If I perform average clinically, what will be my options as a mid-tier MSTP grad applying to PSTPs?

[ChordaEpiphany]

As I progress into MS3, I'm realizing that much of my performance is out of my hands. Thus far, I've been an excellent student and researcher. I was a top student at a top undergrad, but attended a mid-tier MSTP program for personal reasons. I obtained an F30. I'll have ~10 manuscripts by the time I apply, with hopefully at least one at a top journal (in review at Nature [My Field] right now). I have a number of other accomplishments like patents, obtaining significant funding for a startup, and working as a consultant for a biotech company that is translating some of my research. I also scored >250 on step 1, but that is no longer relevant I suppose.

However, so far third year has been a toss up. I honored my first rotation with flying colors. I received 100% 5/5 evaluations from attendings, with some saying I was one of the best medical students they'd ever had. I scored a 90+ on the shelf. On my second rotation I can't seem to break out of getting 4/5 evals (which is firmly HP, which is effectively the lowest grade my school gives) from attendings who work with me for 2-3 days at most. It seems the entire game is getting the right site placement and knowing the right attendings to send evaluations to. Without significant connections within my class, I can't navigate this as effectively as others. It's mostly a game, and clinical skill is very much secondary to all the other factors at play. Older students, including those from my program who've gotten all Honors and AOA, completely acknowledge this. AOA is really only given out to people who get all honors, which I think I'm already disqualified for given I'll almost definitely HP this rotation. I believe I can do well. Maybe 3-4 Hs out of 8 rotations. However, I don't see any clear path to better performance unless I could go back in time and win the site placement lottery. Further, the rotation with the lowest chance of Honors is IM (~15%).

I can't shake the feeling that my entire future, and this insane 9 year investment I made (which came with incredible sacrifice), is just floating in the wind and totally dependent on arbitrary evaluations from attendings who don't even understand our grading system. Ideally I'd be looking to match a PSTP in a city with significant biotechnology industry (not just for me, but for my partner, who works in biotech). This would be somewhere like Boston (MGH/BWH), San Diego (UCSD), Seattle (UWash), Maryland (JH), SF (UCSF, Stanford), Research Triangle/NC (Duke, UNC), LA (UCLA), and maybe Philadelphia (Penn).

Most of these seem like reaches based on current resident profiles. They seem to heavily favor candidates from top tier schools, and many of them have far more impressive CVs than I do. My dream is to be an NIH-funded investigator at an institution where I can do meaningful research. However, if my chances of matching are slim, I'm not sure if I see a point in continuing to pursue this path. I will not pursue a PSTP and drag my partner away from their own career opportunities if the most likely outcome is a clinical role with some research on the side. My passion is biotechnology, and I'm not interested in being a pure clinician. I would sooner do a pathology residency with the sole intention of immediately exiting to industry or leave medicine altogether for management consulting and try to get on the executive track in biotech.

If anyone has insight, I'd be very grateful.

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[Fencer]

PM me... for everybody else. Please read: JCI Insight - Pearls of wisdom for aspiring physician-scientist residency applicants and program directors

Manuscripts and grants are the currency that excites PSTP directors. MSTP pedigree is much less important. AOA and grades are not so important. But as an attending, I need to know that you are SAFE and ACCURATE in your H&P and formulation at 3 am when you are waking me up to present a case.

 

[SurfingDoctor]

As I progress into MS3, I'm realizing that much of my performance is out of my hands. Thus far, I've been an excellent student and researcher. I was a top student at a top undergrad, but attended a mid-tier MSTP program for personal reasons. I obtained an F30. I'll have ~10 manuscripts by the time I apply, with hopefully at least one at a top journal (in review at Nature [My Field] right now). I have a number of other accomplishments like patents, obtaining significant funding for a startup, and working as a consultant for a biotech company that is translating some of my research. I also scored >250 on step 1, but that is no longer relevant I suppose.

However, so far third year has been a toss up. I honored my first rotation with flying colors. I received 100% 5/5 evaluations from attendings, with some saying I was one of the best medical students they'd ever had. I scored a 90+ on the shelf. On my second rotation I can't seem to break out of getting 4/5 evals (which is firmly HP, which is effectively the lowest grade my school gives) from attendings who work with me for 2-3 days at most. It seems the entire game is getting the right site placement and knowing the right attendings to send evaluations to. Without significant connections within my class, I can't navigate this as effectively as others. It's mostly a game, and clinical skill is very much secondary to all the other factors at play. Older students, including those from my program who've gotten all Honors and AOA, completely acknowledge this. AOA is really only given out to people who get all honors, which I think I'm already disqualified for given I'll almost definitely HP this rotation. I believe I can do well. Maybe 3-4 Hs out of 8 rotations. However, I don't see any clear path to better performance unless I could go back in time and win the site placement lottery. Further, the rotation with the lowest chance of Honors is IM (~15%).

I can't shake the feeling that my entire future, and this insane 9 year investment I made (which came with incredible sacrifice), is just floating in the wind and totally dependent on arbitrary evaluations from attendings who don't even understand our grading system. Ideally I'd be looking to match a PSTP in a city with significant biotechnology industry (not just for me, but for my partner, who works in biotech). This would be somewhere like Boston (MGH/BWH), San Diego (UCSD), Seattle (UWash), Maryland (JH), SF (UCSF, Stanford), Research Triangle/NC (Duke, UNC), LA (UCLA), and maybe Philadelphia (Penn).

Most of these seem like reaches based on current resident profiles. They seem to heavily favor candidates from top tier schools, and many of them have far more impressive CVs than I do. My dream is to be an NIH-funded investigator at an institution where I can do meaningful research. However, if my chances of matching are slim, I'm not sure if I see a point in continuing to pursue this path. I will not pursue a PSTP and drag my partner away from their own career opportunities if the most likely outcome is a clinical role with some research on the side. My passion is biotechnology, and I'm not interested in being a pure clinician. I would sooner do a pathology residency with the sole intention of immediately exiting to industry or leave medicine altogether for management consulting and try to get on the executive track in biotech.

If anyone has insight, I'd be very grateful.

You must realize… most residents haven’t successfully competed for an F30…

You may also realize, the residency review committee doesn’t really review anything as a PSTP applicant that isn’t science related. I’ll admit, I avoid residency interviews like the plague. They always ask me, and I always say “no”. Frankly, I view it as a waste of my time. But unless there is some scheduling conflict, I always take the time to review and interview PSTP applicants. Mostly for personal reasons in that if I really want the program to be successful, I don’t care which medical student petted the most dogs as a volunteer, I want the applicants who ask questions and are inquisitive to actually move the field forward. In that respect, I look at what you’ve published and “why”, not what some assistant professor who had an inflated self-worth thought. This is what the article that @Fencer linked was alluding too (I also know a couple of those authors, one rather personally).

Lastly, and most importantly, you must realize… and this is speaking as a person is reviews way too many NIH grants… … the study section doesn’t give a crap what some touchy-feely attending wrote on a clinical evaluation.

 

[darkamgine]

Also been looking into PSTPs and talked to recent graduates who matched into them. My opinion is you would still be a very competitive candidate for these spots at places you list. As long as you can do well enough clinically, you meet the requirements and should be fine. It is the same for MSTP admissions, after a certain point, it is more about research rather than volunteering hours and clinical experience. It sounds like your research experience was productive and if you can get a high IF paper, I feel you should have few issues getting interviews at some of these programs.

If you are still worried about clinicals and want to increase your chances, do well on step 2, your acting internship and get a good LoR. I don't think you would have major issues getting a shot at these programs but the final match and ranking might be very competitive.

There are some discrepancies with PSTP in terms of what field you are looking into. I heard hec/onc is the most common among applicants but has most slots. GI and Cards have few slots though less people apply for them but is relatively competitive (because fellowship in general is very competitive for these). ID I think is less competitive.

One possible thing you can consider is dual applying IM and pathology. You should basically have the residency of your choice in pathology but you can try to see if you can match PSTP as well.

 

[ChordaEpiphany]

If you are still worried about clinicals and want to increase your chances, do well on step 2, your acting internship and get a good LoR. I don't think you would have major issues getting a shot at these programs but the final match and ranking might be very competitive.

That's my worry. If I go whole hog on PSTP and fall short, where do I go? Realistically, I'll start an IM residency somewhere mid-tier, which doesn't set me up for success at all. If my goal is a productive career in science, are my odds better leaving medicine?

 

[darkamgine]

That's my worry. If I go whole hog on PSTP and fall short, where do I go? Realistically, I'll start an IM residency somewhere mid-tier, which doesn't set me up for success at all. If my goal is a productive career in science, are my odds better leaving medicine?

Unfortunately, that appears to be the reality of academic research because there is no guarantee. There is the ideal pipeline from MSTP-PSTP-K grant-R01 but the K grant and R01 are no guarantees. I think that is just how academic research is nowadays (unless you got something like a CNS paper).

I guess your second part depends on your definition of mid-tier IM residency and success. There are a number of good PSTPs outside of the big cities you talked about such as WashU, Vanderbilt, UMich, and more that would give you a great chance of making it to academic research. If you want to prioritize your chances of getting the K grant during the PSTP, these are good options to consider and it feels like you should have a very good chance of matching into at least one of these. If you just do an IM residency in a big city at a mid/lower ranked program, it will likely affect your chances of academic research in the future as you will have to put in more time and effort to do research (though not impossible).

