Strategies for keeping Research interest during residency

[Fencer]

I would like to start a thread on ideas, strategies, in formal or informal programs that have been successful at keeping research interest during residency. Fellowship is a natural time for a physician-scientist to jump back into research, but the clinical-heavy gap that truly begins with MS re-entry after completing PhD, followed by internship and residency. While formal PSTPs might provide a home (and some activities for them), what do you feel/have seen that works and why?

A. Community - monthly/bi-weekly JC, presentations, etc.
B. Research supplement
C. Attending lab meetings of mentor's lab
D. Mentoring w research mentor (keep in mind this is prior to entering fellowship) - if so, what frequency, etc.
E. Help writing/editing manuscripts
F. Peer writing club for applications and manuscripts.
G. Competitive institutional Research slot (w one clinical week per month).
H. ....
I. ....

Add your ideas/strategies, and develop these above. Add citations too if work has been published.

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[StilgarMD]

There seems to be a recently renewed interest in the training pipeline of physician scientist:




I think all the ideas you mentioned are fantastic. One idea of something to add may be smaller events where you have to write a one page proposal with some aims and talk it through as part of a seminar, maybe inviting the relevant faculty members to attend and give feedback. I'd emphasize making it iterative, where maybe a rough draft written in month one is refined over the course of a semester.

I think a difficult balance to strike is finding something active and engaging to really stimulate the research part of our brains, while also not being so demanding as to either exhaust us during clinical times, or all together disincentivize participation all together for risk of exhaustion.

 

[Lucca]

Incubating the Research Independence of a Medical Scientist ... : Academic Medicine

est upwards of $500,000 to fully train each of the 900+ MD/PhD students enrolled in these programs. Nevertheless, graduates face the challenges of navigating fragmented intervals of clinical training and research engagement, reinitiating research upon completing their residencies, managing...

journals.lww.com

I'm a big fan of this case-study where a startup research program is developed with a senior faculty mentor to get the ball rolling on your science while you enter residency, with more frequent and structured research time integrated into the residency training pipeline instead of chunking off clinical and research training completely. Assuming one has completed a PhD, the research "training" of fellowship and postdoc is more about trying to find the right ideas to startup your own program. So why not give people the money, time, mentorship and support to do that? At this point these individuals are each multimillion dollar and decades-long investments.

The individual for which this plan was generated from earned tenure 9 years earlier than average in spite of doing a full MD/PhD + residency and is now an HHMI investigator. Are they exceptional? Probably in many ways yes, but also if more people had this kind of structure and support (and institutional buy-in for their success!) I suspect we would have far more physician scientist success stories and help tighten and/or shorten the leaky pipeline.

In keeping with my general theory of academic success, I think if there were more programs like this, Sandler, or Whitehead where people are given early independence and startup resources at the transition from MD/PhD to dedicated clinical training, and then time and flexibility to continue to do both, the pipeline would be better than it is and we would find that we would suddenly create far more "exceptional" individuals than we thought were around

 

[Fencer]

Kaf and I were part of a NIH task force on PSW (Physician Scientist Workforce) development. We discussed this in the early 2010s. His career path is difficult to scale up.

 

[Lucca]

Kaf and I were part of a NIH task force on PSW (Physician Scientist Workforce) development. We discussed this in the early 2010s. His career path is difficult to scale up.

Certainly no doubts about that. but it does seem to me that period (MD/PhD to intern and beyond) is where the biggest mismatch of time-spent-on-science / funding and fundraising / clinical duties appears to be. Why should we accept that the PhD is only of so much value to the MD/PhD because ultimately we have to start from zero after 6-9 ish years of clinical training (aka three decades at the current pace of science)? Why not create a pipeline that adapts to the changing landscape of knowledge production by helping early investigators create and maintain momentum and capitalize on the fact that clinical training truly can be more flexible if we allow it to be while research projects and labs most definitely cannot.

 

[Fencer]

When you step up in clinic as part of your 20%, you must be 100% for the patient. This is what accrediting and licensing bodies argue. I would like to hear more about your vision of "a pipeline that adapts to the changing landscape of knowledge production by helping early investigators create and maintain momentum and capitalize on the fact that clinical training truly can be more flexible if we allow it to be while research projects and labs most definitely cannot."

Is it like: Internship year - followed by 4 years of 2 months research / 2 months clinical?

 

[Lucca]

When you step up in clinic as part of your 20%, you must be 100% for the patient. This is what accrediting and licensing bodies argue. I would like to hear more about your vision of "a pipeline that adapts to the changing landscape of knowledge production by helping early investigators create and maintain momentum and capitalize on the fact that clinical training truly can be more flexible if we allow it to be while research projects and labs most definitely cannot."

Is it like: Internship year - followed by 4 years of 2 months research / 2 months clinical?

It’s not a particularly elaborated vision, but I feel like it would be practical to give trainees time to set up projects / get the ball rolling and ensure they are placed in labs with ample support staff where they are not the sole person doing the technical / manual labor for the project after the initial prelim data and planning stage all BEFORE PGY2 even begins.

Imagine you match into IM, but on the PSTP track u spend the first year as an intern with some exposure to the research environment / learn the landscape of your new institution / talk with potential mentors when you get a chance and then the second year immersed in starting a project. Then you go back to PGY2 in your third year but hopefully your project is now at a stage where techs and other lab members can contribute to advancing experiments. In other words, tailor the time spent going back to clinic to the needs of the research project instead of the other way around. That way you can be fully focused on one thing (clinic or research) 100% of the time. By the time you get to fellowship stage instead of thinking “what postdoc do I do” you will be at the stage of “I need to send out the paper / finish preparing this K / R and think about my independent program”. Instead of short tracking + 3 extra years of postdoc beyond fellowship one could theoretically short track, finish all in 6-7 total and be ready to go without the extra 3 year timeline.

I don’t think this would ever work in surgery, but in cognitive specialties I feel like it could be achieved. The people I know who have done this path “quickly” have all done a version of this: finding the right support to keep research going during their 100% clinical periods and the right mentor/lab to support that while still being the intellectual lead of a project.


I’m many years away from residency but my broader point/question is do we really think for most specialties that it’s absolutely essential PGY2 come immediately after PgY1 or even that X rotation in PGY2 happen right immediately after Y rotation? It would require completely redoing how we do staffing at hospitals with residents as I bet that is the tighter bottleneck than educational value.

 

[tortuga87]

From my n=4, this early research experience works for very motivated MD PhDs who go in with a clear target and a sniper rifle. You are basically doing work exclusively for the K award. These people generally already have a good publication record. They know what they want to do. There is no time for BSing with side projects. They now must find well-funded mentors, get great letters and optimize their preliminary data for the grant. They are guided by a super mentor who knows how to f-ing get grants.

 

[ChordaEpiphany]

I'm conflicted on Dr. Hohl's "achievement rate" analysis. I'm a huge believer that pushing matriculation further and further from college is harming the MD/PhD pipeline, especially since we are simultaneously elongating the time to graduation. Favoring high achievers out of college would help. I think many MD/PhDs fall off the path because they are forced to choose between security for their family and continuing to chase poor odds of K and R funding. Burnout also hits way harder when you've got young children and are still vying for K funding in your late 30s. When I describe this pathway, my friends and family in any other field want to check me into a mental institution. We should target average graduation time of ~29-30 to remain competitive. The pipeline is leaky, and we're not just losing less talented candidates. A lot of the better students I know (e.g., high impact papers, F30 recipients, AOA) already have their sights set on greener pastures just after doing the math on their life timeline, time with family, financial security, etc... None of them will be forthright with a program director about this, but it's rampant among my colleagues.

At the same time, undergraduate research productivity is essentially meaningless. Great undergrads who worked on my projects in my 1st or 2nd year of graduate school walked away with nothing or a 2nd or 3rd author abstract. A very average undergrad who joined me as a 4th year graduate student is getting 2 mid-author pubs despite costing me significantly more time in training than I ever got back in meaningful data. Unless you are 1st author, I don't really believe in assigning credit for undergraduate research deliverables. I say look at 1st author papers, grades, test scores, experience, letters, and commitment. The rest is luck, riding coattails, field-specific publication rates, etc...

I'd imagine MSTP directors favor accomplished applicants because they are then favored for further awards (e.g., F30) and have a more established publication record for a K award. Again, I'd say that study sections are making a mistake weighing mid-author pubs highly. Give credit for good data and 1st author pubs, and then give some bonus points for being a team player. There is very little difference in the work I've done for a mid-author pub in high impact journals vs. mid- or low-impact journals, and my mid-author:1st author work ratio is probably 1:25 if not more extreme.

 

[Fencer]

I calculated the national MSTP time to dual-degree at 8.6 years from a dataset I had in 2017. What is worse is that LOA (due to life events) are typically not included in these numbers. Furthermore, as indicated here, there is an increase appetite for accomplished Post-bacs. This is clearly a COI for someone like me. But the increased frequency of post-bac experiences (2010-20) will eventually worsen the Age to 1st R01, perhaps to a point that it is unpalatable to leaders, forcing the rethinking of the Physician-Scientist Workforce. I am working on an editorial on the issue.

 

[ChordaEpiphany]

I calculated the national MSTP time to dual-degree at 8.6 years from a dataset I had in 2017. What is worse is that LOA (due to life events) are typically not included in these numbers. Furthermore, as indicated here, there is an increase appetite for accomplished Post-bacs. This is clearly a COI for someone like me. But the increased frequency of post-bac experiences (2010-20) will eventually worsen the Age to 1st R01, perhaps to a point that it is unpalatable to leaders, forcing the rethinking of the Physician-Scientist Workforce. I am working on an editorial on the issue.

This will get worse. All but one person in my cohort extended their PhD by a year due to COVID-related disruptions.

All of this discussion is also predicated on the idea that MSTP and PSTP training prepares you to run a lab. Is there any evidence that all this extra training actually makes for better lead investigators, or have we simply stretched out the pathway because NIH funding is limited and investigators need to spend time to be competitive with each other?

