Recent JAMA article on Intention to Leave Academic medicine

[The kitchen sink]

Well-Being Parameters and Intention to Leave Current Institution Among Academic Physicians

This cross-sectional study describes the prevalence of burnout, professional fulfillment, and intention to leave among physicians at academic-affiliated health care systems and identifies institutional and individual factors associated with intention to leave.

jamanetwork.com

Thoughts?

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[operaman]

There’s no physician more miserable than a mediocre academic.

I would be interested to see some added measure looking at how good each doc was. Maybe add things like clinical volume, research about, quality of research, etc. My gut says most of the burnout is coming from the mediocre academics.

It’s so easy to get into the rat race and lose sight of what you really care about. Personally I stumbled into sort of the perfect academic job for me. I hate doing bs research and playing the networking game to climb the academic ladder. I enjoy complex pathology and teaching, and found a place where that’s all I really have to do and nobody cares that I haven’t churned out some bs papers this year. I think if I had taken one of the other academic positions I would have ended up rather burned out too.

The flip side of academic medicine is that many of the things on which you’re judged and promoted require time outside of work. I see many of my more traditional academic friends spending many hours on weekends or before/after clinical time on weekdays working on research and grants and other admin projects. If you’re a gifted academic and well funded and getting notoriety and promotions, it may be a lot of fun. If you’re a struggling mediocre academic struggling for funding or trying to squeeze out papers with minimal protected time, your life probably sucks.

 

[gutonc]

There’s no physician more miserable than a mediocre academic.

That's why I got out before I could be that guy. I was definitely on the fast track to academic mediocrity.

 

[Apollyon]

That's why I got out before I could be that guy. I was definitely on the fast track to academic mediocrity.

Somehow I doubt that. It's easy to be an average or below average ER doc or primary care doc in the office. But, I've always said, it is hard to be cards or ortho without being good at it. Is that true for heme/onc, too? Can you do onc and not be good at it?

 

[gutonc]

Somehow I doubt that. It's easy to be an average or below average ER doc or primary care doc in the office. But, I've always said, it is hard to be cards or ortho without being good at it. Is that true for heme/onc, too? Can you do onc and not be good at it?

Oh, I'm a f***ing phenomenal oncologist. I just wouldn't have been a very good physician scientist or academic.

 

[The kitchen sink]

Somehow I doubt that. It's easy to be an average or below average ER doc or primary care doc in the office. But, I've always said, it is hard to be cards or ortho without being good at it. Is that true for heme/onc, too? Can you do onc and not be good at it?

uhh what? Have you ever worked with with a VA cardiologist?

 

[Apollyon]

uhh what? Have you ever worked with with a VA cardiologist?

Never! Maybe just my experience, like, a time lock vault - setting it is winding it, and winding it is setting it.

And I didn't say impossible - just hard to do!

 

[anonperson]

Well-Being Parameters and Intention to Leave Current Institution Among Academic Physicians

This cross-sectional study describes the prevalence of burnout, professional fulfillment, and intention to leave among physicians at academic-affiliated health care systems and identifies institutional and individual factors associated with intention to leave.

jamanetwork.com

Thoughts?

Academic medicine is a huge pyramid scheme.

If you're on top, life is good. The suckers on the bottom suffer. It's quite the scam.

Most academics is fake anyways. If you're on the clinical track, you're no different than the average private practice physician except you have a .edu email.

If you start on the academic track, unless you can generate money through grants etc which is getting tougher and tougher, you will wash out relatively quickly.

Most of the research getting published isn't that great anyways. Surveys, database stuff etc. People are just trying to boost their pubmed citations and throwing anything against the wall. The paper you posted is a survey with a 50% response rate.

Advancing in academia is getting much more political. I have an acquaintance who was an attending and fellowship director who was basically told there was no more room for advancement for him(he is a white guy) and they were looking to promote a more diverse faculty ( female minorities).

I felt bad for him because he's a good surgeon and a nice guy. He left and easily joined a well known health system and is doing well.

 

[operaman]

Oh, I'm a f***ing phenomenal oncologist. I just wouldn't have been a very good physician scientist or academic.

Exactly.

Good academic =\= good clinician

If anything, pure academia rewards all the non clinical things more than all the rest. You make less money generally speaking than similarly situated private docs, and you're required to devote many hours outside work to ancillary things like writing papers or grants or going to meetings and lectures.

Personally, doing all those other things sounds like abject misery to me. They could call and offer me the chairmanship of any ENT dept in the world at double its usual salary and I would turn it down on the spot.

 

[dozitgetchahi]

Somehow I doubt that. It's easy to be an average or below average ER doc or primary care doc in the office. But, I've always said, it is hard to be cards or ortho without being good at it. Is that true for heme/onc, too? Can you do onc and not be good at it?

I have encountered a number of mediocre orthos. It’s not impossible at all.

 

[dozitgetchahi]

I’ve expounded on my feelings about academic rheumatology around here before…suffice it to say, I think academic medicine is a really bad deal for most doctors. I think working twice as hard for 50% less pay is ridiculous. The work life balance is horrific whether you want to be a grant chasing, research heavy academician…or even just a “clinician educator”.

(And I think “fakedemia”/clinician educator jobs are the biggest rip off of all. There, you get paid diddly squat to flex nuts in front of a bunch of medical students and residents, while the “real research attendings” look down on you like some wealthy douchebag looks down on the people that scrub the toilets. Never mind that the “real research attendings” still mostly get paid trash, and work way more hours to earn that measly salary than is reasonable.)

Having done fellowship at one of these “highly ranked” places, I always thought it was remarkable that virtually all the attendings either came from money or were married to a much higher-earning spouse (usually a surgeon of some sort) - and the handful that didn’t had egos so huge that they couldn’t see how badly they were being ripped off. Nobody is choosing to halve their salary when they have to pay their own debts.

