IM Subspecialty Competitiveness (2022 appt year)

[Renal_Prometheus]

Apparently, interest for Nephro is so low that some programs can't even find someone to scramble into. Nephro can be lucrative, but only for those with some ownership (eg partner and owns dialysis centers) which tends to be limited to those who are more established. Overall the job market is saturated, especially for new grads. In the Nephro forums, they were saying that about 30-40% of Nephro grads will stop practicing Nephro within 5 years post-fellowship. Right now the pay per hour for hospitalist is the same or often slightly higher (and with 2 less years of training), and Nephro tends to have a very busy call schedule. Also, unless you're at a larger hospital with good volume and not too much competition, it's common to have to travel between multiple sites in a single work day which can significantly cut down on your efficiency.

Rad onc and EM are already in a similar boat as well. However, the difference here is even after Nephro fellowship, if you can't find a decent job as a Nephrologist you can still work as general IM. For rad onc, there doesn't seem to be much of an alternative unless you go back re-do another residency (but the older and more established rad oncs are still killing it).

You got it man. I'm glad you are paying attention. Wish more people read the SDN forums before embarking on these adventures with non-competitive specialties.

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[CCM-MD]

Percent matched isn't a good marker for competitiveness, because physicians are generally smart enough to self-select.

For example, I don't believe for 1 second that radiation oncology (99.1% match rate) is way less competitive than psychiatry (89.6%) or gen surg (83%). The average Rad onc resident has a 243 step 1, the average psychiatry resident has an average 227 step 1, and the gen surg has a 237 step 1.

pg.10 of pdf for match percentages

https://www.nrmp.org/wp-content/uploads/2020/07/Charting-Outcomes-in-the-Match-2020_MD-Senior_final.pdf

Rather, applicant characteristics is the best measure (e.g. average step score of matched applicants, # of pubs, AOA, etc.)

Ideally we'd probably just sort by step 1, but based on the data above, we only have US MD (more competitive) vs IMG/FMG which are less competitive.

Fellowships ranked by the % of new fellows who are US MD

1. Allergy/Immunology 70.1%
2. Gastroenterology 60.4%
3. Heme/Onc 53.6%
4. Cardiology 50.8%
5. Pulm/CC 48.9%
6. ID 46.1%
7. Sleep 43.6%
8. Rheum 42.1%
9. Geri 40.2%
10. Endocrine 32.2%
11. Nephrology 28.7%

He/she applied A&I. It makes sense now.

You previously stated: "I'm defining competitiveness as if you took a random med student/resident, how easy it is for them to match into that specialty." I interpret that to be the probability of a candidate with randomly generated metrics (step scores, AOA, research etc) to match into each specialty.

You haven't shown that the match rate isn't important. I would argue that it would be almost impossible for the match rate to NOT affect the model itself. In fact, it IS the outcome - the dependent variable - the DATA. How can the data itself not affect the likelihood?

Take this simplified example with only one variable (step score) in a normal distribution. Specialty A has applicants with mean step 1 score of 240 with standard deviation of 10, and specialty B has an mean step 1 score of 230 with SD of 12. If match rate for specialty A is 99.99% and match rate for specialty B is 50%, then a randomly generated step score would have a higher probability of matching A than B, even though the mean score is higher in the former.

Agree.

20 people with 240 want a specialty A which has 20 spots versus 50 people with 230 want a specialty B which has 20 spots. It’s obvious which one is more competitive.

 

[BorntobeDO?]

Have you visited the rad onc section of this website recently? If you had, you would know why it has become so undesirable.

Agreed that was a terrible example. Rad Onc residencys are closing and I know of an open spot off hand. Not competative.

Lol, that’s a classic SDN meme driven by people who are desperate to match at all but reality doesn’t bear out.

The average neuro resident has a higher step score, has more research, is more likely to be in AOA, and is more likely to be is a top 40 med school based on charting outcomes. The average neuro resident is objectively more competitive than the psych resident.

Now this is some popcorn popping fun right here

 

[Loog567]

You previously stated: "I'm defining competitiveness as if you took a random med student/resident, how easy it is for them to match into that specialty." I interpret that to be the probability of a candidate with randomly generated metrics (step scores, AOA, research etc) to match into each specialty.

You haven't shown that the match rate isn't important. I would argue that it would be almost impossible for the match rate to NOT affect the model itself. In fact, it IS the outcome - the dependent variable - the DATA. How can the data itself not affect the likelihood?

Take this simplified example with only one variable (step score) in a normal distribution. Specialty A has applicants with mean step 1 score of 240 with standard deviation of 10, and specialty B has an mean step 1 score of 230 with SD of 12. If match rate for specialty A is 99.99% and match rate for specialty B is 50%, then a randomly generated step score would have a higher probability of matching A than B, even though the mean score is higher in the former.

You’re looking at step scores as a part of the whole but comparing them as the end all be all. In real life there’s more than just step.

If we say the totality of your app was your “competitiveness score” (eg the sum of your step, research, etc) and specialty A had a competitiveness score of 100 and specialty B had a competitiveness of 50, then an applicant with a score of 75 is not able to displace somebody who was previously going to match A, but can displace somebody who was gonna match B.

See my example below after continuing CCM’ hypothetical.

20 people with 240 want a specialty A which has 20 spots versus 50 people with 230 want a specialty B which has 20 spots. It’s obvious which one is more competitive.

Well let’s take your example further. An extra person with a score of 235 then applies specialty A. He can’t match because all 20 spots are taken by people by people with 240. He can match specialty B because he now beats one of the 230’s.

So this extra person could match B but does not match A. Specialty A is more competitive. Match rate didn’t matter.

Btw, attacking the person and not the argument is in poor taste.

 

[Loog567]

Now this is some popcorn popping fun right here

Not really, the fact that neuro residents have an average higher step, more research, higher rates of AOA membership, higher rates of top 40 med school is just fact from NRMP’s charting outcomes. Repeating fact isn’t inflammatory.

 

[bronx43]

You’re looking at step scores as a part of the whole but comparing them as the end all be all. In real life there’s more than just step.

If we say the totality of your app was your “competitiveness score” (eg the sum of your step, research, etc) and specialty A had a competitiveness score of 100 and specialty B had a competitiveness of 50, then an applicant with a score of 75 is not able to displace somebody who was previously going to match A, but can displace somebody who was gonna match B.

See my example below after continuing CCM’ hypothetical.

Well let’s take your example further. An extra person with a score of 235 then applies specialty A. He can’t match because all 20 spots are taken by people by people with 240. He can match specialty B because he now beats one of the 230’s.

So this extra person could match B but does not match A. Specialty A is more competitive. Match rate didn’t matter.

Btw, attacking the person and not the argument is in poor taste.

