Is the future of academia for physcian-scientists that bleak?

[doctor_engineer]

This reddit post brought me here:

Reddit - Dive into anything

reddit.com

I am a rising G1 in a mid-tier MSTP. I had thought that with my dual degree, it would be relatively easier to climb the academic ladder as many PDs have told me repeatedly that “there are not enough physician-scientists, so you will be in high demand in academia.”

I’m getting the feeling that it’s not the whole picture. I read comments saying that obtaining R01 is getting harder by the year. Would I be dreaming too big if I wanted to be a tenured/established scientist-physician (80-20) split in academia? Is this not really realistic anymore in the current academic/funding climate? Love to get some more insight.

---

Members don't see this ad.

 

[SurfingDoctor]

80/20 is not the norm and never should be considered as such. Are there people who achieve that? Sure. Are most of them in senior people who are near the ends of their career? Yes. But 1 R01 is going to protect somewhere between 20 to 40% of your time. So you need 2 to 3 R01 (or U effort) to protect you that much. It's just incredibly unlikely that most people get that, unless they are in their late 50s to 60s+. Generally speaking, if you have 1 R01 (or RPG equivalent), you're doing awesome and about the best you're going to do for awhile or ever. That's been my experience.

I would also say, again speaking personally, only about 1/2 of MD/PhDs attempt to go the physician-scientist track anyway. By the time they are done with clinical training, the ones who don't pursue science either 1) forgot to perform and ask basic scientific questions because they were so far removed from that environment or 2) being a person finally done with training in their mid-30s, just don't want to do science anymore or 3) a combination of the two. This becomes far more likely when those MD/PhD people pick a procedural based speciality where the hours can be more demanding, there is more in house call and generally, they can generate a lot more money billing than pipetting.

Then of course, there are those that abandon academia all together and go into administration or take the pharma parachute.

 

[tr]

This reddit post brought me here:

Reddit - Dive into anything

reddit.com

I am a rising G1 in a mid-tier MSTP. I had thought that with my dual degree, it would be relatively easier to climb the academic ladder as many PDs have told me repeatedly that “there are not enough physician-scientists, so you will be in high demand in academia.”

The letters after your name don't provide any intrinsic advantage.

The advantage of the dual degree is that it allows you to stay in a faculty position by doing clinical work. This can float you through periods of low research funding (vs a PhD who is at the mercy of their chair, and then likely out of a job pretty quickly if the funding tap ceases to flow), and if you are smart you can arrange your clinical work so that it complements and supports your research agenda.

It's a double-edged sword though, because the clinical commitment reduces the time available for scientific productivity, leading to a death spiral of no protected time --> no research productivity --> no ability to get grants to protect your time. Thus, clinical work tends to push out the research altogether.

I’m getting the feeling that it’s not the whole picture. I read comments saying that obtaining R01 is getting harder by the year.

I actually think the paylines have bounced back a bit from the 2010s. I feel like there were a lot of paylines in the teens at that time, and now I see more like mid-20s.

There was a big ricochet/corrective effect from the doubling of the NIH budget in the 90s, which led to excess production of PhDs and postdocs, who were all then competing desperately for funding in the 2000s and 2010s.

It's possible that most of that excess labor force has by now drained off to alternate career paths, relieving the competitive pressure for funding just a bit.

Would I be dreaming too big if I wanted to be a tenured/established scientist-physician (80-20) split in academia? Is this not really realistic anymore in the current academic/funding climate? Love to get some more insight.

It's not that it isn't realistic, but it certainly isn't a sure thing. My MSTP alumni class seems to align with @SurfingDoctor 's estimate of 50% maintaining research activity of some type (detectable by cursory internet search).

80/20 is a rigid description that doesn't fit with the reality of a physician-scientist career. Sure, you might be 80/20 for some portion of your career. It's unlikely that you would stick to that exact breakdown for years or decades. The distribution varies from year to year based on the funding situation.

 

[darkamgine]

I am a rising G1 in a mid-tier MSTP. I had thought that with my dual degree, it would be relatively easier to climb the academic ladder as many PDs have told me repeatedly that “there are not enough physician-scientists, so you will be in high demand in academia.”

I would say it is "relatively easier" to climb the academic ladder as a MD/PhD than a PhD alone. Having the MD definitely helps in biological sciences as you have a wider medical knowledge base and more relevant clinical training. And there are not enough physician-scientists in general, which most people would agree is true. However, as mentioned previously by others, most MD-PhDs do not end up doing majority research in the end. This is for a number of reasons which have been discussed before including overall competitiveness of grants, sacrifice regarding pay/locations, and just not enjoying research and its current environment.

I’m getting the feeling that it’s not the whole picture. I read comments saying that obtaining R01 is getting harder by the year. Would I be dreaming too big if I wanted to be a tenured/established scientist-physician (80-20) split in academia? Is this not really realistic anymore in the current academic/funding climate? Love to get some more insight.

I don't think it is dreaming too big to be a 80-20 split physician-scientist in academia. The real question is how badly do you want it and what sacrifices are you willing to make? There will be more MD/PhD than the ending number of available grants/faculty positions for the group. Unless you can differentiate yourself with research productivity/impact in your early career, the main thing that will determine your chances are how willing are you to keep trying for grants. Are you willing to sacrifice additional years after fellowship to be a junior faculty to try to get a K/R grant? Are you willing to write multiple R type/level grants while still working nearly full time clinical to get a big grant? Are you willing to keep writing grants applications for weeks and months even though most of your previous attempts failed? Are you willing to delay or decrease your pay so you can continue to work on research? How willing are you to sacrifice time with family to work on research? Are you willing to endure the politics of research at the national/university/field level? These are the sacrifices that you have to think about because others who are considering this path are probably doing this. I think if you are dead-set on the 80-20 split, it is still very much possible as a MD/PhD but for many people, they ask "at what cost" and decide maybe the 80-20 split path isn't for them. Honestly, until you go through similar experiences yourself, it is hard to answer these questions but I encourage you to think about them as they are important for your decision.