I'd imagine almost none of the R01 recipients in 1970 would receive an R01 under today's standards. Taken at face value, it would imply that investigators in 1970 were universally under-prepared, which is obviously not true. I would instead apply Dr. Hohl's "rate of achievement" to K and R awardees and make every effort to recruit and retain high achievers at a younger age, when they're more likely to find the academic grind palatable and they're more likely to grow into their roles as lead investigators (instead of learning the ropes until their 50s).

Time to first R01 (or equivalent) over time

 

[ChordaEpiphany]

While we're on the subject, I've noticed a striking change in attitude towards the MD/PhD path since I was an undergrad.

Based on my (anecdotal) experiences, I would strongly urge you to rally the field in the direction of shortened training pathways, greater focus on alternative careers as a backup, and creation of better hybrid positions for physician scientists in academia. Be it in-house, at conferences, or in casual settings, I'd estimate at least 50% of my MSTP colleagues describe the pathway as "malignant" or "soul sucking." These are not things they would divulge to a PD. These are also not people who are "failing" along the pathway. These are F30 recipients with high impact papers and $500K-1M of federal money invested in them. Many are developing plans to run to pharma or highly paid specialties with no intention of pursing NIH funding. Some have even embraced the FIRE movement and plan to accumulate $5M in ortho/plastics/derm and then stop working entirely in their 50s. COVID accelerated the burnout exponentially.

My interpretation is that the information age is bringing to light a lot of inadequacies of this pathway, and that over time the pathway is going to lose a ton of talent without changes. In 2014, when I decided to pursue an MD/PhD, my decision was influenced by close mentors and physician scientists (all advising me from their experiences training in the 70s-90s). I didn't think about K-to-R conversion rates, added post-doc time, or how useless my PhD/lab training would be if I failed along the funding pathway.

Today, the talented undergrads I mentor are hyper-connected and hyper-informed by the internet and social media. They are all asking the same questions my fellow MSTPers are asking behind closed doors. Is this pathway really worthwhile for a top student who could redirect their resume towards top 20 MD, T14 law, FAANG, or high finance? Increasingly the answer I'm getting from these students is, "not a chance." We're seeing a massive cultural divide with the coming generations and their attitudes towards work, and I think it's incompatible with retaining talent while asking people to grind well into their 30s or 40s for little financial gain (compared to the alternatives).

 

[SurfingDoctor]

My global anecdotal experience for graduate (and/or) medical education, having not gone through a PhD but developed an NIH funded lab and been involved in post-graduate fellowship training for over a decade, is that the curriculum of training was developed over 30 years ago and has not adapted well to the changing medical and research environment. I don’t know precisely why, but if I had to bet, it’s mostly inertia from the top down and the most senior people saying “that’s the way I was trained” without realizing (or not caring) they the way they were trained is no longer relevant or meaningful toward success.

This is why, no matter the industry, senior leadership is useful for experience but detrimental for innovation and progress.

 

[ChordaEpiphany]

My global anecdotal experience for graduate (and/or) medical education, having not gone through a PhD but developed an NIH funded lab and been involved in post-graduate fellowship training for over a decade, is that the curriculum of training was developed over 30 years ago and has not adapted well to the changing medical and research environment. I don’t know precisely why, but if I had to bet, it’s mostly inertia from the top down and the most senior people saying “that’s the way I was trained” without realizing (or not caring) they the way they were trained is no longer relevant or meaningful toward success.

@SurfingDoctor I do greatly respect your opinions on here, I'm going to challenge this assertion. It's absolutely not the way they were trained.

The training pathway is longer and less flexible at every step. For students without family funds, loans are $400K+, and LRP and PSLF programs don't really cut into that enough, so MSTP becomes the best pathway. Gaining admission to an MSTP program now often requires a first author paper and a few gap years, so add 1-2 years. PhDs are longer than they used to be, add another year. Residencies are increasing in length, and fellowships are being tacked on left and right, add 1-3 years.

The overall trend in both medicine and research is that the gatekeepers are asking for more than the standard pound of flesh from trainees. MD/PhDs are getting hit from both ends.

I'm reluctant to believe that this is as innocent as some boomer docs pulling a "back in my day" argument based on their ideal vision of physician/scientist training. My PI barely knew what a nucleic acid was when he finished grad school, and now he's the PI on 4 R01s related to genetic engineering. He finished his PhD in 4 years at 26, but he expects 6 years out of most of his students and 3 years from his post-docs. Meanwhile I haven't seen a single K-award from these post-docs. The chief of CT surgery at my institution completed his fellowship at one of the nations top cardiac centers seven years post-MD with no gap between med school and undergrad and no research years, but he emphatically claims he'd never accept a fellow who didn't take two research years during their gen surg residency, and he insists 3 years of fellowship is necessary (for a total of 10 years of residency/fellowship to complete the training). He also claimed he valued residents who had some work experience prior to med school, and he hates work hour restrictions regardless of how many studies come out showing that patient outcomes are the same before and after.

Those at the top of the academic hierarchy understand that all these extra years pipetting or doing grunt work as a resident/fellow aren't necessary to train a physician or scientist, but administration and leadership recognize that the short-term payoff of forcing people into longer training pathways is good for them, even if it is bad for the field and the future leaders (who are now nearing retirement by the time they even get established).

 

[Lucca]

Re: gap years, as someone who went through the 2019 cycle with 2 and had a very successful cycle I don’t think I would’ve had even 2 of the interviews I did without those gap years. That said I don’t regret those at all. I regret that med school is as long as it is, that expectations for publication are increasingly ludicrous and detached from reality, and that residency and fellowship training get longer and longer but I don’t regret those gap years. If you don’t go to an elite research university for undergrad, that time is a great equalizer for you to work somewhere with the right mentorship and resources to give you a shot at the career. It’s also a good time to figure out if full-time science is something you even remotely want to do. I also had a lot of fun during that time, the likes of which I have not had during med school or grad school (admittedly the pandemic likely has a lot to do with this).

I’m not really for speeding people into the med school meat grinder. I’m convinced med school has made me a worse, less interesting, more burned out, more cynical person. I’m trying to unlearn and reprogram that in grad school. Why rush bright young people into that? Give them a few years to live life that also helps their career if they so choose it. During that time they might learn that something else entirely is more appealing / attractive to them — one of the best things that could possibly happen to them in terms of long term happiness and financial stability.

I will agree that the CV arms race is nuts though, but I doubt there is anything we can do to change this. As long as it’s competitive or desirable to get into MSTPs, cv arms race will get worse.

MSTP PDs should be advocating for every school to have a one-year preclin program though IMO. Stop wasting your MD/PhD students time.

 

[SurfingDoctor]

@SurfingDoctor I do greatly respect your opinions on here, I'm going to challenge this assertion. It's absolutely not the way they were trained.

The training pathway is longer and less flexible at every step. For students without family funds, loans are $400K+, and LRP and PSLF programs don't really cut into that enough, so MSTP becomes the best pathway. Gaining admission to an MSTP program now often requires a first author paper and a few gap years, so add 1-2 years. PhDs are longer than they used to be, add another year. Residencies are increasing in length, and fellowships are being tacked on left and right, add 1-3 years.

The overall trend in both medicine and research is that the gatekeepers are asking for more than the standard pound of flesh from trainees. MD/PhDs are getting hit from both ends.

I'm reluctant to believe that this is as innocent as some boomer docs pulling a "back in my day" argument based on their ideal vision of physician/scientist training. My PI barely knew what a nucleic acid was when he finished grad school, and now he's the PI on 4 R01s related to genetic engineering. He finished his PhD in 4 years at 26, but he expects 6 years out of most of his students and 3 years from his post-docs. Meanwhile I haven't seen a single K-award from these post-docs. The chief of CT surgery at my institution completed his fellowship at one of the nations top cardiac centers seven years post-MD with no gap between med school and undergrad and no research years, but he emphatically claims he'd never accept a fellow who didn't take two research years during their gen surg residency, and he insists 3 years of fellowship is necessary (for a total of 10 years of residency/fellowship to complete the training). He also claimed he valued residents who had some work experience prior to med school, and he hates work hour restrictions regardless of how many studies come out showing that patient outcomes are the same before and after.

Those at the top of the academic hierarchy understand that all these extra years pipetting or doing grunt work as a resident/fellow aren't necessary to train a physician or scientist, but administration and leadership recognize that the short-term payoff of forcing people into longer training pathways is good for them, even if it is bad for the field and the future leaders (who are now nearing retirement by the time they even get established).

I agree. I think globally what I was saying is more it line what you are saying, where expectation doesn’t meet reality, but that expectation is somewhat based on a misguided or just forgotten memories. I also agree and know for a fact training is being extended, partly because the knowledge is more vast than it used to be, which the public justification given, but I think there is also an underpinning of more senior people realizing that trainees function as cheap labor and there are actually very personal and selfish reasons to keep labor as cheap as possible, which is the private justification kept in secret. And of course, this is a complete detriment to the finances, which are vastly worse than they were even a decade ago and senior people and/or leadership simply don’t care because it’s viewed as “not their problem”.

I also think the gap year is globally stupid, but has become a necessary from a competition standpoint. Relevant to my own particular field, it’s interesting that trainees are having more protracted lengths of training and are coming in with better CVs, but then just kinda stop when they land their first job. It’s probably because the academic ladder remains a high bar but for the most part, isn’t worth the headache and personal struggles for something that doesn’t really improve pay. We also, at least in my field, do a terrible, and I mean, terrible job at career development because those attendings who have lost the inertia are expected to provide career development, but really don’t have the will or knowledge to do so. It’s all a cluster..,

 

[ChordaEpiphany]

Re: gap years, as someone who went through the 2019 cycle with 2 and had a very successful cycle I don’t think I would’ve had even 2 of the interviews I did without those gap years. That said I don’t regret those at all. I regret that med school is as long as it is, that expectations for publication are increasingly ludicrous and detached from reality, and that residency and fellowship training get longer and longer but I don’t regret those gap years. If you don’t go to an elite research university for undergrad, that time is a great equalizer for you to work somewhere with the right mentorship and resources to give you a shot at the career. It’s also a good time to figure out if full-time science is something you even remotely want to do. I also had a lot of fun during that time, the likes of which I have not had during med school or grad school (admittedly the pandemic likely has a lot to do with this).