 

[Goro]

In reading this thread, I'm reminded of all the pre-meds who either:

A) what to go to Harvard/Stanford class schools to be researcher/clinicians OR

B) the naive kids who think that they can do bench research and see patients in a private practice. You know, the "I want to help humanity by advancing research" mindset.

Perhaps we can pin this thread?

 

[akwho]

My 2 cents.

If you go into academics all promotions are research based and specifically volume based. They don't care if you produce 5 high impact practice changing papers in a year, they will still promote the researcher that published 40 database studies a year ahead of you. So don't go into academics if you just like complex pathology/interesting cases & teaching -- you can get all that in the private practice / privademic world with more pay and a better lifestyle.

If you love publishing high volume research than academics is the place for you. There are very few people with the focus, organization and mental bandwidth to do this. You also need good social skills to build a network of med students, residents and other attendings to do research with. If you can pull it off and make it into the academic penthouse (chairmanship at a major University) you will make far more than most private practice surgeons due to patent opportunities and industry sponsorship as companies will try to ride your large coattails for influence. I know several academic surgeons in ortho that have consistently made 10M + a year due to the above, but they are rare unicorns.

I agree with Operaman academic medicine is a pyramid scheme. If you are in the top 1% life is gravy. Anything less than that it probably isn't worth it.

 

[operaman]

My 2 cents.

If you go into academics all promotions are research based and specifically volume based. They don't care if you produce 5 high impact practice changing papers in a year, they will still promote the researcher that published 40 database studies a year ahead of you. So don't go into academics if you just like complex pathology/interesting cases & teaching -- you can get all that in the private practice / privademic world with more pay and a better lifestyle.

If you love publishing high volume research than academics is the place for you. There are very few people with the focus, organization and mental bandwidth to do this. You also need good social skills to build a network of med students, residents and other attendings to do research with. If you can pull it off and make it into the academic penthouse (chairmanship at a major University) you will make far more than most private practice surgeons due to patent opportunities and industry sponsorship as companies will try to ride your large coattails for influence. I know several academic surgeons in ortho that have consistently made 10M + a year due to the above, but they are rare unicorns.

I agree with Operaman academic medicine is a pyramid scheme. If you are in the top 1% life is gravy. Anything less than that it probably isn't worth it.

Amen.

What’s sad is that just like other MLMs, the bottom 90% act like everything is just fine. Just like all those old high school and undergrad friends on my FB feed back in the day hocking their latest MLM scheme and bragging about how rich they were becoming (spoiler: none of them got rich).

I’m stupidly lucky to have stumbled into the position I have now. Had it not been for Covid hiring freezes, I’d probably be in a more traditional academic position right now, and maybe even been happy since I wouldn’t have known what was possible. But now that I’ve tasted the Privademic world where you get the great cases, teaching students and residents, but PP pay scale and no publishing pressure, I can’t imagine ever going back! I work <40 hours a week and make more than my last 2 academic chairmen. Combined.

I’d love to see a paradigm shift where we tell students it’s ok to just be a really great doctor. You don’t need an NIH funded lab, you can just go take care of patients and be very happy. The research pressures we put on students, especially in fields like mine, seem to create a pathway that leads many into academia who would be better suited elsewhere.

 

[mvenus929]

My 2 cents.

If you go into academics all promotions are research based and specifically volume based. They don't care if you produce 5 high impact practice changing papers in a year, they will still promote the researcher that published 40 database studies a year ahead of you. So don't go into academics if you just like complex pathology/interesting cases & teaching -- you can get all that in the private practice / privademic world with more pay and a better lifestyle.

If you love publishing high volume research than academics is the place for you. There are very few people with the focus, organization and mental bandwidth to do this. You also need good social skills to build a network of med students, residents and other attendings to do research with. If you can pull it off and make it into the academic penthouse (chairmanship at a major University) you will make far more than most private practice surgeons due to patent opportunities and industry sponsorship as companies will try to ride your large coattails for influence. I know several academic surgeons in ortho that have consistently made 10M + a year due to the above, but they are rare unicorns.

I agree with Operaman academic medicine is a pyramid scheme. If you are in the top 1% life is gravy. Anything less than that it probably isn't worth it.

While I don't disagree with the overall premise that promotion is about volume rather than quality...

I will point out that *many* institutions have been working on changing their promotion criteria so that it isn't primarily research focused. At my institution, research is one component of 4, and you need to have portfolios for 3 of the components to promote (the other three are clinical, teaching, and service). So, theoretically, you can promote all the way up to Professor without doing research.

 

[dozitgetchahi]

While I don't disagree with the overall premise that promotion is about volume rather than quality...

I will point out that *many* institutions have been working on changing their promotion criteria so that it isn't primarily research focused. At my institution, research is one component of 4, and you need to have portfolios for 3 of the components to promote (the other three are clinical, teaching, and service). So, theoretically, you can promote all the way up to Professor without doing research.

In theory.

Look at who actually does get promoted to professor and see if they actually did heavy amounts of research (or not)…I have seen a couple of exceptions in my time but the vast majority did.

 

[dozitgetchahi]

Amen.

What’s sad is that just like other MLMs, the bottom 90% act like everything is just fine. Just like all those old high school and undergrad friends on my FB feed back in the day hocking their latest MLM scheme and bragging about how rich they were becoming (spoiler: none of them got rich).