 

[StilgarMD]

This reddit post brought me here:

Reddit - Dive into anything

reddit.com

I am a rising G1 in a mid-tier MSTP. I had thought that with my dual degree, it would be relatively easier to climb the academic ladder as many PDs have told me repeatedly that “there are not enough physician-scientists, so you will be in high demand in academia.”

I’m getting the feeling that it’s not the whole picture. I read comments saying that obtaining R01 is getting harder by the year. Would I be dreaming too big if I wanted to be a tenured/established scientist-physician (80-20) split in academia? Is this not really realistic anymore in the current academic/funding climate? Love to get some more insight.

I'm not a practicing physician-scientist yet (MS4), but at this phase, I'd say the absolute most important thing for you is making sure the lab is the right lab for you. The biggest immediate threat to the dream you describe is having a terrible PhD experience. I'd be happy to chat at length about what goes into picking the 'right lab', but I'd say the Tl;dr is make sure they are invested in you as a scientist and not as a widget to get papers, and seriously consider swapping labs as an option if things aren't going well. thinking you can just 'tough it out for a few years' is a sure fire way to lose the desire to be a scientist.

 

[Neuronix]

This reddit post brought me here:

Reddit - Dive into anything

reddit.com

Why is SDN not fashionable anymore? Social media seems to have turned into a big self-promotion fest these days. I guess I'm just old. Is it not fashionable to be open and honest these days? You have problems, we're here to help. Anyway, I'm open to feedback as always.

I am a rising G1 in a mid-tier MSTP. I had thought that with my dual degree, it would be relatively easier to climb the academic ladder as many PDs have told me repeatedly that “there are not enough physician-scientists, so you will be in high demand in academia.”

The bolded is untrue in my experience, but it's a subjective statement so it's hard to prove or disprove.

I’m getting the feeling that it’s not the whole picture. I read comments saying that obtaining R01 is getting harder by the year. Would I be dreaming too big if I wanted to be a tenured/established scientist-physician (80-20) split in academia? Is this not really realistic anymore in the current academic/funding climate? Love to get some more insight.

It is really hard, but not impossible. My pay lines were around 10th percentile, and I've managed to get two R01 equivalents in the past year (one solo-PI, the other MPI). I'm working on a third.

I'm 42 years old.

Yes there is a component of luck. It has been hell getting to this point in a lot of ways. I still feel insecure trying to maintain all of this. I did lose an industry grant recently due to a problem with the sponsor so that knocked down some research effort.

I do make good money and do cool stuff. Though it is a high cost location and I've had basically no choice of location throughout this process, which can be a challenge.

My effort is currently 60% research / 40% clinical for what it's worth. I've been everywhere from 80% clinical to 25% clinical over the years, but it's all a game. At 25% clinical you can easily cram your clinics so full that you're producing at a 50% level. I've been doing stuff like that for years.

Work hours have been 50-80 hours/week throughout.

AMA. I've been pretty open about everything over the years. I never blow smoke up anyone's butt or cheerlead. The training is long and difficult. As an MD/PhD the pressure is on you to be great at everything to succeed. But you can always proceed down one track or the other depending on your opportunities and preferences. I've always enjoyed trying to walk all the lines of education, clinic, research, and admin. It sure keeps it interesting.

 

[dl2dp2]

This reddit post brought me here:

Reddit - Dive into anything

reddit.com

I am a rising G1 in a mid-tier MSTP. I had thought that with my dual degree, it would be relatively easier to climb the academic ladder as many PDs have told me repeatedly that “there are not enough physician-scientists, so you will be in high demand in academia.”

I’m getting the feeling that it’s not the whole picture. I read comments saying that obtaining R01 is getting harder by the year. Would I be dreaming too big if I wanted to be a tenured/established scientist-physician (80-20) split in academia? Is this not really realistic anymore in the current academic/funding climate? Love to get some more insight.

It's feasible and realistic. However, be mindful of a few things:
1. Many much more appealing options pop up after your training and throughout your career. Sometimes half of the work for 3x+ the pay.

2. It's more feasible and realistic if you stay mid-tier. At upper tier the prevailing model is no tenure pure soft money eat what you kill. In some ways that's a *better* model because when you kill a lot you end up ... eating a lot. You can also kill exactly how much you want to eat. However, this pathway is not for people who want rigid "80-20 split" and have anxiety about income instability. You have to do whatever it takes that *works for you*. It really feels like running a small business.

3. If you prefer to get that "traditional" midtier pre-packaged "tenured" 80-20 job, salary will be low for traditional cognitive specialties. Sometimes *very* low. You can easily find this out by doing a search of public university department chairs as they are all public information.

4. The wait can be very long. The median age of first R01 for an MD PhD is at 44. So the low salary non-tenure low status can be very protracted. This connects to point #1.

For a variety of reasons, graduates of mid-tier programs also have a lower "success" rate. Be mindful that when you move on to upper tier very commonly you start to compete with people with family money/pedigree or who married a wealthy spouse. Very often both (>50%). If you can do that try to do that. Sheryl Sandberg said something like "The biggest factor in your career success is who you marry".