I’m not really for speeding people into the med school meat grinder. I’m convinced med school has made me a worse, less interesting, more burned out, more cynical person. I’m trying to unlearn and reprogram that in grad school. Why rush bright young people into that? Give them a few years to live life that also helps their career if they so choose it. During that time they might learn that something else entirely is more appealing / attractive to them — one of the best things that could possibly happen to them in terms of long term happiness and financial stability.

I will agree that the CV arms race is nuts though, but I doubt there is anything we can do to change this. As long as it’s competitive or desirable to get into MSTPs, cv arms race will get worse.

MSTP PDs should be advocating for every school to have a one-year preclin program though IMO. Stop wasting your MD/PhD students time.

I can actually really appreciate your points about gap years. I could be swayed either way.

The real answer is probably to incorporate career flexibility at later stages, and I think the answer to that is to pick the winners earlier. If MD/PhDs knew with some sort of reasonable certainty that they could (or could not) run a lab some time before 40, that would allow them to target their career progression accordingly. It would also put a hard time cap on the CV arms race.

As is, sometime between graduation and fellowship, most MD/PhDs look at their options and decide if continuing to pursuing bench research is worthwhile. You're faced with two options:

1) Continue chasing a bench research career knowing the most likely outcome is that you are paid poorly, fail to get your grants, and are not well-positioned for lateral career moves when it all falls apart (because all your qualifications are in bench research).

2) Transition to a lateral pathway like translational research, clinical trials, pharma, academic admin/leadership, private practice, etc... and be reasonably sure you can keep progressing along those pathways and put your training to use (while also making considerably better money than option #1).

MD/PhDs are ambitious and risk averse. Who wants to go through all this training and all this sacrifice when the most likely outcome is that you're booted from your career path at 45-50 years old while financially and professionally at least a decade behind your peers in clinical medicine? And that's why you get attrition.

 

[dl2dp2]

Today, the talented undergrads I mentor are hyper-connected and hyper-informed by the internet and social media. They are all asking the same questions my fellow MSTPers are asking behind closed doors. Is this pathway really worthwhile for a top student who could redirect their resume towards top 20 MD, T14 law, FAANG, or high finance? Increasingly the answer I'm getting from these students is, "not a chance." We're seeing a massive cultural divide with the coming generations and their attitudes towards work, and I think it's incompatible with retaining talent while asking people to grind well into their 30s or 40s for little financial gain (compared to the alternatives).

Very true. I don't think there's anything at the level of institutions that can really change the situation, frankly. Institutional interventions are often counterproductive, because the *core* of the main issue is lack of NIH funding.

Those at the top of the academic hierarchy understand that all these extra years pipetting or doing grunt work as a resident/fellow aren't necessary to train a physician or scientist, but administration and leadership recognize that the short-term payoff of forcing people into longer training pathways is good for them, even if it is bad for the field and the future leaders (who are now nearing retirement by the time they even get established).

The same dynamic though plays out for PhDs. So this pathway still compares favorably vs. straight PhD. As to straight MD: if you have family money, then yes, you should probably do straight MD. If you don't have family money, you sort of don't have a choice, and the math actually favors MD/PhD--I wrote several "infamous" posts on this a number of years ago in this very forum.

The MD/PhD training program itself, if "deviously" used as a replacement for MD-only, with an eye on derm, etc., has a year-over-year yield that's comparable to an entry-level job at any of the valid alternatives--SO FAR, assuming that the gap year, PhD year etc aren't too long-winded. If the duration of low-paying PhD/gap years becomes longer, this pathway will lose more talent at the new college grad level.

The hedge though here is MD-tuition explosion. If MD tuition explodes more, MD/PhD would still be at parity vs. high finance/FAANG, etc.

 

[dl2dp2]

I would like to start a thread on ideas, strategies, in formal or informal programs that have been successful at keeping research interest during residency. Fellowship is a natural time for a physician-scientist to jump back into research, but the clinical-heavy gap that truly begins with MS re-entry after completing PhD, followed by internship and residency. While formal PSTPs might provide a home (and some activities for them), what do you feel/have seen that works and why?

A. Community - monthly/bi-weekly JC, presentations, etc.
B. Research supplement
C. Attending lab meetings of mentor's lab
D. Mentoring w research mentor (keep in mind this is prior to entering fellowship) - if so, what frequency, etc.
E. Help writing/editing manuscripts
F. Peer writing club for applications and manuscripts.
G. Competitive institutional Research slot (w one clinical week per month).
H. ....
I. ....

Add your ideas/strategies, and develop these above. Add citations too if work has been published.

None of these will work.

The problem with losing research interest during residency is because: research careers lead to a pathway of filing 3 grants a year each with a probability of funding of 15%, AND a pay-cut of 50%+.

Mentoring generally involves senior researchers lying to your face or manipulating you into thinking that you'll be in that 15% if you "persist" a little longer. The more mentoring you get the worse off you are. All the mentoring you need you can get on SDN. Delaying residency graduation is a really bad idea because unless you are guaranteed a job down the line, you are just throwing money into fire.

If you want science ideas you just make an appointment and discuss science ideas. To me that's not mentoring that's just normal work.

The math is not complicated because they have become so large in numerics. The differential between a clinician salary and a researcher salary is now in the hundreds of thousands each year even for cognitive specialties, especially if you consider the instability resulting from grant uncertainty. Unless universities are willing to cough up that differential (which they never will), attrition will be the norm.

Universities aren't to be blamed, either, though--they don't really have the funds to cough up. The salary differential EASILY >>> indirects you bring in writing grants. I get paid more doing clinical work than the majority of department chairs in the country.

Being a researcher means that you KNOW all of this and make a DECISION about the way you live. Institutional programming is all a distracting sideshow.

 

[Dormouse]

A. Community - monthly/bi-weekly JC, presentations, etc.
B. Research supplement
C. Attending lab meetings of mentor's lab
D. Mentoring w research mentor (keep in mind this is prior to entering fellowship) - if so, what frequency, etc.
E. Help writing/editing manuscripts
F. Peer writing club for applications and manuscripts.
G. Competitive institutional Research slot (w one clinical week per month).
H. ....
I. ....

For a lowly MD/PhD student what concerns me the most is time off from clinical duties during residency/fellowship, having a reasonable chance of getting independent early career grants and startup money, and being hired with competitive salaries. The points listed above like mentorship and help with grant writing are secondary, something I will seek out on my own IF the funding/job opportunities are there.

I would also be more likely to stay in research if my productivity is judged in the context of team science rather than individual investigator grants/publications. Like I can see myself filling a niche in a multi-investigator team as a junior researcher with my clinical expertise or knowledge within a specific research domain, but it would be very difficult to compete with established investigators or any PhD-only 100% researchers while doing additional clinical work.

 

[ChordaEpiphany]

The same dynamic though plays out for PhDs. So this pathway still compares favorably vs. straight PhD. As to straight MD: if you have family money, then yes, you should probably do straight MD. If you don't have family money, you sort of don't have a choice, and the math actually favors MD/PhD--I wrote several "infamous" posts on this a number of years ago in this very forum.

The MD/PhD training program itself, if "deviously" used as a replacement for MD-only, with an eye on derm, etc., has a year-over-year yield that's comparable to an entry-level job at any of the valid alternatives--SO FAR, assuming that the gap year, PhD year etc aren't too long-winded. If the duration of low-paying PhD/gap years becomes longer, this pathway will lose more talent at the new college grad level.

The hedge though here is MD-tuition explosion. If MD tuition explodes more, MD/PhD would still be at parity vs. high finance/FAANG, etc.

Straight PhD has been a scam for at least 20 years. MD has never competed with high finance from a compensation perspective and never will, but at least you can take some pride in your work with the MD. FAANG also trounces an MD at similar levels of accomplishment. MD is more of a sure thing. That's the advantage. I also find it infinitely more satisfying, but that's a personal call.

I'm a huge personal finance nerd and have run the MD vs. MD/PhD numbers a thousand times. There are basically no situations (even 90k/yr loans that are never refinanced vs. 3-year PhD) where MD/PhD makes sense financially. It would have to be a situation where the PhD allowed you to match a specialty you otherwise couldn't. This is a rare situation and handled much better with a research year.

You do MD/PhD because you need to do bench research, you're okay with a huge chance of failure, you're okay with a 25-50% pay cut on top of that huge chance of failure, and you're okay being uncertain about your career path until 45 or even 50 years old. Finances shouldn't even factor into it. There are some MD/PhD paths that make bank. Directors of big time cancer centers and Chiefs/Chairs of big departments do fantastic financially. Planning to get those positions is like planning to be a rockstar. If you want money, and you are talented enough to do an MSTP, there are a million better options.

 

[dl2dp2]

I'm a huge personal finance nerd and have run the MD vs. MD/PhD numbers a thousand times. There are basically no situations (even 90k/yr loans that are never refinanced vs. 3-year PhD) where MD/PhD makes sense financially. It would have to be a situation where the PhD allowed you to match a specialty you otherwise couldn't. This is a rare situation and handled much better with a research year.

I'm pretty sure your math is wrong.

See this link:
What percent of MD/PhD grads end up with 80-20 research-clinical academic appointments?

In the original thread, none of the responders were able to give me a solid response as to why my math is wrong. Perhaps you can.

