So Thanksgiving has arrived and I have much to be thankful for. I have a beautiful family that I helped to build and an amazing wife who built it with me. I have a job I am passionate about and look forward to every day, even if my 2 year old's 6am wakeup makes me curse the gods of sleeplessness. I have a home that feels like home.
But I am also thankful for some other, less spoken things. I am Thankful for my attendings who have the grey hairs and years of knowledge and time and patience to have taught me everything I know about medicine. I am thankful for the patients who have done just as much teaching without trying. I am thankful for my health- something no one in my profession takes for granted.
I've been thinking, these days, about decisions and patience. A good decision can take years to pay off, but when it does there is no better feeling than the wait. Medicine feels like a good decision to me, and 9 years into the career, still in training but near the end of the tunnel, I know how grateful I will be for the decision to be on this crazy path. The truth is, I watch people every day suffer from bad decisions. Some of those decisions are made just beforehand- like not showing up to the ICU as a loved one dies, then feeling guilt in the final hour when the visit is finally made. But most of the decisions I see patients suffer from are ones made years before- like sleeping with a prostitute in Southeast Asia and contracting Hepatitis C, or using IV Heroin and ruining many lives along the way only to be left a shell of the person who once was, or not telling children about a cancer and watching their rage and helplessness as they find out with only weeks left to live. I have witnessed all of those scenarios and more.
We are a society fixating on instant gratification. It seems as though many people have lost sight of the patience our parents and grandparents exhibited when they worked long, hard hours at jobs that may not have "thrilled" them every day but in the end paved the roads and lit the lights of the 1950's American dream. My grandfather, for one, snuck out of Russia on a hay wagon, crossed the Atlantic and worked odd jobs for his entire life. He wasn't the dad of the year, but his son, my father, was a graduate-degree-educated success. My mother's parents worked odd jobs as well- her dad sold cigarettes door to door back in an age when such jobs were real. And out of the ghetto my mom came, and a successful career followed. The point is, my parents are a common 2nd generation story, which followed on the heels of long-term 1st generation thinking.
On this Thanksgiving I ask you all to be as thankful as I am for what is good and think equally hard about how to make decisions that are worth waiting for.
Wednesday, November 25, 2009
Tuesday, November 3, 2009
Wanted
So this week I'm attending a course on clinical investigation, something I am actively engaged in for the later 2 years of my fellowship. Lectures on medical ethics, statistics, study design and patient confidentiality are among the many topics I am engaging in. It is a course run by Harvard and the course is under the heading of a new umbrella called "The Catalyst" which is a new way of building the future of science and medicine.
In 2009, Harvard, and other academic institutions have recognized that the ideal product of their investment in training is a doctor or PhD who 1) stays at the institution 2) contributes more than their salary to the institution and 3) furthers the prestige of the institution. In order to carry this out, they are investing in fostering training across specialties and levels in fundamentals of research. The truth is, research drives the money boat for any academic medical center. The "ideal" faculty bring in NIH or other source grant money in much larger dollar values than his or her salary. He or she works for a salary of $125,000 a year at most for several years as the career builds. In the long-term, those lucky enough to develop a drug or get millions of dollars of NIH grant funds become department heads. But most flounder at low salaries for years in someone else's lab and eventually fail (there is less and less money) and go into private practice or industry). Of all of the small molecules investigated as possible drugs, only 15-20% ever make it to trial and far fewer become usable, and profitable.
So as I sit here I think: Why would anyone engage in this long endeavor? For one, there is the prestige factor. Harvard is better than most at relying on this factor. Who doesn't want to be among the "who's who" of Boston doctors. Who doesn't want to be the Chair of Cardiology (or any field) at a Harvard hospital? But those elder statesmen who have set up Catalyst have overlooked a few key items in 2009:
1) Cost of living. While $100,000 (the average starting salary for a Harvard investigator with an MD or PhD) may seem like a lot of money, in Boston or other large cities, this is not a big salary. Lawyers one year out of Harvard Law average $140,000. MBAs in their first year average the same salary. So why would a doctor, after 4 years of medical school, 2-4 years of residency and an additional 1-3 years of fellowship work for $100,000? It simply doesn't make financial sense unless you are independently wealthy. In fact, at the program where I complete my residency, I was asked by the Chair of GI how much loan debt I was in. At the time I thought nothing of it, and only now realize that my honest answer put me lower on the list: I am not rich enough to afford to be a clinical investigator in Boston without a struggle. My wife is a teacher. We need my income to support our family. $120,000 or so won't cut it if we want to buy a home, send the kids to camp- have a decent life.