I’m stupidly lucky to have stumbled into the position I have now. Had it not been for Covid hiring freezes, I’d probably be in a more traditional academic position right now, and maybe even been happy since I wouldn’t have known what was possible. But now that I’ve tasted the Privademic world where you get the great cases, teaching students and residents, but PP pay scale and no publishing pressure, I can’t imagine ever going back! I work <40 hours a week and make more than my last 2 academic chairmen. Combined.

I’d love to see a paradigm shift where we tell students it’s ok to just be a really great doctor. You don’t need an NIH funded lab, you can just go take care of patients and be very happy. The research pressures we put on students, especially in fields like mine, seem to create a pathway that leads many into academia who would be better suited elsewhere.

Agreed.

My fellowship attendings definitely frowned upon the idea of any of their trainees not doing academic medicine - going into PP was seen as something of a cop-out, being lazy, not using your training from their institution to its proper advantage, etc etc. If academia was the major league, PP was seen as the AA minors at best - a place for the people that couldn’t really hack it. At my exit interview, I explained to my PD and dept chair that I had big time debt from college and med school and that I was going for a community job because I needed the financial firepower to actually pay it off…let’s just say that they made no attempt to conceal their disappointment.

 

[Drrrrrr. Celty]

Agreed.

My fellowship attendings definitely frowned upon the idea of any of their trainees not doing academic medicine - going into PP was seen as something of a cop-out, being lazy, not using your training from their institution to its proper advantage, etc etc. At my exit interview, I explained to my PD and dept chair that I had big time debt from college and med school and that I was going for a community job because I needed the financial firepower to actually pay it off…let’s just say that they made no attempt to conceal their disappointment.

During fellowship I've heard constantly that 1) I'm going to be burnt out by productivity in PP 2) you're going to be stuck managing a lot of complicated diseases alone without having back up from other specialties or it will take months to have them seen by other specialties 3) you're going to be bored or worse practice bad medicine because you'll be slave to your metrics and yelp score.

I think it's just people don't actually understand the world outside of academia or a tertiary referral center.

 

[gutonc]

During fellowship I've heard constantly that 1) I'm going to be burnt out by productivity in PP 2) you're going to be stuck managing a lot of complicated diseases alone without having back up from other specialties or it will take months to have them seen by other specialties 3) you're going to be bored or worse practice bad medicine because you'll be slave to your metrics and yelp score.

I think it's just people don't actually understand the world outside of academia or a tertiary referral center.

The bolded is the key here. We're asking people with zero personal experience to give advice/mentorship on what a career outside of their tiny realm looks like and how best to achieve it.

 

[Drrrrrr. Celty]

The bolded is the key here. We're asking people with zero personal experience to give advice/mentorship on what a career outside of their tiny realm looks like and how best to achieve it.

I think some of it is how IM residents think all patients in clinic are revolving door patients who on the verge of a COPD AE or CHF AE or about to go into DKA.

Most people have difficulty ascertaining what are real patients who you see in the clinic.

 

[DoctwoB]

The bolded is the key here. We're asking people with zero personal experience to give advice/mentorship on what a career outside of their tiny realm looks like and how best to achieve it.

My program also pushed the academic kool-aid. The funny thing is that now I am out and private, have a great practice that I enjoy, work-life balance, and great pay, when I speak with them they just seem wistful like they wish it had gone another way.

 

[operaman]

Agreed.

My fellowship attendings definitely frowned upon the idea of any of their trainees not doing academic medicine - going into PP was seen as something of a cop-out, being lazy, not using your training from their institution to its proper advantage, etc etc. At my exit interview, I explained to my PD and dept chair that I had big time debt from college and med school and that I was going for a community job because I needed the financial firepower to actually pay it off…let’s just say that they made no attempt to conceal their disappointment.

Yeah I was fortunate that mine were a bit more understanding, plus mine was still technically an academic appointment which helped. We also had the Covid and hiring freeze issues so jobs were tight nationwide that year.

Academic pay really baffled me. It truly ranged from the absurdly low to pretty darn high. One position quoted near $250k for ent and another $700k, both for asst prof positions, similar col. The high one in retrospect would have been miserable given the publishing and funding expectations, but the low end is basically half the national median which seems insane now. Both would have required incredible time commitments outside the office, and I doubt either would give me the sort of control I have over my schedule right now.

I was very gung ho about academics in training but now I can’t fathom taking a massive pay cut, less control of my schedule, and more uncompensated time outside of office hours, for what?!

Privademic for the win!

 

[operaman]

The bolded is the key here. We're asking people with zero personal experience to give advice/mentorship on what a career outside of their tiny realm looks like and how best to achieve it.

Preach.

I often wonder whether primary care would attract more people if students got to experience it outside the academic world. Like managing a nice suburban panel making good money working banker hours isn’t a bad gig, and my friends doing it seem awfully happy. Hard to see that in the ivory tower though where pcp practices are full of complicated train wrecks and social dispo nightmares.

But I definitely think academic docs have no idea what’s possible outside their realm, and the inherent referral patterns created by a major center play a big role. PP docs in that region aren’t going to get complex referrals because the ivory tower is so close. But a PP 100+ miles away may get a ton of good stuff and send along on a few to the mothership.

I think students and trainees have to be really honest with themselves about what they want their day to day to be and make decisions accordingly. And thankfully with the Internet it’s really easy to link up with docs outside their immediate area and get some different perspectives.

 

[Giovanotto]

When my highly academic program got whiff of me not staying in academia after training, I was immediately cast as the black sheep. I feel some guilt over it, but ultimately I would not be a good academic and doing it to please my higher ups was a clear path to failure. I'm happy to be on the track that I'm in, and in my field, privademics is common, but I want to see what the other side looks like first. I'm blessed to not have large medical school debt, but it's still there. Once I've amassed a certain degree of wealth and financial security, I may decide that an academic setting suits me better. Life is long!