I don't think anyone here attacked you as a person? If you feel that i did, then I apologize. Was certainly not my intention. This is all in good fun, and a refresher back to statistics class.

To your first point, I wasn't just looking at step scores as part of a whole. It was just to simplify a core concept, which is that the outcome data necessarily affects the probability of match of a random candidate. This is your definition of "competitiveness" which I am using and adhering to as the framework of this whole discussion. In fact, I said previously that a multivariable model would give the best predictive capabilities. Adding more variables/dimensionality doesn't change the core concept that the outcome affects your probability.

But I actually think I have found the fundamental difference in our framework. For me, I interpreted your original definition of competitiveness to be "probability of match for a random candidate." You may have meant that or, not. But, what you actually describe in your subsequent responses is a process with an immutable set of rules, such that higher competitiveness score (however that is determined) will ALWAYS beat out a lower score. This isn't really probability or statistics, but rather a logic puzzle with infinite outcomes which are all unknown. In the real world (where probability and statistics reside), there is no such thing as "always," or probability of zero or 1.

In this framework, the most important things is HOW candidates will distribute themselves, which pertains to what we discussed previously with self selection. There is literally an infinite array of possible distributions, which cannot be determined a priori. Even if you think you can guess the general trend of distribution, you never know how each chess piece will move. Once this distribution occurs, then the prior rules of a RANK list necessitates the outcome. So to say "how easy it would be for a random candidate to match" is confusing, because it wouldn't be "easy" - it would simply BE or NOT BE, once candidates distribute themselves.

Here's a scenario. If the results of the distribution results in specialty A having 50 spots, but only 49 applicants ended up in those spots, then the random candidate would simply end up in that spot ( no need for probability). It doesn't matter at all what the "competitiveness scores" are of the other inhabitants of specialty A. That same candidate, if placed within the ranks of specialty B, would need to find where he/she ends up in said rank.
Here's another scenario. There are 50 applicants for the same 50 spots, and 48 have 240, 1 has 220, and 1 has 260. Neither mean, median, or mode has changed for this applicant pool. But now a 221 can match and displace the 220. The same 221 cannot match and displace the specialty where 40 applicants have 230, 5 have 225 and 5 have 235.
It all depended on the initial distribution, and the match rate (matched/total) is just a property of this distribution.

And within this framework, what is actually being measured is only one thing... after the applicants distribute themselves, what is the lowest competitiveness score to match. Nothing else matters. So, specialties should just be lined up that way. No need for mean or median scores.

Please correct me if my interpretation of what you are saying is wrong.

 

[hotsaws]

Percent matched isn't a good marker for competitiveness, because physicians are generally smart enough to self-select.

For example, I don't believe for 1 second that radiation oncology (99.1% match rate) is way less competitive than psychiatry (89.6%) or gen surg (83%). The average Rad onc resident has a 243 step 1, the average psychiatry resident has an average 227 step 1, and the gen surg has a 237 step 1.

pg.10 of pdf for match percentages

https://www.nrmp.org/wp-content/uploads/2020/07/Charting-Outcomes-in-the-Match-2020_MD-Senior_final.pdf

Rather, applicant characteristics is the best measure (e.g. average step score of matched applicants, # of pubs, AOA, etc.)

Ideally we'd probably just sort by step 1, but based on the data above, we only have US MD (more competitive) vs IMG/FMG which are less competitive.

Fellowships ranked by the % of new fellows who are US MD

1. Allergy/Immunology 70.1%
2. Gastroenterology 60.4%
3. Heme/Onc 53.6%
4. Cardiology 50.8%
5. Pulm/CC 48.9%
6. ID 46.1%
7. Sleep 43.6%
8. Rheum 42.1%
9. Geri 40.2%
10. Endocrine 32.2%
11. Nephrology 28.7%

I agree that percent of US MDs is a good marker of competitiveness. There is certainly an element of self selection with applicants. Small programs like A/I also are essentially limited to major academic institutions and do not have community programs. Shame they didn't include A/I into the NRMP data that shows objective things like USMLEs. The applicants we interview have great stats, like could easily have done derm/ortho/ENT/whatever.

Anyways, highly biased A/I guy over here.

 

[Siggy]

Does ID even have a big role in COVID? I would think most COVID related treatment decisions are up to IM and pulm/CC. I'm outpt so I actually don't know...

The most important thing for ID at one of my sites is that baricitinib is restricted to ID.

Besides that, the most important thing is when the patient is a month in, immunosuppressed, near death from COVID and they spawn some nasty bacterial or fungal infection.

 

[AlbinoHawk DO]

But I never claimed step was the end all.

I wrote “average neuro resident has a higher step score, has more research, is more likely to be in AOA, and is more likely to be is a top 40 med school than psych”.

I clearly stated that being from a top 40 med school is also a factor.

Applicant characteristics determine how competitive a specialty is, because if a hypothetical generic person wanted to match into that specialty, their applicant characteristics will compared with the other applicants. Match rate % isn’t important.

Why are you so worked up about this? Who gives a ****? Just do whatever specialty you're into. If it's easy to match into, then better because you don't have to run through a lot of the stupid hoops. Aren't you tired already from the time since before undergrad having to do bull**** volunteering or having to study a million more hours just to be one of the only 10 As some jackoff awarded in a class of 200 people?

But just for funsies, neuro has a lot of good people at the top and a lot of ****ty people at the bottom. This is the same as IM. Average step for both is the same and chances of matching roughly the same

 

[CluvK]

Hem/onc is one of the self-selective fields. Many residents don't apply to Hem/onc because they don't like research or have enough research, so the #of applicants is less than that of Cardiology or GI. And Hem/onc is not a heroic field - you can't physically put something into someone's body...

 

[CCM-MD]

Hem/onc is one of the self-selective fields. Many residents don't apply to Hem/onc because they don't like research or have enough research, so the #of applicants is less than that of Cardiology or GI. And Hem/onc is not a heroic field - you can't physically put something into someone's body...

What it comes down to is this:

“My specialty is X, and thus specialty X is the most competitive specialty.”

 

[bobow98]

Hem/onc is one of the self-selective fields. Many residents don't apply to Hem/onc because they don't like research or have enough research, so the #of applicants is less than that of Cardiology or GI. And Hem/onc is not a heroic field - you can't physically put something into someone's body...

My experience in residency a few years ago was:
Me, 2 co residents: wow PD-L1 as a biomarker for stratification of patients most likely to experience response to therapy in the front line for XYZ tumor is really important!

The other several dozen residents: These people be cray cray. Cancer? Consult heme/onc.

