IMO, the ideal route is to go to school and train at the most prestigious places you can get into and then ditch for private practice right after graduating. That way, you have the name and brand on your card to attract all the customers for private practice.
IM Subspecialty Competitiveness (2022 appt year)
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AITA for enjoying academic practice??? In fairness I have a super specialized clinical job that can only be done in academic practice or in a cancer hospital. I am more physician educator than clinician investigator/clinical researcher/translational scientist (and have not been back in the lab since fellowship) but I get to do a little bit of everything. I understand the ego problem but it’s not something I’ve routinely encountered. I genuinely love my job, am very fairly compensated despite academic practice (rvu bonus) and have some great colleagues who have both mentored and supported me (though it did get off to a bit of a rocky start). Maybe my experience is more the exception than the rule…
Academics sucks I was offered <200k for a cardiology position and <150k at a different place in Boston (Tufts Fwiw). Said **** that and now make legit >3x that.
Bro I feel like you are telling my story exactly. I also had this experience where some overzealous fellow in my program (a 1st year, when i was a 2nd year...no less) started suggesting extra work, like case presentations and morning report style stuff in our already overloaded academic conference day. Of course, the attending who lead that portion of the conference loved it. Boom more extra work. Also, echo the countless grand rounds. We also had to give grand rounds lectures at other departments with specialty overlap. I get that part of fellowship is becoming more of an "expert" but some of the stuff was very low yield and time consuming. I hate journal clubs but i get it...you can't really complain that much. Learning to read and analyze the primary literature in your field is a must and is very reasonable. Spending 20 hours making a powerpoint to lecture a group of your colleagues about an obscure and very rare immunodeficiency is what leads to burn out.
Also, very much agree that residency was less exhausting than fellowship. IM residency was busy, especially intern year. I trained at a medicine program that was more "blue collar." We had lots of autonomy and saw lots of sick patients. A 60 hour week was a light week. But the vast majority of what I did was clinical work. We occasionally did a morning report but the expectations on those were pretty low and it wasn't too stressful. 2nd yr had added stress because I was trying to publish stuff in A/I to play the fellowship game. Fellowship (and I'm sure A/I is like Rheum here) has far less "clock in, clock out" type hours where I was in a clinic or hospital. On the surface, that seems very lifestyle friendly. But because of that, there is a constant amount of crap piled on fellows. It felt like there was no true free time. There was always a journal to read, a lecture give, a project to work on, a powerpoint to make, or some other thing that was on the back burner. Don't get me wrong...I was an A/I fellow...I slept through the night, worked out most days, and rarely was in a clinic or hospital after 5pm. But I carried so much stress that I needed a mouth guard not to chew through my jaw at night.
I guess it really depends what exactly you envision for a clinical/translational investigator career...especially if you don't want a lab. If you want a "high impact" research career, you probably need an academic career or at least a real academic appointment to do this. I'm assuming you mean you want to be designing and implementing clinical trials, publishing on these, and perhaps doing things like writing guideline updates or being on workgroup committees that change practice for the field. Not sure about other fields but a lot of this can be done in PP and/or industry. There are A/I docs with successful private practices that also have clinical research departments that participate in the same clinical trials as large academic centers. If you really want to be translational, like legit bench to bedside, it would seem like working for industry might be a good option.
I guess you have to really ask yourself exactly what you want and why you want that career. I've been having some private DMs with someone on here interested in A/I and the topic of prestige and ego have come up.
At some point on our path through life and medicine, we all could benefit from an introspective reality check. I get it. Most of us who have made it to the point of residency and/or fellowship are high functioning individuals. We like to do well, we like feathers in our cap, we like As and high scores, titles, awards, hoodies with ivy league names on them, and all sorts of things that make our moms proud. We have egos. Some of us hide them well and some may truly be humble. Some have just outgrown the childish oneupmanship or had it burnt out of them and turned into apathy. Either way, we should strive for happiness and quality of life. Maybe that comes through 2am STEMI call or maybe it comes from treating eczema and being home before 5. I actually get the motivation to treat STEMIs at 2am more than I do staying in academics to treat eczema. Here's the deal. No one gives a hoot about you (even your parents are probably plateauing on pride). Really, at some point its a job. Most people won't care where you trained or what your title is. Once we get out of the bubble of medicine, there's so many more facets to us and our lives that results in happiness and fulfillment. I'm sure academics is right for some people but just make sure you really do it for the right reasons.
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Agree so much with that last paragraph.
I actually kind of like research and teaching, but by the end of fellowship I had concluded I didn’t like them more than personal well being, financial well being, work life balance, free time, family time, sleep, and overall happiness. If I wanted to be a “clinician educator” at some big medical center, I’d have to be rounding on weekends (or hell, rounding in the hospital period), trying to do unpaid clinical research in my spare time, and spending my evenings prepping still more of those godawful departmental presentations that consumed my life as a fellow - all for a 30-50% pay cut over community or PP medicine. No thanks.