 

[Drrrrrr. Celty]

Preach.

I often wonder whether primary care would attract more people if students got to experience it outside the academic world. Like managing a nice suburban panel making good money working banker hours isn’t a bad gig, and my friends doing it seem awfully happy. Hard to see that in the ivory tower though where pcp practices are full of complicated train wrecks and social dispo nightmares.

But I definitely think academic docs have no idea what’s possible outside their realm, and the inherent referral patterns created by a major center play a big role. PP docs in that region aren’t going to get complex referrals because the ivory tower is so close. But a PP 100+ miles away may get a ton of good stuff and send along on a few to the mothership.

I think students and trainees have to be really honest with themselves about what they want their day to day to be and make decisions accordingly. And thankfully with the Internet it’s really easy to link up with docs outside their immediate area and get some different perspectives.

I'd argue that we on SDN have a habit of trash talking FM/PCP as less desirable because we do adhere towards a subspecialty medicine is true medicine paradigm.

Problem is that the excitement wears off and you start to see these complicated medical problems for what they are, treatment resistant/refractory extended paper work trails. There's nothing worse than getting a new patient with a dx which requires me to transcribe an entire volume of their scanned in PDF so that the next time they visit I don't have to read through a 99 page pdf that looks like something before people discovered printer ink. And then decides they didn't like the drive, wait, or parking situation and never come back....

I'll gladly take community medicine with relatively simple diseases, highly functional patients, and patients coming on time.

 

[dozitgetchahi]

My program also pushed the academic kool-aid. The funny thing is that now I am out and private, have a great practice that I enjoy, work-life balance, and great pay, when I speak with them they just seem wistful like they wish it had gone another way.

Right? One of my attendings’ jaw dropped when she heard what I’d be making at my first community rheumatology job. She started grumbling about how little she was paid at that institution. (That said, within 2-3 years of me graduating fellowship, she had left her academic job of about 15 years or so to take a PP job on the other side of the country.)

 

[DoctwoB]

Preach.

I often wonder whether primary care would attract more people if students got to experience it outside the academic world. Like managing a nice suburban panel making good money working banker hours isn’t a bad gig, and my friends doing it seem awfully happy. Hard to see that in the ivory tower though where pcp practices are full of complicated train wrecks and social dispo nightmares.

But I definitely think academic docs have no idea what’s possible outside their realm, and the inherent referral patterns created by a major center play a big role. PP docs in that region aren’t going to get complex referrals because the ivory tower is so close. But a PP 100+ miles away may get a ton of good stuff and send along on a few to the mothership.

I think students and trainees have to be really honest with themselves about what they want their day to day to be and make decisions accordingly. And thankfully with the Internet it’s really easy to link up with docs outside their immediate area and get some different perspectives.

PCPs are also viewed very differently in the real world then at big subspecialty centers.

In the academic systems, they are often treated as an afterthought, paid less, and have less of that sweet, sweet, prestige and respect that academicians crave. Usually primary care is not given the priority it deserves in med school and residency training.

In the real world people love PCPs (especially those whose referrals aren't captive within a big health system). Their patients value them above all their other docs. Specialists appreciate you and want your referrals. They may come by your office and by lunch for your staff. They will make themselves available to chat or text to curbside about your patients or facilitate getting your consults in asap, rather then consulting pissed off junior surgery residents who will try to get out of any consult or non juicy referral. Pay is still (relatively speaking) too low and too much admin work, but there are a lot of positives.

Source: Specialist who both respects pcps for their work and also wants to keep them happy to keep the referrals coming.

 

[VA Hopeful Dr]

PCPs are also viewed very differently in the real world then at big subspecialty centers.

In the academic systems, they are often treated as an afterthought, paid less, and have less of that sweet, sweet, prestige and respect that academicians crave. Usually primary care is not given the priority it deserves in med school and residency training.

In the real world people love PCPs (especially those whose referrals aren't captive within a big health system). Their patients value them above all their other docs. Specialists appreciate you and want your referrals. They may come by your office and by lunch for your staff. They will make themselves available to chat or text to curbside about your patients or facilitate getting your consults in asap, rather then consulting pissed off junior surgery residents who will try to get out of any consult or non juicy referral. Pay is still (relatively speaking) too low and too much admin work, but there are a lot of positives.

Source: Specialist who both respects pcps for their work and also wants to keep them happy to keep the referrals coming.

You'd be surprised how well some of us are making out.

 

[operaman]

PCPs are also viewed very differently in the real world then at big subspecialty centers.

In the academic systems, they are often treated as an afterthought, paid less, and have less of that sweet, sweet, prestige and respect that academicians crave. Usually primary care is not given the priority it deserves in med school and residency training.

In the real world people love PCPs (especially those whose referrals aren't captive within a big health system). Their patients value them above all their other docs. Specialists appreciate you and want your referrals. They may come by your office and by lunch for your staff. They will make themselves available to chat or text to curbside about your patients or facilitate getting your consults in asap, rather then consulting pissed off junior surgery residents who will try to get out of any consult or non juicy referral. Pay is still (relatively speaking) too low and too much admin work, but there are a lot of positives.

Source: Specialist who both respects pcps for their work and also wants to keep them happy to keep the referrals coming.

Oh yeah all my referring docs have my cell number and I always say yes to any personal request. It’s a very different world from training!

The flip also seems to be true - the hospitalists here will always say yes to any admit, even a simple post op for overnight obs. I didn’t really believe it the first time I did it - that admit would have been blocked in seconds back in residency!

It does seem that once we’re all getting paid for our work, good old fashioned market economics kick in and people play nicer together.

 

[dozitgetchahi]

Oh yeah all my referring docs have my cell number and I always say yes to any personal request. It’s a very different world from training!