 

[WhiteCoatWonder]

Does ID even have a big role in COVID? I would think most COVID related treatment decisions are up to IM and pulm/CC. I'm outpt so I actually don't know...

definitely! at our shop, ID and pharmacy are driving the creation of all the power plans and med approvals (along w/ pharmacy, of course). they may not be actively consulted anymore to determine rx regimen, as they were at first, they they sit on all the decision making boards for discharge vaccines, surge planning, etc.

 

[HemeOncHopeful19]

Hem/onc is one of the self-selective fields. Many residents don't apply to Hem/onc because they don't like research or have enough research, so the #of applicants is less than that of Cardiology or GI. And Hem/onc is not a heroic field - you can't physically put something into someone's body...

There may be some self selection but at the end of the day we make less money than Cards/GI but more than Nephro/Rheum/ID/Endo.

If Endo/Renal started making tons of $$$ all of a sudden you’d find people who are “super passionate” about diabetes and “supremely fascinated” by dialysis.

 

[Drrrrrr. Celty]

There may be some self selection but at the end of the day we make less money than Cards/GI but more than Nephro/Rheum/ID/Endo.

If Endo/Renal started making tons of $$$ all of a sudden you’d find people who are “super passionate” about diabetes and “supremely fascinated” by dialysis.

I think a lot of outpatient subspecialties will become more competitive the longer covid19 remains a major force.

 

[CluvK]

There may be some self selection but at the end of the day we make less money than Cards/GI but more than Nephro/Rheum/ID/Endo.

If Endo/Renal started making tons of $$$ all of a sudden you’d find people who are “super passionate” about diabetes and “supremely fascinated” by dialysis.

Yes, definitely money and lifestyle play an important role in selecting a specialty. Even though Hem/onc makes less than Cards/GI, but lifestyle is much better in line with endo/rheum

 

[aafisahar]

I think a lot of outpatient subspecialties will become more competitive the longer covid19 remains a major force.

dunno about that, i'm getting prn hospitalist offers for 250/hr. as long as these idiots keep refusing the vaccine, i'll be laughing all the way to the bank. keeping up with the vaccine essentially protects you 99% and ppe covers the rest. ez as **** to see 10 covid patients sucking on high flow.

 

[Splenda88]

dunno about that, i'm getting prn hospitalist offers for 250/hr. as long as these idiots keep refusing the vaccine, i'll be laughing all the way to the bank. keeping up with the vaccine essentially protects you 99% and ppe covers the rest. ez as **** to see 10 covid patients sucking on high flow.

The hospitalist market is crazy right now. I wonder if things will stay that way for another 3-5 yrs.

 

[Osteoth]

dunno about that, i'm getting prn hospitalist offers for 250/hr. as long as these idiots keep refusing the vaccine, i'll be laughing all the way to the bank. keeping up with the vaccine essentially protects you 99% and ppe covers the rest. ez as **** to see 10 covid patients sucking on high flow.

Wtf where?

 

[aafisahar]

Wtf where?

sent a pm

 

[Drrrrrr. Celty]

dunno about that, i'm getting prn hospitalist offers for 250/hr. as long as these idiots keep refusing the vaccine, i'll be laughing all the way to the bank. keeping up with the vaccine essentially protects you 99% and ppe covers the rest. ez as **** to see 10 covid patients sucking on high flow.

Idk, maybe I just don't find dealing with covid a particularly interesting enough thing as I don't like losing patients and seeing the folks I talked to hours ago die...

 

[gutonc]

Idk, maybe I just don't find dealing with covid a particularly interesting enough thing as I don't like losing patients and seeing the folks I talked to hours ago die...

Nobody is doing it for the intellectual satisfaction. They're making hay while the sun shines.

 

[Drrrrrr. Celty]

Nobody is doing it for the intellectual satisfaction. They're making hay while the sun shines.

Yah, I'd rather just go do lip fillers if I wanted to make easy money....

 

[aafisahar]

Yah, I'd rather just go do lip fillers if I wanted to make easy money....

doing lip fillers carries significant medicolegal risk. all it takes is one **** up and it will bite you in the ass.

literally no one gives a **** about some anti-vaxxer dying on the vent after 30+ days in the hospital.

 

[marq2221]

Anecdotally, my ID program had more applications and got significantly more "competitive" applicants this year. My home IM program also had a spike in people who applied and macthed.

Wonder if there is some selection bias, as in some people only apply to 1-2 HPM programs and also look for hospitalist jobs so the match rate is lower, but for ID this is less prevalent? Also the starting rate for ID jobs in my city is very close to on par with hospitalist starting (if not 10-20k more) with no nights, and ~1:6 weekends 8-4(or 5) M-F (and include admin FTE for time for stewardship, infection control or other area of your choice) so some could say a better lifestyle.

Could I ask what city or region of the country you are in and what the salary starts at? Or if you know these numbers from different regions of the country? Going to be an ID fellow next year so super curious!

 

[Kaustikos]

literally no one gives a **** about some anti-vaxxer dying on the vent after 30+ days in the hospital.

You just have to pretend to. And the N95 makes it easier to pretend to smile.

 

[Drrrrrr. Celty]

doing lip fillers carries significant medicolegal risk. all it takes is one **** up and it will bite you in the ass.

literally no one gives a **** about some anti-vaxxer dying on the vent after 30+ days in the hospital.

You just have to pretend to. And the N95 makes it easier to pretend to smile.

It's the family meetings. The demands for ivermectin and the being blamed for not saving them. And albeit less applicable to hospitalists, the days I was placing multiple lines and spending multiple hours a day dealing with CRRT/pressor issues.

Also I'm like 90% sure my septum is deviated from wearing n95s at this point.

 

[Kaustikos]

It's the family meetings. The demands for ivermectin and the being blamed for not saving them. And albeit less applicable to hospitalists, the days I was placing multiple lines and spending multiple hours a day dealing with CRRT/pressor issues.

Also I'm like 90% sure my septum is deviated from wearing n95s at this point.

I'm trying to make light of a situation. I know what you're saying. Had the joyous pleasure of dealing with this pre-vaccine in Queens. MOLST forms and N95's were the only things stocked in my coat.
It's not fun and I don't wish it on anyone.

 

[The kitchen sink]

Supply demand is basically proxied by how competitive the applicants are. Psychiatry being lower in match is due to it typically being a safety or a target for those who can’t match/at risk for not matching. Again, you miss the phenomenon of self-selection.

Tens of thousands of applicants CANNOT EVEN MATCH INTO ANY residency. You think FMGs are too stupid to know about the fact that they can apply rad onc or something? No matter how bad the job market is, it’s way better than being an unmatched fmg. They don’t apply because they don’t have any reason to waste their money. They all talk about applying FM or psych a 2nd go around, they never talk about applying rad onc. Just like how tons of people don’t apply Harvard, they know it’s a waste of time/money. Physicians at this point have enough self awareness to self select.

