The Shortening of Post-Graduate Training

[SurfingDoctor]

JCI Insight - Is it time to reduce the length of postgraduate training for physician-scientists in internal medicine?

insight.jci.org

I'm not sure I entirely agree with the conclusion, but I get where they are coming from. Being a MD-only K08, I definitely needed extra time post-graduate to bring myself up to speed. That being said, because I was MD-only, there was no fast track for me like MD-PhDs who can skip some of the fluff of clinical training to have a more research heavy post-graduate period. But then again, I don't know why they would necessarily allow for that anyway when most MDs have no track record of research.

Anyway, I guess it's kinda food for thought, though also not really.

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[tr]

I'm not sure that I find this as alarming as all that.
All our life milestones are moving out to older ages. People are living longer, and having longer productive careers as well.

Why not accept these timelines as according with our longer lifespans and healthspans?

I think the problem is not the long duration of the early career positions per se, but the fact that they are often precarious and poorly paid. But this is actually less of a problem for physicians than for PhDs. Also I think those aspects could be improved without focusing excessively on the number of years spent in a given position.

 

[tr]

Dropping updated numbers here. Median age at first R01 for MDs and MD/PhDs in 2023 was 45.

Age of Principal Investigators at the Time of First R01-Equivalent Remains Level with Recent Years in FY 2023 – NIH Extramural Nexus

nexus.od.nih.gov

 

[SurfingDoctor]

Dropping updated numbers here. Median age at first R01 for MDs and MD/PhDs in 2023 was 45.

Age of Principal Investigators at the Time of First R01-Equivalent Remains Level with Recent Years in FY 2023 – NIH Extramural Nexus

nexus.od.nih.gov

It’s all way too long. For most other careers, that’s well into a mid-career. Not “early”.

 

[tr]

It’s all way too long. For most other careers, that’s well into a mid-career. Not “early”.

So R01 is a mid-career level type of grant. Early career is supported by career development mechanisms.
That's not really surprising. The publication record and prelim data you need to present to get an R01 funded pretty much bring you past the early career point.

 

[SurfingDoctor]

So R01 is a mid-career level type of grant. Early career is supported by career development mechanisms.
That's not really surprising. The publication record and prelim data you need to present to get an R01 funded pretty much bring you past the early career point.

Sure, but the people who typically apply for it are assistant professors and are considered early-stage, irrespective of the amount of work one has to do to obtain it.

Also, slightly unrelated, but they need to get rid of instructorship positions. Those are just rubbing salt in the wound.

 

[tr]

I think the mindset that an R01 defines the beginning of one's mature scientific career is just not representative of the facts on the ground.
An R01 is a 5-year project grant, for which you have to have a substantial research track record in order to be competitive.

The process of science has also resulted in an ever-accelerating accumulation of new information, which it now takes years to synthesize and master for any particular subfield. In an empirical field like biomedicine, it's really not surprising that it takes many years to get to the point of knowing enough to push the boundary forward.

The problems with early-career positions are not the titles, but the fact that they are often poorly paid, poorly supported, and precarious.
If these issues could be fixed I don't think there would be a quibble about the letter names of the funding mechanisms.

 

[Mr.Smile12]

I think the mindset that an R01 defines the beginning of one's mature scientific career is just not representative of the facts on the ground.
An R01 is a 5-year project grant, for which you have to have a substantial research track record in order to be competitive.

The process of science has also resulted in an ever-accelerating accumulation of new information, which it now takes years to synthesize and master for any particular subfield. In an empirical field like biomedicine, it's really not surprising that it takes many years to get to the point of knowing enough to push the boundary forward.

The problems with early-career positions are not the titles, but the fact that they are often poorly paid, poorly supported, and precarious.
If these issues could be fixed I don't think there would be a quibble about the letter names of the funding mechanisms.

Just wondering: can anyone on promotion/tenure committees if getting an R01 at your institution helps to retain assistant professors? Is it required for associate professor promotions, or should you get it after the raise in rank?

 

[SurfingDoctor]

Just wondering: can anyone on promotion/tenure committees if getting an R01 at your institution helps to retain assistant professors? Is it required for associate professor promotions, or should you get it after the raise in rank?

If you are on the tenure track, it's absolutely a requirement you get an R01 (or RPG equivalent) before you are even considered for promotion to associate professor. For non-tenure tracks, it is not.

Though, I will say, the variation in metrics necessary for promotion are highly institution dependent.

 

[Neuronix]

If you are on the tenure track, it's absolutely a requirement you get an R01 (or RPG equivalent) before you are even considered for promotion to associate professor. For non-tenure tracks, it is not.

Though, I will say, the variation in metrics necessary for promotion are highly institution dependent.

R01 equivalent funding is not a criteria for promotion to associate here even on tenure track.

However, 2x R01 equivalent funding is a requirement to get tenure.

I can't see how someone would make professor on tenure track without getting tenured either previously at associate level or at the same time with promotion to professor.

Just wondering: can anyone on promotion/tenure committees if getting an R01 at your institution helps to retain assistant professors? Is it required for associate professor promotions, or should you get it after the raise in rank?

Getting an R01 makes a faculty member much more desirable in general. But, I don't have any data on whether R01 equivalent funding makes people stay or makes them more likely to be recruited elsewhere. I have seen it go both ways.

There are other possible pathways. Nobody would give me a research-track position at all, and I was willing to do fellowships, instructorships, etc. At that time in my life I was ready to fight for grants and research tracks, and nobody was willing to even give me that chance despite a strong CV. So I was an associate professor on clinical track when I got my R01s. I switched to tenure-track after that.

 

[SurfingDoctor]

R01 equivalent funding is not a criteria for promotion to associate here even on tenure track.

However, 2x R01 equivalent funding is a requirement to get tenure.

