just "lose money" on staff in a generalized way if you want to grow your institution. This part should be obvious.

For the sake of trainees reading this thread: yes, sluox is correct. You should assume that there is no free lunch, and as you look for residencies, fellowship, faculty positions, pay attention to how revenue is generated, because your position is most likely to be at least revenue neutral.

For the trainees - you should also know that there are opportunities out there in academic medicine. Broaden your horizons. If I had trained as a neurologist instead of an anesthesiologist, I would probably not be doing what I'm doing now. There is no free lunch, but someone else is most certainly paying for mine, for now. I hope to pay it forward to my trainees and collaborators, and, hopefully, by generating a return on that investment with federal funding.