If you are willing to keep submitting grants and sit on low salary, I do think there's technically a "high demand"--though @Neuronix claims that he wasn't even able to get that...which is true for some departments in some specialties that just don't care about research at all. Say that 20% clinical revenue nets the department 200k (not an uncommon scenario), the chair pays you 120k and give you 80% "protected time" indefinitely. It's still a win for me as the chair, hence the "demand" is *infinite*. Meanwhile, you can work in private practice 50% and generate 300k of revenue, and get paid 250k. You see how this works now? This is the real cause of "bleakness". It's not so much bleakness as silliness. It's kind of a farce. This effect is apparent already for cognitive specialties and is uber-amplified for procedural specialties. There was a surgeon talking about the in the other thread. The reality is that even for well-funded physician-scientists, the scientist part is very often a shell game that's a take it or leave it.

This salary differential effect has become so extreme that in many departments it's more efficient for the physician-scientists to work more clinically, take his own clinical salary dollars to HIRE PhDs to ghostwrite their grants for them. Sometimes that's under the table. Sometimes it's directly sponsored by the department.

In my mind, there's nothing hard about getting an R01 if you just keep sending grants in, month in and month out. Lots of garbage get funded. If you send in 10 rewrites and follow your reviewer's instructions EVENTUALLY something will get scored well, and then you wait another year or two before Congress decided to fund it. The only hard part is you won't get paid well for all that time and your spouse might hate you. If you don't care about that, it's not really that hard. This is in contrast to PhD-only, as they can't generate clinical revenues for the department to break even, so there are a limited number of tenure track spots opening up and people age out at various levels. That being all said, in theory if you truly "don't care about money" any postdoc can eventually secure a research assistant professor position and eventually get on the internal tenure track by submitting rejected R01s for 10 years, write a bunch of "mid-tier" papers nobody reads, and teach mid-tier undergrads and grad students. Which is exactly what a mid-tier (or even upper-tier) research professor's life looks like. If anything, that's "bleak" to me. Meanwhile, you can use your mid-tier MD PhD and get an upper-tier residency and fancy clinical job and retire at 50. Then at THAT point feel FREE to go back to write your R01s with a few million bucks in the bank. Interestingly, SOME people *do* do that. I've seen it at my "upper-tier" institution. Do you see how this is all very dumb as an exercise?

 

[tr]

It is really hard, but not impossible. My pay lines were around 10th percentile, and I've managed to get two R01 equivalents in the past year (one solo-PI, the other MPI). I'm working on a third.

I'm 42 years old.

45 here with one R01, working on submitting more. (Also of possible relevance, 3 kids and spent ~3 years playing intensive cancer mom to one of them - he's fine thanks - which may have contributed to some career slowing)

Yes there is a component of luck. It has been hell getting to this point in a lot of ways. I still feel insecure trying to maintain all of this. I did lose an industry grant recently due to a problem with the sponsor so that knocked down some research effort.

This just happened to me too! Maybe domino effect from the failure of the Silicon Valley Bank? We were just about to start recruiting when the project got shut down.

I do make good money and do cool stuff. Though it is a high cost location and I've had basically no choice of location throughout this process, which can be a challenge.

I make lame money and do a variety of stuff, some of it cool. Also in HCOL, but by choice. Spouse makes more than I do and needs to be in an area with tech, plus we have family support where we are now. There's just no way we were going to move to some random location for a job offer for the person with the lower salary. LCOL/middle of the country does seem to offer more institutional support based on my informal observations/discussions with colleagues, but that was really never going to work for our family so I just duked it out in the unforgiving coastal institutions.

My effort is currently 60% research / 40% clinical for what it's worth. I've been everywhere from 80% clinical to 25% clinical over the years, but it's all a game. At 25% clinical you can easily cram your clinics so full that you're producing at a 50% level. I've been doing stuff like that for years.

Yes same, I'm currently 45% clinical/55% research. It bounces around a fair but but probably averages 50/50. Agree that the 'on-paper' division doesn't always bear a whole lot of resemblance to how I actually spend my time.

Work hours have been 50-80 hours/week throughout.

I have definitely not worked an 80 hour week since residency. I have way too much domestic demand for that. I really think it's just about 40 hours most of the time, maybe 45. Might have been less when kids were little and I used to scramble to write a paragraph or two during nap time.

In my mind, there's nothing hard about getting an R01 if you just keep sending grants in, month in and month out. Lots of garbage get funded. If you send in 10 rewrites and follow your reviewer's instructions EVENTUALLY something will get scored well, and then you wait another year or two before Congress decided to fund it. The only hard part is you won't get paid well for all that time and your spouse might hate you. If you don't care about that, it's not really that hard.

THIS IS SO TRUE

 

[tortuga87]

If you are willing to keep submitting grants and sit on low salary, I do think there's technically a "high demand"--though @Neuronix claims that he wasn't even able to get that...which is true for some departments in some specialties that just don't care about research at all. Say that 20% clinical revenue nets the department 200k (not an uncommon scenario), the chair pays you 120k and give you 80% "protected time" indefinitely. It's still a win for me as the chair, hence the "demand" is *infinite*. Meanwhile, you can work in private practice 50% and generate 300k of revenue, and get paid 250k. You see how this works now? This is the real cause of "bleakness". It's not so much bleakness as silliness. It's kind of a farce. This effect is apparent already for cognitive specialties and is uber-amplified for procedural specialties. There was a surgeon talking about the in the other thread. The reality is that even for well-funded physician-scientists, the scientist part is very often a shell game that's a take it or leave it.

I have definitely not worked an 80 hour week since residency. I have way too much domestic demand for that. I really think it's just about 40 hours most of the time, maybe 45. Might have been less when kids were little and I used to scramble to write a paragraph or two during nap time.

How do you guys publish enough while working so little in research? The tenure committee where I am at only counts first and last author papers (unless its some big clinical trial or genetics paper).

I have noticed that a significant number of chairs adopt the following strategy with MDs which exploits the energy of the youth. They specifically recruit *mediocre* fresh residency graduates because they are the only people who are willing to work for the academic medical center for a sustained period of time. If they are too good clinically or too good at research, then there is a high chance that they will leave and cause instability. A rugged sailing boat is always better than a nice sinking boat.

