7 things to know before entering academic medicine

0:00 Welcome to the Clinician Researcher podcast, where academic clinicians learn the skills to build their own research program, whether or not they have a mentor. As clinicians, we spend a decade or more as trainees learning to take care of patients. When we finally start our careers, we want to build research programs, but then we find that our years of clinical training did not adequately prepare us to lead our research program. Through no fault of our own, we struggle to find mentors, and when we can't, we quit. However, clinicians hold the keys to the greatest research breakthroughs.

0:40 For this reason, the Clinician Researcher podcast exists to give academic clinicians the tools to build their own research program, whether or not they have a mentor. Now introducing your host, Toyosi Onwuemene. Welcome to the Clinician Researcher podcast. I'm your host Toyosi Onwuemene, and it is my absolute pleasure to be talking with you today. Thank you so much for tuning in. I'm excited to bring you today's episode called Seven Things You Should Understand, You Should Know, Before You Go Into Academic Medicine. Seven Things You Should Know Before You Go Into Academic Medicine.

1:22 This comes from a coaching session that we had yesterday, and I thought I needed to come on and share with my audience and to share with those of you who missed the coaching session what you really, really should understand about going into academic medicine. I have to say that I think people were somewhat shocked, but it was a good shock because it's good to know, to have a clear understanding of the lay of the land, because then you're able to go in strategically. You're not like me, like a dare stuck in the headlights when you start your academic position. And just to recall, and for those of you who've been listening to me for some time, you'll remember that I started my academic job totally clueless.

2:10 I said, I want to do research. I want to do research. That's why I'm here in academia. And I ended up with a full-time clinical job, totally confused as to how it was that I wanted to do research, and I ended up with a 100% clinical position. I'm sorry, it was 80%, even though I was seeing patients five days a week. It was technically 80%. How did that happen to me? And so I want to share with you what the challenges are and what some of the drivers are that may be driving decisions that are happening outside of your purview so that you can prepare yourself to be ready to take on an academic job whenever you choose. Or at the end of this episode, you might say, well, academia is probably not for me.

2:52 Thank you. And that's okay too, because what you want to do is you want to have a realistic picture of how you're going to move forward. Okay? All right, here we go. So first of all, you need to recognize that academic medical centers operate a business. Okay? I want to say that again. Academic medical centers operate as a business. Now, I know that you are a wonderful person. You are altruistic. You really want to take care of patients, and actually you feel like patient care should be free. And I'm not disagreeing with you there. I'm just saying that in this year, right now, 2024, it's not. And for that reason, you're going to have to reckon with the fact that you take care of patients within a business model.

3:40 And for many physicians, especially my group of coaching clients who don't really care very much about money and don't necessarily want money to be front and center of the conversations that they're having, especially around patient care, I want you to know that even though it's not front and center for you, it is front and center for the people who run the business. Academic medical centers are businesses. Academic medicine is a business enterprise. Okay. Why is it important for you to know that? Businesses exist only when they profit. Okay. If a business is only able to meet its operating costs, that means that it is not able to really provide the services that it needs to.

4:24 Businesses that operate at a profit are able to keep going. For that reason, the security of your job lies in the profit-making ability of your business enterprise. Okay. Again, this is not front and center for you, but when it comes to the powers that be at any academic medical center, the administrative team is thinking very seriously about the business enterprise. And whether you like it or not, you play an important role in the success of the business enterprise. Now, I'm talking about physicians as a group, right? I'm talking about you individually.

5:04 You may not think your contribution is very much, but when it all comes together, you play a significant role in the success of the academic medicine business enterprise. I would like you, if you would please indulge me, would you just say after me, I play an important role in the success of my academic business enterprise. Okay. Now, I'm saying that to people clearly who are already in academic medicine. I am hoping that people who are not yet in academic medicine, at least committed as faculty members, are listening to me so that perhaps when you repeat after me, you're saying, I am going to play a role in the revenue generating capacity of the business enterprise.