If you are like 99% certain that you want to maximize your chances of scientific research, pathology is something that you mentioned you consider. Overall, pathology isn't as competitive as IM PSTP and with your application, and I think you can probably choose where you want to end up for pathology. In terms of chances of getting a grant, it probably won't be that big of a deal of what your medical training specialty was (though it will give you different perspectives and training). I have seen people go into ped hec/onc but also then also dabble in adult oncology (and vice versa). For pathology, you can probably begin research earlier and do the exact same or similar research that you can in an IM PSTP. However, the only caveat is that even with a pathology residency/research track at a top school, that does not guarantee you will get a grant. You can say it might set up you with a better chance at success but that is it.

I also think it is a bit funny how sometimes our future is sometimes determined by random people who know nothing about you. I have gotten fair and appropriate criticism on reviews as well as biased and unqualified comments by others. These reviews have directly affected my research life without any impact to theirs. You can only do your best and be resilient in the face of such adversity. Things will work out eventually (or so we hope). An example was my PI did not get funding for a grant because he did not have a model that did not exist. On his resubmission, he addressed it and added another model (though not the type suggested) and he got a superb score. However, it also leaves a sour taste in my mouth knowing that my thousands of hours of work can be so easily dismissed by someone who misjudges my work (which I have personally experienced). As such, even as much as I like research, I am keeping my options open.

 

[ChordaEpiphany]

Unfortunately, that appears to be the reality of academic research because there is no guarantee.

Maybe this is an entitled take, but I think if you're going to ask for a decade of someone's life, there should be some guarantee. If not a guarantee, then at least an appreciation of the sacrifice made and an effort to ensure the student has the opportunity to prove themself.

Frankly, it's an insult to our 8-10 years of effort when clinical grades have such a large luck component, and clerkship directors just shrug their shoulders. It's an insult when attendings know you've sacrificed nearly a decade of your life to get to this point and then spam "competent" with no comments. The university asks for 8-10 years upfront, and when you get to the back end of that and earned them millions in grants they won't even ask the attendings for 8-10 minutes to understand the scoring and ensure you get a fair shake.

It's also an insult when MD/PhD program heads continue to call for more MD/PhD training and more MSTP slots when the pathway is already overcrowded. I cannot think of a single other pathway that requires 15+ years of training at minimal pay for a mere chance at the job. The rhetoric that MSTP programs hawk to fresh college grads today is more propaganda than honest recruitment. Where was the nuanced discussion on the importance of randomly distributed clinical grades? Where was the detailed data on MSTP-PSTP-K-R success rates?

I'm here 30+ years old having torn my life apart trying to meet the demands of the powers that be in medicine. I could have been anything. Instead I'm broke, living with roommates, growing apart from friends, straining my relationship, and destroying my mental and physical health for a profession that doesn't seem to care about anything now that they've already extracted enough data out of me for a couple R01s.

 

[tr]

As I progress into MS3, I'm realizing that much of my performance is out of my hands. Thus far, I've been an excellent student and researcher. I was a top student at a top undergrad, but attended a mid-tier MSTP program for personal reasons. I obtained an F30. I'll have ~10 manuscripts by the time I apply, with hopefully at least one at a top journal (in review at Nature [My Field] right now). I have a number of other accomplishments like patents, obtaining significant funding for a startup, and working as a consultant for a biotech company that is translating some of my research. I also scored >250 on step 1, but that is no longer relevant I suppose.

However, so far third year has been a toss up. I honored my first rotation with flying colors. I received 100% 5/5 evaluations from attendings, with some saying I was one of the best medical students they'd ever had. I scored a 90+ on the shelf. On my second rotation I can't seem to break out of getting 4/5 evals (which is firmly HP, which is effectively the lowest grade my school gives) from attendings who work with me for 2-3 days at most. It seems the entire game is getting the right site placement and knowing the right attendings to send evaluations to. Without significant connections within my class, I can't navigate this as effectively as others. It's mostly a game, and clinical skill is very much secondary to all the other factors at play. Older students, including those from my program who've gotten all Honors and AOA, completely acknowledge this. AOA is really only given out to people who get all honors, which I think I'm already disqualified for given I'll almost definitely HP this rotation. I believe I can do well. Maybe 3-4 Hs out of 8 rotations. However, I don't see any clear path to better performance unless I could go back in time and win the site placement lottery. Further, the rotation with the lowest chance of Honors is IM (~15%).

I can't shake the feeling that my entire future, and this insane 9 year investment I made (which came with incredible sacrifice), is just floating in the wind and totally dependent on arbitrary evaluations from attendings who don't even understand our grading system. Ideally I'd be looking to match a PSTP in a city with significant biotechnology industry (not just for me, but for my partner, who works in biotech). This would be somewhere like Boston (MGH/BWH), San Diego (UCSD), Seattle (UWash), Maryland (JH), SF (UCSF, Stanford), Research Triangle/NC (Duke, UNC), LA (UCLA), and maybe Philadelphia (Penn).

Most of these seem like reaches based on current resident profiles. They seem to heavily favor candidates from top tier schools, and many of them have far more impressive CVs than I do. My dream is to be an NIH-funded investigator at an institution where I can do meaningful research. However, if my chances of matching are slim, I'm not sure if I see a point in continuing to pursue this path. I will not pursue a PSTP and drag my partner away from their own career opportunities if the most likely outcome is a clinical role with some research on the side. My passion is biotechnology, and I'm not interested in being a pure clinician. I would sooner do a pathology residency with the sole intention of immediately exiting to industry or leave medicine altogether for management consulting and try to get on the executive track in biotech.

If anyone has insight, I'd be very grateful.

You sound really frustrated, but also very accomplished and not like you need to be worrying as much as you are.
I think you are terribly overestimating the importance of your clinical grades for an IM-PSTP match.

With 10 papers including high-impact ones plus an F30, I really can't imagine you would need AOA to match to a good PSTP.
AOA is for clinicians who are trying to match into derm or whatever the kids like to gun for these days.

PSTP program directors are not going to care about whether you honored your ob-gyn rotation. They will be too dazzled by your awesome research track record.

I think you should relax, try to learn the parts of medicine that will be relevant to you, be a pleasant team player, and enjoy the knowledge that your clinical grades aren't half as important for you as they will be for your classmates.

 

[phonyreal98]

AOA is for clinicians who are trying to match into psych or whatever the kids like to gun for these days.

FIFY @tr

 

[darkamgine]

Maybe this is an entitled take, but I think if you're going to ask for a decade of someone's life, there should be some guarantee. If not a guarantee, then at least an appreciation of the sacrifice made and an effort to ensure the student has the opportunity to prove themself.

Frankly, it's an insult to our 8-10 years of effort when clinical grades have such a large luck component, and clerkship directors just shrug their shoulders. It's an insult when attendings know you've sacrificed nearly a decade of your life to get to this point and then spam "competent" with no comments. The university asks for 8-10 years upfront, and when you get to the back end of that and earned them millions in grants they won't even ask the attendings for 8-10 minutes to understand the scoring and ensure you get a fair shake.

It's also an insult when MD/PhD program heads continue to call for more MD/PhD training and more MSTP slots when the pathway is already overcrowded. I cannot think of a single other pathway that requires 15+ years of training at minimal pay for a mere chance at the job. The rhetoric that MSTP programs hawk to fresh college grads today is more propaganda than honest recruitment. Where was the nuanced discussion on the importance of randomly distributed clinical grades? Where was the detailed data on MSTP-PSTP-K-R success rates?

I'm here 30+ years old having torn my life apart trying to meet the demands of the powers that be in medicine. I could have been anything. Instead I'm broke, living with roommates, growing apart from friends, straining my relationship, and destroying my mental and physical health for a profession that doesn't seem to care about anything now that they've already extracted enough data out of me for a couple R01s.

I wish it were true and that more MD/PhD knew how difficult the entire process is. I don't think clinical grades are that big of a barrier as you may think. I know people who had low step 1 scores (200s) that still matched into good IM PSTP because they had a high IF paper highlighting that research > clinical for PSTPs. I wouldn't worry about a couple non-honors as the only flaw on the application.

Looks like there is some research into the whole process.

Predoctoral MD-PhD grants as indicators of future NIH funding success - PMC

MD-PhD trainees constitute an important source of physician-scientists. Persistence on this challenging path is facilitated by success in garnering independent (R grant) support from the NIH. Published research tracks academic appointments and ...

www.ncbi.nlm.nih.gov

The numbers looks ... not great at all. The article suggest about a 15% F30-K conversion rate and approximately 50% K to R conversion rate. Of course, most MD-PhD probably do research but maybe not with a R01 or take longer to get their R grant than the survey's follow-up. There are probably other flaws in the study and that it is with older MD-PhD who graduated decades ago but overall, I think it is safe to say that most MD-PhDs do not end up with R grants.

Some of it might be incentives and responsibilities. The article suggested that balancing clinical and research duties is difficult. In addition, during the early periods of research, you may be making less than your MD counterparts. In the end, doing research may cost more time and money in an already time intensive path. Doing a IM residency and then going full-time clinical will likely make more money than a hec-onc IM PSTP that is 80% research and 20% clinical. While finances may not be a concern for everyone, some people who lives in a large city in their 30s will likely want enough money to not live in a small apartment, or have considerations for a family.