I can't see how someone would make professor on tenure track without getting tenured either previously at associate level or at the same time with promotion to professor.



Getting an R01 makes a faculty member much more desirable in general. But, I don't have any data on whether R01 equivalent funding makes people stay or makes them more likely to be recruited elsewhere. I have seen it go both ways.

There are other possible pathways. Nobody would give me a research-track position at all, and I was willing to do fellowships, instructorships, etc. At that time in my life I was ready to fight for grants and research tracks, and nobody was willing to even give me that chance despite a strong CV. So I was an associate professor on clinical track when I got my R01s. I switched to tenure-track after that.

Yes, high variation. At my institution, you can't switch to the tenure-track as an associate professor, you can only switch off. Also, non-procedural specialities have a higher bar for number of grants and promotion compared to procedural specialities, I suspect because the latter generate more clinical revenue which is more important to the institution than indirects, but you still need R01-equivalents either way.

Of course, at peer institutions, I've known tenured, full professors who have had less NIH-support than I have, so again, institutions vary highly.

As for the bolded, that has never been my experience. I don't know who it would be valuable to besides the individual (and maybe globally society at some distant juncture). My own department chair has repeated told us that from a financial standpoint, RPG are money losers. That's probably not really true on face value if the annual directs are in the millions (and they do often bring prestige which can help donor money), but for the more individual RPG, the more you can bill clinically and generate RVUs, that is definitely true. Therefore, I've always viewed research and funding as a personal professional award (ie, I get to keep doing what I'm interested in even though most others, and the institution, don't care). It's really more of a paid hobby than anything else.

 

[tr]

As for the bolded, that has never been my experience. I don't know who it would be valuable to besides the individual (and maybe globally society at some distant juncture). My own department chair has repeated told us that from a financial standpoint, RPG are money losers. That's probably not really true on face value if the annual directs are in the millions (and they do often bring prestige which can help donor money), but for the more individual RPG, the more you can bill clinically and generate RVUs, that is definitely true.

I guess from the dept's perspective it must depend on what the alternative use of that individual's time would be. Personally I can see that the R01 indirects completely dwarf whatever clinical revenue I would have brought in with 5 years of 25-30% FTE in clinical work. But presumably if I were doing expensive, high-volume procedures instead of expressing sympathy and handing out Prozac, that calculus would look quite different.

There are other possible pathways. Nobody would give me a research-track position at all, and I was willing to do fellowships, instructorships, etc. At that time in my life I was ready to fight for grants and research tracks, and nobody was willing to even give me that chance despite a strong CV. So I was an associate professor on clinical track when I got my R01s. I switched to tenure-track after that.

I had a very similar trajectory. Clinical assistant --> clinical associate, scraping together a research program on a shoestring budget with foundation funding, then got R01 and switched to associate (without tenure) on tenure track. If I turn out to be a one-hit wonder I guess I will drop back over to clinical track when my 5 years run out.

This is why it really boggles my mind when I see posts like

Research options after fellowship

I am currently in my last few months of my IM residency training. I matched into a Nephrology/critical care care fellowship training. I plan on doing Nephrology research work after graduating from fellowship but I would like to keep my critical care to be my primary bread winner option. In...

forums.studentdoctor.net

High unfilled numbers this year in pediatrics

And now with the hospitalist fellowship and decreasing ICU time in residency … what the F is the ABP doing? I’m not saying anything new here, just agreeing that peds is becoming kind of like surgery in the sense that if you could see yourself doing anything else, then maybe you should.

forums.studentdoctor.net

Clinical Psychology (Neuropsychology) Academic Career Outlook?

I’m a 2nd year PhD student in clinical psych specializing in neuropsych and I’m hoping to be a professor. Obviously the academic job market isn’t great at the moment, but I’ve heard that clinical psych positions are relatively easier to obtain due to the increased flexibility of the degree. Is...

forums.studentdoctor.net

where people without external grant funding are getting showered with gratis protected time and/or offered research-track appointments.
That's just never something I've seen. In my world, any research time requires external funding. Otherwise, get to bringing those RVUs.

 

[SurfingDoctor]

I guess from the dept's perspective it must depend on what the alternative use of that individual's time would be. Personally I can see that the R01 indirects completely dwarf whatever clinical revenue I would have brought in with 5 years of 25-30% FTE in clinical work. But presumably if I were doing expensive, high-volume procedures instead of expressing sympathy and handing out Prozac, that calculus would look quite different.




I had a very similar trajectory. Clinical assistant --> clinical associate, scraping together a research program on a shoestring budget with foundation funding, then got R01 and switched to associate (without tenure) on tenure track. If I turn out to be a one-hit wonder I guess I will drop back over to clinical track when my 5 years run out.

This is why it really boggles my mind when I see posts like

Research options after fellowship

I am currently in my last few months of my IM residency training. I matched into a Nephrology/critical care care fellowship training. I plan on doing Nephrology research work after graduating from fellowship but I would like to keep my critical care to be my primary bread winner option. In...

forums.studentdoctor.net

High unfilled numbers this year in pediatrics

And now with the hospitalist fellowship and decreasing ICU time in residency … what the F is the ABP doing? I’m not saying anything new here, just agreeing that peds is becoming kind of like surgery in the sense that if you could see yourself doing anything else, then maybe you should.

forums.studentdoctor.net

Clinical Psychology (Neuropsychology) Academic Career Outlook?

I’m a 2nd year PhD student in clinical psych specializing in neuropsych and I’m hoping to be a professor. Obviously the academic job market isn’t great at the moment, but I’ve heard that clinical psych positions are relatively easier to obtain due to the increased flexibility of the degree. Is...

forums.studentdoctor.net

where people without external grant funding are getting showered with gratis protected time and/or offered research-track appointments.
That's just never something I've seen. In my world, any research time requires external funding. Otherwise, get to bringing those RVUs.