5:49 Okay. I forgot what I said the first time, so now I switched it up. But you know what I'm saying. The money that comes into the institution happens because of the work that you do. Thank you for keeping our academic medical centers funded. Thank you for doing the work that moves money into the academic medical center. You may be like, well, I'm a fellow. Yes. Thank you so much for the work you do that brings money into the academic medical centers. Thank you. Okay. This is important to recognize that academic medicine is a business. Here's a problem with the academic medical enterprise as a business. It's that things are shifting and businesses have to be able to pivot to stay afloat. So you can't just be like, this was my business model 20 years ago and it's a business model that we're still using.

6:34 Businesses have to evolve. Okay. I'm going to stop at that for number one, which is recognize that academic medicine is a business. Now I'm going to move on to number two, which is to understand how academic medical centers make money. Okay. So think about all the things I said in number one, but now I want you to recognize how academic medical centers make money. Now the stuff that's really easy is like, of course, clinical dollars. Yes. Clinical services. Okay. And part of the clinical services are physician payments. So yes, you as a physician, whether you're in training or a faculty member, you help to make clinical revenue for the academic institution, right?

7:16 Because you see patients, you generate bills. Ooh, you send patients off to get procedures. Okay. There are clinical services that may not necessarily require or depend on the physician, but the physician is helping to generate these clinical services. You send someone off to get PFTs. You send someone off to get different studies. Gosh, they're all escaping me now. You're generating revenue because now the clinical services are able to generate revenue. You send people to get lab draws. The lab services are generating revenue. So clinical services are a huge part of how academic medical centers make money. Now are clinical services the only way? No. Academic medical centers are academic.

7:57 And so they are providing an academic service. And so yes, there are students, there are trainees within that academic framework. So medical students pay fees. So that also is part of the income. And also, GME is funded largely by Medicare. And so the government funds education as well. And so educational dollars are coming into the institution either through fees or through payments by the people who are invested in this education, or maybe even the VA as you're training some fellows who work at the VA. But dollars are coming in to support the education mission.

8:38 Another way that academic medical centers make money is through philanthropy. Now philanthropy for some institutions is a big chunk of that, never bigger than clinical dollars, but still a significant portion. However, there are some institutions that don't really necessarily make a lot of philanthropy dollars. That's another strategy in which, and that's another way in which money comes into the academic medical center. And I want to talk about one more way. There are a couple of other ways, but I want to talk about one other way. One other way is providing operational services to hospitals that are part of the system. So if I'm going to use MD Anderson as an example, there's MD Anderson in Houston, which is the original MD Anderson, but there are MD Anderson's now all over the country.

9:20 And there is a price, a cost to using the MD Anderson name. There is benefit, and there's also a cost to the people who are using the name. And that's another way that revenue can be generated. So there are a number of ways that academic medical centers generate revenue, but by far, the most important, the most critical to an academic medical center's business enterprise is clinical dollars. And you as a physician are very important part of that revenue generation process. Now here's what's happening in the landscape of academic medicine and the landscape of medicine in general, is that there are declining reimbursements for the same services. And so people are still sick, we're still doing the things that we've been doing to them for ages, and we're getting more sophisticated.

10:06 Our treatments are becoming more expensive. Everything is becoming more expensive, but guess what's happening in the government circles? Reimbursements are declining for government paid services. So Medicare is a huge portion of any academic medical center's practice in terms of who are the insurance providers that are paying for people to be seen, and over time, less and less money is coming in, and we're seeing more and more people come in who are Medicare population, the part of Medicare population. What does that mean? It means with declining reimbursements, you need to do more with less to be able to keep the business afloat.