I don't think this is specifically to MD-PhDs though because the competition among PhD for tenure R1 positions is even more cutthroat. I heard there are typically 200+ applications for every R1 tenure position and that you basically need some high IF paper for even a chance at some of these schools. Meanwhile, industry can pay more for these highly qualified applicants with less career risk.

 

[tr]

FIFY @tr

O tempora! O mores! 😄

 

[tr]

I wish it were true and that more MD/PhD knew how difficult the entire process is. I don't think clinical grades are that big of a barrier as you may think. I know people who had low step 1 scores (200s) that still matched into good IM PSTP because they had a high IF paper highlighting that research > clinical for PSTPs. I wouldn't worry about a couple non-honors as the only flaw on the application.

Looks like there is some research into the whole process.

Predoctoral MD-PhD grants as indicators of future NIH funding success - PMC

MD-PhD trainees constitute an important source of physician-scientists. Persistence on this challenging path is facilitated by success in garnering independent (R grant) support from the NIH. Published research tracks academic appointments and ...

www.ncbi.nlm.nih.gov

The numbers looks ... not great at all. The article suggest about a 15% F30-K conversion rate and approximately 50% K to R conversion rate.

I see this idea of a linear progression from F to K to R, with dropouts at each stage, on here a lot. I don't think it's a good representation of the actual biomedical funding landscape. ~70% of first time R01 awardees have never previously held a K (black circles):

The increasing importance of fellowships and career development awards in the careers of early-stage biomedical academic researchers

Excessive competition for biomedical faculty positions has ratcheted up the need to accumulate some mix of high-quality publications and prestigious grants to move from a training position to university faculty. How universities value each of these attributes when considering faculty candidates...

journals.plos.org

 

[SurfingDoctor]

I will just say having seen a number of MD-PhDs go through clinical training, most (granted this is a personal “n” of 5) just peter out by the time they are done and have no interest in science anymore (if they ever really did to begin with).

This is all to say, wanting to do research as a career and being persistent in that goal, has been the best predictor of success in my observations and experience and likewise, there are a good number of MD-PhD who don’t end up having that as a goal, hence some of the “success” rates you see.

Therefore, interest and persistence, have been in my experience, the only real driving factors in getting NIH grants.

 

[SurfingDoctor]

I see this idea of a linear progression from F to K to R, with dropouts at each stage, on here a lot. I don't think it's a good representation of the actual biomedical funding landscape. ~70% of first time R01 awardees have never previously held a K (black circles):

View attachment 374898

The increasing importance of fellowships and career development awards in the careers of early-stage biomedical academic researchers

Excessive competition for biomedical faculty positions has ratcheted up the need to accumulate some mix of high-quality publications and prestigious grants to move from a training position to university faculty. How universities value each of these attributes when considering faculty candidates...

journals.plos.org

I know a guy in my field. Typically regarded as the godfather of it in some regards. I don’t think he got his first R01 (and first NIH grant) till he was 60 or so.

However, the trends of this graph are true. While not required to have a K, I think many institutions are willing to support junior faculty on Ks as a stepping stone, no matter their path or degree. Ks were historical not grant mechanisms for MD-PhDs or PhDs in general. They were designed for people without a strong scientific background eg MDs, who wanted to pursue a scientific career. Nowadays however, that isn’t the case and there are even specific mechanisms (K01, K99) designed specifically for PhDs after post-doc training.

It would be interesting to see the age breakdown of those first time R01 without training grants versus those with. That couldn’t be found in the NIH ExPORTER, but I bet those without are older these days. Just a hunch.

 

[darkamgine]

I see this idea of a linear progression from F to K to R, with dropouts at each stage, on here a lot. I don't think it's a good representation of the actual biomedical funding landscape. ~70% of first time R01 awardees have never previously held a K (black circles):

View attachment 374898

The increasing importance of fellowships and career development awards in the careers of early-stage biomedical academic researchers

Excessive competition for biomedical faculty positions has ratcheted up the need to accumulate some mix of high-quality publications and prestigious grants to move from a training position to university faculty. How universities value each of these attributes when considering faculty candidates...

journals.plos.org

For MD-PhD, the paper suggested it around about 50% of R grant receivers did not have K grants.

Almost half of those who did receive an R award, in this F30 cohort, did not receive an antecedent K award. Multiple factors could contribute to this finding, including a decision by MD-PhDs to forego this opportunity in order to limit training duration, institutional pressure to forego the smaller grant (e.g., in procedural specialties), or less emphasis on the K award in the earlier MD-PhD cohort that we targeted for R award analysis. For a subset of F30 awardees, pursuit of a K award may be perceived as too costly an extension of the training period. The need to shorten training time was noted as one of the main action items by the 2014 Physician-Scientist Workforce Working Group. This group suggested shortening the time to independent research by 5 years (14, 15).

K awards were rarer among the primarily PhD-only recipients of predoctoral F31 training grants. This likely reflects the limited use of K awards by the NIH for PhD scientists (whereas the K08 and K23 mechanisms are limited to clinicians), as well as the fact that the major K award used, the K99, was introduced late in the capture period. Notably, the percentage of R awards was higher in the F31 recipient pool (similar to the rate among male F30 recipients in the 1990–2007 cohort). This could be a manifestation of the higher reliance on independent R awards early in the academic PhD career and/or a shorter training period compared with MD-PhDs. While beyond the scope of this study, it is conceivable that receipt of F31 grants by PhD trainees tracks with persistence in academic careers.

I think if you are doing an IM-PSTP, you probably are aiming for a K grant. Talking to MSTP graduates going into research track, their focus was getting the K grant (none of them said they would apply for a R grant without applying for the K grant). For other fields, I can see forgoing the K grant to directly try for the R grant. In addition, you can see the trend on the graph that more R grants now have preceding K grants. This is likely because the K99 is newer and getting more accepted as a transition step for the R01. Back in the day, there were researchers, some of which became very well-known, who got their R grants right after their PhD (skipping the postdoc). That is basically impossible nowadays as the median age of first R01 is 42 and for MD-PhD, it is 44.

Therefore, interest and persistence, have been in my experience, the only real driving factors in getting NIH grants.

I agree but for me, I really do not think I can wait until my 40s before I get my own lab started. There was a time when I thought that was fine but I realize time is too precious. One of my mentors just passed away and did not see that the drugs he help develop and research for over 20 years being recently FDA approved. Perhaps, I am too eager but I already devoted my 20s to medical/research training. I don't want to also devote my 30s to more training before I can have a chance to make my own impact. If that is what is required for R01 these days, I think someone else who is more willing to devote their life to research can take it. I am looking at other ways outside of academic research that would let me start making an impact on patient care much earlier. Selfishly, I want to see my life's work help patients because I believe I have that ability and patients have an need for better care.

 

[tr]

I'm just saying this idea of a cursus honorum defined by NIH letters specific to each stage is not a reflection of the reality that I see around me.

It's more like you are constantly, at every stage, applying for many different funding opportunities, both within and without the NIH, most of which you will not get.

Every time you get one it's fantastic and allows you to make some scientific progress, which you can use to convince people to give you more money so you can make more progress.

I didn't have a K - not because I didn't apply, just because it never got funded. I did get a bunch of little foundation grants during my early faculty years that allowed me to keep a small but productive research program going.
I have an R01 now but I would say that that project is actually less "independent" as it's a biggish, two site collaboration that was very much jointly developed. (I'm sole PI for grantsmanship reasons, as I had ESI status when we applied.)

I believe @ Fencer has said he was supported by a VA Merit award during his early career period, which is a great mechanism that is not NIH based and therefore wouldn't show up in the NIH based career trajectory analyses.

All research funding is good research funding is what I'm saying. No single specific funding mechanism is an absolute requirement to maintain scientific momentum.

 

[tr]

It would be interesting to see the age breakdown of those first time R01 without training grants versus those with. That couldn’t be found in the NIH ExPORTER, but I bet those without are older these days. Just a hunch.

Here's an answer to that ( from @darkamgine's link above). Panel C.

Looks like no age difference for first R01 between F recipients who did or did not hold a K in between. If anything, the earliest R recipients were in the no-K pool.

Again, no NIH K doesn't mean no funding. Many of them might have had internal KL2s, VA Merits, or other non-NIH career support mechanisms.

 

[dl2dp2]

I had a K. I just got the NOA for my R01. However, a lot of things have happened in the last year that I am ready to quit my job and/or this dumb system all together.

I think the entire system is really dumb and poorly designed at every juncture. You keep applying if you want but I honestly think you just need to marry well and make a ton of money to begin with. Here’s an the absolute absurdity: with retirement contribution and DCFA and so forth I’m now paid LESS per pay period than when I was a GRAD STUDENT based on my non clinical/research income. This is NOMINAL take home. Not even factoring in inflation. Luckily I do well with clinical and other activities and married well. So I can sort of support this hobby. But make no mistake. This is a hobby. Not a real job. The academic job is a complete utter joke. And not a very fun hobby at that. The only solace I have is that I am wealthy and very much enjoy all my other engagements and am paid handsomely for it so I can say F U and peace out at any time so that makes me feel marginally better.

I enjoy the science. My colleagues are great. I even enjoy grant writing as a hobby. But everything else around this system is utter garbage. The promotion and tenure system. The politics. Interacting with the Feds. The corruption of peer review. The never ending wait. The political and virtue signaling and posturing. The extremely low pay.