The chair offers the mediocre graduates 80-90% clinical and 10-20% research at 80-90% the academic pay, if the graduates want to do research. The fresh graduates work hard in research, publish a lot of case reports or retrospective analyses thinking that they will eventually be rewarded, but they invariably struggle. A minority succeed here and there (maybe a K or even an R), but nearly all fail to get sustained R level funding because no one cares about research without experiments. Most of the recruits burn out within 5 years (some even stay as long as 10 years) and end up going 100% clinical, which the department gladly offers at 50% the private practice pay, then leaving. The chair rinses and repeats this strategy every year, so there is always a slow churn of new attendings. Nearly all attendings are replaced every decade or so.

 

[SurfingDoctor]

How do you guys publish enough while working so little in research? The tenure committee where I am at only counts first and last author papers (unless its some big clinical trial or genetics paper).

I have noticed that a significant number of chairs adopt the following strategy with MDs which exploits the energy of the youth. They specifically recruit *mediocre* fresh residency graduates because they are the only people who are willing to work for the academic medical center for a sustained period of time. If they are too good clinically or too good at research, then there is a high chance that they will leave and cause instability. A rugged sailing boat is always better than a nice sinking boat.

The chair offers the mediocre graduates 80-90% clinical and 10-20% research at 80-90% the academic pay, if the graduates want to do research. The fresh graduates work hard in research, publish a lot of case reports or retrospective analyses thinking that they will eventually be rewarded, but they invariably struggle. A minority succeed here and there (maybe a K or even an R), but nearly all fail to get sustained R level funding because no one cares about research without experiments. Most of the recruits burn out within 5 years (some even stay as long as 10 years) and end up going 100% clinical, which the department gladly offers at 50% the private practice pay, then leaving. The chair rinses and repeats this strategy every year, so there is always a slow churn of new attendings. Nearly all attendings are replaced every decade or so.

They get replaced? I’ve never seen an attending get replaced. That’s generally a tough sell because 1) it’s expensive for an institution to fire and hire someone new and 2) a vast majority of attendings in academics produce nothing of value, so it would be hard to fire someone for doing the same as other attendings. When you say replaced, do you mean switched off the physician-scientist track?

 

[tortuga87]

They get replaced? I’ve never seen an attending get replaced. That’s generally a tough sell because 1) it’s expensive for an institution to fire and hire someone new and 2) a vast majority of attendings in academics produce nothing of value, so it would be hard to fire someone for doing the same as other attendings. When you say replaced, do you mean switched off the physician-scientist track?

Replaced as in they leave voluntarily and younger attendings fill their jobs

 

[SurfingDoctor]

Replaced as in they leave voluntarily and younger attendings fill their jobs

Ah. Gotcha. There’s not a lot of private practice in my field since it’s a hospital-based speciality, so people who don’t stay at an academic institute either just go to another one and make a lateral move or get out of medicine entirely.

As for your other points, yes promotion committees generally only care about 1) funding 2) national committees and 3) first-last author papers. Likewise, at least when you are more junior, study section members generally only care about 1) the science and 2) the productivity. To get first-last author papers and be productive, I personally generate mostly LPUs (least publishable unit). I mean, I’ve published a handful of higher impact (IF>10) papers as first or last author but those generally require more work and tend to be valued nearly the same so why bother. My lab is also me and one tech, who is generally low skill, so when I’m doing 60-100% of the work, sometimes getting something out and showing I’m doing work is better than not producing anything.

 

[tr]

How do you guys publish enough while working so little in research? The tenure committee where I am at only counts first and last author papers (unless its some big clinical trial or genetics paper).

There are a lot of answers to this but for me, the main one was a very intentional selection of my research field.

I did my PhD in a wet lab and in that field it was entirely possible to slave away for years doing 60-70 hours per week and end up publishing nothing, either due to risky choice of question, chasing artifacts, getting scooped, or just persistent negative data. By the time I was done I knew I wanted no more of that.

I used my fellowship to lateral into a clinical/translational field and I now do exclusively human subjects research.
In this field, when you carry out a study you are pretty much guaranteed to be able to publish the results, usually plus a whole bunch of secondary post hoc analyses if you want (the scientific validity of those remains under debate but you can consider them 'hypothesis generating'). Negative data are just as publishable as positive data.

I don't publish a ton and usually stick with midrange IF journals, but I have pretty steady productivity, with solid representation as both first and last author. Usually something between 3 and 8 papers per year, where on maybe 1-3 of those I would be either first or last author. Last author becomes very easy once you have a database of completed studies where you can farm out new hypotheses to trainees using the existing dataset. Middle author papers also become extremely trivial once you have something of a track record and some connections in your field. People start seeking you out for your specific expertise and you end up a middle author for basically doing a couple of Zoom meetings and making a few edits to the final manuscript.

Middle author papers may not count for tenure (I have no idea, I don't have tenure and I'm not sure what sort of benefit it would have for me if I did, it seems like some kind of irrelevant decoration honestly) but they do help demonstrate expertise and productivity in an area when applying for additional funding.

 

[SurfingDoctor]

I used my fellowship to lateral into a clinical/translational field and I now do exclusively human subjects research.
In this field, when you carry out a study you are pretty much guaranteed to be able to publish the results, usually plus a whole bunch of secondary post hoc analyses if you want (the scientific validity of those remains under debate but you can consider them 'hypothesis generating'). Negative data are just as publishable as positive data.

Easily the most well funded people at my institution do clinical/translational stuff. I likewise did previously just wet lab stuff and my K was just wet lab. But when I applied for an R, I made sure to have clinical/translational parts to it on top of the basic science stuff.