The only assumption that *might* not be true is that student loans can't be refi-ed into a 30-year low rate amortization, which at the time of writing it can't but since then there are now some emerging options to re-fi into low rate 10-20 years. Still, what we are looking at here is a difference in yield, not a difference in principle in compounding earlier.

You are making a mistake in thinking that the 150k you make during PhD years as a 25-year-old can be directly subtracted from the 250k salary you make as an attending at 35. It can't be because the latter is 10 years later in compounding.

 

[ChordaEpiphany]

I'm pretty sure your math is wrong.

See this link:
What percent of MD/PhD grads end up with 80-20 research-clinical academic appointments?

In the original thread, none of the responders were able to give me a solid response as to why my math is wrong. Perhaps you can.

The only assumption that *might* not be true is that student loans can't be refi-ed into a 30-year low rate amortization, which at the time of writing it can't but since then there are now some emerging options to re-fi into low rate 10-20 years. Still, what we are looking at here is a difference in yield, not a difference in principle in compounding earlier.

You are making a mistake in thinking that the 150k you make during PhD years as a 25-year-old can be directly subtracted from the 250k salary you make as an attending at 35. It can't be because the latter is 10 years later in compounding.

Like I said, I'm a huge personal finance nerd. I'm not making that mistake. A few years ago I built a script that would calculate net worth based on income by year and then spit out tables/graphs with the data. This script accounts for taxes (federal and state), loans (including compounding and refinancing), PSLF, interest rate on investments, and of course expenditure/savings.

It's impossible to perfectly "simulate," because people will do wildly different things with their money. However, it's a perfect tool for asking, "which pathway makes you more given the same historically average conditions?"

Below is MD vs. MD/PhD for a number of scenarios. In each scenario med school starts at 22, retirement happens at 65, investments show 6% real growth (I'm lumping primary residence in with stocks here, so lower than 7%), loans are refinanced from 6% to 4.5% after med school, all of them save/invest 30% of their post-tax, post-loan payment income.

Derm/Mohs. $600K/year as an attending. 3 year PhD. 90K/yr loans for MD-only. MD/PhD saves more in residency (20% vs. 10%) because of lack of loans. Even here, MD-only retires with $15.8M. MD/PhD retires with $14.3M.

Here's a more realistic one. Anesthesiology. $400K/year as an attending. 4 year PhD. 70K/year loans for MD-only. MD/PhD saves more in residency as above. MD-only retires with $11.4M. MD/PhD retires with $9.8M.

That said, the even more realistic comparison is an average MD-only career vs. an average academic career and a wildly successful one. Here's the comparison of an average employed MD oncologist ($450K/yr, no loan forgiveness) vs. MD/PhD academic oncologist running a lab ($200K/yr --> $400K/yr) vs. prominent MD/PhD academic oncologist who eventually directs a major cancer center at age 55 ($200K/yr --> $400K/yr --> $700K).

One takeaway from above is that mathematically MD/PhD will basically never be worthwhile financially unless you manage to match a specialty you otherwise couldn't and then ditch academics. At that point I say take the loans and research year and save yourself the stress. All things held constant, more earnings years > no loans.

The other takeaway is that they all end up plenty wealthy (given they actually save 30% of post-tax income each year). The bigger consideration financially is that you spend more time living and working like a student. Retiring with $7M vs. $11M is functionally the same. You do MSTP so you can roll the dice on trying to run a lab (knowing you'll probably lose).

To bring this back to the original point of the post, while the money is obviously worse in academics, the real problem is the training pathway and insecurity, not the overall pay. I'm not at all deterred by the prospect of $4M+ in career losses. I am deterred by the probability of having a mediocre research career that effectively ends with a grant rejection at 45-47 years old. That basically leaves you as a late-40s attending who put all their career development into a pathway that is no longer open to you. I imagine at this point you transition to mostly clinical work and other academic endeavors (e.g., admin, clinical research, directing particular clinics/programs, etc...), and that your MD-only colleagues who've been developing themselves in this arena are well ahead of you. To stay with the pathway I'd need to be reasonably convinced that I could still transition and have a fulfilling career in academics, with a high ceiling on prestige/advancement, even after failing along the K-to-R pathway. Otherwise this career has a lot of downside without promising much to make up for it.

 

[CheGuevaraMD]

I'm pretty sure your math is wrong.

See this link:
What percent of MD/PhD grads end up with 80-20 research-clinical academic appointments?

In the original thread, none of the responders were able to give me a solid response as to why my math is wrong. Perhaps you can.

The only assumption that *might* not be true is that student loans can't be refi-ed into a 30-year low rate amortization, which at the time of writing it can't but since then there are now some emerging options to re-fi into low rate 10-20 years. Still, what we are looking at here is a difference in yield, not a difference in principle in compounding earlier.

You are making a mistake in thinking that the 150k you make during PhD years as a 25-year-old can be directly subtracted from the 250k salary you make as an attending at 35. It can't be because the latter is 10 years later in compounding.

You make the assumption that the MD-PhD never does a fellowship or goes into academia. But why go through the whole rigamarole of physician science just to save a few hundred thousand?

Just go into tech post college and forget all about medicine.

 

[dl2dp2]

Below is MD vs. MD/PhD for a number of scenarios. In each scenario med school starts at 22, retirement happens at 65, investments show 6% real growth (I'm lumping primary residence in with stocks here, so lower than 7%), loans are refinanced from 6% to 4.5% after med school, all of them save/invest 30% of their post-tax, post-loan payment income.

Something is wrong with your math. I want to see the figures between age 20 and 40 with a scale between -0.5 and 0.5M, then I can tell you what's wrong with it.

Secondly, the main conclusion you are drawing is that MDs who work longer careers end up with more money. This seems trivially true and not really what we are talking about. The effect you are describing is simply that the MD-only had more years to compound. The apple to apple comparison is at the end of medical school. At that point, the MD only has 400k of loan, and the MD-PhD has zero. You say the average MD-only is younger than the MD-PhD, which is fair enough an argument, but do people work longer because they start out younger? I think a much more realistic assumption is that people work the same duration AFTER training.

There's also no evidence that MDs graduates end up in the same career positions younger than MD PhDs, especially not in acdaemia. See:
NIH RePORT - Physician Scientist-Workforce Report 2014 - Physician-Scientists with a Medical Degree in the NIH-Funded Workforce

My impression is that MD PhDs generally are slightly younger and have lower age variance at medical entrance than MD-onlys. This data is not easily found online though at a cursory search.

You make the assumption that the MD-PhD never does a fellowship or goes into academia. But why go through the whole rigamarole of physician science just to save a few hundred thousand?

Just go into tech post college and forget all about medicine.

No this is not what I'm assuming. You need to read my posts more carefully and actually learn to be more numerate. It's a bore to try to explain over and over that the math has nothing to do with post-medical school career choice. The mathematical argument is very simple. It's about the scaling of compound interest to straight yearly income.

It's like, why bother saving a few thousand dollars a year in Roth IRA in your 20s? You'll be making 250k+ later! No dum dum, because it blows up into millions when you are 65. If you don't learn this soon you'll be poor forever.

And here's why you wouldn't "just go into tech" post-college: most tech jobs pay way worse than the post-tax yield of up to 150k a year during the PhD years of your MD PhD programs.

 

[dl2dp2]

I am deterred by the probability of having a mediocre research career that effectively ends with a grant rejection at 45-47 years old. That basically leaves you as a late-40s attending who put all their career development into a pathway that is no longer open to you. I imagine at this point you transition to mostly clinical work and other academic endeavors (e.g., admin, clinical research, directing particular clinics/programs, etc...), and that your MD-only colleagues who've been developing themselves in this arena are well ahead of you. To stay with the pathway I'd need to be reasonably convinced that I could still transition and have a fulfilling career in academics, with a high ceiling on prestige/advancement, even after failing along the K-to-R pathway. Otherwise this career has a lot of downside without promising much to make up for it.

That's fair enough a point. But this point applies whether you trained as an MD or MD-PhD or PhD. In fact, you are much better off if you trained as an MD-PhD vs. the other two alternatives, which is why these other two paths have even HIGHER dropout rates.

Keep in mind most people who end up doing research fellowships are MDs with a ton of student loans.

Again, apple to apple comparison favors MD-PhD. If you don't make apple to apple comparisons, you end up with illogical conclusions. The fact that the post-training pathway in academic research sucks regardless of where you come from is irrelevant to the point that MD-PhD is [slightly] superior to the other pathways.

One implicit moral here is that IF you don't like the odds and the content of the job (3 grants a year at 15% odds each), the sooner you drop out the better off you are. Again, this is true regardless of PhD vs. MD vs. MD PhD in an apple to apple comparison.

 

[dl2dp2]

For a lowly MD/PhD student what concerns me the most is time off from clinical duties during residency/fellowship, having a reasonable chance of getting independent early career grants and startup money, and being hired with competitive salaries. The points listed above like mentorship and help with grant writing are secondary, something I will seek out on my own IF the funding/job opportunities are there.

I would also be more likely to stay in research if my productivity is judged in the context of team science rather than individual investigator grants/publications. Like I can see myself filling a niche in a multi-investigator team as a junior researcher with my clinical expertise or knowledge within a specific research domain, but it would be very difficult to compete with established investigators or any PhD-only 100% researchers while doing additional clinical work.

Is 15% per cycle, 3 cycles a year with a total survival at 10 years of about 20-25% "reasonable"? Second paragraph is not gonna happen. If you don't like the odds, my "mentorship" to you is to start to plan for an exit now.

 

[Dormouse]

Is that to me or are you making a general comment? Chance of funding success ranges from very low for some individuals to very high for others depending on who they are, who is supporting them, where they can get money from, etc so looking at the NIH average without taking into account individual circumstances is not very useful. Different people will have different definitions for what is reasonable.

 

[Dormouse]

The people I know who have done this path “quickly” have all done a version of this: finding the right support to keep research going during their 100% clinical periods and the right mentor/lab to support that while still being the intellectual lead of a project.

