Becoming a Physician Scientist: A View Looking up from Base Camp

Abstract

The process to becoming a physician–scientist is a long and often harrowing one. The author reflects on her own experience deciding to commit to a career as a physician–scientist and setting out on that career path. She identifies the largest challenges as the lack of clear direction to becoming a physician–scientist; the long lag time between the end of graduate medical education and becoming faculty, resulting in lower wages, less job security, and conflicts with personal goals; and a tension between traditional definitions of success and her own areas of interest. The author also reviews the advantages that led to her first faculty position as a physician–scientist: innovative educational programs that integrate medical and research training, financial support for physician investigators, a supportive educational milieu, and appropriately tailored promotion tracks. Advances on these three fronts could support increasing numbers of trainees pursuing careers as physician–scientists.

As a child, I visited Mt. Rainer with my parents. I remember desperately wanting to reach the snow line, but even after we hiked all day, we still had only reached the base of the mountain. Some days, that’s how my career feels. To get here, I’ve gone through 11 years of secondary and post-secondary education, passed three specialty board exams, published over a dozen papers and half a dozen book chapters, and successfully received a National Institutes of Health grant, and yet I’m just poised to “start my career.” Becoming a successful physician investigator sometimes feels as elusive as the snow line.

But, having just made it to base camp, it seems like a good place to reflect on the systemic obstacles that I’ve surmounted thus far, what I see looming in the near future, and what the academic medicine community can do to support junior faculty like me.

Barriers in Transition From Training to Faculty

The biggest challenge I faced in starting my career as a physician scientist was making the decision to commit to being a physician–scientist. Medical training is extremely structured with clear expectations, full of set rotations and standardized examinations, and it selects for people who thrive in those conditions. In contrast, the time between completing training and starting an academic career as a physician–scientist—the so-called “holding zone” —has none of those things¹. Advice about when to apply for grants, which grants to apply for, and how to measure “success” during this period was either lacking or highly conflicting. In contrast, continuing as a pure clinician, a job for which I was highly trained and understood well, felt temptingly secure. I feel that the lack of structure on the pathway from trainee to faculty is one of the major reasons only 1.5% of physicians choose to initiate a career as a physician–scientist¹.

The period of time between fellowship graduation and faculty appointment is another major hurdle. My own father was five years younger than I am now when he started as an assistant professor. I myself am younger still than 38, the average age of appointment to assistant professor for MDs (MD-PhDs tend to be even older when they reach this milestone²). The length of time between training and appointment is highly variable, even within a single institution. This is clearly a double-edged sword: on one hand, these gap years can provide protected time to build a foundation for future success, without which promotion to associate professor can be challenging. On the other hand, these years exist without any commitment that the physician–scientist’s career will continue at the institution, and the salary is deeply reduced compared to a faculty salary. In my case, I’ve received a graduate medical education base salary for the last two years, despite being an attending physician (I received “moonlighting” pay for my clinics and service time, resulting in a salary just under two-thirds that of a starting assistant professor). The timing of this gap can be particularly challenging. Like many female physician scientists, my mid-thirties corresponded to the time when I wanted to start a family and settle into a permanent home with my partner, a physician with a nascent clinical career. Many of my colleagues also struggle to support aging parents and to pay off their education debts. We manage financial insecurity by moonlighting and institutional insecurity by taking on additional administrative responsibilities, ultimately decreasing the value of these years as protected academic time.

Finally, sometimes the path of “success” feels frustratingly narrow. Over the course of the career of many of my mentors, science has become a bigger and more collaborative enterprise, but much of the advice I receive is still focused on the idea that the only way to be successful is to independently run a research lab. Correspondingly, every second of clinical time is expected to be a burdensome distraction. As a physician who came to science to answer the medical needs of my patients, the strict avoidance of clinical responsibilities feels uncomfortable. The tenure track, alluring to my mentors because of the high-status associated, has little cachet to me. Rather, in this era of uncertain research funding, I associate the idea of the tenure track with high anxiety and rigidity of focus.. It may be time to broaden the definition of academic success to include contributions in the fields of bioinformatics, medical education research, natural history studies, and more.

Reflections on Optimizing Training Conditions

Despite these hurdles, however, I’ve made it this far largely because of an incredibly supportive educational milieu and mentorship team. Many of my benefits have come from novel educational programs aimed at reducing barriers for young physician scientists. For example, I attended the Cleveland Clinic Lerner College of Medicine (CCLCM), now a tuition-free medical school. CCLCM eliminated tuition explicitly to enable students to become physician–scientists with the attendant lower salaries and prolonged training time³ -- without this, I could not have afforded the extra years I spent receiving a resident’s salary. Additionally, CCLCM’s five-year integrated research curriculum, which provides training in research approaches and methods in parallel to the standard medical school curriculum, in addition to providing 3 research blocks for a total of 18 months of dedicated research time, has allowed me to reach faculty status at a younger age than average by shortening my training. Similarly, I trained in a fast-track pediatrics/clinical genetics residency program, which allowed for early research exposure and shorter training.

Now entering my first faculty job, I have been afforded additional opportunities to enable me to become successful in my way, including a promotion track that allows flexibility throughout my career in my clinical and research efforts and rewards collaborative science, clinical publications, and educational work. I have a rich and diverse mentorship team, including research mentors, clinical mentors, and, critically, peer mentors, who are coming of age as physician–scientists in the same climate as I am.

The path I have been able to find so far speaks to concrete systematic changes that can be implemented to foster the career of other budding physician–scientists by integrating and shortening training, providing financial support, creating promotion tracks to allow for modern notions of success, and cultivating strong mentorship programs. From here, the path to the summit is still unclear, but I feel fortunate to have made a strong start at base camp.