In variably, when you create and finish a wet experiment and data collection, you’re basically done and those experiment take a long time for animals and cells to grow. With patient sample collection and data, you can milk it forever. I still have data from a project six years ago that I occasionally still publish on. Again, the well funded people at my institution (directs > $1 million annually) essentially milk the same patient sample database they created 20 years ago. None of them are groundbreaking papers, but for me, they keep the up the appearance of productivity while the animals and cells are growing in the background.

 

[ProReduction]

The chair offers the mediocre graduates 80-90% clinical and 10-20% research at 80-90% the academic pay, if the graduates want to do research. The fresh graduates work hard in research, publish a lot of case reports or retrospective analyses thinking that they will eventually be rewarded, but they invariably struggle. A minority succeed here and there (maybe a K or even an R), but nearly all fail to get sustained R level funding because no one cares about research without experiments. Most of the recruits burn out within 5 years (some even stay as long as 10 years) and end up going 100% clinical, which the department gladly offers at 50% the private practice pay, then leaving. The chair rinses and repeats this strategy every year, so there is always a slow churn of new attendings. Nearly all attendings are replaced every decade or so.

You just wrote what is likely the most succinct summary of the logistics of "academic medicine" that exists. For 95% of "academic" physicians, there is nothing academic about their job. They do a ton of clinical. They teach. They sit through endless committee meetings. They do case reports and reviews. The few MD-only without a PhD in my field that have Rs are usually a one-off and only got the R because they ended-up at a high-donation medical center with tons of private donations where early in their career they were gifted a grant while doing 1 FTE clinical that afforded them the ability to buy a PhD in Neuroscience or CS or EE that did all the work and where the MD got to put their name as last author on the PhD's papers. To me, a research career is not flying to obscure conferences talking about what your 1 PhD Research Scientist did with the money you gave him. It is understanding the work and driving the progress.

 

[dl2dp2]

How do you guys publish enough while working so little in research? The tenure committee where I am at only counts first and last author papers (unless its some big clinical trial or genetics paper).

Being able to publish well is only tenuously related to how many hours you spend working. In fact, they are often inversely correlated. Working hard on a project often means it’s not going well. When a project is going well, it glides forward without a lot of work. So if you start 10 projects and drop the ones that aren’t going well, you end up getting publications without a lot of work.

The actual writing of a paper is not that time consuming. It also eventually becomes kind of a bore… so the optimal way to do this is to pay for people ghostwrite your grants, hire people off the grants to write the papers. Put your name on last on those papers. Write a paper as a first author when it’s an “important” paper or a review/metanalysis for fun, and have your friends review it. This generates the most “passive” academic model. Almost all senior academics (who would be chair-eligible at a mid tier dept) use this model and it’s often shocking how little they work. Everyone is in Italy for a month in August and doing weird pet admin projects or making a lot of dough with outside activities. They rarely write anything de novo on their own. Many grants they submit were pre-vetted and the reviews were essentially formalities. They are part of large consortia that get blocked out ongoing carved out budgets. Once you reach that level (of corruption) where you and your friends control the input (NIH purse) and the output (high impact journals), the job is pretty sweet. It’s almost similar to being a senior surgeon where each case you come in doing the most challenging parts and your assistants and fellows open and close.

 

[solitude]

You just wrote what is likely the most succinct summary of the logistics of "academic medicine" that exists. For 95% of "academic" physicians, there is nothing academic about their job. They do a ton of clinical. They teach. They sit through endless committee meetings. They do case reports and reviews. The few MD-only without a PhD in my field that have Rs are usually a one-off and only got the R because they ended-up at a high-donation medical center with tons of private donations where early in their career they were gifted a grant while doing 1 FTE clinical that afforded them the ability to buy a PhD in Neuroscience or CS or EE that did all the work and where the MD got to put their name as last author on the PhD's papers. To me, a research career is not flying to obscure conferences talking about what your 1 PhD Research Scientist did with the money you gave him. It is understanding the work and driving the progress.

I don't think this is true for 95%. Case reports, reviews, retrospective analyses... are a heck of a lot more research than almost any non-academic alternative. Yes, some of this can be done in PP, but in reality, almost nobody is doing anything but grinding as many pts as possible to make as much money as possible. In academics, one does not need a wet lab or R01 to be understanding the work and driving progress. Progress moves on many fronts, and this work is very important in its own way. An MD/PhD often has a major advantage in this type of work because they understand the scientific method, how to write, and how to publish. Most MDs never learn these skills.

In academics, an MD/PhD can collaborate with basic scientists, who ARE on the hook for grant money and funding their salaries. Yet the MD/PhD is just collaborating for fun (and arguably, prestige, or perhaps a long shot at eventually getting his/her own grant etc). If the project doesn't pan out, just see more pts or do more cases. Wait until another grant is funded, or another basic scientist comes along who wants a collaborator. Very low risk. An MD/PhD can have a long and successful career in academics without ever bothering to write a grant, or having somebody ghost-write one for you.

Another advantage to practicing in academics is the variety of pathology, and working with trainees. These two features make the job much, much more intellectually interesting. My friends in PP are bored because of the mostly routine pathology, have no time to explore interesting cases or ideas, and don't have trainees around to keep them honest and engaged. With time, they wither.

Although I recommend people go into the specialty they like the most, if you're on the fence, I recommend a highly compensated, procedural specialty: something surgical, or GI, Cards, Derm, etc. It gives you an incredible amount of flexibility, and a very nice lifestyle even with a sizable research time % allocation. There is no need for a second household income (i.e., you can have a stay at home spouse and a family), and no worries about financial security, even on an academic salary (look up salaries for public institutions of MD/PhDs you know in procedural specialties who have plenty of research time; and by the way, that doctor may make A LOT more in outside activities such as industry or legal consulting...I charge 600/hr to industry, 900/hr for legal consulting, and there is plenty of work to be done). And if you get tired of academics for various reasons, you can always just leave for PP and make bank.