Well, in no defense of those people who referenced in the thread you linked about pediatrics, most of those folks are insufferable as hell and complain about how they don’t have effort academic time AND don’t get paid enough, not realizing that they are pissing away their academic time AND also not seeing patients to generate revenues. They are the reason that I would never choose to be a division chief. I don’t have time for that victimhood mentality.

And don’t get me started on the person who was given 75% protected time and intentionally pissed it away who I ranted about.

And as I stated, those aimless academics are training the next generation of aimless academics to continue the cycle till we end up in idiocracy till I end up looking like “Not Sure”.

 

[solitude]

I guess from the dept's perspective it must depend on what the alternative use of that individual's time would be. Personally I can see that the R01 indirects completely dwarf whatever clinical revenue I would have brought in with 5 years of 25-30% FTE in clinical work. But presumably if I were doing expensive, high-volume procedures instead of expressing sympathy and handing out Prozac, that calculus would look quite different.




I had a very similar trajectory. Clinical assistant --> clinical associate, scraping together a research program on a shoestring budget with foundation funding, then got R01 and switched to associate (without tenure) on tenure track. If I turn out to be a one-hit wonder I guess I will drop back over to clinical track when my 5 years run out.

This is why it really boggles my mind when I see posts like

Research options after fellowship

I am currently in my last few months of my IM residency training. I matched into a Nephrology/critical care care fellowship training. I plan on doing Nephrology research work after graduating from fellowship but I would like to keep my critical care to be my primary bread winner option. In...

forums.studentdoctor.net

High unfilled numbers this year in pediatrics

And now with the hospitalist fellowship and decreasing ICU time in residency … what the F is the ABP doing? I’m not saying anything new here, just agreeing that peds is becoming kind of like surgery in the sense that if you could see yourself doing anything else, then maybe you should.

forums.studentdoctor.net

Clinical Psychology (Neuropsychology) Academic Career Outlook?

I’m a 2nd year PhD student in clinical psych specializing in neuropsych and I’m hoping to be a professor. Obviously the academic job market isn’t great at the moment, but I’ve heard that clinical psych positions are relatively easier to obtain due to the increased flexibility of the degree. Is...

forums.studentdoctor.net

where people without external grant funding are getting showered with gratis protected time and/or offered research-track appointments.
That's just never something I've seen. In my world, any research time requires external funding. Otherwise, get to bringing those RVUs.

kudos to you and Neuronix for struggling along the clinical track and securing funding and the switch over to TT.

As a proceduralist, I know plenty of folks with "gratis protected time", usually 1-2 days per week, with no external funding or associated revenue whatsoever. It's just a paycut, where you have less clinical time, make less money than 100% clinical colleagues, but you are free to pursue research or do activities of any type. Many people do this for their first few years, but others indefinitely. Most people do use this time well, but not everybody as SurfingDoctor referenced.

However, for most of these people it makes no sense from a financial angle to use protected time to even apply for NIH grants. It's a ton of work and admin overhead that would eat up most of one's protected time. Even if one were to say, get a K then an R to provide 3-4 days of research time...given the NIH salary cap and various institutional compensation minutiae, cutting back clinically would result in a huge paycut.

Of course there are other reasons to apply for these grants, such as if they enable one to do research that would otherwise be impossible with multi-PI/center grants, philanthropy, or industry funding. Prestige, etc. Most proceduralist MD-PhDs I know who get these grants do it because of some combination of the following:
1) they are clinically extremely unproductive because of a lack of skills/hard work
2) they hate clinical medicine and basically will do anything to avoid seeing patients
3) flexibility. They don't want to work 7a-6p doing clinical medicine (similar to above).
4) it is a hobby. Typically these live in LCOL areas and/or have a spouse who makes a lot of money.

It is not necessary for tenure at many institutions in my specialty. But as stated in other threads, tenure is meaningless. Some of my friends don't even bother to apply for it until the very end of their eligibility period because it's not worth their time to fill out the paperwork.

I think it is important to note that grants, although sometimes required to do some research, are not really important per se. Grants do not advance the field. Grants do not help patients. They are an epi-phenomenon of our current scientific structure, but it is papers, patents, presentations at conferences, clinical trials, etc that are the real currency of success (although not always recognized as such by tenure committees and the community at large).

I am a bit off-topic from the age at 1st grant. 45/46 is insane. Manage your money well in a proceduralist specialty, and you can retire at that age.

 

[tr]

kudos to you and Neuronix for struggling along the clinical track and securing funding and the switch over to TT.

As a proceduralist, I know plenty of folks with "gratis protected time", usually 1-2 days per week, with no external funding or associated revenue whatsoever. It's just a paycut, where you have less clinical time, make less money than 100% clinical colleagues, but you are free to pursue research or do activities of any type. Many people do this for their first few years, but others indefinitely. Most people do use this time well, but not everybody as SurfingDoctor referenced.

However, for most of these people it makes no sense from a financial angle to use protected time to even apply for NIH grants. It's a ton of work and admin overhead that would eat up most of one's protected time.

On the admin overhead issue, I'm part of a center and we had multiple PIs pool money to pay for a whiz program manager who manages all the bureaucratic tasks associated with our funding applications. It's been amazing to have the program manager handle all the biosketch reformatting and stuff so we can focus on the science.

Even if one were to say, get a K then an R to provide 3-4 days of research time...given the NIH salary cap and various institutional compensation minutiae, cutting back clinically would result in a huge paycut.

Right, I think the incentive structures around research vs clinic are so heavily determined by the economic return on clinical activity for each specialty.

It sounds like for highly recompensed procedural specialties, there is so much extra cash sloshing around in the dept that chairs are fine to hand out a bit of protected time if it keeps people happy.