2) Years of training. In 1965, residency was 2 years and fellowships were optional. To specialize, several of today's department chairs simply did a year or so of work in the field of their choice. Younger chairs (50+) in GI did a one year fellowship in the 70s. Then residency became 3 years. Then fellowships like GI and Cardiology became 2 years and finally 3. (There is now a push for 4!). The argument the grey hairs make is that the knowledge is too overwhelming to learn in 3 years. The truth: fellows at academic centers like myself are being asked to devote 80% of our time to research in our 2nd and 3rd years. They are grooming me to be a clinical investigator. And yes, I signed up willingly to an academic program, mostly for the training experience, knowing what I know now (and there are more clinical programs out there- not at Harvard.) Regardless, 3 and soon 4 years of post residency training puts the total number of post college years at 10 (14 including college). I am in year 9. That's a lot to ask of anyone at any age. Perhaps for someone who goes straight into med school from college, 32 isn't too old to launch. Perhaps that 32 year old can even afford the $100,000-$120,000 for 5+ years before they make it or fail ("making it" is $150,000, not $400,000 by the way- to make the big bucks there's an additional 20 years until you are professor at Harvard). But at 37, someone like myself will finish fellowship ready to have a career, not start one.
3) Grant money is disappearing: As we engage in a war a week, and fix our roads, and insure everyone (even immigrants), tax money is being allocated everywhere but to research. Bill Clinton expanded the National Institute of Health like no one else and remains a hero to many investigators. George Bush undid that, bankrupted our country with a one way ticket on the Halliburton express, and now science is struggling with anemic funds. The percent of new K awards applications, the grants awarded to young investigators like myself, funded in 1990 was 40 or so. Last year it was 18. There is no money to support people like myself even if we do everything right. And those with K awards then need to secure the R awards (million dollar plus grants from the NIH) for "job security" and the competition becomes every chairman in every division in America with 30+ years of experience. Even with ideas that seem cutting edge and important, there isn't money right now for growth in science.
So is the Catalyst doomed? Well, most investigators don't share my view. Many are spirited and engaged and buy into the "low salary, earn it yourself" mentality that this career requires. Many don't have my perspective on what used to be, and focus on what is (probably a healthier and happier way to live!) And many aren't as old as I am, with families to feed on their salaries. But I worry for these people when they turn 35. 5 or 10 years into this research career, will they be happy? I have grown accustomed to seeing people at Harvard with blinders on. Some are barely English speaking folks who are grateful to have work in the US on visas which require them to work at academic centers. Others are Americans who think that they will beat the odds. It's kind of like playing the stock market- no one knows where this will head, where funding will be in several years- and ideas are exciting and young investigators are invigorated.
Regardless, I see a propaganda machine, one that is spinning out joint MD/PhDs from medical schools (yes, many extra years of training and cheap research labor) and labeling them as "future department heads." In truth, there are only so many departments. I look forward to the data in 30 years from Catalyst. The idea is brilliant- getting us trained together, interacting with one another, cross specialty, calling us "translational researchers"- but in the end, how many people will live their lives in labs that other people benefit from. How many young brilliant doctors won't treat patients, but will inject mice instead with 80% of their time.
The academic institutions say we need them. And we do. But we also need our best minds in the clinic, where I am heading in a year, when I get out of this cage.
In 2009, Harvard, and other academic institutions have recognized that the ideal product of their investment in training is a doctor or PhD who 1) stays at the institution 2) contributes more than their salary to the institution and 3) furthers the prestige of the institution. In order to carry this out, they are investing in fostering training across specialties and levels in fundamentals of research. The truth is, research drives the money boat for any academic medical center. The "ideal" faculty bring in NIH or other source grant money in much larger dollar values than his or her salary. He or she works for a salary of $125,000 a year at most for several years as the career builds. In the long-term, those lucky enough to develop a drug or get millions of dollars of NIH grant funds become department heads. But most flounder at low salaries for years in someone else's lab and eventually fail (there is less and less money) and go into private practice or industry). Of all of the small molecules investigated as possible drugs, only 15-20% ever make it to trial and far fewer become usable, and profitable.