 

[SurfingDoctor]

Ironically, you know what doesn’t pay well, sitting on study section. Last time I calculated, it paid about $2.50 to $3.00/hr. When I’ve done international grant reviewers for foreign countries, it becomes such a hurdle giving them accounts and the like, I just forego the payment.

That’s not to dissuade anybody, but nobody goes into true academics for money or prestige. Personally, I’ve done it because I like science and like asking/answering questions that everyone else was either too lazy or too FOS to bother answering themselves.

On another note, because you are less bound by the “eat what you kill” model of clinical or PP medicine, you are given enough flexibility to actually have a family and make time for them. Most of my colleagues are childless or only have one and can’t make time for them because they feel “burned out”. Life is all about trade offs.

 

[tr]

In academics, an MD/PhD can collaborate with basic scientists, who ARE on the hook for grant money and funding their salaries. Yet the MD/PhD is just collaborating for fun (and arguably, prestige, or perhaps a long shot at eventually getting his/her own grant etc). If the project doesn't pan out, just see more pts or do more cases. Wait until another grant is funded, or another basic scientist comes along who wants a collaborator. Very low risk. An MD/PhD can have a long and successful career in academics without ever bothering to write a grant, or having somebody ghost-write one for you.

Yes to all of this, but also, you don't have to be the basic scientist to be the money person.
Being the person with the money gives you control over the choice of research question and direction of the project, which is really nice.

I haven't been on the payroll of anyone with a wet lab since I defended. I collaborate with basic scientists, but so far it has mostly been them on my payroll. Typically I write some %FTE for the PI, some % for the tech, and all the relevant lab supplies into my budget. I recruit the patients and send the biosamples to the lab (or core) for analysis. Then we write the paper together.

Basic science PIs are always happy for a little extra income and a collaborative paper with clear clinical relevance, and I don't have to get my hands dirty, which as I said I realized long ago was not for me.

 

[Neuronix]

On another note, because you are less bound by the “eat what you kill” model of clinical or PP medicine, you are given enough flexibility to actually have a family and make time for them. Most of my colleagues are childless or only have one and can’t make time for them because they feel “burned out”. Life is all about trade offs.

That's an interesting take. My experience has been that all the successful physician scientists, and even most of the prominent researchers, I work with are childless, while all the clinical faculty have children.

The chair offers the mediocre graduates 80-90% clinical and 10-20% research at 80-90% the academic pay, if the graduates want to do research. The fresh graduates work hard in research, publish a lot of case reports or retrospective analyses thinking that they will eventually be rewarded, but they invariably struggle. A minority succeed here and there (maybe a K or even an R), but nearly all fail to get sustained R level funding because no one cares about research without experiments. Most of the recruits burn out within 5 years (some even stay as long as 10 years) and end up going 100% clinical, which the department gladly offers at 50% the private practice pay, then leaving. The chair rinses and repeats this strategy every year, so there is always a slow churn of new attendings. Nearly all attendings are replaced every decade or so.

This was almost exactly my setup, and me in that minority who was successful. The problem is that it feels like my department never wanted to give me the resources necessary to be successful, and my pushing for resources and eventual successes have created significant friction.

But yes as pointed out, they rarely fire in academics. They just make attendings miserable until they quit. I had to get an R01 equivalent and a solid job offer elsewhere to get a pay raise and many of my issues fixed, or I would no longer be in academics today.


@solitude without quoting your post, I wonder what other departments are like with regards to clinical effort for academic faculty. I am in a procedural, high revenue generating department, and the wRVU target and productivity for clinical faculty is above private practice metrics on surveys like MGMA.

So I see things a little different. It's not like being a clinician somehow gives you a better lifestyle. Publishing is necessary to get promoted and pay raises, but small percentage grants won't do much for you. I've taken an even harder road, but I see my clinical colleagues working 50+ hour weeks as well.

 

[SurfingDoctor]

That's an interesting take. My experience has been that all the successful physician scientists, and even most of the prominent researchers, I work with are childless, while all the clinical faculty have children.

Maybe this is field specific.

 

[ProReduction]

I don't think this is true for 95%.

If you only consider Top 15 research institutions you are probably correct, but "academic medicine" broadly encompasses any teaching hospital these days if you consider the core of the work to be clinical + teaching + admin without research. There are tons of community-based allopathic programs and DO programs where the "academic physicians" operate in no distinguishable way from PP physicians other than they have residents instead of PAs/NPs and they do more teaching for their subordinates.
The other problem is that major academic centers are now mirroring PP but without the pay and this is only getting worse. NYU has had some departments triple the number of clinicians they have over the last decade. These physicians are not doing research but are grinding patient encounters and RVUs as NYU goes to war with NorthWell and other systems over dominating the local RVU grab. Same thing for U Penn, UCLA, etc. A tiny fraction of new hires end up on a tenure-track salary line. Most are PP at 25% of the pay.

 

[SurfingDoctor]

If you only consider Top 15 research institutions you are probably correct, but "academic medicine" broadly encompasses any teaching hospital these days if you consider the core of the work to be clinical + teaching + admin without research. There are tons of community-based allopathic programs and DO programs where the "academic physicians" operate in no distinguishable way from PP physicians other than they have residents instead of PAs/NPs and they do more teaching for their subordinates.
The other problem is that major academic centers are now mirroring PP but without the pay and this is only getting worse. NYU has had some departments triple the number of clinicians they have over the last decade. These physicians are not doing research but are grinding patient encounters and RVUs as NYU goes to war with NorthWell and other systems over dominating the local RVU grab. Same thing for U Penn, UCLA, etc. A tiny fraction of new hires end up on a tenure-track salary line. Most are PP at 25% of the pay.