To the person who asked if it was really worth it to do academics - the short answer, IMHO, is that it isn’t. The longer answer is that if you really really want to do hardcore research, and you are ok being one of these academic total workaholic types who either doesn’t have kids or doesn’t spend any time with your family because you’re basically married to your job, *and* you’re ok with taking a huge pay cut and massively increased workload to facilitate this, go knock yourself out. But as @hotsaws said, take a step back and ask yourself if that’s what you really want for your life. It really is just a job on some level, and IMHO most physicians would do well to broaden their horizons and try to derive more satisfaction from things other than just being physicians or “clinician educators”. Academic medicine these days is set up to extract as much energy, effort and time from young clueless docs as possible before they burn out and bail out. Wash, rinse, repeat on a 3-5 year cycle. It’s a bit like working for Tesla or SpaceX or something - you get the name on your resume, it seems prestigious and such, but they also work the **** out of you and squeeze every drop of whatever they can get before you decide to walk away.
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Yup. That strategy has worked out splendidly for me.
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I was offered $200k to stay at my fellowship institution as a rheumatologist, and one of my co fellows took a first academic job at a different “prestigious” academic institution for $125k. My first community job started at $250k, and my current PP job started me at $325k. If you’re ok with doing academia for literally $200k less, then either you come from money, you have a huge ego that won’t let you see how much you’re getting ripped off, or you’re a fool.
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My cousin is a non-physician PhD at a medical school, so have learned a good bit about physician-scientist careers. Others who are farther along can probably comment more accurately, but for a true “physician-scientist” carrier where you have protected research time and a significantly lighter clinical schedule, requires obtaining NIH funding (usually a K grant to start out), and nowadays that is like winning the lottery. You are competing against the best of the best.
So many who even initially want to be clinician scientists, usually end up in clinician-educator roles where they are still able to do research on the side, but most of your time is clinic and teaching. If you can go to one of the top tier places (the usuals) for fellowship, and can get good mentors and research experience, although it will be extremely competitive, you can set yourself up to potentially get a K award. If you get that, you may have a shot as a true clinician scientist career, but from my cousin and other academic attendings I’ve talked to, many don’t make it.
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All true except the putting your name first. Now it's better to put your name last as it signifies that you are in the senior leadership position, which counts more for grants. It's much more rare to see a PI punch their way in front of the resident/fellow who did the actual work, though it can happen on clinical projects (e.g., a NEJM article for a big trial).
As for fabricating data, it's a sad phenomenon, but it's hard to tell exactly how often it happens (too taboo to talk about). It's inevitable in a high competition, low oversight environment, and we're foolish to be as trusting as we currently are. I have to imagine the top echelon of science is a lot like pro cycling. You have to be a beast to get there, but it's probably impossible to compete without a little boost. Even if you are completely honest yourself, it's highly likely that someone you're working with or publishing with uses suspect practices to bias their results so you can publish more and better. Plus, everyone is way too busy grinding their own work to go through the exhausting (and potentially career damaging) process of accusing and then proving fraud unless it's obvious.
In my experience dishonesty stems from the extremes of science: the desperate and the egotistical.
1) Grad student/post-doc/fellow needs some sort of result to publish and move on. After years of presenting work that fails miserably, they suddenly have miraculous results 6 months before their intended graduation.
2) Overly ambitious students (often at top institutions) need a top paper to satisfy their ego and/or get the next position. They've been the best their whole life and have a gold-plated resume, but they spend 4-5 years on a project and the results are good, but not great. They could probably publish it in a mid-top tier field-specific journal (e.g., Microbiome, Biomaterials, Molecular Cell), but that won't signal them as a top student. Their lab buddies are prepping submissions to CNS, and their big name PI no longer cares about the project (or the student). This is the point where the line between biased analysis and outright data fabrication tends to blur. Effect sizes suddenly get larger after further analysis. Caliper measurements are grossly distorted between control and treatment groups. Control experiments appear out of thin air. Every experiment for the last 6 months of the degree perfectly supports the hypothesis, and by the time it starts falling apart, everyone involved is complicit enough that they just drop the project.
I'm not ashamed to admit that I've had some intrusive thoughts along the lines of situation #2. I think anyone in a PhD program, post-doc, or research fellowship probably butts up against either 1 or 2 at some point. Aside from general human decency, the biggest motivator for my going by the book has been a newfound indifference towards success in academia. I'm just not willing to potentially sacrifice my reputation for a Nature paper when I can still become a successful physician (and probably wind up happier than the version of me that lands a Harvard professorship).