Tens of thousands can’t match?
Really?? Why all the unfilled spots then?

 

[jdh71]

good grief

I liked it better when we were the misfits

 

[Watchmaker]

There's a lot of truth to your point...but I would just be cautious for future CCM applicants as I reviewed applications for my program this year and due to the fact that there are 1 & 2 year positions, and applicants from IM, EM, and IM subspecialities (multiple people who had completed/were completing cardiology fellowships in addition to the usual ID/nephro), the applicant pool is actually pretty competitive. And places definitely like taking their own for the 1 year spots. Cards-CCM (sometimes with interventional cards as a 3rd fellowship), despite the long training path, seems to be becoming a thing for academic CVICU director type positions.

How do you reconcile your statement that at least on publically available info pulm/crit applicants don't come form necessarily "top tier" IM programs while for example in cards the percentage that come from top tier is higher?

 

[grt398]

How do you reconcile your statement that at least on publically available info pulm/crit applicants don't come form necessarily "top tier" IM programs while for example in cards the percentage that come from top tier is higher?

So first off just going to say I don't have any real dog in this fight so I'm not interested in spending the hours probably required to source the data...but since you do seem interested in it, and I'd certainly enjoy seeing the data, I'd love a citation for that data with actual specifics, aka, percentage of cardiology fellows in the last 3 years who did an IM residency at a "top tier" program (maybe define that as a med school ranked in the Top 20 on USNEWS b/c the correlation there is likely very high, and it's something commonly used, but if not, what's your definition and why) vs the same number for PCCM applicants. Obviously you would need the IM residency info for every cardiology and PCCM fellow in the last 3 years. I don't know if that's easily available somewhere or not.

I will suggest this leaves out some important information b/c I've met numerous people like myself over the years who chose their IM program for personal reasons rather than rankings. I went to a top 20 med school (per USNEWS rankings), and could've matched derm/integrated plastics etc based on my board scores/publications had I been interested in those fields. Some of the best junior residents I had were at my program b/c of family/personal reasons, but were AOA w/Step scores 260+ etc. Several stayed for fellowship (including cardiology), again b/c of personal/family reasons.

I'll also say that fellowships outside the big names (Hopkins/Harvard types) frequently seem to be looking for a "good fit" for the program, and that may take precedence over objective data. And personal recommendations from people the faculty know go a LONG way for fellowship, as they do in the small surgical subspecialties for residency. So it's really hard to figure out how much any of these factors weighs vs the others in any particular program unless you were able to speak directly to the PD and get an honest opinion from them.

Anyway, I think it's probably just best for everyone to do the best they can in residency, and know that if you really really want to get into a particular fellowship, it's likely possible if you put in the work. That could mean working as a hospitalist at a big academic center while you do extra research and make the needed mentor connections, or maybe even full time research, but it's possible. And I don't know how helpful this debate over competitiveness is for future applicants really. I'm open to having my mind changed. Anyway, there's my verbose response.

 

[ChordaEpiphany]

Nobody is doing it for the intellectual satisfaction. They're making hay while the sun shines.

This seems true for every specialty. Intellectual fulfillment tends to come from learning new things. Obviously that happens as a clinician, but more rarely than a lot of other paths since so much is crammed into med school and residency.

If you want intellectual fulfillment, stay in academia, preferably a massive T20 in NIH funding, take the corresponding pay cut, and find a way to muscle up to the top of that system. I've yet to speak to a physician-scientist who finds clinical medicine fascinating enough that they aren't vying for more protected time for research. Among people with the most leverage (i.e., bigwigs at HMS and the like), the preferred path seems to be: as little clinical time as possible while still maintaining cred as a clinician, enforcing academic rent on your inferiors to keep up your academic cred, writing non-technical blog posts in the NEJM, writing non-technical books to supplement your income, and schmoozing wealthy donors. Not exactly shocking that those who have more leverage, and thus more control of their responsibilities, choose to avoid scuttling around the wards or seeing 15 patients/day in the clinic.

Even in the community, intellectual fulfillment usually comes from other ventures. Physicians are pretty eager to expand to new things, which is probably why so many have side hustles and whatnot. Medicine seems to afford a lot of life satisfaction, but almost every community attending I've met pays the bills with clinical medicine and then has a laundry list of hobbies that scratch the intellectual itch.

 

[PugsAndHugs]

Is there anyway someone can post the data for each fellowship for this most recent year? Thank you in advance

 

[MD46]

Is there anyway someone can post the data for each fellowship for this most recent year? Thank you in advance

 

[mszzeta]

This seems true for every specialty. Intellectual fulfillment tends to come from learning new things. Obviously that happens as a clinician, but more rarely than a lot of other paths since so much is crammed into med school and residency.

If you want intellectual fulfillment, stay in academia, preferably a massive T20 in NIH funding, take the corresponding pay cut, and find a way to muscle up to the top of that system. I've yet to speak to a physician-scientist who finds clinical medicine fascinating enough that they aren't vying for more protected time for research. Among people with the most leverage (i.e., bigwigs at HMS and the like), the preferred path seems to be: as little clinical time as possible while still maintaining cred as a clinician, enforcing academic rent on your inferiors to keep up your academic cred, writing non-technical blog posts in the NEJM, writing non-technical books to supplement your income, and schmoozing wealthy donors. Not exactly shocking that those who have more leverage, and thus more control of their responsibilities, choose to avoid scuttling around the wards or seeing 15 patients/day in the clinic.

Even in the community, intellectual fulfillment usually comes from other ventures. Physicians are pretty eager to expand to new things, which is probably why so many have side hustles and whatnot. Medicine seems to afford a lot of life satisfaction, but almost every community attending I've met pays the bills with clinical medicine and then has a laundry list of hobbies that scratch the intellectual itch.

Why only speak to physician-scientists? these are rare folks even in academic center, except very top institutions such as HMS. Most of physicians in academic centers are clinicians or physician-educators. And intellectual fulfillment is often a factor or even strong driver for their career selections.

 

[dozitgetchahi]

Why only speak to physician-scientists? these are rare folks even in academic center, except very top institutions such as HMS. Most of physicians in academic centers are clinicians or physician-educators. And intellectual fulfillment is often a factor or even strong driver for their career selections.

And as someone who has done a very academic fellowship and spent some time in a near-fakedemia setting afterwards, I can tell you that most of those people are delusional. “Fakedemia” is the worst of all possible worlds.