10:50 Remember, number one, academic medical centers are a business and they've got to stay profitable. So what happens if you are getting less money for the same services, then the squeeze starts to happen, right? People are asked to do more, they're asked to do more with less. People start to feel the pressure, they feel the pressure of the business, they feel like, oh my gosh, I thought I was here to care for patients, I hate this feeling. People are calling you all the time, close charts. Yes, you are feeling the squeeze because in healthcare generally, everyone is feeling the squeeze of declining reimbursements with increasing cost of care. It's one thing if the reimbursements are declining and the cost of care is the same, the cost of care is increasing and the reimbursements for care continue to decrease.

11:37 Okay, now, why does this matter to you? Why does this matter to you? Number three is for you to recognize your role in the business, recognize your role in the business. If academic medical centers are a business that can only profit, that profit to be able to stay afloat and their biggest revenue generation is clinical services and you are a provider of clinical services, then recognize that you are an important piece of the revenue generation framework. When it comes to your institution, when it comes to your academic medical center, you are a critical piece of the revenue generation framework and the more your specialty brings in dollars, the more you are critical.

12:22 Even if your specialty does not bring in a lot of dollars, wow, you still got to be able to make that revenue. The reality of the pressure you feel to see more patients with less resources is real. It is a real thing. That is what's happening at academic medical centers across the country. It's been a trend that's been shifting over time. We're going to continue to feel it more and more and more. Okay, I want to share that, you know, for many people, I hear people say, oh, yeah, yeah, yeah, I really am just here for, I mean, I really want to take care of patients. So it's a win, right? It's a win because you take care of patients, you love to care for patients and the academic medical center wants you to take care of patients because it's generating some revenue.

13:11 And so it's a win-win. But here's the thing though, you didn't come to academic medical center to only see patients, right? Yesterday, I had the privilege of being with a fantastic group of early career people who were really thinking critically about how they contribute to the academic mission. And when they talked about the things that they really love about academic medicine, they talked about things like, you know, the ability to really think about the patient problem and really help somebody. They talked about the ability to teach and really pass on to the next generation. They talked about the ability to do research and generate new knowledge. And they love that academic medicine gives you all these things that you can do.

13:53 And oh my gosh, it was so beautiful listening to them. I was like, academic medicine is so beautiful. Yeah. But here's the challenge now. There is increasing pressure to generate clinical revenue with declining reimbursements. And so over time, people are going to be asked to do more. But over time too, the question is, well, how can we continue to provide care in a way that's not so expensive? And to some extent, physicians, though they're the most, you know, one of the biggest revenue generators in an academic medical center, also tend to cost a lot, right? Because the biggest cost to any environment is payroll. And to any business environment is payroll. You got to pay the people who are working for you.

14:35 And so here's why it now becomes important. Number four is understand how your academic pursuits fit within the revenue generation model. OK. So now when I talked about how academic medical centers make money, I talk about the importance of GME. I talked about, you know, fees from medical schools and things like that. But remember, I told you that the most important is clinical. OK. Now, you come into an academic medical environment and you're like, well, you know, I want to see patients, but I don't want that to be all that I do. I want to be able to teach and I want to be able to do research. And then you've got to say, well, how is what I'm doing making money relative to my ability to generate revenue from seeing patients?

15:22 That's an important consideration that while you may not be thinking about the math, somebody's thinking about the math. And they're looking at you saying, hmm, so this person is able to generate significant clinical revenue with their specialized degree. And they want instead to forego that revenue generation so they can do some academic stuff. OK. OK. All right. OK. Let's let's make the math work here. Who is going to have to work extra so that this person can be covered in the academic pursuits? I think it's a well, I'm going to bring in grant funding like, OK, OK, when are you going to bring in the grant funding that allows you to contribute to the profitability of the of the of the of the enterprise?

16:05 When are you going to do that? When you think about it, it takes years, especially for a physician to be able to grow in their research skills. So in prior episodes, I've talked about the fact that your clinical training, as amazing as it is, is really clinical training. It's not research training. And if you as a physician say, well, I want to do research, it's like great. But you have no research skills. You don't have a significant amount of research skills. So now you're going to forego your clinical dollars to get the skill that, you know, to be honest, my PhD researchers already have. Right. And so when you are a physician saying I want protected time, and I'm on to number five, to understand what it means to request protected time.