The creation of ACGME accredited programs that are run by for-profit healthcare companies has certainly diluted the concept of "academics" even more so than previously.

The general problem with research is that it doesn't really generate money. It offers salary support and indirects that cover some of the overhead, but none of that compares to the generation of money from the clinical enterprise. It never has and likely never will. As for all the clinicians in academics who don't actually practice academics, which is a majority, their pay will also always be reduced compared to PP people for the same reason, an academic institution doesn't receive the reimbursements a PP institution can and because all academic institutions provide some degree of welfare care who tend to be more complex, that invariably will hurt their bottom line. That money deficit has to come from somewhere. I mean it would be nice if it instead came out of administrative bloat and the C-suite people, but that doesn't happen in any organization, ever (also, my wife is in hospital admin so it would hurt my bottomline if that ever happened )

Now, transparency in "academics" is terrible. Also the bar of "success" is vastly different. I know of people who have a tenured, full professorship at Wossamotta U but their accomplishments could be boiled down into a political appointment of "Medical Director" and they published ~10 papers. Heck, in my field, most division directors have 20 papers or less. And of course, they feel the need to brag about these "accomplishments" to their colleagues and it just makes everyone pissed off because everyone feels like they deserve what others get at a different institution with different financials who have a different metric of production. Even though there is a lack of transparency in all that, sometimes its actually hard to make direct comparisons. Incredibly hard, or at least, not without a lot of effort. I had some people in my division, who given this lack of transparency and from word of mouth, thought they were being paid unfairly. So they went around and asked a whole bunch of other people about work hours and bonuses and CME and call-pay differentials and so on. Of course, every place has a different schedule and pay and bonus structure. When all was said and done and someone went through the process of trying to "normalize" the data, it all ended up being the same within a magnitude of several thousands of dollars up or down between institutions. They didn't look at PP hospital groups, though those groups tend to get paid more because they do 28 weeks of service as opposed to 18 weeks of service. In fact, all their friends who made more tended to work more clinical hours (of course, most of the people complaining wanted more pay AND to work less clinical hours... which didn't add up). So the lack of transparency in academic institutions creates a lot of problems, because the reality is, most places are kinda the same. Of course, there are places that aren't, where you "pay for the privilege" of working at Ivory Tower University and more often than not, people grind at those institutions so they can jump off at some juncture to be recruited to a better job elsewhere.

 

[tr]

The chair offers the mediocre graduates 80-90% clinical and 10-20% research at 80-90% the academic pay, if the graduates want to do research.

This was almost exactly my setup, and me in that minority who was successful. The problem is that it feels like my department never wanted to give me the resources necessary to be successful, and my pushing for resources and eventual successes have created significant friction.

Yes this was (is) my setup too. The day I signed my contract for my first real doctor job, my division chief shook my hand and said, "Welcome to the faculty... Don't ask me for any money." As a fundamentally nonconfrontational person, I didn't bother trying to negotiate. I had 10-20% FTE research support as CoI from a mentor who was trying to help me, something like 5% for teaching, and beyond that it was whatever time I could buy out myself.

Which is still pretty much how it works now. I switched institutions a few years ago and my new one nominally gives me 10% FTE departmental support in addition to what I have covered from my own R01 and from CoI on a couple of others, but when you get into the weeds, New Institution's RVU requirements are higher than Old Institution's and they consider teaching to be a pro bono freebie, so really, it's all the same **** and there's no free lunch.

My understanding of this is that department chairs have pretty much zero incentive to support new researchers. Researchers are only a net positive for the department's bottom line once they get to the point of getting large grants with fat indirects. The likelihood that any individual early-career researcher is going to hit that point is sufficiently low that it's not worth the chair's while to hand out lots of protected time and resources to launch new people. It's just a net financial drain with low likelihood of future payoff.

So I see things a little different. It's not like being a clinician somehow gives you a better lifestyle. Publishing is necessary to get promoted and pay raises, but small percentage grants won't do much for you. I've taken an even harder road, but I see my clinical colleagues working 50+ hour weeks as well.

I actually think the research portion of my job has a way better lifestyle than the clinician portion. What I do for research mostly involves reading, writing, data analysis, and communicating with other people, and probably 80% of it could be done from any location and 70% of it can be done at any time of my choosing. In contrast to my clinic days which have a rigid schedule with no flexibility and very little down time.

 

[solitude]

That's an interesting take. My experience has been that all the successful physician scientists, and even most of the prominent researchers, I work with are childless, while all the clinical faculty have children.



This was almost exactly my setup, and me in that minority who was successful. The problem is that it feels like my department never wanted to give me the resources necessary to be successful, and my pushing for resources and eventual successes have created significant friction.

But yes as pointed out, they rarely fire in academics. They just make attendings miserable until they quit. I had to get an R01 equivalent and a solid job offer elsewhere to get a pay raise and many of my issues fixed, or I would no longer be in academics today.


@solitude without quoting your post, I wonder what other departments are like with regards to clinical effort for academic faculty. I am in a procedural, high revenue generating department, and the wRVU target and productivity for clinical faculty is above private practice metrics on surveys like MGMA.

So I see things a little different. It's not like being a clinician somehow gives you a better lifestyle. Publishing is necessary to get promoted and pay raises, but small percentage grants won't do much for you. I've taken an even harder road, but I see my clinical colleagues working 50+ hour weeks as well.

My experience matches yours. Kids cost money and time, so the faculty with money and time tend to have them, or more of them.