My salary as an academic psychiatrist is neck and neck with the NIH cap. Clinical revenue I bring is well above my salary, but nowhere near what a proceduralist brings. So my chair is working with tighter margins and has less ability to hand out freebies. On the other hand, at least I'm not financially disincentivized to do research. The big pay discrepancy in our field is between academics and private practice; but that would be a totally different job, and not one I personally want to do.

Of course there are other reasons to apply for these grants, such as if they enable one to do research that would otherwise be impossible with multi-PI/center grants, philanthropy, or industry funding. Prestige, etc. Most proceduralist MD-PhDs I know who get these grants do it because of some combination of the following:
1) they are clinically extremely unproductive because of a lack of skills/hard work
2) they hate clinical medicine and basically will do anything to avoid seeing patients
3) flexibility. They don't want to work 7a-6p doing clinical medicine (similar to above).
4) it is a hobby. Typically these live in LCOL areas and/or have a spouse who makes a lot of money.

Right. #4 is it for all of us really. Research is a hobby. #3 is big for me too. I love seeing patients.... 2 days per week. Forty hours of it I wouldn't want to do.

I think it is important to note that grants, although sometimes required to do some research, are not really important per se. Grants do not advance the field. Grants do not help patients. They are an epi-phenomenon of our current scientific structure, but it is papers, patents, presentations at conferences, clinical trials, etc that are the real currency of success (although not always recognized as such by tenure committees and the community at large).

Well it's a ratchet system. You have to have money to support the time and materials to make scientific progress, and then you use the evidence of that progress to bootstrap yourself into more money.

The critical thing about funding is it gives you a lot of power to determine the goals and direction of the work. That's worth a ton to me.

I am a bit off-topic from the age at 1st grant. 45/46 is insane. Manage your money well in a proceduralist specialty, and you can retire at that age.

Honestly I love my job and retirement doesn't sound particularly appealing. When it gets to that point that I'm tired of the research hustle, I'd probably just switch to very part time high fee cash only private practice.

 

[Neuronix]

As for the bolded, that has never been my experience. I don't know who it would be valuable to besides the individual (and maybe globally society at some distant juncture). My own department chair has repeated told us that from a financial standpoint, RPG are money losers. That's probably not really true on face value if the annual directs are in the millions (and they do often bring prestige which can help donor money), but for the more individual RPG, the more you can bill clinically and generate RVUs, that is definitely true. Therefore, I've always viewed research and funding as a personal professional award (ie, I get to keep doing what I'm interested in even though most others, and the institution, don't care). It's really more of a paid hobby than anything else.

I know this is all specialty and department specific, but I can say in my case I would not still be in my current institution had my first R01 not gotten the fundable summary statement when it did. There were a lot of issues that I faced at the time that were fixed because I negotiated with that grant and a job offer somewhere else. If I didn't have that grant, there would have been no negotiation to keep me here.

It is also quite common in my specialty and some other specialties I work with for people to get that first R01 equivalent and go somewhere else with it. I talked to my NIH program officer about this possibility, and they also told me it's quite common. I've had a few unsolicited informal offers come my way over the past few years that I don't believe I would have received without the grants. I don't recall ever receiving unsolicited informal offers before my grants got funded. Obviously, more has happened over the past few years than just my grants, but they are a major factor. All of that written, the job offers have never had sufficient pull to make me want to leave.

Well, in no defense of those people who referenced in the thread you linked about pediatrics, most of those folks are insufferable as hell and complain about how they don’t have effort academic time AND don’t get paid enough, not realizing that they are pissing away their academic time AND also not seeing patients to generate revenues. They are the reason that I would never choose to be a division chief. I don’t have time for that victimhood mentality.

And don’t get me started on the person who was given 75% protected time and intentionally pissed it away who I ranted about.

And as I stated, those aimless academics are training the next generation of aimless academics to continue the cycle till we end up in idiocracy till I end up looking like “Not Sure”.

I have seen so many people demand academic protected time and then do nothing with it.

Regarding the 50%+ academic types failing to do anything worthwhile, this has resulted from poor hiring decisions in my opinion. In my opinion, people being hired for a physician-scientist track need to have a strong track record, a clear plan to obtain funding, and the proper resources and environment to actually do it. The leadership I've seen has just kind of like "we like this person, so here's protected time" without adequately addressing if the person has the correct track record, a clear plan, and the right institutional environment for success of their proposed research program. It's just kind of a "well they'll figure it out" sink or swim. The faculty member feels great because they can do a lot less and collect full academic salary for a number of years before transitioning to full clinical or bailing to the private world. They'll blame all their issues on the institutional issues that reflect that I'm not sure they should have been hired in the first place. Then the institution or department turns around and says "that's why we don't support physician-scientists." It's an absolutely bizarre dynamic that I think is a function of poor leadership.

Regarding the 20-30% protected time, that's pretty useless to build a physician-scientist career except for the most motivated and/or insane. That is, I did it, but it was a combination of insane luck and work ethic that I don't think you can expect from most faculty. This protected time is standard in a lot of academic departments because 20% protected time at some institutions is actually full time RVUs elsewhere because they cram in the patients while they're in clinic. Such faculty need a day or so to catch up and hopefully publish one soft paper a year to get promoted and get pay rises down the road.

However, for most of these people it makes no sense from a financial angle to use protected time to even apply for NIH grants. It's a ton of work and admin overhead that would eat up most of one's protected time. Even if one were to say, get a K then an R to provide 3-4 days of research time...given the NIH salary cap and various institutional compensation minutiae, cutting back clinically would result in a huge paycut.

Of course there are other reasons to apply for these grants, such as if they enable one to do research that would otherwise be impossible with multi-PI/center grants, philanthropy, or industry funding. Prestige, etc. Most proceduralist MD-PhDs I know who get these grants do it because of some combination of the following:
1) they are clinically extremely unproductive because of a lack of skills/hard work
2) they hate clinical medicine and basically will do anything to avoid seeing patients
3) flexibility. They don't want to work 7a-6p doing clinical medicine (similar to above).
4) it is a hobby. Typically these live in LCOL areas and/or have a spouse who makes a lot of money.

