September 2005
In part 1 of this essay, I discussed the evolving concept of tenure in today's medical schools. The principle of shared governance is another important part of the academic ideal. Junior faculty think they are entering a community of equals only to find that they must wheel and deal like Wall Street financial mavens. Instead of shared governance, they must navigate a complex medieval world of fiefdoms characterized by sections, divisions, departments and schools, each of which is ruled by an autocratic chief.
Forward-thinking program directors recognize that ours is an incredibly long and intensive training process, and have tried to institute measures that protect and support their junior people while pushing them to achieve the necessary goals. These leaders recognize that budding faculty represent the future. However, many others are unaware of or minimize the importance of creating an environment that values the funded and unfunded efforts of their faculty. At a grant writing postgraduate course at this year's ATS International Conference it was mentioned that the R01 funding rates were dipping to the mid-teens. Perseverance! We were told. Try and try again! We can persevere all we want, but shared governance has little meaning in a system in which an investigator's salary and job depend on his/her chiefs.
Does the struggle to survive outweigh the return? Is it reasonable to ask young faculty members starting their families and buying houses to accept salaries that are nearly one-half of the going rate (for fewer hours of work no less!) at private institutions. Is the prestige of academics sufficient to make up for the lack of job security?
It's not just about money. A recent interview with the 12-year-old winner of this year's national Spelling Bee ended with this quote about his future plans, "I want to get a good job that makes me happy." With typical child-like simplicity, this spelling genius managed to elucidate the simple principle that guides many of us in academic medicine. Academics can be incredibly fulfilling. As Peter Bitterman once said, "This is a good job." Lately, the question seems to be, does this good job make me happy? The declining number of physician-scientists seem to argue that for many, the answer is no.
At the recent ATS Conference, I was happy to hear from some of you who have found my columns valuable. But I was dismayed by the many who have left or are considering leaving academics. Many of you have faced difficult, heart-wrenching choices to leave academics, after investing so much of your lives in training. You are finding that there are fulfilling jobs outside of academics. Surely it is time that academic medicine acknowledge the increasing competition for this elite pool of highly trained physician-scientists. This represents an enormous loss of resources, considering the time and effort it has taken the system to train these physician-scientists. While this works out great for biotechnology, pharmaceutical and community practices, how long can the system afford this loss?
As I wrote a year ago,
The tendency is to dismiss those who leave the system as failures as not having what it takes to make it. But could it be that the system itself is flawed? That the loss of bright, dedicated and creative young physicians reflects a system failure and ultimately harms the system by draining it of needed talent and diversity ?
This has enormous practical implications as academic medicine seeks to fill mid-level and upper level positions as the current generation begins to retire.
Numerous studies and articles have stated the need to re-examine the paradigm of training academic physicians (1). Academic medicine can no longer afford to have a "take it or leave it" attitude and needs to work harder to convince trainees that opportunities offered are worth the additional responsibilities despite the fact that academic salaries typically run lower than practice and industry. For a young faculty member burdened with a heavy debt load and struggling to support a family, the concepts of academic freedom and self-governance have little meaning or security in comparison to job security. The real and perceived decrease in available research training support combined with the instability of federal research grants make a long-term career in academics appear highly uncertain to many trainees finishing their fellowship. It may seem to be a "no-brainer" for an overwhelmed physician-investigator-in-training to choose the financial rewards and relatively straightforward demands of private practice. Training programs need to re-establish and convince trainees and junior faculty of the value of tenure in academic medicine.
Medical schools need to address the inherent conflict between the demands of clinical medicine and the expectations of traditional academic promotions by re-defining the entire training paradigm for physician-scientists and clarifying expectations for those just starting their academic careers. Because non-medical school faculty play an important role in the evaluation and promotion of medical school faculty and the decision to not promote a physician-faculty member, in essence, terminating his/her employment, it becomes imperative to educate them on the importance of the medical school's mission to that university as a whole. Training programs and medical schools must recognize that simply throwing a fellow or junior faculty member in the lab with a mentor who may or may not be cognizant of the current complex realities of academic medicine is not sufficient for success. In fact, starting at the fellowship level may be too late. Institutions must develop or promote existing programs designed to bridge critical gaps in the pipeline, such as the need to encourage more extended research opportunities for medical students.
The fact remains, that many medical schools have never satisfactorily dealt with the issue of balancing clinical responsibilities and academic promotion and reimbursement. Instead, increasingly complex operations have evolved to calculate salary support. One junior faculty member I know was recently offered a job involving ten different sources of salary support. Furthermore, is it unreasonable to expect that a faculty member brought on solely to perform clinical duties be reimbursed on a scale comparable to that of their colleagues in practice? Their performance and contract would be evaluated on the basis of their clinical performance. Tenure may not be necessary for these positions. However, anyone who participates in teaching or research missions of a university should be granted some form of limited tenure and FTE. This simply acknowledges what many of us were hired to do. Expanding the recently established loan repayment program of the National Institutes of Health (NIH) to include physicians training in basic and translational research would also be beneficial to decrease the financial burdens faced by physician-scientists in training.
Finally, special attention also needs to be given to the unique hurdles faced by women, who are underrepresented in the physician-scientist pool. The lack of role models, concerns about balancing academic careers and having/caring for a family and the perception of having to "super-compete" against men at the upper echelons of academia are all consistently cited as reasons for women not choosing to become physician-scientists(2). Currently, women make up more than 40% of those entering medical school and by the year 2010 they are expected to represent 30% of the total physician population. Despite the increasing numbers of women in the medical profession, women have not attained equal status. Women lag behind men in income, academic rank, leadership roles and participation in scientific research and measurements of professional success and accomplishment (3).
The problem is particularly acute for clinically demanding sub specialties such as pulmonary and critical care. Solutions like the development of a Generalist Physician-Scientist Pathway assume that subsequent clinical sub specialty training is not essential for a serious research career (1). I would argue that sub specialty training such as pulmonary and critical care provides in-depth knowledge and experience that is invaluable for pulmonary disease-based research. There is little doubt that structured mentoring can be a cost-effective way to improve skills needed for academic success and retention in academic medicine (4). But more than mentoring is needed in a system designed for men with stay-at-home spouses. The entire paradigm for training physician-scientists needs to be re-examined. Given the length of time needed to train subspecialty-trained clinician-scientists, national organizations such as the ATS urgently need to take a leadership role in developing innovative solutions to address the critical shortage of young pulmonary physician-scientists.
- Varki A., Rosenberg LE. Emerging opportunities and career paths for the young physician-scientist. Nat Med 2002;8: 437-439.
- Andrews NC. The other physician-scientist problem: Where have all the young girls gone? Nat Med 2002; 8:439-441.
- http://www.4woman.gov/owh/col/mentoring.htm
- Wingard DL, Garman KA, Reznik V. Facilitating faculty success: outcomes and cost benefit of the UCSD National Center of Leadership in academic medicine. Acad Med 2004; 79:S9-11.