I honestly would just focus on making as much money as possible as quickly as possible. Realizing that the feasibility of your academic career is very much secondary to that.

I had a female faculty crying in my group zoom because her fiancé’s K was stuck in limbo for 3 years and now will soon be out of a job and they can’t afford rent. She’s almost 40. Childless. Not married. Tenure track at a state university and getting paid less than a soft money funded postdoc at her old school. Like wtf is this ****. This kind of story is so every day in academia now.

I have a friend who just moved from tier 1 to tier 3 to get tenured. Md PhD. Full residency. Super star. NIH directors new innovator, multiple R01s. Mid 40s have less than 50k to his name after putting down a down payment for a 600k house. 3 kids. Literally can’t afford a vacation. Stay at home wife. He didn’t marry well. Do you want to really live in a tier 3 metro in your 40s with less than 50k to your name? Do you need Dave Ramsey? This is truly truly pathetic.

I had one female Md PhD tenure track faculty who told me she can’t afford having a child 6 months ago and one male K awardee who told me he can’t afford a deposit on a rental or a wedding at a party I went to this weekend. Are you SURE you want to move to San Francisco or Boston?

And I wish it was just my “toxic” “high prestige” institution. No. Based on discussions with colleagues, job market (oh man I actually applied for jobs, jeez thinking other places would be less exploitative) this is par the course with every high prestige place on your list. Be very much prepared for a future of being poorly paid and exploited by the system for a long long time. It’s just really dumb. It’s hard to describe how dumb it all is. I mean honestly not matching at a prestige place is maybe a blessing. And if you only do clinical work you’d probably be way happier net net.

Literally every single person in this track constantly complains. The only people who don’t complain are either wealthy or married well and often both. Given I’m both I never complain in public—it seems silly to complain about a dumb hobby. So this is the only place you’ll hear the truth.

 

[tr]

I had a K. I just got the NOA for my R01.

Yay! Congrats!!!

 

[dl2dp2]

Yay! Congrats!!!

Yeah well. I basically prepared for a year for an exit. And the mafia wants to pull me back in and I’m not so sure. We will see.

 

[tr]

Yeah well. I basically prepared for a year for an exit. And the mafia wants to pull me back in and I’m not so sure. We will see.

Ok well like you said, this is a fun hobby as long as you aren't banking on paying your mortgage with NIH money. Totally agreed that it's so much easier to let the nonsense roll off your back when your finances are covered and you have other good options in life. Hence the utility of the MSTP. I would put that down under the 'good life decisions ' thread in the psych forum except I don't think it's relevant to the posters there.

By the way, based on my limited n of 3 I do think your institution might be at the front of the pack for toxicity. Not that I would suggest moving, obviously it's all working out well for you there.

 

[dl2dp2]

Totally agreed that it's so much easier to let the nonsense roll off your back when your finances are covered and you have other good options in life. Hence the utility of the MSTP.

I honestly just don’t think people get “good mentorship”. People are constantly being lied to in academia, across the board. Aggressive, dangerous lies. Sometimes you get lied to a little more. Sometimes a little less. But ultimately you live in a cesspool of lies.

And not to get political but academia and the associated system (ie “nonprofit”) represents a toxic strain of hypocritical lies on the left that it needs to grow, tumor-like into the rest of the society.

It’s not until I’m exposed to things entirely outside of academia that I started to see through the lies. Clinical medicine is very nice in a way, but people should open their eyes to an even broader range of things out there.

 

[darkamgine]

I had a K. I just got the NOA for my R01. However, a lot of things have happened in the last year that I am ready to quit my job and/or this dumb system all together.

I think the entire system is really dumb and poorly designed at every juncture. You keep applying if you want but I honestly think you just need to marry well and make a ton of money to begin with. Here’s an the absolute absurdity: with retirement contribution and DCFA and so forth I’m now paid LESS per pay period than when I was a GRAD STUDENT based on my non clinical/research income. This is NOMINAL take home. Not even factoring in inflation. Luckily I do well with clinical and other activities and married well. So I can sort of support this hobby. But make no mistake. This is a hobby. Not a real job. The academic job is a complete utter joke. And not a very fun hobby at that. The only solace I have is that I am wealthy and very much enjoy all my other engagements and am paid handsomely for it so I can say F U and peace out at any time so that makes me feel marginally better.

I enjoy the science. My colleagues are great. I even enjoy grant writing as a hobby. But everything else around this system is utter garbage. The promotion and tenure system. The politics. Interacting with the Feds. The corruption of peer review. The never ending wait. The political and virtue signaling and posturing. The extremely low pay.

I honestly would just focus on making as much money as possible as quickly as possible. Realizing that the feasibility of your academic career is very much secondary to that.

I had a female faculty crying in my group zoom because her fiancé’s K was stuck in limbo for 3 years and now will soon be out of a job and they can’t afford rent. She’s almost 40. Childless. Not married. Tenure track at a state university and getting paid less than a soft money funded postdoc at her old school. Like wtf is this ****. This kind of story is so every day in academia now.

I have a friend who just moved from tier 1 to tier 3 to get tenured. Md PhD. Full residency. Super star. NIH directors new innovator, multiple R01s. Mid 40s have less than 50k to his name after putting down a down payment for a 600k house. 3 kids. Literally can’t afford a vacation. Stay at home wife. He didn’t marry well. Do you want to really live in a tier 3 metro in your 40s with less than 50k to your name? Do you need Dave Ramsey? This is truly truly pathetic.

I had one female Md PhD tenure track faculty who told me she can’t afford having a child 6 months ago and one male K awardee who told me he can’t afford a deposit on a rental or a wedding at a party I went to this weekend. Are you SURE you want to move to San Francisco or Boston?

And I wish it was just my “toxic” “high prestige” institution. No. Based on discussions with colleagues, job market (oh man I actually applied for jobs, jeez thinking other places would be less exploitative) this is par the course with every high prestige place on your list. Be very much prepared for a future of being poorly paid and exploited by the system for a long long time. It’s just really dumb. It’s hard to describe how dumb it all is. I mean honestly not matching at a prestige place is maybe a blessing. And if you only do clinical work you’d probably be way happier net net.

Literally every single person in this track constantly complains. The only people who don’t complain are either wealthy or married well and often both. Given I’m both I never complain in public—it seems silly to complain about a dumb hobby. So this is the only place you’ll hear the truth.

Thanks for sharing all of this. I recently have thoughts that the academic track may not be everything that is being sold to us but I barely hear it directly from the people who made it. Survivorship bias aside, it is hard to badmouth the career path you and all your friends were once on. Everyone acknowledges the system has issues but defends or accepts it because it is the only way to do academic research. However, the more I look into it, the more I feel I need to investigate other viable pathways.

With an academic salary, you are right that there is almost no way to live well in large cities and top universities. In some places and ways, academic research has become a rat race of who can sacrifice the most for these positions and get exploited by the universities who can pay as little as possible for very qualified people. I mean, with so many qualified researchers, if you do not take it, they will find someone else to do it. They are not short on candidates. And the constant virtue signaling of not doing it for the money while simultaneous exploitation by the university is truly ironic.

The never-ending grant writing and uncertainty of it leaves everyone constantly applying for more and more grants. My PI told me how it used to be he would write a couple grants a year to try to get a R01/additional funding. Now, he is writing/working on almost a dozen grant applications a year because that is the game. Every grants has a lower chance so you just keep applying more and more. You hope the rest of the lab does the science while the PI just writes for funding. Other PIs say similar things where they spend more time writing than before. It is like the same thing with virtual med school/residency apps, everyone applies for more and so everyone is spending more time writing and applying. It becomes a rat race of writing and trying to get funding instead of doing science.

The overall peer review process is quite disgusting the more you understand the nuances. We certainly believe peer review has value but there are many issues that are not well-addressed. There are some absolute BS articles published in higher tier journals just because of connections. Here is one of the clearest examples. There is no way I could get that published in that journal but they could simply because of their name. My personal experiences with the process have exposed issues of inconsistent, unresponsive, and potentially unqualified reviewers, leading to mistrust in the system. The voluntary nature of the reviewing task and lack of repercussions for poor performance exacerbate these problems. Ultimately, the peer review system is a lottery in which you hope you get a responsible and respectful reviewer more than actual reviewing. And this journey may take months if lucky or years if things are not smooth. It utterly does not respect your time. The preprint side of things has helped in some respects but still has a long ways to go.

There also seems to be a culture of secrecy and competitive advantage in academia, often at the expense of transparency and reproducibility. Instances of scientific misconduct at high levels further erode faith in the system, as survival bias perpetuates these behaviors. Reproducibility and science is secondary to getting funding and publishing big papers. We just saw the president of stanford step down due to misconduct. And long-time harvard scientist has multiple instances of fraud. It is a culture of wanting things to fit a story or narrative so they can continue their careers instead of actually doing real science and understand how things are. After all, if people had to choose between their career and misconduct, guess what the decision is for people who remain in academic science. Its survivorship bias in the worst way.

This is just what we know and can observe on the surface. There are many things that we may never hear about. One lab member told me how he used to be part of a group focused on a niche pathway. They had most of the experts of the field in that group and would regularly meet up and talk to each other but never collaborated directly. When it came to grant reviews or peer reviews, they had each other backs and made sure they could continue things. It essentially circumvented the traditional uncertainties of reviews using politics and connections. I won't go into the other issues I have with academia such as wasteful spending and accumulated trash instead of recycling in every lab. The biotech and publishing companies are reaping fortunes while the most researchers are struggling.