As what I guess you could call a proceduralist MD/PhD, I disagree. First, the academic mission of the University is to have academics. Grants are a nationally competitive way of certifying that the research you are doing is meaningful. Is it perfect? OF COURSE NOT. But, anyone who has managed to pull down an R01-equivalent, or especially several, is someone who is at least trying to do research. It's a decent enough filter. Sure, they're money losers, but if you're not going to support people to do research and get meaningful grants, what is the academic department even doing?

Second, I write grants because I need them to support my lab since I trained to be a physician-scientist and I believe in being a physician-scientist. Regarding 1 and 2, nobody would say that about me. In fact, I love to keep up my clinical skills so I can pivot back to clinic if things ever go unfavorably for me in the lab. Regarding 3, I am here 10-12 hours a day anyway, though I do like the variety of lab and clinic. Regarding 4, if I didn't have to work, this is not what I would do for fun.

It is not necessary for tenure at many institutions in my specialty. But as stated in other threads, tenure is meaningless. Some of my friends don't even bother to apply for it until the very end of their eligibility period because it's not worth their time to fill out the paperwork.

I like the job security that tenure provides. It's not fool proof, but it's not meaningless, at least around here, historically.

I think it is important to note that grants, although sometimes required to do some research, are not really important per se. Grants do not advance the field. Grants do not help patients. They are an epi-phenomenon of our current scientific structure, but it is papers, patents, presentations at conferences, clinical trials, etc that are the real currency of success (although not always recognized as such by tenure committees and the community at large).

Grants allow you to have (or keep) the lab. If you can have a lab without grants, good for you, I guess.

I am a bit off-topic from the age at 1st grant. 45/46 is insane. Manage your money well in a proceduralist specialty, and you can retire at that age.

I was a spring chicken at 41 when I got my first. It is kind of crazy, especially because a lot of people view the first R01 as independence. At the end of the day, I think you have to view your research trajectory as a continuum, and view a lot of the start-up package/K-award level work as your own, even if others don't see it that way.

As for retiring at 45/46... With a family? I doubt it. I mean anything is possible and it depends on your income and expectations in retirement, but I think that's a stretch.

 

[solitude]

I know this is all specialty and department specific, but I can say in my case I would not still be in my current institution had my first R01 not gotten the fundable summary statement when it did. There were a lot of issues that I faced at the time that were fixed because I negotiated with that grant and a job offer somewhere else. If I didn't have that grant, there would have been no negotiation to keep me here.

It is also quite common in my specialty and some other specialties I work with for people to get that first R01 equivalent and go somewhere else with it. I talked to my NIH program officer about this possibility, and they also told me it's quite common. I've had a few unsolicited informal offers come my way over the past few years that I don't believe I would have received without the grants. I don't recall ever receiving unsolicited informal offers before my grants got funded. Obviously, more has happened over the past few years than just my grants, but they are a major factor. All of that written, the job offers have never had sufficient pull to make me want to leave.



I have seen so many people demand academic protected time and then do nothing with it.

Regarding the 50%+ academic types failing to do anything worthwhile, this has resulted from poor hiring decisions in my opinion. In my opinion, people being hired for a physician-scientist track need to have a strong track record, a clear plan to obtain funding, and the proper resources and environment to actually do it. The leadership I've seen has just kind of like "we like this person, so here's protected time" without adequately addressing if the person has the correct track record, a clear plan, and the right institutional environment for success of their proposed research program. It's just kind of a "well they'll figure it out" sink or swim. The faculty member feels great because they can do a lot less and collect full academic salary for a number of years before transitioning to full clinical or bailing to the private world. They'll blame all their issues on the institutional issues that reflect that I'm not sure they should have been hired in the first place. Then the institution or department turns around and says "that's why we don't support physician-scientists." It's an absolutely bizarre dynamic that I think is a function of poor leadership.

Regarding the 20-30% protected time, that's pretty useless to build a physician-scientist career except for the most motivated and/or insane. That is, I did it, but it was a combination of insane luck and work ethic that I don't think you can expect from most faculty. This protected time is standard in a lot of academic departments because 20% protected time at some institutions is actually full time RVUs elsewhere because they cram in the patients while they're in clinic. Such faculty need a day or so to catch up and hopefully publish one soft paper a year to get promoted and get pay rises down the road.



As what I guess you could call a proceduralist MD/PhD, I disagree. First, the academic mission of the University is to have academics. Grants are a nationally competitive way of certifying that the research you are doing is meaningful. Is it perfect? OF COURSE NOT. But, anyone who has managed to pull down an R01-equivalent, or especially several, is someone who is at least trying to do research. It's a decent enough filter. Sure, they're money losers, but if you're not going to support people to do research and get meaningful grants, what is the academic department even doing?

Second, I write grants because I need them to support my lab since I trained to be a physician-scientist and I believe in being a physician-scientist. Regarding 1 and 2, nobody would say that about me. In fact, I love to keep up my clinical skills so I can pivot back to clinic if things ever go unfavorably for me in the lab. Regarding 3, I am here 10-12 hours a day anyway, though I do like the variety of lab and clinic. Regarding 4, if I didn't have to work, this is not what I would do for fun.



I like the job security that tenure provides. It's not fool proof, but it's not meaningless, at least around here, historically.



Grants allow you to have (or keep) the lab. If you can have a lab without grants, good for you, I guess.



I was a spring chicken at 41 when I got my first. It is kind of crazy, especially because a lot of people view the first R01 as independence. At the end of the day, I think you have to view your research trajectory as a continuum, and view a lot of the start-up package/K-award level work as your own, even if others don't see it that way.