I saw the same thing.

 

[ChordaEpiphany]

Is that to me or are you making a general comment? Chance of funding success ranges from very low for some individuals to very high for others depending on who they are, who is supporting them, where they can get money from, etc so looking at the NIH average without taking into account individual circumstances is not very useful. Different people will have different definitions for what is reasonable.

I think the general point here is 1) average success rates are quite low for the whole pathway, and 2) don't assume you'll be the exception to the rule. Look, if you are just an absolute monster from a top 5 MSTP with multiple Nature/Science/Cell papers, AOA, top PSTP match, etc... You'll probably get a K. Then, maybe you'll also be a killer PI and an NIH funding rainmaker. There are some people who literally just can't be ignored, and maybe that's you. If it's not, then you're really just relying on the randomness of NIH/private grant study sections, institutional support, finding good mentors, etc...

No one is saying, "don't pursue this pathway." We're saying that you better know the odds and the risks if you do. If all you care about is being an academic physician and doing some research, you can't ask for a better pathway. You don't need continuous independent research support to be an 80% clinical faculty who collaborates on someone else's grants doing translational work as a secondary investigator. The issue is that most of us aren't satisfied with that. We either specifically want to do basic science research/run our own lab or we want the freedom to excel at something else. This pathway offers a low chance of success for the former and gives you very little time to pursue the latter if you fail.

That's fair enough a point. But this point applies whether you trained as an MD or MD-PhD or PhD. In fact, you are much better off if you trained as an MD-PhD vs. the other two alternatives, which is why these other two paths have even HIGHER dropout rates.

Fair point, the PhD does offer somewhat better lateral exit paths (relative to the initial upside of the degree). I don't think anyone is debating that MD/PhD is still the best pathway in terms of maximizing your chances of running a lab. It's just that the training pathway is so long that if you fail you're sort of up s*** creek having to change your path so drastically in mid-late career.

 

[Dormouse]

I think the general point here is 1) average success rates are quite low for the whole pathway, and 2) don't assume you'll be the exception to the rule. Look, if you are just an absolute monster from a top 5 MSTP with multiple Nature/Science/Cell papers, AOA, top PSTP match, etc... You'll probably get a K. Then, maybe you'll also be a killer PI and an NIH funding rainmaker. There are some people who literally just can't be ignored, and maybe that's you. If it's not, then you're really just relying on the randomness of NIH/private grant study sections, institutional support, finding good mentors, etc...

I most definitely wasn't implying that I am lol, only that the odds are different for different people. Just because the chance of getting into a single MD-PhD program is, say for example, 10% or less on average, it doesn't mean that the chance of a given applicant getting into a program is 10%. There are those few who get multiple acceptances everywhere while the majority likely have only one acceptance at the end of the cycle or none at all. Similar issue for survivorship in research. Blanket statements about whatever paths people choose are not all that useful.

No one is saying, "don't pursue this pathway." We're saying that you better know the odds and the risks if you do.

Why presume that MD-PhD students are not well aware of the nature of academic research or the risks and benefits of the dual degree path when they chose it? Most of my classmates have parents who are MDs, PhDs, or both, or have some family connections to medicine or research in some way (it's ridiculous how many...). Most spent many years around PhDs where funding and hiring woes have been bemoaned forever.

It's just that the training pathway is so long that if you fail you're sort of up s*** creek having to change your path so drastically in mid-late career.

What is "failing"? You're not only trained as a researcher, half of your time is training to be a clinician. Even MD-only students do research or even research year(s). Both degrees are terrific preparation for many career paths. It's 8 years of free tuition and small stipend to do something you presumably enjoy.

 

[CheGuevaraMD]

No this is not what I'm assuming. You need to read my posts more carefully and actually learn to be more numerate. It's a bore to try to explain over and over that the math has nothing to do with post-medical school career choice. The mathematical argument is very simple. It's about the scaling of compound interest to straight yearly income.

It's like, why bother saving a few thousand dollars a year in Roth IRA in your 20s? You'll be making 250k+ later! No dum dum, because it blows up into millions when you are 65. If you don't learn this soon you'll be poor forever.

And here's why you wouldn't "just go into tech" post-college: most tech jobs pay way worse than the post-tax yield of up to 150k a year during the PhD years of your MD PhD programs.

You seem both illiterate AND innumerate, which I suppose is par for the course for most physicians.

Your bizarre math counts free medical school tuition as "income," but by that measure, anyone who just never goes to med school also earns that income.

Yes, saving in your 20s is paramount for retiring early, which is why most bright and motivated youth are skipping graduate and professional school altogether now. Getting a $200k position at Google or Facebook at 22 will net you millions more over the course of your career than continuing to go to school for any profession, even medicine.

 

[Fencer]

I believe that you are missing the biggest point... WHY do you do this? If your PURPOSE is to make lots of $$$, then do FAANG, Financials or other things. If your PURPOSE is to contribute to the understanding of human disease and help potentially millions of people (even by just contributing to one step, one signaling regulatory interaction, etc.), then pursue a MD PhD route. The age of 1st R01 is the same for MDs and MD PhDs. Thus, if biomedical research is your journey then the appropriate comparison is NOT jumping into private practice but for a MD-only to stay as Post-doc (w MD debt)/Instructor for a bit longer so that AGE eventually equalizes to those who pursued MD PhD.

This is NOT a debate about the economic value of the pursuits of non-academic paths... Jumping into R&D and/or start-up companies is quite exciting with a lot economic dynamic range. In my start-up, I contributed to 10 patents and FDA de-novo clearance but it is almost defunct. Journeys are exciting... read @gbwillner (a MD PhD graduate - w PhD legitimacy in Cancer Bioinformatics). If he had taken the position at the SF company (see post #92 of this thread), he would have been worth "tens of millions". He did not but he is doing amazingly well. See also the story on two MD PhD graduates becoming billionaires.

 

[ChordaEpiphany]

I believe that you are missing the biggest point... WHY do you do this? If your PURPOSE is to make lots of $$$, then do FAANG, Financials or other things. If your PURPOSE is to contribute to the understanding of human disease and help potentially millions of people (even by just contributing to one step, one signaling regulatory interaction, etc.), then pursue a MD PhD route. The age of 1st R01 is the same for MDs and MD PhDs. Thus, if biomedical research is your journey then the appropriate comparison is NOT jumping into private practice but for a MD-only to stay as Post-doc (w MD debt)/Instructor for a bit longer so that AGE eventually equalizes to those who pursued MD PhD.

This is NOT a debate about the economic value of the pursuits of non-academic paths... Jumping into R&D and/or start-up companies is quite exciting with a lot economic dynamic range. In my start-up, I contributed to 10 patents and FDA de-novo clearance but it is almost defunct. Journeys are exciting... read @gbwillner (a MD PhD graduate - w PhD legitimacy in Cancer Bioinformatics). If he had taken the position at the SF company (see post #92 of this thread), he would have been worth "tens of millions". He did not but he is doing amazingly well. See also the story on two MD PhD graduates becoming billionaires.

@Fencer, this reminds me of a recent business/entrepreneurship lecture I attended (which was funded by our MSTP). In this lecture, the businessmen running the course gave an example of a luxury chocolate company that built its business model around being objectively better than other luxury chocolates. It ultimately succeeded in this aim, but the business failed. Why? Because the competition wasn't other luxury chocolates. It was other luxury goods, like TVs, sports cars, or any material object that could make a person feel special. The product wasn't the chocolate, it was the feeling of satisfaction that consumers got when they bought the chocolate.

You are trying to solve the problem of keeping research interest during residency. The implication here is that MD/PhDs can become disinterested. Thus, you are trying to sell MD/PhDs continued engagement in the research community. The consumers (MD/PhDs) aren't buying the research. The consumers are buying career satisfaction. They are buying a feeling of importance within their community, and research is simply the conduit to achieve that. So if you're looking for ways to keep MD/PhDs interested in research, and you're thinking about ways to keep MD/PhD an attractive route to begin with, then stop thinking about journal club, mentorship, grant writing workshops, etc... If you think MD/PhDs are motivated by signaling pathways, then you are as out of touch as the medical school deans who try to improve mental health with mandatory wellness sessions.

MD/PhDs lose interest in research because it stops giving them career satisfaction. The MD/PhD career pathway has lost its dignity. Every one of these matriculants entered their MSTP program with a sense of pride. Yet here they are almost 15 years later, still financially insecure, still a trainee getting yelled at by attendings younger than them, praying for a K award so they can continue to grind, knowing they could be (and probably will be) dropped from the path at any point. Meanwhile, clinical work is satisfying, secure, far better compensated, and dignified, commanding respect at a much younger age. The consumers buy the product that gives them the feeling of satisfaction.

You think your only responsibility is to compete with careers in biomedical research. You're wrong. Your responsibility as a leader in the community is to voice the failures of these pathways and culture better ones so that you can attract top talent. If you read through this thread and think it's irrelevant to your mission, then you're going to fail. If you want to invigorate interest from MD/PhDs, then find ways to inject dignity and security back into the pathway.

 

[Fencer]

Thank you for sharing your perspective @ChordaEpiphany ... While I still remain more idealistic than you seem to be, your point-of-view is valid, reasonable, and might be representative of many others who we lose in the PSW path. Your request of "find ways to inject dignity and security back into the pathway" is a Systems-Based Practice issue that is not easily addressable by a single training director or individual. The luxury chocolate market is a tough business... nice analogy! The Holiday season is coming up, and then it is Valentine's day. Your business model must be predicated on burst sales with many dry months. Even K awards can travel. When you get it, it is your point of maximum leverage to get the most protected time (w salary) in negotiation. There are skill sets not taught during MD-PhD training that are critical for successful transition into academic medicine. At the very least, this HHMI pdf book should be required reading.

 

[ChordaEpiphany]

Your request of "find ways to inject dignity and security back into the pathway" is a Systems-Based Practice issue that is not easily addressable by a single training director or individual.