In spite of my fondness for discovery and academic freedom, these issues are too significant to be ignored. While reform from NIH may eventually occur, in the near term, we need to coexist with these problems. As such, I am considering industry and start-ups as potential alternatives. It seems not only reasonable but also prudent, given the sacrifices, politics, and elements of luck that academia requires. There is no way that all MD/PhDs can get a R01 even if they wanted to. The system does not permit that just like most research grants will never get scored or funded. Lastly, when considering the impact on patients, start-ups and industry can have an equal, if not greater, effect than academia. Naturally, these sectors also have their own set of challenges to address but the skillset of a MD/PhD can be appropriately utilized.

 

[tr]

Thanks for sharing all of this. I recently have thoughts that the academic track may not be everything that is being sold to us but I barely hear it directly from the people who made it. Survivorship bias aside, it is hard to badmouth the career path you and all your friends were once on. Everyone acknowledges the system has issues but defends or accepts it because it is the only way to do academic research. However, the more I look into it, the more I feel I need to investigate other viable pathways.

With an academic salary, you are right that there is almost no way to live well in large cities and top universities. In some places and ways, academic research has become a rat race of who can sacrifice the most for these positions and get exploited by the universities who can pay as little as possible for very qualified people. I mean, with so many qualified researchers, if you do not take it, they will find someone else to do it. They are not short on candidates. And the constant virtue signaling of not doing it for the money while simultaneous exploitation by the university is truly ironic.

The never-ending grant writing and uncertainty of it leaves everyone constantly applying for more and more grants. My PI told me how it used to be he would write a couple grants a year to try to get a R01/additional funding. Now, he is writing/working on almost a dozen grant applications a year because that is the game. Every grants has a lower chance so you just keep applying more and more. You hope the rest of the lab does the science while the PI just writes for funding. Other PIs say similar things where they spend more time writing than before. It is like the same thing with virtual med school/residency apps, everyone applies for more and so everyone is spending more time writing and applying. It becomes a rat race of writing and trying to get funding instead of doing science.

The overall peer review process is quite disgusting the more you understand the nuances. We certainly believe peer review has value but there are many issues that are not well-addressed. There are some absolute BS articles published in higher tier journals just because of connections. Here is one of the clearest examples. There is no way I could get that published in that journal but they could simply because of their name. My personal experiences with the process have exposed issues of inconsistent, unresponsive, and potentially unqualified reviewers, leading to mistrust in the system. The voluntary nature of the reviewing task and lack of repercussions for poor performance exacerbate these problems. Ultimately, the peer review system is a lottery in which you hope you get a responsible and respectful reviewer more than actual reviewing. And this journey may take months if lucky or years if things are not smooth. It utterly does not respect your time. The preprint side of things has helped in some respects but still has a long ways to go.

There also seems to be a culture of secrecy and competitive advantage in academia, often at the expense of transparency and reproducibility. Instances of scientific misconduct at high levels further erode faith in the system, as survival bias perpetuates these behaviors. Reproducibility and science is secondary to getting funding and publishing big papers. We just saw the president of stanford step down due to misconduct. And long-time harvard scientist has multiple instances of fraud. It is a culture of wanting things to fit a story or narrative so they can continue their careers instead of actually doing real science and understand how things are. After all, if people had to choose between their career and misconduct, guess what the decision is for people who remain in academic science. Its survivorship bias in the worst way.

This is just what we know and can observe on the surface. There are many things that we may never hear about. One lab member told me how he used to be part of a group focused on a niche pathway. They had most of the experts of the field in that group and would regularly meet up and talk to each other but never collaborated directly. When it came to grant reviews or peer reviews, they had each other backs and made sure they could continue things. It essentially circumvented the traditional uncertainties of reviews using politics and connections. I won't go into the other issues I have with academia such as wasteful spending and accumulated trash instead of recycling in every lab. The biotech and publishing companies are reaping fortunes while the most researchers are struggling.

In spite of my fondness for discovery and academic freedom, these issues are too significant to be ignored. While reform from NIH may eventually occur, in the near term, we need to coexist with these problems. As such, I am considering industry and start-ups as potential alternatives. It seems not only reasonable but also prudent, given the sacrifices, politics, and elements of luck that academia requires. There is no way that all MD/PhDs can get a R01 even if they wanted to. The system does not permit that just like most research grants will never get scored or funded. Lastly, when considering the impact on patients, start-ups and industry can have an equal, if not greater, effect than academia. Naturally, these sectors also have their own set of challenges to address but the skillset of a MD/PhD can be appropriately utilized.

Look it's all true. Peer review is basically a big game of roulette for the newbies, which evolves into a mutual back-scratching setup for the people who have been on the inside for decades. The NIH is run like a medieval artisan's guild, where it's all about connections at the top and grandfathering/apprenticeship is the main mode of induction. The academic training pyramid scheme positively rewards and incentivizes narcissistic behavior and exploitation of trainees by PIs.

There are rumblings about trying to change, and maybe it will change, but this is a huge system and change is slow. I think there have been some good faith efforts at reform from within the NIH, though the actual impact so far has been small. I notice the postdocs are starting to rebel which is fantastic. I see more grad student and postdoc unions forming, and I also notice that it's getting extremely hard to hire postdocs because young people are waking up and refusing to drink the Kool-Aid. Good for them.

I think the key to survival is just not to hang all your personal life satisfaction on this job, because it's not going to love you back. Live where you want to live. Prioritize your personal relationships and other things that matter to you. Make sure your financial back is covered. Remain open to other ways of making scientific contributions vs buying into the academic biomedicine machine. It's too easy for others to exploit you when they know your other options are limited. When you have an out, it's your willingness to step away that gives you bargaining power. Hence the enormous advantage of the MSTP over the straight PhD.

 

[Neuronix]

As I progress into MS3, I'm realizing that much of my performance is out of my hands. Thus far, I've been an excellent student and researcher. I was a top student at a top undergrad, but attended a mid-tier MSTP program for personal reasons. I obtained an F30. I'll have ~10 manuscripts by the time I apply, with hopefully at least one at a top journal (in review at Nature [My Field] right now). I have a number of other accomplishments like patents, obtaining significant funding for a startup, and working as a consultant for a biotech company that is translating some of my research. I also scored >250 on step 1, but that is no longer relevant I suppose.

However, so far third year has been a toss up. I honored my first rotation with flying colors. I received 100% 5/5 evaluations from attendings, with some saying I was one of the best medical students they'd ever had. I scored a 90+ on the shelf. On my second rotation I can't seem to break out of getting 4/5 evals (which is firmly HP, which is effectively the lowest grade my school gives) from attendings who work with me for 2-3 days at most. It seems the entire game is getting the right site placement and knowing the right attendings to send evaluations to. Without significant connections within my class, I can't navigate this as effectively as others. It's mostly a game, and clinical skill is very much secondary to all the other factors at play. Older students, including those from my program who've gotten all Honors and AOA, completely acknowledge this. AOA is really only given out to people who get all honors, which I think I'm already disqualified for given I'll almost definitely HP this rotation. I believe I can do well. Maybe 3-4 Hs out of 8 rotations. However, I don't see any clear path to better performance unless I could go back in time and win the site placement lottery. Further, the rotation with the lowest chance of Honors is IM (~15%).

I can't shake the feeling that my entire future, and this insane 9 year investment I made (which came with incredible sacrifice), is just floating in the wind and totally dependent on arbitrary evaluations from attendings who don't even understand our grading system. Ideally I'd be looking to match a PSTP in a city with significant biotechnology industry (not just for me, but for my partner, who works in biotech). This would be somewhere like Boston (MGH/BWH), San Diego (UCSD), Seattle (UWash), Maryland (JH), SF (UCSF, Stanford), Research Triangle/NC (Duke, UNC), LA (UCLA), and maybe Philadelphia (Penn).

Most of these seem like reaches based on current resident profiles. They seem to heavily favor candidates from top tier schools, and many of them have far more impressive CVs than I do. My dream is to be an NIH-funded investigator at an institution where I can do meaningful research. However, if my chances of matching are slim, I'm not sure if I see a point in continuing to pursue this path. I will not pursue a PSTP and drag my partner away from their own career opportunities if the most likely outcome is a clinical role with some research on the side. My passion is biotechnology, and I'm not interested in being a pure clinician. I would sooner do a pathology residency with the sole intention of immediately exiting to industry or leave medicine altogether for management consulting and try to get on the executive track in biotech.

If anyone has insight, I'd be very grateful.

Your chances depend very much on specialty. Competitive specialties and programs that are not physician-scientist heavy will filter you out based on clinical metrics more than non-competitive specialties that are physician-scientist heavy.

Based on what you've written I have a hard time believing that you wouldn't match at one of those programs you listed in a traditional MD/PhD research heavy specialty. It's always a crapshoot though, and you have to make the best of whatever cards you're handed. Such is the life of a physician-scientist.

That's my worry. If I go whole hog on PSTP and fall short, where do I go? Realistically, I'll start an IM residency somewhere mid-tier, which doesn't set me up for success at all. If my goal is a productive career in science, are my odds better leaving medicine?