I'm not sure I understand your comment about the wRVU target and productivity. Are you saying their targets match the MGMA? That's the case for my targets too, but the targets are meaningless numbers propounded by the admins. All that matters is: If you make X RVUs, you get Y dollars times X. Plus a few minor fudge factors, but it's basically that simple. I know other faculty who are collections based instead, so if you have X collections, you take home Y% of that. Pretty rare to see a straight salary with an annual chair negotation nowadays in clinical medicine, at least from what my colleagues at other institutions tell me. It is eat what you kill.

Pure clinical lifestyle can still be a busy life, but it's generally not 60-80 hours a week, unless by design, e.g. an on-call week on a neurosurgery trauma service, or one takes on many extraneous admin activities and is inefficient with one's time. Academic physician-scientists with some research time sacrifice some income, but then have more flexilibility to write those publications and accomplish the miscellany charting and admin/teaching tasks that pure clinicians do after hours. Most pure academic clinicians I know are working 45-50 hours a week, and they have a very nice lifestyle outside of work based on the $$$ generated by that. 45-50 hours a week is just par for the course in America, but instead of struggling to make ends meet, you can be highly respected, work with your mind, make half a million dollars (or more) in a HCOL area, and you have job security and financial security. Meanwhile, essential workers like the poor souls watching the kids at daycare make 15 bucks an hour and struggle to pay rent. And this is a "bleak" outlook for us?


point being: the path provides incredible flexibility. If you want to keep going for traditional 80-20 split and grind it out until mid-40s to get an R01, with potentially low income, you can do that. If you want to do more like 30-70 and make good money in academics doing mostly clinical and some translational/clinical research, you can do that. If you want to do pure clinical and make great money, you can do that. Most people decide on #2 or #3 because at the end of the day, the tradeoffs of #1 are just not worth it.

 

[tr]

Updating here because I just ran across this analysis of funding inequality in RPGs.

Inequalities in the distribution of National Institutes of Health research project grant funding

Funding inequalities for NIH-supported research project grant investigators and organizations have increased over the past 25 years, but have modestly decreased over the past 3 years.

elifesciences.org

It's from 2021 but wow. MDs and MD/PhDs dominate the top centile of RPG funding (holding 10% of the total RPG dollar pool). Is this just because clinical studies cost more than lab-based work?

Also from this paper, physician-scientists appear to be nowhere near an endangered species. It's just that more of us now also hold PhDs than in the past (panel D). I guess it used to be easier to do research with an MD alone back in the '80s when the biomedical enterprise was less specialized.

In other funding disparity news, look at the differences between ICs. Not that we didn't already know this but good Lord, the graph really hammers it home. Some of us need to get out of the pit of funding despair that is child health and human development and find us some sweet human genome work or ophthalmology-adjacent kind of projects to do. Look at that Eye Institute payline, it's nudging 30%.

Institute and Center Award Rates and Funding Disparities – NIH Extramural Nexus

nexus.od.nih.gov

Finally, apropos of that dead-last bar on the 'Minority Health and Health Disparities' IC payline above, some other disparity related food for thought. Topic choice apparently explains a large portion of the racial disparity in RPG funding.

Topic choice contributes to the lower rate of NIH awards to African-American/black scientists

Topic choice is a previously unappreciated contributor to the lower rate of NIH awards to AA/B scientists.Despite efforts to promote diversity in the biomedical workforce, there remains a lower rate of funding of National Institutes of Health R01 applications ...

www.ncbi.nlm.nih.gov

Translation: Black/AA PIs want to study topics that white study section reviewers don't care about. Apparently lots of topics with direct applicability towards relieving human misery, with topic-defining terms like 'health care,' 'socioeconomic,' 'adolescent,' 'risk.' Look at the below average funding rates for the left side of the topics graph where Black/AA PIs cluster.

Seems like an easy fix would be to put some more Black/AA people on study section. Including unfunded investigators given the chicken-or-egg nature of this problem.

 

[SurfingDoctor]

Finally, some other disparity related food for thought. Topic choice apparently explains a large portion of the racial disparity in RPG funding.

Topic choice contributes to the lower rate of NIH awards to African-American/black scientists

Topic choice is a previously unappreciated contributor to the lower rate of NIH awards to AA/B scientists.Despite efforts to promote diversity in the biomedical workforce, there remains a lower rate of funding of National Institutes of Health R01 applications ...

www.ncbi.nlm.nih.gov

Translation: Black/AA PIs want to study topics that white study section reviewers don't care about. Apparently lots of topics with direct applicability towards relieving human misery, with topic-defining terms like 'health care,' 'socioeconomic,' 'adolescent,' 'risk.' Look at the below average funding rates for the left side of the topics graph where Black/AA PIs cluster.

Seems like an easy fix would be to put some more Black/AA people on study section. Including unfunded investigators given the chicken-or-egg nature of this problem.

View attachment 378111

Having sat on some DEI-oriented study sections, grants that have topics related to socioeconomic disparity often have a challenging time because the topic is challenging to write about concisely, and in my opinion, that’s why they get poor score. I don’t remember exactly, but in these study sections, I would say they are about 20-30% black/AA, so there’s usually a good chance one of the reviewers is black. Could there be more? Sure, but it’s still an issue when a grant (which is generally supposed to be hypothesis testing, mechanism based) is being written to attempt healthcare disparities, which is an important issue, but generally is so multifaceted, that any grant that attempts to tackle it seems too pie in the sky. I mean, the real root cause is education and resources and generally income disparity. It’s hard to write a NIH grant about fixing healthcare disparity when it ignores the root causes simply because they can’t be addressed by the NIH, it needs to be addressed by Congress or society as a whole. That grant always is challenging to write and review compared to gene/protein Y causes disease X. Anyway, that’s just my two cents.