Before my fellowship, I might have agreed with you. Then I saw how much of a Byzantine joke high-octane academic medicine really was, and especially how poorly the “physician educator” types are treated. BRB while I see community patient volumes at a 50% pay cut, all while spending my spare time writing grant proposals hoping to win the lottery and get a grant. If you don’t succeed with that, then your remaining options are to a) spend your spare time kissing rich peoples’ asses for cash at fundraisers or b) hope you win the “Hunger Games” of institutional grants. If you want to go “fakedemic” aka “clinician educator”, then you’ll be expected to see a lot more patients, do a lot of teaching, and also sometimes try to do unfunded clinical research in your own personal time. You’re not really going to get paid better for doing all of this, either.

Also, the amount of arrogance, self righteousness, and all around douchebaggery among academic docs is simply nauseating to have to deal with. So much pointless penis measuring, competitiveness, etc etc. So happy to be done with that.

Academic medicine (esp. fakedemia) takes a specific personality type, and IMO it has more to do with the size of your ego, how much you like working for big bureaucratic institutions, how much of a workaholic you are, and how little you care about being properly compensated for your (immense) work than anything else. I didn’t find much intellectual satisfaction there.

 

[PugsAndHugs]

@mszzeta
@anandiyermd

Hmm not sure how accurate what you posted is...

https://www.nrmp.org/wp-content/uploads/2022/03/2022-SMS-Results-Data-FINAL.pdf

According to the NRMP pdf: Endo says there were 4 unfilled programs (6 spots were unfilled) vs what you posted said 14 programs unfilled.
According to the NRMP pdf: Pulm/CC says there were 3 unfilled programs (3 spots unfilled) vs what you posted said 11 programs unfilled.

 

[MD46]

@mszzeta
@anandiyermd

Hmm not sure how accurate what you posted is...

https://www.nrmp.org/wp-content/uploads/2022/03/2022-SMS-Results-Data-FINAL.pdf

According to the NRMP pdf: Endo says there were 4 unfilled programs (6 spots were unfilled) vs what you posted said 14 programs unfilled.
According to the NRMP pdf: Pulm/CC says there were 3 unfilled programs (3 spots unfilled) vs what you posted said 11 programs unfilled.

This was from a twitter post from an Oncology Professor at a University. I dont have any way to verify.

 

[rokshana]

If you use percent matched as a marker for competitiveness, it looks like people are still primary chasing for the money, and somewhat for lifestyle. If ID and Nephro paid as much as GI on average (and their fellowships are 2 yrs instead of 3 years) I'm sure they would be similarly competitive with more applicants. Besides the money you get from scoping nonstop all day, there's not much else going for GI - lifestyle is mixed at best with a good amount of call, and you literally have to deal with poop all time. And the money is far from guaranteed for the long run for GI or any specialty. All it takes is for CMS to decide to steeply cut reimbursements for GI procedures a few years down the line since they think GI is getting paid too much (and this will also drive down reimbursements from private insurers), and the money factor for GI can quickly go away.

A bit surprised that endocrine match rate was that low. Good lifestyle but but essential pays the same as just being a PCP. Rheum pay isn't super high either but I guess people are going after the lifestyle.

Most endocrinologists go into the field because they like the topic…and would rather have someone poke them in the eye with a hot stick than be a pcp…🙋🏽‍♀️
No offense pcps… can’t do your work and mad respect for the fact that you do what you dp.

 

[rokshana]

@mszzeta
@anandiyermd

Hmm not sure how accurate what you posted is...

https://www.nrmp.org/wp-content/uploads/2022/03/2022-SMS-Results-Data-FINAL.pdf

According to the NRMP pdf: Endo says there were 4 unfilled programs (6 spots were unfilled) vs what you posted said 14 programs unfilled.
According to the NRMP pdf: Pulm/CC says there were 3 unfilled programs (3 spots unfilled) vs what you posted said 11 programs unfilled.

This is because the previous posts were about LAST years match… you woke up a year old thread to say this.

 

[PugsAndHugs]

This is because the previous posts were about LAST years match… you woke up a year old thread to say this.

I was responding to @MD46’s post from
yesterday in which they posted THIS year’s match data. For some reason it did not quote his post from yesterday which probably caused the confusion.

This was from a twitter post from an Oncology Professor at a University. I dont have any way to verify.

No worries - thank you for sharing it though!

 

[dozitgetchahi]

Most endocrinologists go into the field because they like the topic…and would rather have someone poke them in the eye with a hot stick than be a pcp…🙋🏽‍♀️
No offense pcps… can’t do your work and mad respect for the fact that you do what you dp.

Yeah, exactly.

I’m a rheumatologist and I’m beyond happy with the decision to become one. 8-5 work hours, work 4.5 days a week, zero call, zero hospital rounding, and I have a $325k base salary with significant bonus boost from ancellaries as a PP doc. Easy to make $400k plus. I enjoy the work. It’s easy to see why rheumatology is heading up the list of competitiveness. Personally I’d hate being cards or GI almost as much as being a PCP - I don’t like hospital rounding, procedures, or call.

 

[mszzeta]

And as someone who has done a very academic fellowship and spent some time in a near-fakedemia setting afterwards, I can tell you that most of those people are delusional. “Fakedemia” is the worst of all possible worlds.

Before my fellowship, I might have agreed with you. Then I saw how much of a Byzantine joke high-octane academic medicine really was, and especially how poorly the “physician educator” types are treated. BRB while I see community patient volumes at a 50% pay cut, all while spending my spare time writing grant proposals hoping to win the lottery and get a grant. If you don’t succeed with that, then your remaining options are to a) spend your spare time kissing rich peoples’ asses for cash at fundraisers or b) hope you win the “Hunger Games” of institutional grants. If you want to go “fakedemic” aka “clinician educator”, then you’ll be expected to see a lot more patients, do a lot of teaching, and also sometimes try to do unfunded clinical research in your own personal time. You’re not really going to get paid better for doing all of this, either.

Also, the amount of arrogance, self righteousness, and all around douchebaggery among academic docs is simply nauseating to have to deal with. So much pointless penis measuring, competitiveness, etc etc. So happy to be done with that.

Academic medicine (esp. fakedemia) takes a specific personality type, and IMO it has more to do with the size of your ego, how much you like working for big bureaucratic institutions, how much of a workaholic you are, and how little you care about being properly compensated for your (immense) work than anything else. I didn’t find much intellectual satisfaction there.

I am totally aware about the ****ty staff in academic centers......I just meant to say, there is an intellectual reason driving specialty selection.

 

[ChordaEpiphany]

Why only speak to physician-scientists? these are rare folks even in academic center, except very top institutions such as HMS. Most of physicians in academic centers are clinicians or physician-educators. And intellectual fulfillment is often a factor or even strong driver for their career selections.

And as someone who has done a very academic fellowship and spent some time in a near-fakedemia setting afterwards, I can tell you that most of those people are delusional. “Fakedemia” is the worst of all possible worlds.