As for retiring at 45/46... With a family? I doubt it. I mean anything is possible and it depends on your income and expectations in retirement, but I think that's a stretch.

As I stated, for certain forms of lab-based research, grant funding is usually required. But it is a small minority of MD-PhDs who actually do this type of physician-scientist research. My list of 1-4 is not meant to be insulting. You are one of those unicorns who is clinically productive/skilled at a proceduralist specialty, and also highly motivated to pursue lab-based research as a hobby at a very high-level. Most MD-PhDs with R01s in a procedural specialty are not like you, in my experience.

Tenure provides a modicum of job security, but not income security. At my institution multiple tenured professors have been fired for various offenses (fraud, abuse, etc.). Admin can drop your salary to less than a resident's salary if you are completely unproductive. Your MD and frankly, even your PhD provides more income security than tenure does.

I have no plans to retire at that age, but it is easily doable as a highly paid subspecialist to accumulate 4-5M by one's mid-40s if you manage your money well. Even in academics.

 

[SurfingDoctor]

I know this is all specialty and department specific, but I can say in my case I would not still be in my current institution had my first R01 not gotten the fundable summary statement when it did. There were a lot of issues that I faced at the time that were fixed because I negotiated with that grant and a job offer somewhere else. If I didn't have that grant, there would have been no negotiation to keep me here.

It is also quite common in my specialty and some other specialties I work with for people to get that first R01 equivalent and go somewhere else with it. I talked to my NIH program officer about this possibility, and they also told me it's quite common. I've had a few unsolicited informal offers come my way over the past few years that I don't believe I would have received without the grants. I don't recall ever receiving unsolicited informal offers before my grants got funded. Obviously, more has happened over the past few years than just my grants, but they are a major factor. All of that written, the job offers have never had sufficient pull to make me want to leave.

Interesting. I have actually never seen that at my own institution. At least not within my own department. The only thing I have seen is people use their grant funding as leverage to get a promotion at another institution, ie chief, chair, etc. Those folks however typically abandon research for administrative roles, so the grant funding ends up being just that, a stepping stone, but not a career pursuit.

I have seen so many people demand academic protected time and then do nothing with it.

Regarding the 50%+ academic types failing to do anything worthwhile, this has resulted from poor hiring decisions in my opinion. In my opinion, people being hired for a physician-scientist track need to have a strong track record, a clear plan to obtain funding, and the proper resources and environment to actually do it. The leadership I've seen has just kind of like "we like this person, so here's protected time" without adequately addressing if the person has the correct track record, a clear plan, and the right institutional environment for success of their proposed research program. It's just kind of a "well they'll figure it out" sink or swim. The faculty member feels great because they can do a lot less and collect full academic salary for a number of years before transitioning to full clinical or bailing to the private world. They'll blame all their issues on the institutional issues that reflect that I'm not sure they should have been hired in the first place. Then the institution or department turns around and says "that's why we don't support physician-scientists." It's an absolutely bizarre dynamic that I think is a function of poor leadership.

Yes, a vast majority of academic physicians do nothing with their academic time, but at the same time, complain about not getting enough. It’s painful to listen to. Frankly, I think it’s better to just put those people in clinical tracks, but then they complain about working to much. Then there was a hire, a hire who I knew from personal experience should not have been hired as a physician-scientist with 75%, and I voiced my concern. But did anyone care? Nope. And they submitted a K, it got a decent score. But they never resubmitted it and went to go work in private practice. In the end, that was the best path for that individual and what they should have done from the get go, but the whole thing was a massive waste of time and resources. And the person who hired them insinuated that while it was mostly their fault, that I had some shared responsibility for that outcome. Yeah, f--- that...

Regarding the 20-30% protected time, that's pretty useless to build a physician-scientist career except for the most motivated and/or insane. That is, I did it, but it was a combination of insane luck and work ethic that I don't think you can expect from most faculty. This protected time is standard in a lot of academic departments because 20% protected time at some institutions is actually full time RVUs elsewhere because they cram in the patients while they're in clinic. Such faculty need a day or so to catch up and hopefully publish one soft paper a year to get promoted and get pay rises down the road.

Frankly, I think most research careers are a combination of work ethics, luck and just persistence (which is part of the work ethic).

 

[SurfingDoctor]

And yes, tenure is basically a sham. It doesn't functionally mean anything anymore. I mean, the ONLY benefit I've found is that I don't have to go through stupid re-appointments every year and fill out dumb paperwork that took up a couple hours of time. That's basically it. Supposedly, it allows one to get paid the bare minimum of whatever that level of professorship gets at the university, but I've never seen that in writing and therefore, it doesn't really exist in my mind.

Tenure equates to a sense of self-accomplishment, nothing more. Heck, I'm the only person in the history of division to ever be promoted to tenure, and the rest of my colleagues couldn't get a sh-t. And why would they? They just get their panties in a bunch because I have grant funding and don't have as much clinical time and therefore, and I quote "don't really contribute".

 

[Neuronix]

Tenure gives you the ability to remain employed through inquisitions. I have already felt some of the inquisitors flames, though I have been able to repent and evade the executioners for the time being.

My experience is that when you have tenure, they can make you miserable and want to quit. But, they actually can't fire you, force you to quit, or throw you out of the clinic unless they have serious dirt on you.

 

[SurfingDoctor]

Tenure gives you the ability to remain employed through inquisitions. I have already felt some of the inquisitors flames, though I have been able to repent and evade the executioners for the time being.

My experience is that when you have tenure, they can make you miserable and want to quit. But, they actually can't fire you, force you to quit, or throw you out of the clinic unless they have serious dirt on you.