The flip also seems to be true - the hospitalists here will always say yes to any admit, even a simple post op for overnight obs. I didn’t really believe it the first time I did it - that admit would have been blocked in seconds back in residency!

It does seem that once we’re all getting paid for our work, good old fashioned market economics kick in and people play nicer together.

Yes and no.

I’m rheumatology. I’m still not loving OA and fibro (and most other rheums hate that stuff too.) Y’all can keep that stuff, PCPs 😂

 

[VA Hopeful Dr]

Yes and no.

I’m rheumatology. I’m still not loving OA and fibro (and most other rheums hate that stuff too.) Y’all can keep that stuff, PCPs 😂

I sent a guy to hand surgery for pretty bad OA, he suggested I send the guy to rheumatology...

 

[dozitgetchahi]

I sent a guy to hand surgery for pretty bad OA, he suggested I send the guy to rheumatology...

Severe OA is a tough issue to deal with.

If the joint can be replaced, great.

If it can’t for whatever reason, then I don’t have a magic solution for that just because I’m an “arthritis doctor” (when I tell patients this, it’s not uncommon for them to shoot back “but aren’t you an arthritis doctor?” In reality, we’re inflammation doctors, not “arthritis doctors” per se. I can and do decline the kind of OA referrals you’re describing.) I’m not the type of old school rheum who likes to load people up with controlled substances and gabapentin either. If the OA pain is that bad and none of the basic interventions have worked, I’m not dealing with it. Go to pain management.

 

[VA Hopeful Dr]

Severe OA is a tough issue to deal with.

If the joint can be replaced, great.

If it can’t for whatever reason, then I don’t have a magic solution for that just because I’m an “arthritis doctor” (when I tell patients this, it’s not uncommon for them to shoot back “but aren’t you an arthritis doctor?” In reality, we’re inflammation doctors, not “arthritis doctors” per se. I can and do decline the kind of OA referrals you’re describing.) I’m not the type of old school rheum who likes to load people up with controlled substances and gabapentin either. If the OA pain is that bad and none of the basic interventions have worked, I’m not dealing with it. Go to pain management.

I tell patients you're an auto-immune doctor. If your immune system isn't attacking your own joints, you don't need a rheumatologist.

 

[SurfingDoctor]

In academics, the people who burnout and leave are the ones who can’t develop a purpose for themselves.

Fortunately… they are usually easily replaceable in the call schedule by other fresh graduates who also have no purpose. From a division/department budgetary standpoint, they are also cheaper… so hurrah.

The only real downside is I have to cover the burnouts when they leave (though I get paid a bonus) and have to interview their future replacements… which is frankly a waste of my time, anyone with a pulse will do.

As for joining PP, I encourage it. Way better to have a purpose and goal from the get go then pretending you have one, and then wasting your time and making everyone else around you listen to you complain about your idleness. Use your extra time training to develop a skill set that behoves you (budgeting, marketing, management, etc.) instead of some terrible clinical research project that no one gives a fart about.

It’s all actually incredibly freaking simple. If your goal/purpose is to generate money for yourself, don’t go into academics. If your goal/purpose is to do actual research whilst seeing patients, go into academics. It’s the people who want the former, but choose the latter that go out in a blaze of misery, and they are the most insufferable people to be around and always end up being terrible hires.

 

[dozitgetchahi]

In academics, the people who burnout and leave are the ones who can’t develop a purpose for themselves.

Fortunately… they are usually easily replaceable in the call schedule by other fresh graduates who also have no purpose. From a division/department budgetary standpoint, they are also cheaper… so hurrah.

The only real downside is I have to cover the burnouts when they leave (though I get paid a bonus) and have to interview their future replacements… which is frankly a waste of my time, anyone with a pulse will do.

As for joining PP, I encourage it. Way better to have a purpose and goal from the get go then pretending you have one, and then wasting your time and making everyone else around you listen to you complain about your idleness. Use your extra time training to develop a skill set that behoves you (budgeting, marketing, management, etc.) instead of some terrible clinical research project that no one gives a fart about.

It’s all actually incredibly freaking simple. If your goal/purpose is to generate money for yourself, don’t go into academics. If your goal/purpose is to do actual research whilst seeing patients, go into academics. It’s the people who want the former, but choose the latter that go out in a blaze of misery, and they are the most insufferable people to be around and always end up being terrible hires.

I both agree and disagree here, and I think a lot of what you have written disagrees with itself.

The problem with new attendings fresh out of training is that a lot of them don’t have a vision for how their lives should look, and don’t yet understand what their “purpose” should be. This isn’t their fault. I blame the grueling GME training process for a lot of it. Some of these folks end up in academia for a variety of reasons, including years of being bluffed and buffaloed into the idea of academic medicine by academic training programs, a sense that they need to keep chasing “prestige” as they have been for their entire lives up to that point, and inertia (“well I trained here and I guess everyone seems nice enough, and oh wow that paycheck is 3x my resident salary!” Even though it really should be 5-6x in most situations etc.)

Given this, it is hardly surprising that a significant fraction of these people burn out and bail out when they realize that the academic pay and working hours suck hard. IMHO, the institutions don’t help clarify this for people because they *want* to keep a steady stream of these fresh “burnouts” to carry the clinical load of their departments while the research focused attendings do research. IMHO a lot of what academic hospitals do is pretty exploitative, especially for fresh attendings who often are naive.

 

[SurfingDoctor]

I both agree and disagree here, and I think a lot of what you have written disagrees with itself.