I did not do my residency or get a faculty job at places considered top-tier. It wasn't for lack of trying--I can't tell you how many times I've been rejected including from people and places I thought would be interested in my skillset. My specialty doesn't have many fellowships, and I got rejected from a few of them. I managed to still transition to significant NIH funding. Persistence and making the best out of your situation are the keys.

If you don't see a path forward you always have that option to transition to clinical medicine or industry. This is the best part of being a physician-scientist in my opinion.

(PS: My path was F30->K12->R37 and U01 for what it's worth from the other discussion, not the usual sequence of numbers and letters and may not show up as positive datapoints)

 

[tr]

Your chances depend very much on specialty.
If you don't see a path forward you always have that option to transition to clinical medicine or industry. This is the best part of being a physician-scientist in my opinion.

Absolutely. Physician-scientists don't fail out, they bail out. The availability of attractive alternatives means you can decide when the academic nonsense is no longer worth it to you. Hopefully before you hit some of the tragic scenarios described above by @dl2dp2

This can be condescendingly depicted as "lack of persistence" by those who have drunk the NIH Kool-Aid, but I would consider it more like making intelligent life choices.

(PS: My path was F30->K12->R37 and U01 for what it's worth from the other discussion, not the usual sequence of numbers and letters and may not show up as positive datapoints)

Yes exactly. @Neuronix is killing it, but by this description would show up in that dataset above as F30 yes, K08/R01 no.

That's why the metric of training grant "conversion" to R01 as a measure of scientific career success is meaningless. There are too many other funding mechanisms that it doesn't account for.

 

[Fencer]

The most impactful "easily-obtainable" measure is original peer-review manuscripts. Awarded patents are equivalent to peer-review manuscripts. Maintaining a manuscript track-record at 10 or 20 years post-graduation is a better signal of ROI from the NIH investment during T32, NRSA, etc. than grants as it shows broader impact. That is a direct contribution to the research enterprise. I have brought this point up at meetings and/or workforce task forces with NIH leadership. Nevertheless, NIH insists in focusing upon grants awarded as a better measure due to their need of justifying investing in developing their workforce. While some top professional societies/awards and promotion/tenure mechanisms value my proposed approach (for example, provide the 10 most impactful original manuscripts), institutions focus their love to "current" research revenue (i.e.: most often grants). This last point is memorialized into Simone's Maxim # 1.

 

[SurfingDoctor]

The most impactful "easily-obtainable" measure is original peer-review manuscripts. Awarded patents are equivalent to peer-review manuscripts. Maintaining a manuscript track-record at 10 or 20 years post-graduation is a better signal of ROI from the NIH investment during T32, NRSA, etc. than grants as it shows broader impact. That is a direct contribution to the research enterprise. I have brought this point up at meetings and/or workforce task forces with NIH leadership. Nevertheless, NIH insists in focusing upon grants awarded as a better measure due to their need of justifying investing in developing their workforce. While some top professional societies/awards and promotion/tenure mechanisms value my proposed approach (for example, provide the 10 most impactful original manuscripts), institutions focus their love to "current" research revenue (i.e.: most often grants). This last point is memorialized into Simone's Maxim # 1.

Well, from an institutional standpoint, grants generate indirects, manuscripts do not.

On the other hand, it’s been very interesting to see how members of academia view themselves and their worth. I know a good number of successful grant writers who know nothing of actual science and couldn’t generate an original thought if it was handed them on a silver plater. I have had senior professors use my ideas and technique, and spin them to their benefit with their resources, to their advantage. Unfortunately for them, and the NIH, I’m happy to use my resourcefulness to burn them to the ground.

But those indirects…

 

[solitude]

I had a K. I just got the NOA for my R01. However, a lot of things have happened in the last year that I am ready to quit my job and/or this dumb system all together.

I think the entire system is really dumb and poorly designed at every juncture. You keep applying if you want but I honestly think you just need to marry well and make a ton of money to begin with. Here’s an the absolute absurdity: with retirement contribution and DCFA and so forth I’m now paid LESS per pay period than when I was a GRAD STUDENT based on my non clinical/research income. This is NOMINAL take home. Not even factoring in inflation. Luckily I do well with clinical and other activities and married well. So I can sort of support this hobby. But make no mistake. This is a hobby. Not a real job. The academic job is a complete utter joke. And not a very fun hobby at that. The only solace I have is that I am wealthy and very much enjoy all my other engagements and am paid handsomely for it so I can say F U and peace out at any time so that makes me feel marginally better.

I enjoy the science. My colleagues are great. I even enjoy grant writing as a hobby. But everything else around this system is utter garbage. The promotion and tenure system. The politics. Interacting with the Feds. The corruption of peer review. The never ending wait. The political and virtue signaling and posturing. The extremely low pay.

I honestly would just focus on making as much money as possible as quickly as possible. Realizing that the feasibility of your academic career is very much secondary to that.

I had a female faculty crying in my group zoom because her fiancé’s K was stuck in limbo for 3 years and now will soon be out of a job and they can’t afford rent. She’s almost 40. Childless. Not married. Tenure track at a state university and getting paid less than a soft money funded postdoc at her old school. Like wtf is this ****. This kind of story is so every day in academia now.

I have a friend who just moved from tier 1 to tier 3 to get tenured. Md PhD. Full residency. Super star. NIH directors new innovator, multiple R01s. Mid 40s have less than 50k to his name after putting down a down payment for a 600k house. 3 kids. Literally can’t afford a vacation. Stay at home wife. He didn’t marry well. Do you want to really live in a tier 3 metro in your 40s with less than 50k to your name? Do you need Dave Ramsey? This is truly truly pathetic.

I had one female Md PhD tenure track faculty who told me she can’t afford having a child 6 months ago and one male K awardee who told me he can’t afford a deposit on a rental or a wedding at a party I went to this weekend. Are you SURE you want to move to San Francisco or Boston?

And I wish it was just my “toxic” “high prestige” institution. No. Based on discussions with colleagues, job market (oh man I actually applied for jobs, jeez thinking other places would be less exploitative) this is par the course with every high prestige place on your list. Be very much prepared for a future of being poorly paid and exploited by the system for a long long time. It’s just really dumb. It’s hard to describe how dumb it all is. I mean honestly not matching at a prestige place is maybe a blessing. And if you only do clinical work you’d probably be way happier net net.

Literally every single person in this track constantly complains. The only people who don’t complain are either wealthy or married well and often both. Given I’m both I never complain in public—it seems silly to complain about a dumb hobby. So this is the only place you’ll hear the truth.

thanks for sharing. I basically agree.

One path for MD-PhDs is to train in a well-compensated subspecialty, and do some kind of 60/40 or 70/30 clinical/research split in academics. Do fun surgeries, see interesting pts, teach, go to conferences, maintain a clinical research program, and collaborate with basic scientists. I publish a lot of clinical research and a few collaborative studies with basic scientists who do the grant writing and run the experiments while I collect samples or do experimental animal surgeries for them, etc. A few years out as attending, I'm making way, way more than the NIH salary cap, and have a very nice lifestyle with children and a stay-at-home spouse, private school for kids, saving lots for retirement, etc.

I consider this a very successful use of my dual degree, making substantive contributions at the intersection between science and clinical medicine, but the NIH would consider me a failure.

I had an F30 in grad school but saw the writing on the wall. There are some foundation grants in my line of work which I could use to fund a grad student or postdoc, but then I would be writing the grant and doing all that work for free. A K would require a ton of my academic time just to fill out the application, and it would pay me less (at the margin) than I could make if I took a 2 week vacation and did locums work in my specialty.

The reality is, most scientific papers are not reproducible, many are outright fraudulent. In clinical research, at least in my specialty, I have found a higher level of scientific ethics because the authors are literally just doing it for fun. The peer review process is much more fair.

I do have many MD-PhD friends who have bailed out entirely and are doing straight private practice clinical medicine. In general, they are happy with their lifestyle but bored and dissatisfied with their work.

 

[SurfingDoctor]

And if you only do clinical work you’d probably be way happier net net.

I do think this is quite field specific. Nearly all my colleagues constantly talk about burn out. Granted, dealing with angry parents and dying kids can easily lead to that outcome, but most of them have nothing else to lean on in medicine besides their clinical time.

Personally, I've never felt burned out because I can escape into the lab and do research. It's an incredible relief to get paid to do it. My boss, who is the only other NIH funded person in the division feels the same way. And of course, pediatrics doesn't really pay well to begin with so its not like I'm missing out on a ton of lost revenue seeing less patients and doing more research.

Of course, my biggest frustration of the system is the lack of any guarantee. I recently got tenure and my boss was happy for me. On the other hand, I said to him, "Yeah, that's nice and all, but that doesn't mean that grants will continue to be funded and that I won't have to do more clinical time. I'd much rather have that". But that of course, isn't how it works unfortunately. If that happens, I'll probably either look for a pharma job or join the military.

Also to echo tr... congrats on the R01.

 

[solitude]

I do think this is quite field specific. Nearly all my colleagues constantly talk about burn out. Granted, dealing with angry parents and dying kids can easily lead to that outcome, but most of them have nothing else to lean on in medicine besides their clinical time.

Personally, I've never felt burned out because I can escape into the lab and do research. It's an incredible relief to get paid to do it. My boss, who is the only other NIH funded person in the division feels the same way. And of course, pediatrics doesn't really pay well to begin with so its not like I'm missing out on a ton of lost revenue seeing less patients and doing more research.