Agreed 100%, but these things have to start somewhere. I've certainly talked to my PD about it, and it's something more people need to bring into the spotlight. This is some good reading and exactly the sort of message that needs to be disseminated.

We will never reach financial parity with our MD-only colleagues. I don't think this deters many, if any, MD/PhDs. Like I said, $4M+ in lost retirement savings doesn't phase me in the slightest. You also need a certain number of training years to be a physician, and you need a certain number of dedicated research years to run a lab. However, even with these limitations, there is a lot of fat to trim.

1) Shorten medical school. Columbia's 7 year curriculum could be the standard for all MSTPs, though I'd probably prefer 1.5-X-1.5, where X = 3 or 4. If I'm not mistaken, this also saves the medical school some money. Win-win.

2) Pick the right individuals/stop the CV arms race. It's so common to do 2-3 gap years to get a FA pub now. Imo we should phase this out and emphasize rate of achievement. I do appreciate @Lucca's points above, but I think the emphasis should be on outcomes. Being younger during your training years likely results in greater willingness to keep trudging through towards a professorship.

3) Pick the winners earlier. Funding mechanisms should be more secure earlier on for MD/PhDs, and rate of achievement should apply here as well. This could be as simple as awarding fewer Ks and more Rs to physician scientists, or it could be made more elegant by creating separate grants for physician-scientists that establish them as independent researchers within a few years of finishing fellowship. I know it's impossible for a PD to influence this, but it's worth mentioning.

This pathway would be a huge improvement. MSTP (22-29) --> PSTP (29-35) --> 1-2 years as instructor (36-37), Get the grant? Relatively secure junior faculty position. Don't get the grant? Transition to another career and put your training to use.

There are skill sets not taught during MD-PhD training that are critical for successful transition into academic medicine. At the very least, this HHMI pdf book should be required reading.

Thank you for the recommendation. I didn't even know this existed, but I've got a long travel day tomorrow and I'll give it a read.

 

[dl2dp2]

Is that to me or are you making a general comment? Chance of funding success ranges from very low for some individuals to very high for others depending on who they are, who is supporting them, where they can get money from, etc so looking at the NIH average without taking into account individual circumstances is not very useful. Different people will have different definitions for what is reasonable.

Well, now you are talking about a precision medicine issue. We need the estimate of the average effect size first. Subgrouping would require additional predictors. So the data point is quite the opposite of "not very useful." It's foundational.

What is "failing"? You're not only trained as a researcher, half of your time is training to be a clinician. Even MD-only students do research or even research year(s). Both degrees are terrific preparation for many career paths. It's 8 years of free tuition and small stipend to do something you presumably enjoy.

In program evaluation, metrics need to be pre-specified. There's a tendency to use euphemisms to hedge your program's success when it's clearly failing. The problem here isn't that the program is producing one outcome or another, it's that the intended outcome isn't the one that's being measured or evaluated against. E.g. you apply for approval for a medication to the FDA, and it has no mortality benefit. And now you step back and say that it should be approved based on secondary outcomes like "life satisfaction".

I want to know the cold data on whether there IS mortality benefit before you go out there and spill a bunch of salesmanship to me. It turns out there IS a benefit for getting an R01 if you have MD-PhD vs. MD vs. PhD, but the absolute effect size is small. (call it 3-5%, against a background rate of 15%). The relative effect size is large [obviouisly]. Me as the subject matter expert (which I actually can reasonably claim, as this is one of those things I followed around and in fact published a paper on) would say okay this makes me give a stamp of approval to MD-PhD. My recommendation to policymakers would be actually to radically drop the number of PhD programs and increase the number of MD-PhD programs. I actually think most PhDs in biomedical research are more interested in translational questions from the get-go, but high end publications/labs actually are functionally against translational questions. This then trains the translational mind out of youths, which is a terrible mistake. Furthermore, we have a physician shortage, and a scientist excess.

Of course, I got ****storm for this on Twitter. LOL PhDs are so scared of not getting a job outside of science that they'd rather not have their postdoc spots cut. Fine--keep drinking the coolaid and die a miserable impoverished death.

Thank you for sharing your perspective @ChordaEpiphany ... While I still remain more idealistic than you seem to be, your point-of-view is valid, reasonable, and might be representative of many others who we lose in the PSW path. Your request of "find ways to inject dignity and security back into the pathway" is a Systems-Based Practice issue that is not easily addressable by a single training director or individual. The luxury chocolate market is a tough business... nice analogy! The Holiday season is coming up, and then it is Valentine's day. Your business model must be predicated on burst sales with many dry months. Even K awards can travel. When you get it, it is your point of maximum leverage to get the most protected time (w salary) in negotiation. There are skill sets not taught during MD-PhD training that are critical for successful transition into academic medicine. At the very least, this HHMI pdf book should be required reading.

It's addressable, and some versions of it you've already pointed out yourself:
1. the job would be a high-end luxury item, which means it's not scalable.
2. the job would be high paying, guaranteed, and extremely selective. At Rockefeller, not only is your salary guaranteed, your lab has a floor budget even if you lose federal funding. Think about that.
3. the job would be associated with other luxury things (i.e. named fellowships, endowments, famous professors, fancy publications, etc)

There are instructions in the country where such jobs are sponsored (i.e. Rockefeller, Whitehead, etc.)
The University of Texas could start sponsoring these jobs, and it's almost guaranteed that you'll start to get luxury candidates.

3 grants a year at 15% from the feds is the opposite of luxury. It's the definition of white-collar factory work. Which is fine, for some...most people are fine with Macy's.

 

[Dormouse]

It's addressable, and some versions of it you've already pointed out yourself:
1. the job would be a high-end luxury item, which means it's not scalable.
2. the job would be high paying, guaranteed, and extremely selective. At Rockefeller, not only is your salary guaranteed, your lab has a floor budget even if you lose federal funding. Think about that.
3. the job would be associated with other luxury things (i.e. named fellowships, endowments, famous professors, fancy publications, etc)

There are instructions in the country where such jobs are sponsored (i.e. Rockefeller, Whitehead, etc.)
The University of Texas could start sponsoring these jobs, and it's almost guaranteed that you'll start to get luxury candidates.

3 grants a year at 15% from the feds is the opposite of luxury. It's the definition of white-collar factory work. Which is fine, for some...most people are fine with Macy's.

What kind of value would you be able to provide to justify that kind of cost though... Even if it's 3 grants a year at 3% many PhD-only candidates would be extremely happy to take the job.

 

[tortuga87]

ChordaEpiphany -- I am honestly impressed by how insightful you are. Most people are nowhere near as insightful, and this continues when they get older. This may partially explain your frustration with the more senior people. You are absolutely right, but what is obvious to you is not obvious to them. They never thought of it that way.

Couple of things that may be obvious, but I am not sure are noticed.

1. The "smartest and most talented people" (according to metrics developed by said less insightful people) are often not the ones who get K awards. Emotional stability (i.e., being okay not being #1 but still moving forward) and being informed of what the reviewers are looking for are also very important. Slow, steady and informed often wins the race -- as you wait for the "more talented" to drop out.

By the way, do you know why some are "the most talented?" Because they had sufficient ability to optimize metrics made up by other people. Such "talented people" are often anxious and constantly feel a little bit empty/lost inside -- i.e., less emotionally stable. What happens to these people when the carrot at the end of stick is less clear? They leave after fellowship.

2. On a related note, the people who try to optimize their life have a higher chance of becoming disheartened and therefore leave by virtue of their tendency to optimize. Looking for greener pastures can make you feel dissatisfied (and vice versa). Being stubborn and a little bit clueless helps in continuing down the path. Think of the clinicians who work at the VA healthcare system (semi-joke).

3. A lot of (maybe even most?) MD/PhDs will drop their research ambitions during residency. Many of these people still love research but dislike all of the B.S., like politics, associated with research. While most MD/PhDs do continue to do some research, the research is not the type of advanced translational research they thought they would do. Many end up as academic faculty doing "watered down part time research." Now they will not describe it as such, but if you told them that they would be doing the type of research they are doing now back when they were an MS2, they would not feel too hot about it.

 

[ChordaEpiphany]

ChordaEpiphany -- I am honestly impressed by how insightful you are. Most people are nowhere near as insightful, and this continues when they get older. This may partially explain your frustration with the more senior people. You are absolutely right, but what is obvious to you is not obvious to them. They never thought of it that way.

Couple of things that may be obvious, but I am not sure are noticed.

1. The "smartest and most talented people" (according to metrics developed by said less insightful people) are often not the ones who get K awards. Emotional stability (i.e., being okay not being #1 but still moving forward) and being informed of what the reviewers are looking for are also very important. Slow, steady and informed often wins the race -- as you wait for the "more talented" to drop out.

By the way, do you know why some are "the most talented?" Because they had sufficient ability to optimize metrics made up by other people. Such "talented people" are often anxious and constantly feel a little bit empty/lost inside -- i.e., less emotionally stable. What happens to these people when the carrot at the end of stick is less clear? They leave after fellowship.

2. On a related note, the people who try to optimize their life have a higher chance of becoming disheartened and therefore leave by virtue of their tendency to optimize. Looking for greener pastures can make you feel dissatisfied (and vice versa). Being stubborn and a little bit clueless helps in continuing down the path. Think of the clinicians who work at the VA healthcare system (semi-joke).

3. A lot of (maybe even most?) MD/PhDs will drop their research ambitions during residency. Many of these people still love research but dislike all of the B.S., like politics, associated with research. While most MD/PhDs do continue to do some research, the research is not the type of advanced translational research they thought they would do. Many end up as academic faculty doing "watered down part time research." Now they will not describe it as such, but if you told them that they would be doing the type of research they are doing now back when they were an MS2, they would not feel too hot about it.