The problem with new attendings fresh out of training is that a lot of them don’t have a vision for how their lives should look, and don’t yet understand what their “purpose” should be. This isn’t their fault. I blame the grueling GME training process for a lot of it. Some of these folks end up in academia for a variety of reasons, including years of being bluffed and buffaloed into the idea of academic medicine by academic training programs, a sense that they need to keep chasing “prestige” as they have been for their entire lives up to that point, and inertia (“well I trained here and I guess everyone seems nice enough, and oh wow that paycheck is 3x my resident salary!” Even though it really should be 5-6x in most situations etc.)

Given this, it is hardly surprising that a significant fraction of these people burn out and bail out when they realize that the academic pay and working hours suck hard. IMHO, the institutions don’t help clarify this for people because they *want* to keep a steady stream of these fresh “burnouts” to carry the clinical load of their departments while the research focused attendings do research. IMHO a lot of what academic hospitals do is pretty exploitative, especially for fresh attendings who often are naive.

Well, in my experience, trainees gravitate toward the people who they see the most on service, which end up being young attendings who haven’t found a purpose. So those trainees are “mentored” by people who functionally have no idea what they are going to do besides seeing patients. So, the fresh crop end up being a carbon copy of the junior people and the process just repeats itself indefinitely. And if your goal is really to just see patients, that’s academics is the wrong place to be. But alternatively, it makes you easily replaceable when you do burn out.

But I also agree that trainees are by nature naive on what happens on the backend as they are just a form of cheap labor.

At least within my field, the system is invariably broken by old farts who are out of touch with market forces and hospital systems that will do the most for the least. Needless to say, and having done this for long enough, none of this is really new and the gravitation of people into academia out of convenience, not surprisingly, created a work force of grumpy burnouts who are just unpleasant to be around.

But yes, what you are staying is accurate and just a way of rephrasing what I said. And often, institutions are contradictory... by intention.

Everyone is replaceable, but it makes it easier when you bring nothing to the table. Knowing that however, does not bring job satisfaction either but in the end… the system doesn’t care except what makes the most money for the least effort.

Simone’s Maxim #1

 

[SurfingDoctor]

What every trainee and faculty should read.

Understanding Academic Medical Centers: Simone’s Maxims

Academic medical centers today represent a unique fusion of traditional academia, hospital functions, several levels of education, and, above all, patients. They are complex organizations trying to discharge an often conflicting melange of responsibilities. This complexity has grown in recent...

aacrjournals.org

 

[clausewitz2]

There's a thread at least once a year on this forum where I feel the need to post this:

 

[dozitgetchahi]

I both agree and disagree here, and I think a lot of what you have written disagrees with itself.

The problem with new attendings fresh out of training is that a lot of them don’t have a vision for how their lives should look, and don’t yet understand what their “purpose” should be. This isn’t their fault. I blame the grueling GME training process for a lot of it. Some of these folks end up in academia for a variety of reasons, including years of being bluffed and buffaloed into the idea of academic medicine by academic training programs, a sense that they need to keep chasing “prestige” as they have been for their entire lives up to that point, and inertia (“well I trained here and I guess everyone seems nice enough, and oh wow that paycheck is 3x my resident salary!” Even though it really should be 5-6x in most situations etc.)

Given this, it is hardly surprising that a significant fraction of these people burn out and bail out when they realize that the academic pay and working hours suck hard. IMHO, the institutions don’t help clarify this for people because they *want* to keep a steady stream of these fresh “burnouts” to carry the clinical load of their departments while the research focused attendings do research. IMHO a lot of what academic hospitals do is pretty exploitative, especially for fresh attendings who often a

Well, in my experience, trainees gravitate toward the people who they see the most on service, which end up being young attendings who haven’t found a purpose. So those trainees are “mentored” by people who functionally have no idea what they are going to do besides seeing patients. So, the fresh crop end up being a carbon copy of the junior people and the process just repeats itself indefinitely. And if your goal is really to just see patients, that’s academics is the wrong place to be. But alternatively, it makes you easily replaceable when you do burn out.

But I also agree that trainees are by nature naive on what happens on the backend as they are just a form of cheap labor.

At least within my field, the system is invariably broken by old farts who are out of touch with market forces and hospital systems that will do the most for the least. Needless to say, and having done this for long enough, none of this is really new and the gravitation of people into academia out of convenience, not surprisingly, created a work force of grumpy burnouts who are just unpleasant to be around.

But yes, what you are staying is accurate and just a way of rephrasing what I said. And often, institutions are contradictory... by intention.

Everyone is replaceable, but it makes it easier when you bring nothing to the table. Knowing that however, does not bring job satisfaction either but in the end… the system doesn’t care except what makes the most money for the least effort.

Simone’s Maxim #1

My point is that a doctor who is working hard and providing good care *never* should be thought of as “bringing nothing to the table”. Even in academia, these clinical-only doctors are actually providing a service which is very valuable both financially and socially…and they are being grossly under compensated for it, and treated like garbage to boot. All because they don’t churn out research, much of which (as mentioned in this thread) is probably of questionable quality and value to society. Unfortunately, this research (and the grants that go with it) is all these institutions seem to care about anymore.

As for “having a purpose” in academia: my opinion is that academia is now hiring so many physicians that most of them aren’t going to “have a purpose” beyond seeing patients. And academic institutions know this, and in fact deliberately keep it that way because they want to maintain a sort of “caste system” where the churn and burn crowd does the “dirty work” (ie, actually taking care of patients) which the researchers would rather not bother with. And also, what exactly is wrong with your “purpose” being quality patient care? As a physician, you trained for it, and you are well qualified to do it. It’s actually ok if that is your “purpose”.

Your posts, imo, remind me so much of what turned me off about academic medicine. That academic attitude is just so absurd on so many levels.