Of course, my biggest frustration of the system is the lack of any guarantee. I recently got tenure and my boss was happy for me. On the other hand, I said to him, "Yeah, that's nice and all, but that doesn't mean that grants will continue to be funded and that I won't have to do more clinical time. I'd much rather have that". But that of course, isn't how it works unfortunately. If that happens, I'll probably either look for a pharma job or join the military.

Also to echo tr... congrats on the R01.

congrats on tenure. Why a military job? Would you be able to continue doing research?

 

[SurfingDoctor]

congrats on tenure. Why a military job? Would you be able to continue doing research?

Just because... and likely no. Not unless I have a penchant for studying how high school graduates can fail at placing REBOAs in austere conditions.

 

[tr]

thanks for sharing. I basically agree.

One path for MD-PhDs is to train in a well-compensated subspecialty, and do some kind of 60/40 or 70/30 clinical/research split in academics... I consider this a very successful use of my dual degree, making substantive contributions at the intersection between science and clinical medicine.

I completely agree with this.

I had an F30 in grad school but saw the writing on the wall. There are some foundation grants in my line of work which I could use to fund a grad student or postdoc, but then I would be writing the grant and doing all that work for free. A K would require a ton of my academic time just to fill out the application, and it would pay me less (at the margin) than I could make if I took a 2 week vacation and did locums work in my specialty.

The intensity of the financial incentives that push people away from research differ a lot among specialties. In academic psychiatry, I was never going to get a base salary much past the NIH cap even as a pure clinician.

(There is an option for a lucrative side hustle depending on institutional policy, but this can be done at any level of research involvement.)

The reality is, most scientific papers are not reproducible, many are outright fraudulent. In clinical research, at least in my specialty, I have found a higher level of scientific ethics because the authors are literally just doing it for fun. The peer review process is much more fair.

Yes I find this also. The basic science field that I did my PhD in was super toxic and competitive. The clinical/translational field I work in now is not at all like that. A lot of the papers are still garbage but it's not because they're falsified, just not very impactful.

But there's much more collegiality and collaboration across institutions. I don't get the feeling that I am in competition with the others in my field, unlike in my PhD where we were expressly given the message that the other labs were our enemies and we needed to work super hard to scoop them before they scooped us.

Also I feel that clinician-researchers are more motivated to find the truthful answers to clinically relevant (if not always earthshaking) questions, rather than being motivated to put together a splashy story. The incentive to falsify data is not there because nobody's livelihood is hanging on their publication record. Everything is much less fraught when nobody has to sacrifice their scientific integrity to pay their mortgage.

 

[dl2dp2]

The intensity of the financial incentives that push people away from research differ a lot among specialties. In academic psychiatry, I was never going to get a base salary much past the NIH cap even as a pure clinician.

(There is an option for a lucrative side hustle depending on institutional policy, but this can be done at any level of research involvement.)

I find it interesting that the system can be designed in a horrific way, but individuals within the system can counterattack, in a certain sense, and design their lives to be in a much better position than the median. These strategies, one, require you to be constantly thinking outside of the box, two, disregard what you hear from "academic mentors" (or listen to them between the lines), and three, strategize with non-conflicted peers (i.e. not colleagues) you know who are smart and competent. You also have to follow the market a little bit in that blind persistence is a waste of time.

For example, if you want to make as much money as you can, do things that make money. It seems a simple idea, but people in academia constantly feed the idea that you need to "make financial sacrifices" to succeed. People who end up making a lot of financial sacrifices don't necessarily succeed (in fact they rarely succeed). By then they also get old an have no money. It's tragically nonlinear. To me this represents bad risk management. You need to diversify and balance the time you spent on X vs. Y with regard to different aspects of whether something is rewarding to you. You need to plan out the scenarios and say whether these scenarios are acceptable, not acceptable, etc. Institutions do this all the time, but people generally don't. People need to understand how to take calculated risks better.

A lot of people's lives and careers were destroyed by things like sunken cost fallacy, halo effect, the gambler's fallacy, etc. For example, there are established probability of grants succeeding and failing. You should use that to calculate your estimated success rate and expectation in how much salary support you can realistically raise in a certain time frame. When you do this kind of math in this kind of stark way, things start to become clearer, in my mind, than blanket advice on "persistence".

Developing relationships with people in and outside of academic medicine through a variety of means was the most helpful to me. For example, understanding the basics of finance was very helpful in that it allowed me to understand how people can have endowments, how people can "not work" (be financially free), how venture capital and other alternative instruments work, and the statistical assumptions embedded in institutions in planning. My rudimentary knowledge of investment banking and wealth management profoundly changed the way I understood academia. It's really interesting. I was in the position of OP's shoes about 15 years ago, and had similar assumptions and he/she did. Now that I'm exposed to a much bigger and wider world, I don't see any of the assumptions that were embedded at that time to be valid anymore.

I'll just give you one example before I sign off. Everyone in our game thinks the world works in this way:
You make a big financial sacrifice and get paid less ---> later on you succeed more and get paid more

In finance, often you think a different way:
You make money now --> then you INVEST it with a certain allocation --> THEN the *passive income* allows you move on to projects that are higher risk. Earlier dollars are worth more than later (aka discounted cash flow). This seems very obvious thinking in hindsight, but very famous academics don't get this and can struggle a lot in their lives outside of their niche. One example is David Sabatini. If you read articles about him you'd be like, what is going on? You are supposedly famous for decades and you crash on people's couches? LOL

 

[SurfingDoctor]

In general, most physicians (and people) are terrible at managing money. There's really simple things one can do to offset that though and it doesn't require anything fancy. The first is live within your means. Just because you are a physician and want to live in a 7000 sq ft house doesn't mean you NEED to live in a 7000 sq ft house. House poor is no way to live. Being sensible with disposable income (and trying to make it not so disposable) can go along way. And the second is investing in mutual (preferably index) funds. And do that at the earliest moment you can. Most businesses have matching and so by not contributing the maximum, you are literally leaving money on the table that you can never get back. Plus, the earlier you start, the more you accrue.

None of this is rocket science (or a guarantee, all you need to one massive market turndown to get hosed), but they are simple interventions that pay off well down the road.

 

[SurfingDoctor]

Oof, after sitting on study section (something I generally don’t look forward to but feel a responsibility to do to pay it forward to those who gave me a break), the “game” and “luck” aspect of this process always hits home.

It is kinda like playing at a casino. The options really are 1) don’t play at all or 2) play till you win or go broke from trying.

 

[tortuga87]

What is a reasonable salary where you would consider staying in academia doing 80/20 as opposed to spending most of the time in clinical practice? Is it all too low of pay or is there a salary you would consider?

 

[tr]

The first is live within your means. Just because you are a physician and want to live in a 7000 sq ft house doesn't mean you NEED to live in a 7000 sq ft house. House poor is no way to live. Being sensible with disposable income (and trying to make it not so disposable) can go along way.

You know what's funny, this conservative/thrifty approach is my instinct too but it's actually very limiting financially. You can't save your way into money. It works better to use the money you have to make more money. My partner has more of the second approach and while I initially thought some of his financial decisions were nuts, they've all worked out really well for us.

I have to echo @dl2dp2 that finding a financially attuned spouse is a major career move. One big hurdle I haven't personally had to deal with on the academic medicine gauntlet is the breadwinning thing.

 

[tr]

What is a reasonable salary where you would consider staying in academia doing 80/20 as opposed to spending most of the time in clinical practice? Is it all too low of pay or is there a salary you would consider?

That's an individual decision that you have to make based on your own financial situation and career priorities.

It obviously becomes progressively harder to accept academic pay as the gap with clinical remuneration widens, which is strongly specialty dependent.

 

[SurfingDoctor]

You know what's funny, this conservative/thrifty approach is my instinct too but it's actually very limiting financially. You can't save your way into money. It works better to use the money you have to make more money. My partner has more of the second approach and while I initially thought some of his financial decisions were nuts, they've all worked out really well for us.

I have to echo @dl2dp2 that finding a financially attuned spouse is a major career move. One big hurdle I haven't personally had to deal with on the academic medicine gauntlet is the breadwinning thing.

Investing in the stock market is generally how you make money. Individual stocks have a lot of risk, but greater potential reward when/if luck favors the pick. There’s also options trading if one really enjoys risk (since it’s basically gambling).

Certainly there other commodities one can invest in to accrue equity and then sell. Real estate and rental properties come to mind. There are risk associated with that too of course.

You always have to decide 1) risk and 2) how much you are willing to lose with that risk.

And yes, having a two income household (and not getting divorced) carry a significant financial benefit.

 

[Fencer]

Now, this manuscript came today in JAMA. Consider looking into table # 2 showing median Faculty salaries from 2022 (based upon AAMC survey) per rank across 21 specialties: US Postgraduate Trainee Racial, Ethnic, and Gender Representation and Faculty Compensation By Specialty

 

[solitude]

Investing in the stock market is generally how you make money. Individual stocks have a lot of risk, but greater potential reward when/if luck favors the pick. There’s also options trading if one really enjoys risk (since it’s basically gambling).

Certainly there other commodities one can invest in to accrue equity and then sell. Real estate and rental properties come to mind. There are risk associated with that too of course.

You always have to decide 1) risk and 2) how much you are willing to lose with that risk.

And yes, having a two income household (and not getting divorced) carry a significant financial benefit.