Before my fellowship, I might have agreed with you. Then I saw how much of a Byzantine joke high-octane academic medicine really was, and especially how poorly the “physician educator” types are treated. BRB while I see community patient volumes at a 50% pay cut, all while spending my spare time writing grant proposals hoping to win the lottery and get a grant. If you don’t succeed with that, then your remaining options are to a) spend your spare time kissing rich peoples’ asses for cash at fundraisers or b) hope you win the “Hunger Games” of institutional grants. If you want to go “fakedemic” aka “clinician educator”, then you’ll be expected to see a lot more patients, do a lot of teaching, and also sometimes try to do unfunded clinical research in your own personal time. You’re not really going to get paid better for doing all of this, either.

Also, the amount of arrogance, self righteousness, and all around douchebaggery among academic docs is simply nauseating to have to deal with. So much pointless penis measuring, competitiveness, etc etc. So happy to be done with that.

Academic medicine (esp. fakedemia) takes a specific personality type, and IMO it has more to do with the size of your ego, how much you like working for big bureaucratic institutions, how much of a workaholic you are, and how little you care about being properly compensated for your (immense) work than anything else. I didn’t find much intellectual satisfaction there.

@dozitgetchahi said it better than I could have. I'm only speaking to the experience of physician-scientists because everyone else is basically indulging themselves with fancy titles (and paying for it immensely). If you can manage to run a successful lab/research group and create things of actual value, there is a point to doing the academic path. If you're just going to give a half-hearted lecture once a semester and secure $20-100K in grants every year to do garbage research that basically only exists to pad resumes, I say give up. @gutonc is an MD/PhD that, imo, cut his losses at the right time and offers great advice to aspiring academics. If your research career doesn't take off (and most don't), go make some money. Don't bother being directly employed by these academic institutions unless they foster meaningful opportunities, pay higher salaries, or provide much better lifestyle.

There are a lot of people who manage to muscle up the academic ladder and emerge with real accomplishments, but they almost all do it as physician-scientist-entrepreneurs, not as glorified bureaucrats or "clinician-educators". Also, in case you haven't gotten to know the "clinician-educators" or pure clinicians well enough, they almost all come from family money or have spouse money, and the ones that don't are there for ego. Go spend an afternoon hanging out with clinical oncologists at DFCC/MSKCC/Fred Hutch/any high powered, low pay, HCOL cancer center. It will confirm these biases. Very few people are choosing to halve their salary when their family's security depends on their earnings. When you look at physician giants like Drew Weissman, Carl June, Steven Rosenberg, JoAnn Manson, and Eric Topol, you can see an actual point to going the academic route. These people have created companies worth billions or successfully run research groups that truly pushed the field forward. Then there are countless others who do the same at a lower level, but are still major contributors (e.g., Omid Farokhzad, Crystal Mackall, etc...). If you can aspire to that sort of career, then academics is a great pathway. If you're an MD who doesn't want to build companies or make field-changing discoveries, go to the community and offer some limited services pro-bono to the universities in your free time. You could even partner with a local company as a consultant (e.g., orthopedic surgeon consulting for hip implant startup, endocrinologist consulting for diabetic monitoring software startup) and do some meaningful translational work.

I've said this many times, but it's always worth repeating. The biggest boon to academic recruiting is ignorance. Academia has a monopoly on access to young talent, and they go to incredible lengths to keep others out. Talented people flock to academia because the pathway is clear and accessible. Academic centers keep demand for positions high (and salaries low) not by providing something of value for applicants, but by creating a façade that is expertly advertised to a group of people they have exclusive access to for many years.

 

[dozitgetchahi]

@dozitgetchahi said it better than I could have. I'm only speaking to the experience of physician-scientists because everyone else is basically indulging themselves with fancy titles (and paying for it immensely). If you can manage to run a successful lab/research group and create things of actual value, there is a point to doing the academic path. If you're just going to give a half-hearted lecture once a semester and secure $20-100K in grants every year to do garbage research that basically only exists to pad resumes, I say give up. @gutonc is an MD/PhD that, imo, cut his losses at the right time and offers great advice to aspiring academics. If your research career doesn't take off (and most don't), go make some money. Don't bother being directly employed by these academic institutions unless they foster meaningful opportunities, pay higher salaries, or provide much better lifestyle.

There are a lot of people who manage to muscle up the academic ladder and emerge with real accomplishments, but they almost all do it as physician-scientist-entrepreneurs, not as glorified bureaucrats or "clinician-educators". Also, in case you haven't gotten to know the "clinician-educators" or pure clinicians well enough, they almost all come from family money or have spouse money, and the ones that don't are there for ego. Go spend an afternoon hanging out with clinical oncologists at DFCC/MSKCC/Fred Hutch/any high powered, low pay, HCOL cancer center. It will confirm these biases. Very few people are choosing to halve their salary when their family's security depends on their earnings. When you look at physician giants like Drew Weissman, Carl June, Steven Rosenberg, JoAnn Manson, and Eric Topol, you can see an actual point to going the academic route. These people have created companies worth billions or successfully run research groups that truly pushed the field forward. Then there are countless others who do the same at a lower level, but are still major contributors (e.g., Omid Farokhzad, Crystal Mackall, etc...). If you can aspire to that sort of career, then academics is a great pathway. If you're an MD who doesn't want to build companies or make field-changing discoveries, go to the community and offer some limited services pro-bono to the universities in your free time. You could even partner with a local company as a consultant (e.g., orthopedic surgeon consulting for hip implant startup, endocrinologist consulting for diabetic monitoring software startup) and do some meaningful translational work.

I've said this many times, but it's always worth repeating. The biggest boon to academic recruiting is ignorance. Academia has a monopoly on access to young talent, and they go to incredible lengths to keep others out. Talented people flock to academia because the pathway is clear and accessible. Academic centers keep demand for positions high (and salaries low) not by providing something of value for applicants, but by creating a façade that is expertly advertised to a group of people they have exclusive access to for many years.

So much I agree with here:

- Completely agree that the “clinician educator” types are generally rich kids that came in without debt, or people with wealthy spouses making $$$ so they can “indulge” in academia while still living a doctor’s lifestyle. Everyone else generally sees that academia sucks, and gets out, usually at the 5-10 year mark. There are a few stragglers who don’t fall into these categories who stay in it, but they (like the others) generally have such gigantic egos that they can’t see how badly they’re being fleeced. At least the people getting grants to crank out garbage research are getting grants and doing research. Everyone else is there at about a 50% pay cut to puff up their chests like the next William Osler, even if they’re just ordering around their captive audience of enslaved medical students and residents and making them laugh at their terrible jokes. (The worst of these types are usually the ones who want to be there just to be a bureaucrat, like a PD or a dept chair or dean or whatever.)