 

[SurfingDoctor]

My point is that a doctor who is working hard and providing good care *never* should be thought of as “bringing nothing to the table”. Even in academia, these clinical-only doctors are actually providing a service which is very valuable both financially and socially…and they are being grossly under compensated for it, and treated like garbage to boot. All because they don’t churn out research, much of which (as mentioned in this thread) is probably of questionable quality and value to society. Unfortunately, this research (and the grants that go with it) is all these institutions seem to care about anymore.

As for “having a purpose” in academia: my opinion is that academia is now hiring so many physicians that most of them aren’t going to “have a purpose” beyond seeing patients. And academic institutions know this, and in fact deliberately keep it that way because they want to maintain a sort of “caste system” where the churn and burn crowd does the “dirty work” (ie, actually taking care of patients) which the researchers would rather not bother with. And also, what exactly is wrong with your “purpose” being quality patient care? As a physician, you trained for it, and you are well qualified to do it. It’s actually ok if that is your “purpose”.

Your posts, imo, remind me so much of what turned me off about academic medicine. That academic attitude is just so absurd on so many levels.

To be honest, this belief is why advanced practice providers have taken over many markets. From an institutional standpoint, it is very hard to differentiate a NP who just sees patients in an academic center and a physician who just sees patients in an academic center. Both can write the same order and notes. Heck, most patients can't tell the difference. But the one thing that can tell the difference is the institution's bottom line. Which is why NP roles have vastly expanded while physician roles, even in academic centers hasn't (except in things like scholarship and leadership). One doesn't have to like it, nor "feel" satisfaction from it, but it's the truth. Ironically, when I was more junior, it was the clinical physicians who generated more RVUs and therefore had higher salaries then I, but worked less nights and weekends, who complained the most. It's all relative I suppose.

When I was a first year trainee, one of the more senior people came up to me (who later became Dean of a medical school) while I was doing a central line on some ill child and said "SurfingDoc, I could train a monkey to do what you are doing. How are you going to make yourself better than a monkey?" While I'm sure some (or maybe many?) would be offended by that comment, it has always stuck with me as a bitter truth.

But then again, I'm not sure why any of this really matters as one is always able to seek employment in other venues outside academia if they really are in the pursuit of money.

 

[anonperson]

To be honest, this belief is why advanced practice providers have taken over many markets. From an institutional standpoint, it is very hard to differentiate a NP who just sees patients in an academic center and a physician who just sees patients in an academic center. Both can write the same order and notes. Heck, most patients can't tell the difference. But the one thing that can tell the difference is the institution's bottom line. Which is why NP roles have vastly expanded while physician roles, even in academic centers hasn't (except in things like scholarship and leadership). One doesn't have to like it, nor "feel" satisfaction from it, but it's the truth. Ironically, when I was more junior, it was the clinical physicians who generated more RVUs and therefore had higher salaries then I, but worked less nights and weekends, who complained the most. It's all relative I suppose.

When I was a first year trainee, one of the more senior people came up to me (who later became Dean of a medical school) while I was doing a central line on some ill child and said "SurfingDoc, I could train a monkey to do what you are doing. How are you going to make yourself better than a monkey?" While I'm sure some (or maybe many?) would be offended by that comment, it has always stuck with me as a bitter truth.

But then again, I'm not sure why any of this really matters as one is always able to seek employment in other venues outside academia if they really are in the pursuit of money.

What kind of sell out mentality is this?

No difference between APPs and physicians?

What planet are you practicing on?

I see the average physician run circles around the average NP/PA. It's not even a question. Simple stuff gets missed constantly/misdiagnosed by these APPs.

Only reason ivory towers are pimping NPs/PAs is because they rely on their name even if the care is not ideal. Greedy hospital CEOs and equally greedy/weak willed chairs allow it to happen.

Meanwhile, when the CEO needs care for themselves or their family, they always demand a physician.

To any trainees, there is nothing wrong with actually practicing as a physician. You know, the actual thing you go to medical school for. Research is fine and is valuable for higher level stuff but the number of good researchers who not only have institutional support and research acumen is not that much.

Most of the research being pumped out is semi useless qualitative stuff or various database studies that some fellow is trying to publish who usually barely understands the esoteric statistical analysis that is done.

Most academics is fake anyways. These institutions are buying hospitals left and right to increase their revenue. You think UPMC expanded into Harrisburg because of the research process in that city?

 

[SurfingDoctor]

What kind of sell out mentality is this?

No difference between APPs and physicians?

What planet are you practicing on?

I see the average physician run circles around the average NP/PA. It's not even a question. Simple stuff gets missed constantly/misdiagnosed by these APPs.

Only reason ivory towers are pimping NPs/PAs is because they rely on their name even if the care is not ideal. Greedy hospital CEOs and equally greedy/weak willed chairs allow it to happen.

Meanwhile, when the CEO needs care for themselves or their family, they always demand a physician.

To any trainees, there is nothing wrong with actually practicing as a physician. You know, the actual thing you go to medical school for. Research is fine and is valuable for higher level stuff but the number of good researchers who not only have institutional support and research acumen is not that much.

Most of the research being pumped out is semi useless qualitative stuff or various database studies that some fellow is trying to publish who usually barely understands the esoteric statistical analysis that is done.

Most academics is fake anyways. These institutions are buying hospitals left and right to increase their revenue. You think UPMC expanded into Harrisburg because of the research process in that city?

No, institutions at the bottom line are about generating money. They do so in the most cost efficient way as possible. To suggest otherwise would be nonsense because that’s exactly how every business operates and at the end of the day, medicine is a business. The rest of it is noise. It’s all about the WAR (wins above replacement) value.

And if you think physicians are only the top 2% income earners nationally because of greedy CEOs and should instead only be the 1%… well, I guess that is one take.