I guess in theory, though I've yet to see anything like that. In fact, 1) it's often much more expensive to let someone go only to rehire the position and 2) irrespective of tenure, I have seen some seriously incompetent, and sometimes dangerous, individuals who either got a warning or more likely, who just go things swept under the rug.

 

[tr]

Tenure gives you the ability to remain employed through inquisitions. I have already felt some of the inquisitors flames, though I have been able to repent and evade the executioners for the time being.

My experience is that when you have tenure, they can make you miserable and want to quit. But, they actually can't fire you, force you to quit, or throw you out of the clinic unless they have serious dirt on you.

Why would admin ever want to kick you out? Who are they going to find that would do what you are doing?

I have zero concerns about job security. No sane psychiatrist would want my clinical setup when they know they could easily double the salary in private practice. Like who else is my dept going to find to take this crappy deal, never mind successfully compete for external funding on top of it?

My job security is the total lack of appeal of my position to 99% of the population qualified to hold it.

 

[SurfingDoctor]

kudos to you and Neuronix for struggling along the clinical track and securing funding and the switch over to TT.

As a proceduralist, I know plenty of folks with "gratis protected time", usually 1-2 days per week, with no external funding or associated revenue whatsoever. It's just a paycut, where you have less clinical time, make less money than 100% clinical colleagues, but you are free to pursue research or do activities of any type. Many people do this for their first few years, but others indefinitely. Most people do use this time well, but not everybody as SurfingDoctor referenced.

However, for most of these people it makes no sense from a financial angle to use protected time to even apply for NIH grants. It's a ton of work and admin overhead that would eat up most of one's protected time. Even if one were to say, get a K then an R to provide 3-4 days of research time...given the NIH salary cap and various institutional compensation minutiae, cutting back clinically would result in a huge paycut.

Of course there are other reasons to apply for these grants, such as if they enable one to do research that would otherwise be impossible with multi-PI/center grants, philanthropy, or industry funding. Prestige, etc. Most proceduralist MD-PhDs I know who get these grants do it because of some combination of the following:
1) they are clinically extremely unproductive because of a lack of skills/hard work
2) they hate clinical medicine and basically will do anything to avoid seeing patients
3) flexibility. They don't want to work 7a-6p doing clinical medicine (similar to above).
4) it is a hobby. Typically these live in LCOL areas and/or have a spouse who makes a lot of money.

It is not necessary for tenure at many institutions in my specialty. But as stated in other threads, tenure is meaningless. Some of my friends don't even bother to apply for it until the very end of their eligibility period because it's not worth their time to fill out the paperwork.

I think it is important to note that grants, although sometimes required to do some research, are not really important per se. Grants do not advance the field. Grants do not help patients. They are an epi-phenomenon of our current scientific structure, but it is papers, patents, presentations at conferences, clinical trials, etc that are the real currency of success (although not always recognized as such by tenure committees and the community at large).

I am a bit off-topic from the age at 1st grant. 45/46 is insane. Manage your money well in a proceduralist specialty, and you can retire at that age.

You had me until retire at age 45. Why? What the hell else you gonna do for another 45 years? Become a vagabond? I also can imagine you could retire at that age, if you have no debts, no children, and are being incredibly frugal, but that's not the reality for most.

Heck, I'm in a field where I couldn't just switch into private practice, because those jobs in critical care, while generally easier, and more clinical time. Frankly, when I'm too old for this job and the grant money well can no longer be tapped, I'm gonna go bag groceries at Kroger till I'm dead. I gotta do something to pass the time... or maybe create a delivery service with my nephew and a lobster.

 

[solitude]

You had me until retire at age 45. Why? What the hell else you gonna do for another 45 years? Become a vagabond? I also can imagine you could retire at that age, if you have no debts, no children, and are being incredibly frugal, but that's not the reality for most.

Heck, I'm in a field where I couldn't just switch into private practice, because those jobs in critical care, while generally easier, and more clinical time. Frankly, when I'm too old for this job and the grant money well can no longer be tapped, I'm gonna go bag groceries at Kroger till I'm dead. I gotta do something to pass the time... or maybe create a delivery service with my nephew and a lobster.

I agree it's not the reality for most, and it's not my intention, but I think it's easily doable with many fewer sacrifices than you state. An MD-PHD should have no debt, that is one of the purposes of the program. If you graduate MD-only, you make up for the debt with additional years of clinical earnings. Children are expensive, but variably so: you either have a spouse that stays home and takes care of them, making the kids cheap but the spouse expensive, or you have a working spouse, usually a moderately compensated one, making the kids expensive but the spouse not. Extreme frugality is not required except for maybe in NYC or similar metros. Institutions almost invariably offer very generous pre-tax retirement matching programs and additional supplemental plans, and it's easy on a large salary to save money after-tax also, plus you build home equity, spouse's income/retirement contributions, institutional obligations to match college tuition, etc. Then, compound interest. People make bad personal finance choices, mostly by living hand to mouth, then complain about the sky high cost of child care and declining Medicare reimbursements.

My point, and it's not a novel one, is simply the tremendous sacrifices that most people in well-compensated procedural specialties make to pursue a research-heavy career by prolonging their training (the topic of the thread) and then spending years toiling for NIH grants in precarious, poorly paid positions (tr's words). I think age 45/46 is absolutely insane to get independent research funding when one considers the opportunity cost.

 

[solitude]

Tenure gives you the ability to remain employed through inquisitions. I have already felt some of the inquisitors flames, though I have been able to repent and evade the executioners for the time being.

My experience is that when you have tenure, they can make you miserable and want to quit. But, they actually can't fire you, force you to quit, or throw you out of the clinic unless they have serious dirt on you.

I'd also like to hear more about the inquisitors flames. My experience aligns more with Surfing Doctor's. Super rare for anybody, even Instructors or those on the Clinical track, to get pushed out even if they are incompetent, fraudulent, or both. To the admins, a warm body that generates RVUs or grant money is all that matters.