So as I sit here I think: Why would anyone engage in this long endeavor? For one, there is the prestige factor. Harvard is better than most at relying on this factor. Who doesn't want to be among the "who's who" of Boston doctors. Who doesn't want to be the Chair of Cardiology (or any field) at a Harvard hospital? But those elder statesmen who have set up Catalyst have overlooked a few key items in 2009:
1) Cost of living. While $100,000 (the average starting salary for a Harvard investigator with an MD or PhD) may seem like a lot of money, in Boston or other large cities, this is not a big salary. Lawyers one year out of Harvard Law average $140,000. MBAs in their first year average the same salary. So why would a doctor, after 4 years of medical school, 2-4 years of residency and an additional 1-3 years of fellowship work for $100,000? It simply doesn't make financial sense unless you are independently wealthy. In fact, at the program where I complete my residency, I was asked by the Chair of GI how much loan debt I was in. At the time I thought nothing of it, and only now realize that my honest answer put me lower on the list: I am not rich enough to afford to be a clinical investigator in Boston without a struggle. My wife is a teacher. We need my income to support our family. $120,000 or so won't cut it if we want to buy a home, send the kids to camp- have a decent life.
2) Years of training. In 1965, residency was 2 years and fellowships were optional. To specialize, several of today's department chairs simply did a year or so of work in the field of their choice. Younger chairs (50+) in GI did a one year fellowship in the 70s. Then residency became 3 years. Then fellowships like GI and Cardiology became 2 years and finally 3. (There is now a push for 4!). The argument the grey hairs make is that the knowledge is too overwhelming to learn in 3 years. The truth: fellows at academic centers like myself are being asked to devote 80% of our time to research in our 2nd and 3rd years. They are grooming me to be a clinical investigator. And yes, I signed up willingly to an academic program, mostly for the training experience, knowing what I know now (and there are more clinical programs out there- not at Harvard.) Regardless, 3 and soon 4 years of post residency training puts the total number of post college years at 10 (14 including college). I am in year 9. That's a lot to ask of anyone at any age. Perhaps for someone who goes straight into med school from college, 32 isn't too old to launch. Perhaps that 32 year old can even afford the $100,000-$120,000 for 5+ years before they make it or fail ("making it" is $150,000, not $400,000 by the way- to make the big bucks there's an additional 20 years until you are professor at Harvard). But at 37, someone like myself will finish fellowship ready to have a career, not start one.
3) Grant money is disappearing: As we engage in a war a week, and fix our roads, and insure everyone (even immigrants), tax money is being allocated everywhere but to research. Bill Clinton expanded the National Institute of Health like no one else and remains a hero to many investigators. George Bush undid that, bankrupted our country with a one way ticket on the Halliburton express, and now science is struggling with anemic funds. The percent of new K awards applications, the grants awarded to young investigators like myself, funded in 1990 was 40 or so. Last year it was 18. There is no money to support people like myself even if we do everything right. And those with K awards then need to secure the R awards (million dollar plus grants from the NIH) for "job security" and the competition becomes every chairman in every division in America with 30+ years of experience. Even with ideas that seem cutting edge and important, there isn't money right now for growth in science.
So is the Catalyst doomed? Well, most investigators don't share my view. Many are spirited and engaged and buy into the "low salary, earn it yourself" mentality that this career requires. Many don't have my perspective on what used to be, and focus on what is (probably a healthier and happier way to live!) And many aren't as old as I am, with families to feed on their salaries. But I worry for these people when they turn 35. 5 or 10 years into this research career, will they be happy? I have grown accustomed to seeing people at Harvard with blinders on. Some are barely English speaking folks who are grateful to have work in the US on visas which require them to work at academic centers. Others are Americans who think that they will beat the odds. It's kind of like playing the stock market- no one knows where this will head, where funding will be in several years- and ideas are exciting and young investigators are invigorated.
Regardless, I see a propaganda machine, one that is spinning out joint MD/PhDs from medical schools (yes, many extra years of training and cheap research labor) and labeling them as "future department heads." In truth, there are only so many departments. I look forward to the data in 30 years from Catalyst. The idea is brilliant- getting us trained together, interacting with one another, cross specialty, calling us "translational researchers"- but in the end, how many people will live their lives in labs that other people benefit from. How many young brilliant doctors won't treat patients, but will inject mice instead with 80% of their time.
The academic institutions say we need them. And we do. But we also need our best minds in the clinic, where I am heading in a year, when I get out of this cage.
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