 

[anonperson]

No, institutions at the bottom line are about generating money. They do so in the most cost efficient way as possible. To suggest otherwise would be nonsense because that’s exactly how every business operates and at the end of the day, medicine is a business. The rest of it is noise.

And if you think physicians are only the top 2% income earners nationally because of greedy CEOs and should instead only be the 1%… well, I guess that is one take.

No. Academic institutions are supposed to have multiple aims. They have been morphed into our current day monstrosities because of the sole goal of the bottom line.

Clinical care. Research. Helping train the next generation of physicians. Service to the community to an extent. These are supposed to be the goals. There is some sacrifice of revenue to achieve these goals.

Where did I comment on physicians being top 2% because of the CEO? I'm not getting what your last line is referring to.

 

[SurfingDoctor]

No. Academic institutions are supposed to have multiple aims. They have been morphed into our current day monstrosities because of the sole goal of the bottom line.

Clinical care. Research. Helping train the next generation of physicians. Service to the community to an extent. These are supposed to be the goals. There is some sacrifice of revenue to achieve these goals.

Where did I comment on physicians being top 2% because of the CEO? I'm not getting what your last line is referring to.

Are you not blaming CEOs and tying it into physician pay (by instead hiring cheaper NPs) with this quote:

Greedy hospital CEOs and equally greedy/weak willed chairs allow it to happen.

In any case, like all business (medicine or sports) it’s about cost and returns. To assume medicine is anything other than a business these days is a direct disregard to that fact. And the fact that it has literally been that way for decades now, before anyone of this forum was even practicing, yet people seem to not recognize that, strikes me as odd.

 

[ROBINHO]

I’ve expounded on my feelings about academic rheumatology around here before…suffice it to say, I think academic medicine is a really bad deal for most doctors. I think working twice as hard for 50% less pay is ridiculous. The work life balance is horrific whether you want to be a grant chasing, research heavy academician…or even just a “clinician educator”.

(And I think “fakedemia”/clinician educator jobs are the biggest rip off of all. There, you get paid diddly squat to flex nuts in front of a bunch of medical students and residents, while the “real research attendings” look down on you like some wealthy douchebag looks down on the people that scrub the toilets. Never mind that the “real research attendings” still mostly get paid trash, and work way more hours to earn that measly salary than is reasonable.)

Having done fellowship at one of these “highly ranked” places, I always thought it was remarkable that virtually all the attendings either came from money or were married to a much higher-earning spouse (usually a surgeon of some sort) - and the handful that didn’t had egos so huge that they couldn’t see how badly they were being ripped off. Nobody is choosing to halve their salary when they have to pay their own debts.

I think the clinician educator track is not always about how others perceive you, or how much you are making etc. I think some people genuinely enjoy working with trainees and find it stimulating to be kept on their toes about the recent science. Some people enjoy having the trainee be the first call and just co sign notes.

I think we need a mixture of everything- the physician scientist to generate science, clinician educators to teach the next generation, and the private docs who provide the bulk of care. Nowadays I am even careful lumping docs into private and academics. There are some academic practices which seem to be private and there are some private practices who teach students, APPS etc

 

[dozitgetchahi]

I think the clinician educator track is not always about how others perceive you, or how much you are making etc. I think some people genuinely enjoy working with trainees and find it stimulating to be kept on their toes about the recent science. Some people enjoy having the trainee be the first call and just co sign notes.

I think we need a mixture of everything- the physician scientist to generate science, clinician educators to teach the next generation, and the private docs who provide the bulk of care. Nowadays I am even careful lumping docs into private and academics. There are some academic practices which seem to be private and there are some private practices who teach students, APPS etc

I like teaching too. I just do it in private practice, where I’m not underpaid by 50%.

 

[tr]

No. Academic institutions are supposed to have multiple aims. They have been morphed into our current day monstrosities because of the sole goal of the bottom line.

Right.

Clinical care. Research. Helping train the next generation of physicians. Service to the community to an extent.

Sure, but the clinical care bit can be done by interchangeable widgets as far as academic leadership is concerned.
The overwork/underpay/churn-and-burn/37%-intention-to-leave model for young clinicians is a feature, not a bug.

In our fee-for-service system, a seasoned physician with 2 decades of clinical experience bills the same RVUs as a fresh grad.
Since fresh grads at any AMC are in endless supply and easy reach, it is in the interests of the administration to hire new ones every year, overwork/underpay for several years, and replace them when they get disgruntled by the patently exploitative arrangement. Ideally before they get promoted into even the most marginal salary increase.

These are supposed to be the goals. There is some sacrifice of revenue to achieve these goals.

No that's nonsense, there is never any sacrifice of revenue for any reason.

Clinical care makes gobs of money for the institution given they charge the same and pay their faculty half of what they would be worth on the open market.

Research is even more lucrative, which is why it is put on a pedestal as an activity. My institution has a 69.5% indirect cost rate. They are pulling almost twice my (pittance of a) salary in indirects from my NIH funding. The institution would rather have (externally funded) researchers than more clinicians because they are an even bigger cash cow, not because of any high-minded dedication to scientific advancement. Researcher salaries are even lower than clinician salaries because the AMC knows there is not an option to do this type of work in any other kind of context. Leaving the AMC environment means leaving research.

Community service seems mostly to consist of free clinics run by the medical students and residents in their spare time. The institution puts zero dollars into these as far as I have ever been able to ascertain.

 

[SurfingDoctor]

My institution has a 69.5% indirect cost rate.

Board of Regents meeting be like:

 

[mestielest]

(I'm not from the US, am a urologist, dropped-out a physiology PhD in 6th year - just before the defence, now have my private office)

My 2 cents: staying in academia means a quite extended adolescence.