Well I'm a sucker for being called insightful. I completely agree that many talented MD/PhDs pursued the pathway because it was prestigious and optimizable, however "Slow, steady and informed often wins the race -- as you wait for the "more talented" to drop out," could also be interpreted as, "the smartest people will eventually realize it's not worth it to stick around."

Where I disagree is point #3. I don't think most MD/PhDs are nearly as invested in a bench research career as you imagine. Deep inside I think we're mostly optimizers who chase prestige, money, respect, and security, just like everyone else. So while "starting a lab at an R1 university" is a high priority, any path will do as long as it provides those things. If you are a 39 year old Instructor of Medicine applying for K-grants and begging your chair for time and resources, you won't have any of those things. In fact, even after getting a K08 you still won't have those things, but practically everyone you started your MD journey with has all of these things. That's what needs to change.

I find it deeply ironic that the primary motivator of voluntary attrition of talented individuals from the pathway (K-to-R misery) is also the exact mechanism meant to weed out poor performers at the faculty level. Someone at a higher level needs to have a discussion with the NIH and work out a way to change funding mechanisms such that the K-award is the final decider of professorship and independence, not the R01. By the time someone gets a K, they typically have at least 8 years of full time research experience. If Big Law and consulting firms can pick partners managing million/billion dollar deals within 8 years of hiring associates/consultants, then our profession can pick professors for tenure-track spots managing labs with a few hundred thousand in resources.

 

[tr]

3. A lot of (maybe even most?) MD/PhDs will drop their research ambitions during residency. Many of these people still love research but dislike all of the B.S., like politics, associated with research. While most MD/PhDs do continue to do some research, the research is not the type of advanced translational research they thought they would do. Many end up as academic faculty doing "watered down part time research." Now they will not describe it as such, but if you told them that they would be doing the type of research they are doing now back when they were an MS2, they would not feel too hot about it.

I don't know about that. As clinical faculty doing "watered down part time research," I think I would have been totally thrilled as a graduate student to know that this option existed. At that time I remember being completely miserable and disgusted with the exploitative pyramid scheme that fed an endless stream of idealistic youngsters (not to mention countless experimental animals) into the biomedical research machine and spat out jaded forty-year-old postdocs with multiple CNS papers but no money, no job security, and no prospects to show for two decades of 60-hour weeks. I didn't really know what alternatives there might but but I pretty quickly realized I didn't want *that*.

If I had known then that I could have a job where I could both see interesting patients and make a difference in people's daily lives, while simultaneously doing research ranging from basic mechanisms of psychodevelopment through applied clinical trials, publishing (occasionally) in top journals in my area, *and* making a reasonable living with unbeatable job security and very reasonable and controllable hours, I would have said, yeah! Sign me up!

Someone at a higher level needs to have a discussion with the NIH and work out a way to change funding mechanisms such that the K-award is the final decider of professorship and independence, not the R01.

Actually I would argue that what needs to happen is that the government should stop allowing universities to depend on Uncle Sam to fund their faculty lines. Universities should figure out how to pay their employees' salaries themselves. If the government wants to underwrite specific costs associated with projects they deem important that is fine. But university faculty, students, and postdocs are not government employees and it's ridiculous that the universities expect to offload their basic operating costs to the feds - thus ensuring that the sine qua non of professorship is the ability to wheedle funds out of the government, *and* forcing trainees and lab techs who depend on those funds into the inherently uncertain and exploitation-prone positions imposed by 5-year external funding timelines.

 

[StilgarMD]

If I had known then that I could have a job where I could both see interesting patients and make a difference in people's daily lives, while simultaneously doing research ranging from basic mechanisms of psychodevelopment through applied clinical trials, publishing (occasionally) in top journals in my area, *and* making a reasonable living with unbeatable job security and very reasonable and controllable hours, I would have said, yeah! Sign me up!

Yea this sounds like a good deal (especially since I want to do Psych lol) - as someone near the end of the program, I wish there was more discussion about how one aims for such things - I don't hear anyone talk about research paths that don't aim for the R01 funded lab. Does this job require/benefit from a research track? Are the big name research places the only ones where such positions exist, or is there a wider range?

I feel like a great deal of anxiety stems from reasons mentioned before - lack of job security, the great sacrafices the path demands - but some of that could be made more palatable by clear, well developed 'off ramps', where you can take a stab at the R01 funded path, but there are designated exits and attractive options at those points which aren't just 'bail on research and be a clinician'. I suppose this is what many PhD programs are coming to terms with as far as becoming more accepting of 'Alternative' careers.

 

[tr]

Yea this sounds like a good deal (especially since I want to do Psych lol) - as someone near the end of the program, I wish there was more discussion about how one aims for such things - I don't hear anyone talk about research paths that don't aim for the R01 funded lab. Does this job require/benefit from a research track? Are the big name research places the only ones where such positions exist, or is there a wider range?

I feel like a great deal of anxiety stems from reasons mentioned before - lack of job security, the great sacrafices the path demands - but some of that could be made more palatable by clear, well developed 'off ramps', where you can take a stab at the R01 funded path, but there are designated exits and attractive options at those points which aren't just 'bail on research and be a clinician'. I suppose this is what many PhD programs are coming to terms with as far as becoming more accepting of 'Alternative' careers.

There's no bar whatsoever. Clinical faculty positions are a dime a dozen and can be found at every academic medical center. Chairs are happy to hire you as clinical faculty because you make money for the university when you see patients. Most clinical faculty don't do research because they aren't interested in it, but if you are interested in it, you are generally welcome do do as much as you can fund. You can't run a wet lab this way because of the huge overhead associated with maintaining the space and equipment, but you can certainly run a research group (or 'dry lab' if you prefer) if you are sufficiently successful at obtaining funding.

The catch/downside with respect to the full-clinical option is that your salary is much lower than you would get for equivalent clinical work in the private sector (but still generally higher than you would see as a straight PhD with an academic faculty position).

The catch/downsides with respect to the R01-funded track are 1) that you cannot do wet-lab work on your own (but it honestly is not hard to get wet-lab people to collaborate with you, they love human samples; you can also get a lot done with core facilities and mailouts to nonacademic, for-profit biotech), and 2) it's pretty hard to get protected time to write funding applications. In theory, on the tenure track you should have your time protected regardless of external funding. In fact, my experience is that at brand-name institutions the department still will not protect nonclinical time without outside funding, so there is functionally very little difference between being on the tenure or clinical track in that respect. If are on the tenure track and lose your outside funding, you drop over to the clinical track with the rest of us plebes. (Anecdotally, it kind of seems like the lower you drop on the USNews list the more likely you are to be able to get extra support out of your chair, irrespective of track.) On the plus side, if my funding application doesn't get funded, it really makes no difference to my job security or life plans. So I add another day of clinic to my schedule that year. Next year I may get something funded and put that day back toward research again.

I have never been PI on an NIH grant, though I've applied a bunch. I am/have been PI on many smaller grants from foundation and industry. I got a little bit of departmental protected time when I switched institutions a couple of years ago, and I usually also have protected time from being CoI on other people's NIH grants. It's honestly fine. I love my job. I did not leave research. I continue to be productive. I have a ton of autonomy. It helps that I really like clinical work, and I have never had any desire to run a wet lab so that's not a loss for me. It also helps that, as sluox/dl2dp2 has pointed out repeatedly on this board, I have a gainfully employed spouse and am financially secure, so I can afford to do this fun, varied, interesting job that pays very much less than I would get if I were grinding it out as a full-time clinician in a nonacademic setting.

 

[SurfingDoctor]

Just a comment about clinical work being satisfying and having dignity. I will say, at least being a decade plus into this now, that is very relative. I guess the dignity part seems a little hard to define, but in high-acuity fields, there is often a lot of consternation about that and that certainly leads to low job satisfaction and high burnout rates. When I say high-acuity fields, I'm speaking mostly to emergency medicine and critical care, though I'm sure that other subspecialties have high-acuity aspects. In these fields, because their is high-acuity and stress, most families don't necessarily perceive nor convey any sense of dignity toward the treating physicians. I'm not suggesting they don't have it, but when someone dies, that usually isn't the first thing that comes to their mind. Additionally, a lot of families have a hard time letting go (which isn't unexpected) but that can create very antagonist relationships between the physicians and the families. You'll also find that no matter where you practice, to the administration and organization in general, the physician is just another cog in the wheel who is, generally speaking, replaceable. The reason I bring this up is for anecdotes and how burnout is handled differently between the physician-scientist and the solely practicing physician.

I have (or that is to say, had) two colleagues. One was a physician-scientist and one was just a practicing physician. But both worked in the same unit with the same patients. Both burned out. The physician-scientist struggled to get grants (which is a problem in and of itself and a whole different topic of discussion) but they still have enough support that they could buy down clinical time and do some research. They were able to keep going and stay in both the clinical and research game. But the reality is they found clinical time very unsatisfying and did it mostly to continue their salary and generate additional revenue to help support their lab so that when they didn't have clinical time, they could "at least have a place to escape to". The other colleague, who was just a practicing physician though didn't have an escape. All they had was clinical time and the frustrating family interactions and administrative politics that went along with it. Realizing they had no escape, they went back to school to get an MBA and once that was completed, they left medicine all together and went to work for a pharmaceutical company. I saw them recently and we were talked about them leaving and they told me that it got to the point where clinical time made them "feel physically ill". So, in that regard, and again, I'm speaking more to the high-acuity fields, being a physician-scientist is somewhat protective from the lack of dignity and satisfaction of clinical work.

Personally, I like to have the mix. I like going to the lab and doing lab stuff (the lack of "science" and intellectual curiosity, especially in critical care, is just stupid sometimes), but I like the break that clinical service provides too. But both can be too much at times. Currently, I'm over my FTE on clinical work and its becoming a drag working every single weekend for the past 2 months and I haven't been able to work on anything in the lab recently. Alternatively, when I've had only a few shifts of clinical time a month, the lab can feel tedious writing papers/grants and doing experiments, so clinical work is a nice break. My biggest frustration is knowing how to keep the balance going when there is no safety net to prevent the scales from tipping. But that is also true for nearly every job in some way or another.