16:51 So when you as a physician say, I want protected time, it's like, oh, you too. How is it going to be funded? That's the question that people are asking. How is it going to be funded? Who's going to give you money for this protected time? Because here I thought you were coming in to use your specialized surgical skills to build my organization to help keep us profitable. Because hey, payroll every month is as high. Of course, certain salary is kind of, it's a little bit higher than we like to pay. But you're telling me that you're not going to generate the revenue that pays that salary. You want to do what? You're like, I won't protect the time because I want to do research.

17:32 Like, okay. And how are you qualified to lead research? Like, well, you know, I did a fellowship, I did a year and a half of research. Okay. So I was asking how, right? Do you understand the conversations that are going on around physicians wanting to lead research, right? So when you say I want to request protected time, you're saying for the next three years or more, I want to focus just on the research. I don't want to generate this clinical revenue that actually really easily funds my position or actually becoming less easy to fund my position, but it's still funding my position. I would like to forgo all of that. And I would like to focus on research and oh, I don't really have research training.

18:13 So I'd like to invest my time doing the research training. I'm not going to be able to bring in any significant research dollars for the first five, six, seven, maybe 10 years. I hope that's okay with you. So I want you to understand the challenge and it's a big deal. And once upon a time, you know, you could say, well, you know, to be honest, we're making a lot of money from this clinical revenue. Let's just use some of that money to fund the academic mission. And to a great extent, that's still what's happening. But again, remember I told you that the reimbursements are declining, the cost of care is going up. And so there is less and less margin for any medical dollars or clinical dollars to fund the academic mission.

18:54 And so the person who comes in and now says, I want protected time, there has to be a good justification of how this person merits the protected time and is going to use that time and be successful. Because what you're asking your institution to do is to make an investment and they want to see a return on that investment. It's like, okay, okay, we're going to make the investment, right? Because when you come in and you're like, I want protected time, you're not just asking for protected time, you're asking for resources. You're asking for a startup package. And it's like, okay, I'm going to make this investment. I'm going to lose out on your clinical dollars because you are in this space where you're trying to do research and I want to recoup my investment.

19:36 When they look over time and clinicians in general who haven't had a lot of research training are not able to start bringing in significant research dollars very quickly, right? It takes you time to grow in skill and you're a masterful person. You're going to grow in skill, but it'll take you time because it takes time to grow in skill. And all this while people are like, we're not seeing those dollars coming in for research funding. We're not seeing those dollars coming in for research funding, but what we're seeing is loss of clinical revenue because you're not in the clinical space. So I say all that to let you know that there are some real pressures happening in the background.

20:16 They may not be going on in your mind, but there are people crunching the numbers who are saying, where is this funding going to come from for this person who wants to spend a significant portion of time not generating clinical revenue? And you might be like, oh, I'm going to teach the fellows. There's a fixed pot of money that's coming in from GME and that pot of money does not make up for your clinical dollars. And so there is a real pressure and a real conflict of interest to support physicians in leading research programs, especially when they come in and they don't have the training. So I want it to be very explicit to you. So you recognize the currents that you are swimming against when you enter into the academic medical enterprise, or you recognize that it makes less and less sense for a physician who can generate significant clinical revenue to come in and spend all that time doing something that's largely unfunded by that person, at least for a fixed period of time.

21:16 Okay. That brings me to number six, because I think all of that before now, to some extent, it's the good and the bad news because you want to know. You don't want to be naive like I was. This is why I'm here, because I don't want you to be like me and I don't want you to show up and be shocked when people were so shocked yesterday, which is why I was like, this has got to be an episode that I share with the rest of the community that wasn't there yesterday. And with you, my audience who I hope, well, maybe now you already know, or maybe if you didn't know, you know now, but it's important to recognize the reality of what's happening in academic medical centers. So the good news is that now you have this information.