 

[StIGMA]

Not gonna comment on everything here, but the salary for physicians scientists can certainly be on par with similarly ranked clinical faculty. It really depends on how the institution/department handles it. There is zero reason your lab effort needs to be benchmarked to NIH cap; that’s assinine university policy to pull one over on you (take it or leave it if you want to work there). That may mean if you want to get paid better you need to look at institutions away from the coasts. In my first position, I came in about 20% higher salary than the full clinical faculty they hired that year, but I negotiated heavily and was in a fortunate position with grants, other offers, etc. I don’t expect everyone to have a ton of luck negotiating, but you should discuss things with your mentors and give it a fair shot.

 

[SurfingDoctor]

Not gonna comment on everything here, but the salary for physicians scientists can certainly be on par with similarly ranked clinical faculty. It really depends on how the institution/department handles it. There is zero reason your lab effort needs to be benchmarked to NIH cap; that’s assinine university policy to pull one over on you (take it or leave it if you want to work there). That may mean if you want to get paid better you need to look at institutions away from the coasts. In my first position, I came in about 20% higher salary than the full clinical faculty they hired that year, but I negotiated heavily and was in a fortunate position with grants, other offers, etc. I don’t expect everyone to have a ton of luck negotiating, but you should discuss things with your mentors and give it a fair shot.

Yeah, I don't think many institutions are going to use the NIH cap as the benchmark of physician-scientist salaries. I suppose it could happen, but I've never seen it personally. I do think many places are going to put clinical faculty at a higher salary than physician-scientist faculty, because again, RVU generation is way more profitable to the hospital, but I think that is also dependent on how many indirects one brings in AND the seniority of a person. Actually, some of the best compensated physicians in the whole hospital system are orthopedic assistant professors who inject corticosteroids into joints for the local professional sports team. Those people clear salaries higher than the university president. But irrespective of that, an assistant professor physician-scientist is going to be paid a considerable amount lower than a clinical assistant professor, but that gap narrows (actual dollars and percentages) as one climb the ranks and in some instances, probably overtakes clinical physicians in academia assuming some leadership position with administrative compensation.

The reality of all of this is that a successful physician-scientist in academia has a lot more potential for growth than your typical academic clinicians (outside of those tapped for administrative and operational roles). But the start up is much more challenging for the former compared to the latter.

 

[Neuronix]

I'm sorry but my identity is not anonymous enough to speak openly about some of the politics in my institution and specialty. But people ask me why I want tenure, and this is why.

As for startup being more difficult for physician-scientists. we are in some ways million dollar babies. Real startup packages really are worth that kind of money. Despite those investments, there are a lot of duds. A lot of people who waste startups or despite their efforts can never compete for significant funding. So in some ways I do empathize with the institutions trying to be wise with their investments.

 

[tr]

There is zero reason your lab effort needs to be benchmarked to NIH cap; that’s assinine university policy to pull one over on you (take it or leave it if you want to work there). That may mean if you want to get paid better you need to look at institutions away from the coasts. In my first position, I came in about 20% higher salary than the full clinical faculty they hired that year, but I negotiated heavily and was in a fortunate position with grants, other offers, etc. I don’t expect everyone to have a ton of luck negotiating, but you should discuss things with your mentors and give it a fair shot.

Sorry just to be clear, my salary is on par with clinical faculty in my area. It's just that I live in a region that is oversaturated with both AMCs and psychiatrists, which pushes the salaries way down vs other regions. It happens that clinical faculty salaries in my area are in the same ballpark as the NIH cap. Away from the coasts is absolutely good advice; however I need to stay where I am for family reasons, so the money issue is pretty low on my list of priorities.

 

[StIGMA]

Sorry just to be clear, my salary is on par with clinical faculty in my area. It's just that I live in a region that is oversaturated with both AMCs and psychiatrists, which pushes the salaries way down vs other regions. It happens that clinical faculty salaries in my area are in the same ballpark as the NIH cap. Away from the coasts is absolutely good advice; however I need to stay where I am for family reasons, so the money issue is pretty low on my list of priorities.

I appreciate the comment. I heard the 'expect to make less' trope most of my training pathway (in respect to other people in the same department, not vs. private practice)-- and I just want the trainees to know that doesn't have to be the case- but you probably will have to educate yourself, gather data, talk to mentors, and be prepared to negotiate or move.

 

[solitude]

Yeah, I don't think many institutions are going to use the NIH cap as the benchmark of physician-scientist salaries. I suppose it could happen, but I've never seen it personally. I do think many places are going to put clinical faculty at a higher salary than physician-scientist faculty, because again, RVU generation is way more profitable to the hospital, but I think that is also dependent on how many indirects one brings in AND the seniority of a person. Actually, some of the best compensated physicians in the whole hospital system are orthopedic assistant professors who inject corticosteroids into joints for the local professional sports team. Those people clear salaries higher than the university president. But irrespective of that, an assistant professor physician-scientist is going to be paid a considerable amount lower than a clinical assistant professor, but that gap narrows (actual dollars and percentages) as one climb the ranks and in some instances, probably overtakes clinical physicians in academia assuming some leadership position with administrative compensation.

The reality of all of this is that a successful physician-scientist in academia has a lot more potential for growth than your typical academic clinicians (outside of those tapped for administrative and operational roles). But the start up is much more challenging for the former compared to the latter.

One reason ortho makes so much money is worker's comp. When you do surgery for worker's comp, reimbursement is about 3x Medicare rates. Also, things like joint injections and post-op visits can be farmed out to midlevels.

 

[SurfingDoctor]

One reason ortho makes so much money is worker's comp. When you do surgery for worker's comp, reimbursement is about 3x Medicare rates. Also, things like joint injections and post-op visits can be farmed out to midlevels.

Gotta love the US healthcare system.