I think there is also the potential for data fabrication, omission, or "creative" presentation on the low impact side of things. Alot of med students and docs that are not PhD types need to sort of play the game and get some things published as part of the pyramid scheme required to rise through training. The standards and expectations for this are low. These are things like case series, small retrospective data pulls, or maybe even the occasional prospective study. The targeted (or at least where it actually ends up accepted) journals are often low impact or open access type pubs. The scrutiny on these is typically lower and some of the journals are eager to just fill their pages. I'm sure there are lots of us that started a project only to find that after tedious hours digging through charts and numbers, the data and desired narrative isn't coming together like we thought. ....it sure would be nice if the pieces "fit together" a little better...would really help put a bow on this thing. There's a huge bias and pressure when you're a busy resident or med student and you've worked on this project that's supposed to make you're residency or fellowship application complete. More than anything, you just want to be done with it (you know, get it submitted, show your mentor you're a good little servant, and hope that it gets accepted so you can put it on your CV and call it "research"). Messy or inconsistent data at worst can trash the whole project and at best leads to a messy results and discussion section and weak or vague conclusion. This is true even in a simple case series, which are often held to low word count requirements. There's a temptation to just tweak things a bit to make the whole thing much easier. Especially when you know that overall the publication is pretty meaningless in the scheme of things and you're not trying to make a career out of research. Sometimes it might even be something subtle like "well, maybe if I look at the effect of some independent variable change in a slightly different time frame...the data looks better from March - November than february to december...).
I think this scenario is common for those who are trainees just trying to get through the process and get to the other side. I wonder how much of these little random publications in throw away journals are just filled with lies and omissions? It might add up when people start doing meta analysis or review articles. In A/I, there's lots that we do that is only guided by small studies done by a single investigator. In fellowship, we regularly went through textbooks that based entire sections off stuff like this and our PD basically tore it apart and told us how irrelevant and questionable much of it was. Still, it stands in a major textbook.
I think this scenario is common for those who are trainees just trying to get through the process and get to the other side. I wonder how much of these little random publications in throw away journals are just filled with lies and omissions? It might add up when people start doing meta analysis or review articles. In A/I, there's lots that we do that is only guided by small studies done by a single investigator. In fellowship, we regularly went through textbooks that based entire sections off stuff like this and our PD basically tore it apart and told us how irrelevant and questionable much of it was. Still, it stands in a major textbook.
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Might be worth playing the academics game and seeing how far you can go (with the assumption you won’t succeed)
My “goal” was to do the lab based physician scientist thing and go for a young investigator award, K08, start a lab, all that jazz. None of that happened but I expected that
A benefit was that I was able to discuss my work inside and out, hopefully enthusiasm came across in job talks, and managed hybrid heme onc job that pays not quite PP money but at least 2.5x academics. Most clinicians tend to glaze over when you have basic science data, which helps on the job search for clinical jobs.
Ultimately I may do pharma later, I think having a bench research background, despite being very bad at it, is helpful.
My “goal” was to do the lab based physician scientist thing and go for a young investigator award, K08, start a lab, all that jazz. None of that happened but I expected that
A benefit was that I was able to discuss my work inside and out, hopefully enthusiasm came across in job talks, and managed hybrid heme onc job that pays not quite PP money but at least 2.5x academics. Most clinicians tend to glaze over when you have basic science data, which helps on the job search for clinical jobs.
Ultimately I may do pharma later, I think having a bench research background, despite being very bad at it, is helpful.
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Does it matter to pure community PPs that prospective partners have any significant amount of research at all? I ask for "a friend" who managed to get into h/o with minimal research.
This is my current mindset and plan but my goal is not to run a lab but pursue a clinical investigator role (designing, publishing trials, collaborating on translational projects etc.) Unlike a lab PI role, there doesn’t seem to be a point for a CI where I would be able to say Im on track for success and whether it is worth the financial sacrifice. I’m giving myself about 4-5 years post fellowship to see where it goes before I make a decision to seek other options like pharma, hybrid, etc.
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Probably doesn’t matter much compared to being easy to work with and able to move the meat.
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In the community, nobody really cares. Sometimes you will find PP groups that are participating in research studies, but in 99% of situations this is just a group agreeing to be a “community site” for a massive study where they need to recruit lots and lots of patients. Very few PP docs are PIs on their own studies out there (although in rheumatology at least, there are a few who are and who do engineer their own studies - but they usually have very close relationships with a nearby tertiary care institution and are basically working in a quasi-academic role anyway).
Otherwise, getting a good community job is all about seeing volumes of patients, giving good care, and being agreeable to patients and partners alike. I’ve never been asked about my research at a community/PP job interview.
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I had a substantial bit of research and when I looked for jobs, literally no one asked about my research, they asked about my skills. This was for cardiology. Community medicine is about patients and productivity, not research. No one cares once you get out of the ivory tower.