21:59 Number six is pertinent to you. Don't start an academic job until you're ready. Don't. Now here's the pressure that a lot of people feel. They're like, did you understand how much I owe in student loans? Do you understand how much I owe? And I get it. What you're saying is that you're feeling financial pressure. I want you to think about separating your financial pressure from your academic career. Separate the two. What do I mean by that? I'm saying, well, if your problem is revenue, then go do locums or something. Go moonlight. Go do something that generates the revenue for you, but that still leaves you time to really build an academic portfolio. Don't say I'm desperate for clinical dollars. I'm desperate for money.

22:40 So I'm just going to take a job and just whatever. We'll just let whatever will be will be because it doesn't have to be that way. Again, I'm not saying that you shouldn't take the academic job, but I'm saying that if you understand the pressures of an academic medical institution, you recognize that if you're going to come to the table in your negotiations and you're going to say, I want protected time, you've got to show up as a candidate who is ready for that investment. You can't be like, well, I'm going to figure it out in three years because institutions don't have three years for you to figure it out. And at the end of it, you're kind of like right back where you were at the beginning, only now they've invested a couple of hundred thousand dollars to figure that out.

23:21 So understand that people now are very selective in who they're investing in. Yes, there's disparities in that process. There's bias in that process. But if you're going to be the candidate that shows up at the door saying, I want protected time because I want to lead a research program, then you got to show up ready. And what does that mean? You've got to show up with publications. And publications now are the currency of academic medicine. And it's not really publications or the sign really. They're just the evidence of the value you've created in research or in scholarship in general. Sometimes people spend three years doing a research project that doesn't result in a publication.

24:01 Does it mean that you didn't learn or that that time was wasted? It doesn't. But publications are one way of saying, I did it. I did it. And here's the evidence. And then grant funding too. It's like, oh, I'm not just coming and saying, hey, give me money or I'm hopeful or wishful that in the future I'll be able to get grants. When you come in and you've already had experience applying for grants and maybe even have one or two grants, you can say, I know how to do this. I've done this before. And I'm going to continue to grow in skill, but I already know what it takes. So what you want to do is you want to come to the table. You want to come strategically. So that's number seven.

24:42 Prepare yourself strategically. Don't just show up at the door like I did. And this is, again, I think I'm so grateful for my younger self and for how naive she was because here I am now sharing with you so that you don't have to be naive like me. Don't just show up at the door and say, hey, I want the protected time. People who are counting the money in the background, they can start laughing. They're like, ha, ha, ha, ha, ha, ha, ha. No. And then the people who really want you to succeed as a researcher or succeed as a scholar, they want to make a case for you. But then they are like, well, you know, this person only has a clinical background.

25:25 This person has demonstrated prowess in clinical things. I see no evidence that this person has scholarship. There's no real track record of scholarship. How do you ask that person to go make a case for you with the bean counters as to how you're going to succeed as a scholar if they don't have anything to go by? And if they ask you like, OK, so what do you want to do? And you're like, I just want to do research. What do you want to do? I just want to do research. What's your goal? And you're not specific. You have no clarity. You can't show a record of having done the work over time. It just makes your case not very strong. And what does a strong case look like?

26:05 So now I interview faculty who come through our division and people will just show up and say, yeah, I want to do research. OK, how much of your time do you envision doing research? And somebody who's barely had any research training said, you know, I like research, but I like patient care. So I was thinking maybe 25% of my time, maybe 50%. And those of us who know are like, this person doesn't know. Because 25% patient care is kind of like 50%. 50% patient care is kind of like 80%. And 60% to 70% patient care is really like 100%. Actually, to be honest, 50% is really like 100%. But I'm trying to be conservative here. But you understand what I'm saying.