- The difficulty of succeeding at a high level in medical academic research almost can’t be overstated. IMHO, it’s akin to breaking into Hollywood, becoming an astronaut, or something similar. Luck plays a significant factor in research success, on many levels. So many people wash out of it that even if you’re smart, motivated, good at research, and want to make “field changing discoveries”, I wouldn’t advise it (after all, everyone else there is too).

- Even if you DO win the research hunger games and get grants, the academic game doesn’t get much better. Your life will now revolve almost entirely around preserving those grants at any cost, and also on constantly hounding the government to shovel more money in your direction. Grant proposals will loom large until you retire. You will almost certainly publish some total garbage to try to keep the publication number up and the government gravy train running. (If you’re particularly stupid and desperate, you may even find yourself fabricating data and hoping you don’t get caught. This was disappointingly common in some of the departments I saw.) A change in the academic winds can suddenly render your research passé, or at least not what the government wants to be funding right now - and then poof, bye bye goes a significant portion of your income at the end of the next grant cycle. You will farm out research writing to hapless medical students and residents, and make them do the vast majority of the pointless grunt work to keep the publication wheels turning - and then you will put your name first on papers that you barely had anything to do with. (On top of all this, grant pay still sucks, so you’re usually busting your ass way harder than PP docs for much less compensation.)

- I also completely agree with your last paragraph. Academia is very good at promoting this horse puckey to trainees and medical students for years, and unfortunately so many graduates have never seen what their lives could be like in PP or community medicine that they sign on to academic jobs right at graduation and get taken advantage of. (Just look at how many people stay at their training institutions for their first jobs. That’s just pure inertia. Usually you don’t get treated well at those jobs, either - the faculty who trained you won’t exactly take you seriously once you are graduated and an attending.) The work life balance is atrocious, and the pay so awful, that I think most academic types work at least twice as much as I do for half the pay.

 

[HemeOncHopeful19]

I've said this many times, but it's always worth repeating. The biggest boon to academic recruiting is ignorance. Academia has a monopoly on access to young talent, and they go to incredible lengths to keep others out. Talented people flock to academia because the pathway is clear and accessible. Academic centers keep demand for positions high (and salaries low) not by providing something of value for applicants, but by creating a façade that is expertly advertised to a group of people they have exclusive access to for many years.

Love this paragraph, also there is a subtle (sometimes not so subtle) undercurrent that people in private practice are all greedy and don’t take proper care of patients - as if taking a 50% pay cut to work in Academia somehow saves the patient money (usually the opposite).

 

[dozitgetchahi]

Love this paragraph, also there is a subtle (sometimes not so subtle) undercurrent that people in private practice are all greedy and don’t take proper care of patients - as if taking a 50% pay cut to work in Academia somehow saves the patient money (usually the opposite).

The hilarious part is that CMS and the insurance companies get billed at basically the same rate whether the doc is academic, PP, community hospital, whatever. The question is what fraction of your earnings you’re ok with the house eating before they make their way to you. In the case of academia, they’re grabbing an enormous portion of what you earn to pay their vast overhead.

The flip side of this “PP greed and patient care” bit is that a lot of academic medical care consists of pointless mental masturbation and losing the forest for the trees. As a resident, I once witnessed a renal fellow and attending debate whether to use 1/4 NS or 1/2 NS in a certain patient for over 20 minutes. That was just utterly pointless, and yes, in private practice I would have seen another patient in that period of time (and taken good care of them too). Community medicine needs smart docs every bit as much as tertiary care, if not more so. Tertiary care doesn’t remotely have enough capacity to see all (or even most of) the sick people out there. Without the PP and community docs grinding away in the trenches, the tertiary docs would be drowning.

 

[hotsaws]

I agree with the above so much and think it's important to put out there for our community to see. I'll add my 2 cents as an A/I doc in private practice.

Much of what was stated above applies to my field. FWIW, I am clearly biased against academics and think its a terrible choice for most. If it's not naivete and fear then it's gotta be ego. The academic track is laid out and we are exposed to it very early on in training. At the same time, many trainees lack good exposure to private practice. Unless you are dead serious about a legit, proliferative research career, I think academics is an all around bad choice. I trained at a "high end" type place for fellowship -- the egos are huge and the political climate is overwhelmingly homogenous. You can see this reflected at the Academy meetings on a large scale. Very smug, fake-nice types. I also just loathe the whole academic scene -- fellowship squeezed any love for it out of me. The countless lectures, journal clubs, meetings, and fake BS research. I don't think my experience is unique but the vast majority of clinical research projects I've participated in since medical school are like a pyramid scheme that tries to make something out of nothing. Lots of artistic gathering and interpretation of data until you can make something publishable with attendings that are vaguely engaged and not interested in anything other than making sure their name is on another piece of paper. I imagine this gets more palatable when you're the senior author and most of the grunt work is being done by underlings. I'm still bitter...I love being an allergist but I hated being a fellow.

Totally agree with the clinical educators being the kids with money. In fact, in my field, this is evidence based. The AAAAI does a survey of exiting fellows every year. They looked at who stays in academic vs who goes to PP and they separated groups based on student loan debt. I'll paste in a photo if I can but basically it shows that a huge majority of fellows that join academics on graduation are those without any debt. If you got through all of training without debt, you likely come from money save for maybe the few military grads or MD/PhD who also got undergrad scholarships. Academic A/I pays terribly whereas PP A/I ranges from decent to good.

Some might argue that they wanted to practice in a very particular niche and thus stayed in academics. This does apply with clinical immunology. Most of us practice mostly Allergy with a touch of immuno. The true clinical immuno is usually practiced at a large tertiary/academic hospital and by an A/I doc that is VERY into immuno. These are complex patients and the infrastructure of the practice itself needs to be geared toward care coordination and multidisciplinary care. If immuno is your thing, probably only real choice is to stay at a large academic center. A large private childrens hospital might also accommodate but this is basically fakedemics anyway. Some people want to focus on things like food allergy, drug allergy, hereditary angioedema, etc. but these types of practice niches have actually done well in private practice and do not require an academic center.

One of the great and unique things about A/I is that the vast majority of us are trained to see all ages. That's typically an appeal to the field and certainly touted by most training programs. So then why go into academics and segregate yourself back into peds or adult? I'd say the majority of academic centers split there adult and peds a/i docs. Sure, you might see all ages on consults but the day to day clinic is focused. For sure skill atrophy will occur over time.