Max all of your tax-advantaged accounts (403b, 457, HSA, 529, backdoor Roth, and Roth while in training), 100% broad equity index funds, do not buy too big of a house or too nice of a car, and stay the course. It's actually pretty easy to be very well off financially if you can just do this for 15-20 years. Only one income is required except for in very expensive coastal areas, because the tax code favors stay-at-home spouse arrangements when you get into the high tax brackets unless your spouse makes well into 6 figures, and because child care is very expensive but can be "free" with a stay-at-home spouse.

 

[solitude]

That's an individual decision that you have to make based on your own financial situation and career priorities.

It obviously becomes progressively harder to accept academic pay as the gap with clinical remuneration widens, which is strongly specialty dependent.

As the gap with clinical remuneration widens, it also means that you can make a very good living on an academic salary. e.g., in my subspecialty, pure private practice types easily clear 1M per year, some 2-3M. So my comparatively paltry academic salary provides a very nice quality of life, even though I could make multiples more in PP.

 

[SurfingDoctor]

Max all of your tax-advantaged accounts (403b, 457, HSA, 529, backdoor Roth, and Roth while in training), 100% broad equity index funds, do not buy too big of a house or too nice of a car, and stay the course. It's actually pretty easy to be very well off financially if you can just do this for 15-20 years.

Exactly.

As to the 529, my institution pays 50% tuition at their rate for up to 3 kids. When I interviewed at Hopkins a decade plus ago, it was the same but cumulative, 50% per employee per parent. I mean, for 3 kids, that’s nearly $1 million in offset costs that can go to something else with an actual ROI.

 

[dl2dp2]

What is a reasonable salary where you would consider staying in academia doing 80/20 as opposed to spending most of the time in clinical practice? Is it all too low of pay or is there a salary you would consider?

It doesn't work like this. This depends on whether I had kids, have spousal income, a trust fund (not even joking), where I want to live, etc.

The other problem is that the 80 of the 80/20 is objectively more painful right now than straight clinical practice. So you are asking me how much I would want to work in a job that causes me more pain AND get paid less.

Secondly, a pre-packaged 80/20 job is increasingly rare in coastal areas and "high prestige" institutions. A more common approach is to eat what you kill. You write grants to fund your research and then get clinical revenue. Add them together and negotiate with the chair on a yearly basis. So the actual work that results from two supposedly 80/20 jobs can vary wildly, since the RVUs generated by that 20 is very different across different practice settings, etc.

Things can be worked out in general, but they are dynamic. It's a complicated planning process and it's best if you have a team of "consultants" (family members, impartial colleagues, friends in finance, professional advisors/accountant/financial advisors, etc). I see a lot of people who YOLOing and the result is at times VERY tragic.

 

[tortuga87]

It seems like, if someone clearly prefers research over clinical, then avoiding the high prestige institutions is a viable strategy. You work at a mid tier university, you have a lower cost of living, you get a pre-packaged 80/20, you apply for an R grant every cycle and build your research program slow but steady. It will be hard but probably nowhere near as hard as at one of the coastal cities. Big fish in a smaller (but not tiny) pond.

If you go to a prestige institution in a coastal city, you compete against geniuses who are almost impossible to beat, and you measure your financial worth against people in private practice who never liked research to begin with. Both seem to breed discontent.

 

[SurfingDoctor]

It seems like, if someone clearly prefers research over clinical, then avoiding the high prestige institutions is a viable strategy. You work at a mid tier university, you have a lower cost of living, you get a pre-packaged 80/20, you apply for an R grant every cycle and build your research program slow but steady. It will be hard but probably nowhere near as hard as at one of the coastal cities. Big fish in a smaller (but not tiny) pond.

If you go to a prestige institution in a coastal city, you compete against geniuses who are almost impossible to beat, and you measure your financial worth against people in private practice who never liked research to begin with. Both seem to breed discontent.

That is generally true. I know several people in my field who became faculty at Medical University of Nowhere who after getting some small pilot grants and publishing like a total of 10 papers are full tenured professors. That's not to put them down, just to show that the bars are vastly different among universities and the more prestigious the university, the higher the bar typically with more tempered pay. As the old adage goes "You pay to work for Harvard".

There is only one caveat I've seen. Places that have a strong research program generally have more infrastructure to support grants and grant proposals. I'm writing a grant right now and while I have an idea of what I want to do, I have no expertise in it. But there is a center at my university that is a pay-for-service center that has consultation and technical expertise to perform the work and I can just write them into the grant proposal. I've done that with prior grant applications as well. I know plenty of other universities that don't have those kind of resources. There are a good number of private companies and enterprises that one can go to, but its usually easier (and cheaper) if you can get it done internally.

 

[tr]

That is generally true. I know several people in my field who became faculty at Medical University of Nowhere who after getting some small pilot grants and publishing like a total of 10 papers are full tenured professors. That's not to put them down, just to show that the bars are vastly different among universities and the more prestigious the university, the higher the bar typically with more tempered pay. As the old adage goes "You pay to work for Harvard".

There is only one caveat I've seen. Places that have a strong research program generally have more infrastructure to support grants and grant proposals. I'm writing a grant right now and while I have an idea of what I want to do, I have no expertise in it. But there is a center at my university that is a pay-for-service center that has consultation and technical expertise to perform the work and I can just write them into the grant proposal. I've done that with prior grant applications as well. I know plenty of other universities that don't have those kind of resources. There are a good number of private companies and enterprises that one can go to, but its usually easier (and cheaper) if you can get it done internally.

It's a tradeoff for sure. You can get much more done with the resources of a high-powered institution; at the same time, you *have* to get a lot more done just to hang on to a job.

I definitely got a bump in tangible institutional support when I moved from a ~T5-10 on the US News scale to a maybe ~T20-30 (albeit still coastal/HCOL). The people at my last institution were mostly pretty brainy though, and that was actually a huge help. Research faculty tend to be sharp across the board, but so many of the trainees there were just crack, performing way above what one might reasonably expect. We had these incredible undergrad and med student volunteers who were managing data analyses and writeups practically independently, and some of them had an unbelievable amount of computing/bioinformatics expertise. The trainees here often seem a bit deer-in-the-headlights in comparison.

 

[SurfingDoctor]

It's a tradeoff for sure. You can get much more done with the resources of a high-powered institution; at the same time, you *have* to get a lot more done just to hang on to a job.

I definitely got a bump in tangible institutional support when I moved from a ~T5-10 on the US News scale to a maybe ~T20-30 (albeit still coastal/HCOL). The people at my last institution were mostly pretty brainy though, and that was actually a huge help. Research faculty tend to be sharp across the board, but so many of the trainees there were just crack, performing way above what one might reasonably expect. We had these incredible undergrad and med student volunteers who were managing data analyses and writeups practically independently, and some of them had an unbelievable amount of computing/bioinformatics expertise. The trainees here often seem a bit deer-in-the-headlights in comparison.

Well, this is probably specialty specific. Most of the trainees in my specialty couldn’t find science if Bill Nye walked up to them an smacked in the face like they were presenting the Academy Award of Science.

Literally, all the trainees in fellowship have 18 dedicated months of “research” and they gravitate toward clinical faculty and come up with terrible projects like “A survey of why people in our field are sad” and all the other clinical faculty are like “Yeah. Great question!”

:: barf ::

Also, my experience was very different. Even at a top rated school (T10 ish, though I don’t really pay that close attention but high enough), undergrads are a lot of work. Especially in basic science, there’s so much hand holding that it actually becomes an incredible time suck unless you have a lab manager who you can pawn them off onto.

 

[ChordaEpiphany]

It's a tradeoff for sure. You can get much more done with the resources of a high-powered institution; at the same time, you *have* to get a lot more done just to hang on to a job.

I definitely got a bump in tangible institutional support when I moved from a ~T5-10 on the US News scale to a maybe ~T20-30 (albeit still coastal/HCOL). The people at my last institution were mostly pretty brainy though, and that was actually a huge help. Research faculty tend to be sharp across the board, but so many of the trainees there were just crack, performing way above what one might reasonably expect. We had these incredible undergrad and med student volunteers who were managing data analyses and writeups practically independently, and some of them had an unbelievable amount of computing/bioinformatics expertise. The trainees here often seem a bit deer-in-the-headlights in comparison.

The collective environment is more important than the individuals. A lab with 8 brilliant people and 2 "regular smart" people will create an environment where 8 brilliant people are competing and 2 others are rising to the occasion. Everyone will wind up on top publications. Everyone's resume will have a golden hue. However, a lab with 3 brilliant and 7 smart people will create an environment where brilliant alone feels good enough and the merely smart people will have little incentive to try to rise to the occasion. The result is incremental work.

In my experience, high program prestige has a poor PPV for individual researcher brilliance. However, it has an impressive PPV for individual researcher accomplishment.

As an example, we have a postdoc with a PhD from a famous Harvard lab. He's smart, but not brilliant. 3 years into his postdoc he is a middle author on 1 paper. In his 5 year PhD, he co-authored 20 papers, many in top journals, including multiple CNS. Further, my lab had a single year where every new PhD student was top-notch. The whole culture of the lab changed in about 1 year and we pumped out a bunch of IF > 20 papers. Once these students graduated and the mix of students was more like 3:7 instead of 8:2, the overall ambition cratered and the lab was back to publishing voluminous mediocrity in IF 5-10 journals.