26:46 So when someone who's never done any research, who's not had any significant research training shows up at the door and says, I have a lot to learn, but I'd like to do it in 25% of my time, we know that that person doesn't understand what they're getting themselves into. And clearly, they don't know what it takes to succeed as a researcher, because research is a full time job. And when somebody says 75%, that's not even really enough, because you really need 100% to be able to understand, to really learn, to learn the skills, and then later on, you can cut back. But you need a lot upfront. And so when you are coming to your academic job, and you're asking for that time, be clear what you need. Be clear what it's going to give you.

27:27 And be very specific as to how you see your career unfolding. If you are not clear as to how your research career unfolds, you cannot convince anybody else. That's what you're going to fall into the pot of people who are going to generate clinical revenue for the institution. And it's not a bad thing to generate clinical revenue. Again, it's a great service. The institution runs on clinical revenue, but you're not going to achieve your academic pursuits. And for many of you, you're coming to academic medicine, not just so you can see patients, you're coming so you can satisfy that part of you that wants to build the legacy through education, that wants to contribute through research.

28:08 And so if that's what you want to do, then you got to be prepared. You got to be prepared. You got to be prepared. You got to be prepared. All right. I hope this has not been bad news. And even though, even as I say it, I recognize that to some extent, it's an eye-opening conversation, one that I want to have with as many people as possible. And for that reason, I want to invite you to please share this episode. Please, please, please, if you share no other episode on this podcast, I want you to share this episode. Because people need to know. There need to be fewer people showing up wide-eyed and bushy-tailed like a dare stuck in the headlights like I was saying, I want to do research. I have no idea exactly what research I want to do.

28:48 I have no real significant research training. And yes, I don't want to do the clinical time that you say I should do. And in reality, it's not realistic. But when somebody shows up at the door and they're like, yeah, I've been doing research. I've published these number of papers and I've been focused in this area. And in the next three years, I'm going to build this portfolio in this specific area. And then I'm going to apply for funding. That's a different experience. That's someone who's very clear. That's somebody who I can see this because they're telling it to me in a way that's very clear. And so really, this episode is not to bring you bad news. It's to help you be strategic. It's to help you prepare to be strategic.

29:31 It's to help you prepare to show up and get the job you actually want. And be able to craft the job that you actually want. As always, I'm here to help you. I do coach. And I would love to help you craft your strategic plan as you move forward into your research career. And I will tell you that if you are a fellow or you are still in training, you can come to my coaching sessions on Mondays. And they are free to fellows, free to trainees. And just send me an instant message through or direct message through LinkedIn. And I will give you information about registering for these sessions.

30:12 But I really want to help you because I don't want anybody to end up struggling in the way that I did. And maybe struggle is good for you, but people quit. People quit because it's so hard. And even when you have everything, all your docs in a row, it's still hard. And you can make it because you have already made it. You've shown yourself to be someone who can succeed. All right. Let's summarize those seven steps. Number one, recognize that academic medicine is a business. Number two, understand how academic medical centers make money. Number three, recognize your role in the business making, in the money making for the business. Number four, understand how your academic pursuits fit within the revenue generation model. Number five, understand what it means to the business system for you to request protective time.

30:56 Number six, don't start an academic job before you're ready. And number seven, prepare yourself strategically. All right. Next time on this podcast, I'm going to talk about what it means to be prepared strategically. So I hope you'll join us and share this episode widely. I look forward to talking with you again next time on the Clinician Researcher Podcast. Thank you for listening. Thanks for listening to this episode of the Clinician Researcher Podcast, where academic clinicians learn the skills to build their own research program, whether or not they have a mentor.

31:36 If you found the information in this episode to be helpful, don't keep it all to yourself. Someone else needs to hear it. So take a minute right now and share it. As you share this episode, you become part of our mission to help launch a new generation of clinician researchers who make transformative discoveries that change the way we do health care.