Private practice is great so far. My current group sees all ages and we do more well rounded A/I than I did in fellowship. Everything from bread and butter allergy to skin biopsies, nasal endoscopy, exercise challenges, food challenges, etc. We practice the full range of our scope. There's very little bureaucratic headache. We have practice autonomy but still group accountability. It's easy to make changes if they make sense. Earning potential is obviously better than academics. There's no pressure to participate in research or education but docs in our group do so to varying levels, ie having trainees roatate with us, participating in society meetings, engaging in local society leadership, etc. There are many private practice A/Is that are well respected for their clinical trial participation and involvement in advancing the field in food allergy, AERD, HAE, etc. We have plenty of PP docs that hold leadership positions in our college and academy societies as well. There's some subtle but not insignificant lifestyle pluses to PP as well. It's nice to not have to drive into a congested medical complex, park in some giant parking garage, walk into a 10 story building, and take an elevator to some floor where your little space exists. I park right outside my door and can easily leave to run errands, see my kid, grab some food/coffee etc. It's also much easier on my patients.

 

[dozitgetchahi]

I agree with the above so much and think it's important to put out there for our community to see. I'll add my 2 cents as an A/I doc in private practice.

Much of what was stated above applies to my field. FWIW, I am clearly biased against academics and think its a terrible choice for most. If it's not naivete and fear then it's gotta be ego. The academic track is laid out and we are exposed to it very early on in training. At the same time, many trainees lack good exposure to private practice. Unless you are dead serious about a legit, proliferative research career, I think academics is an all around bad choice. I trained at a "high end" type place for fellowship -- the egos are huge and the political climate is overwhelmingly homogenous. You can see this reflected at the Academy meetings on a large scale. Very smug, fake-nice types. I also just loathe the whole academic scene -- fellowship squeezed any love for it out of me. The countless lectures, journal clubs, meetings, and fake BS research. I don't think my experience is unique but the vast majority of clinical research projects I've participated in since medical school are like a pyramid scheme that tries to make something out of nothing. Lots of artistic gathering and interpretation of data until you can make something publishable with attendings that are vaguely engaged and not interested in anything other than making sure their name is on another piece of paper. I imagine this gets more palatable when you're the senior author and most of the grunt work is being done by underlings. I'm still bitter...I love being an allergist but I hated being a fellow.

Totally agree with the clinical educators being the kids with money. In fact, in my field, this is evidence based. The AAAAI does a survey of exiting fellows every year. They looked at who stays in academic vs who goes to PP and they separated groups based on student loan debt. I'll paste in a photo if I can but basically it shows that a huge majority of fellows that join academics on graduation are those without any debt. If you got through all of training without debt, you likely come from money save for maybe the few military grads or MD/PhD who also got undergrad scholarships. Academic A/I pays terribly whereas PP A/I ranges from decent to good.

Some might argue that they wanted to practice in a very particular niche and thus stayed in academics. This does apply with clinical immunology. Most of us practice mostly Allergy with a touch of immuno. The true clinical immuno is usually practiced at a large tertiary/academic hospital and by an A/I doc that is VERY into immuno. These are complex patients and the infrastructure of the practice itself needs to be geared toward care coordination and multidisciplinary care. If immuno is your thing, probably only real choice is to stay at a large academic center. A large private childrens hospital might also accommodate but this is basically fakedemics anyway. Some people want to focus on things like food allergy, drug allergy, hereditary angioedema, etc. but these types of practice niches have actually done well in private practice and do not require an academic center.

One of the great and unique things about A/I is that the vast majority of us are trained to see all ages. That's typically an appeal to the field and certainly touted by most training programs. So then why go into academics and segregate yourself back into peds or adult? I'd say the majority of academic centers split there adult and peds a/i docs. Sure, you might see all ages on consults but the day to day clinic is focused. For sure skill atrophy will occur over time.

Private practice is great so far. My current group sees all ages and we do more well rounded A/I than I did in fellowship. Everything from bread and butter allergy to skin biopsies, nasal endoscopy, exercise challenges, food challenges, etc. We practice the full range of our scope. There's very little bureaucratic headache. We have practice autonomy but still group accountability. It's easy to make changes if they make sense. Earning potential is obviously better than academics. There's no pressure to participate in research or education but docs in our group do so to varying levels, ie having trainees roatate with us, participating in society meetings, engaging in local society leadership, etc. There are many private practice A/Is that are well respected for their clinical trial participation and involvement in advancing the field in food allergy, AERD, HAE, etc. We have plenty of PP docs that hold leadership positions in our college and academy societies as well. There's some subtle but not insignificant lifestyle pluses to PP as well. It's nice to not have to drive into a congested medical complex, park in some giant parking garage, walk into a 10 story building, and take an elevator to some floor where your little space exists. I park right outside my door and can easily leave to run errands, see my kid, grab some food/coffee etc. It's also much easier on my patients.

View attachment 363350

I too trained at a “high end” place in rheumatology, and I can echo so much of what you’ve described. When I started fellowship, I was super excited to be there and felt like the gates of the universe had just opened. When I finished, I was utterly burnt out on a level that even residency hadn’t been able to achieve, and I had sworn off academia permanently. Why?

- It’s utterly exhausting to deal with colleagues day in/day out whose egos are the size of aircraft carriers.

- You hit the nail on the head with all the random bull**** they expected us to do all the time. I got sick of it really fast. Our program made us do 5 hour long grand rounds a year, plus at least 1-2 case conferences a month, plus a journal club almost every month, plus random attendings would sometimes take us aside and give us random lectures on their pet topic and then demand we prepare still more talks on their pet topic of choice, and then one of my co-fellows got the bright idea that we should each pick topics to give MORE freaking presentations on for board prep once a month (and the dept leadership liked this idea so BOOM there’s another presentation for you to do, fella). Oh, and by the way guys, we want to see you do **** tons of research too! I did 5 posters at ACR my second year, and one of my co-fellows did three. Bottom line: there was way too much **** to do all the time. At least when I was a resident, I could sign out my patients postcall and go home and collapse in bed in peace. In fellowship, there was just a neverending tidal wave of bull**** that had to be addressed, and because we supposedly had so much “personal time”, nobody seemed to think anything of it. There were months-long periods where I gave 2-3 lengthy (like 30-60 min) presentations a week…and while I actually like public speaking, I got so sick of giving presentations during that fellowship that I have literally never given one again since I graduated.

- I make the point in the paragraph above because I think that’s the environment of academia in general - just 24/7 slog. I was in clinic with our department chair one day, and at one point she just blurts out “I just had so much to do that I woke up at 1am this morning, and just powered through until 6am to get it all done!” That quip went a long way towards explaining why the environment in that department was as upside down as it was, and why so many people were burning out.

Completely agree that PP has been a lot better. Income has been way better, and I can actually set boundaries on what I do and don’t want to do.