 

[SurfingDoctor]

At the very least, this HHMI pdf book should be required reading.

Agreed.

But now I know I don’t have to loan my copy out. Thanks for the .pdf link!

 

[dl2dp2]

Yea this sounds like a good deal (especially since I want to do Psych lol) - as someone near the end of the program, I wish there was more discussion about how one aims for such things - I don't hear anyone talk about research paths that don't aim for the R01 funded lab. Does this job require/benefit from a research track? Are the big name research places the only ones where such positions exist, or is there a wider range?

This kind of jobs exist in psychiatry. In particular, think VA/State/City Hospital affiliate academic centers. Since it's hard to recruit for these types of settings, often what they come up with is a 50/50 research/clinical job where the research time was fully funded and protected indefinitely without grants.

Some of these jobs don't even have long-term funding expectations (whereas most clinician scholar tracks do--i.e. if you get don't get funded by X, we'll increase your clinical load). However, if you do bring in funding, typically you can buy out your clinical time. Unfortunately, the desirability of that 50% clinical job is variable, and typically on the low side.

These jobs are not immediately obvious, especially if you train at the top 10 centers, as the department typically want you to go for a K after residency. However, if you ask around you can often find these jobs hiding in a nook somewhere. You can't really "aim" for those--typically you have a private discussion with the department chair or the jobs get announced through word of mouth. You need to network, basically.

This is similar to pharma jobs. There's no "aiming" for pharma jobs in academia. If you have an interest, you ask around, jobs often find you. One level down from that, you get a recruiter like any other normal human being. As is explained in a different thread, industry is a good track for MD PhDs.

The reason academic medical centers don't make these pathways transparent is that there's a conflict of interest. Departments want as many people file for grants as possible because each individual grant has a low probability of success. They would prefer anyone who's half-literate to write a grant, because if you were funded, the chance of you leaving is much lower, and if you don't get funded, it's not a loss on their part if you left. Does that make sense? If your boss is honest, they will tell you that explicitly. Most aren't and like to beat around bushes about "persistence" and "mentorship".

 

[StilgarMD]

There's no bar whatsoever. Clinical faculty positions are a dime a dozen and can be found at every academic medical center. Chairs are happy to hire you as clinical faculty because you make money for the university when you see patients. Most clinical faculty don't do research because they aren't interested in it, but if you are interested in it, you are generally welcome do do as much as you can fund. You can't run a wet lab this way because of the huge overhead associated with maintaining the space and equipment, but you can certainly run a research group (or 'dry lab' if you prefer) if you are sufficiently successful at obtaining funding.

The catch/downside with respect to the full-clinical option is that your salary is much lower than you would get for equivalent clinical work in the private sector (but still generally higher than you would see as a straight PhD with an academic faculty position).

The catch/downsides with respect to the R01-funded track are 1) that you cannot do wet-lab work on your own (but it honestly is not hard to get wet-lab people to collaborate with you, they love human samples; you can also get a lot done with core facilities and mailouts to nonacademic, for-profit biotech), and 2) it's pretty hard to get protected time to write funding applications. In theory, on the tenure track you should have your time protected regardless of external funding. In fact, my experience is that at brand-name institutions the department still will not protect nonclinical time without outside funding, so there is functionally very little difference between being on the tenure or clinical track in that respect. If are on the tenure track and lose your outside funding, you drop over to the clinical track with the rest of us plebes. (Anecdotally, it kind of seems like the lower you drop on the USNews list the more likely you are to be able to get extra support out of your chair, irrespective of track.) On the plus side, if my funding application doesn't get funded, it really makes no difference to my job security or life plans. So I add another day of clinic to my schedule that year. Next year I may get something funded and put that day back toward research again.

I have never been PI on an NIH grant, though I've applied a bunch. I am/have been PI on many smaller grants from foundation and industry. I got a little bit of departmental protected time when I switched institutions a couple of years ago, and I usually also have protected time from being CoI on other people's NIH grants. It's honestly fine. I love my job. I did not leave research. I continue to be productive. I have a ton of autonomy. It helps that I really like clinical work, and I have never had any desire to run a wet lab so that's not a loss for me. It also helps that, as sluox/dl2dp2 has pointed out repeatedly on this board, I have a gainfully employed spouse and am financially secure, so I can afford to do this fun, varied, interesting job that pays very much less than I would get if I were grinding it out as a full-time clinician in a nonacademic setting.

This kind of jobs exist in psychiatry. In particular, think VA/State/City Hospital affiliate academic centers. Since it's hard to recruit for these types of settings, often what they come up with is a 50/50 research/clinical job where the research time was fully funded and protected indefinitely without grants.

Some of these jobs don't even have long-term funding expectations (whereas most clinician scholar tracks do--i.e. if you get don't get funded by X, we'll increase your clinical load). However, if you do bring in funding, typically you can buy out your clinical time. Unfortunately, the desirability of that 50% clinical job is variable, and typically on the low side.

These jobs are not immediately obvious, especially if you train at the top 10 centers, as the department typically want you to go for a K after residency. However, if you ask around you can often find these jobs hiding in a nook somewhere. You can't really "aim" for those--typically you have a private discussion with the department chair or the jobs get announced through word of mouth. You need to network, basically.

This is similar to pharma jobs. There's no "aiming" for pharma jobs in academia. If you have an interest, you ask around, jobs often find you. One level down from that, you get a recruiter like any other normal human being. As is explained in a different thread, industry is a good track for MD PhDs.

The reason academic medical centers don't make these pathways transparent is that there's a conflict of interest. Departments want as many people file for grants as possible because each individual grant has a low probability of success. They would prefer anyone who's half-literate to write a grant, because if you were funded, the chance of you leaving is much lower, and if you don't get funded, it's not a loss on their part if you left. Does that make sense? If your boss is honest, they will tell you that explicitly. Most aren't and like to beat around bushes about "persistence" and "mentorship".

Thank you both for the details, I appreciate it. I suppose if they want us to focus on K's, it makes sense to not alert us to the alternatives. I am generally of the mindset of wanting a wet lab, though a human EEG/MEG/fMRI lab would also be suitable for some of my interests (does that count as wet? I imagine not but may be wrong). Of note my partner will also be working a job which would allow me to not sweat the salary, assuming I don't make the mistake of demanding to live in Boston/SF/NYC...

On the topic of 'aim', I suppose I mean in terms of qualifications and skill sets. It certainly seems like someone with exclusively wet lab experience and aspirations would have 'mis-aimed'. In other regards, there is likely little to distinguish those aspiring for RO1 vs these tracks. The Pharma thread w/ gbwillner has definitely tempered my perspectives on industry, though it will stay in the backdrop.

I am curious though, and it has come up in some forms in other threads - On the topic of 50/50 positions where the Research time is guaranteed regardless of funding, but the clinical time is demanding and maybe less desirable - How are these positions distinct from someone running a private practice half the time and working collaboratively with others at the institute the other half? I may not be familiar with some of the practical realities of these jobs and not seeing what opportunities are afforded when you work full time for University X, rather than collaborate.

 

[Fencer]

The Veterans Hospital system really allows you to bracket/protect your time quite well once you get funding. Most VA medical centers with research units are affiliated with Universities, teaching residents and medical students. In my 20+ career, I worked at a VAMC for 15 years (part-time 5/8 - 6/8) while I still worked at the University too. It is a system that allows for career development of physician-scientists, if you have a supportive leader in charge (which is the reason why I left).

 

[dl2dp2]

Thank you both for the details, I appreciate it. I suppose if they want us to focus on K's, it makes sense to not alert us to the alternatives. I am generally of the mindset of wanting a wet lab, though a human EEG/MEG/fMRI lab would also be suitable for some of my interests (does that count as wet? I imagine not but may be wrong). Of note my partner will also be working a job which would allow me to not sweat the salary, assuming I don't make the mistake of demanding to live in Boston/SF/NYC...

Yeah, you can do that. In fact, I would argue this is the predominant model right now. i.e. dual-income couple where the non-academic partner makes a lot more than the academic. There's a rapid increase of female investigators in the last 5-10 years and the majority of them follow this model.

Another popular model is the family money model, where neither partner needs to make a lot of money, and a large portion of the income/savings are driven by things like trust funds. I would say at least 30% of faculty in tier 1 departments follow this model. Rarer at mid-tier institutions.

The traditional model of a single-income household with one academic income is becoming the minority, and often generates some type of hardship, especially in HCOLs. Unfortunately it's not always easy to avoid HCOLs because that's often where the best science is.

Historically, the two academic couple model is popular for academic women. Lately, this is becoming less common as many capable male academics exit for industry or practice. Exceptions exist, but male partners are typically more driven by money per se than other factors such as flexibility in schedule that might be seen as desirable in academia. Nevertheless, female investigators are still underrepresented in general, especially after having children, because the incentives are typically not aligned correctly.

I am curious though, and it has come up in some forms in other threads - On the topic of 50/50 positions where the Research time is guaranteed regardless of funding, but the clinical time is demanding and maybe less desirable - How are these positions distinct from someone running a private practice half the time and working collaboratively with others at the institute the other half? I may not be familiar with some of the practical realities of these jobs and not seeing what opportunities are afforded when you work full time for University X, rather than collaborate.

There's no substantial foundational difference, except most specialties you can't really just "start a private practice" on the side.

Process-wise, there are some differences. The income generated from private practice is highly variable and unreliable, depending on who you are and what you do. Whereas, if you work for the state hospital or the VA, you just get a fixed dependent (albeit low) salary. Grant-driven income is always unreliable, so you trade two unreliable income streams with one reliable income stream.

 

[SurfingDoctor]

Plus, VA systems have VA Merit Awards which essentially is getting access to funds that non-VA physician scientists don’t.