April 15th, 2011
Beyond Fellowship: Academia or Private Practice?
Published literature maintains that 20% of cardiology fellows continue into academic careers, with the remainder going into private practice.
Fellowship Training Co-Moderator John Ryan, a second-year cardiology fellow in Chicago, and Associate Editor Susan Cheng, a fifth-year fellow in Boston, answer CardioExchange’s questions about the transition from fellowship to the next level – whatever that may be.
. Are you surprised that so few fellows choose to remain in academia?
JR: It does surprise me. We spend ten years of training in an almost exclusively academic setting, so at first I would assume we are almost ill equipped to go into private practice
because we are simply not exposed to it.
SC: This figure used to seem quite low to me, too.
More recently, with research funding being very tight and some academic centers having instituted hiring freezes, it seems that academic opportunities are just not as numerous as outside jobs. Also, the pay difference is often enough to drive many people away from academia after they graduate. John’s point about being prepared to go into private practice is important: I think that the ideal fellowship program for most people offers good training for pursuing either an academic or private-practice position or something in between. However, each spectrum can look very different.
: Why do you think the number is so low?
I believe it comes down to mentorship. As I get further along in my training , I am beginning to see the skill sets that are required for a career in academics. To acquire those skills, I think someone needs a dedicated mentor who will show how to write papers, apply for grants, and carve out a niche. Patient care is never easy; however, it is second nature to us by the end of our fellowship. Complementing these skills with an area of expertise — be it research, teaching, whatever — that is the hard part.
There are probably several reasons and I agree with John that one of the biggest factors is a lack of mentorship, as well as prior experience. I realize these two go hand-in-hand. A challenge is that good mentorship is difficult to come by for a variety of reasons, including that it takes hard work and a lot of effort on behalf of the mentor – and mentoring skills are not taught in any structured way. All this probably translates into fewer really good mentors and, in turn, fewer people in training who get high-quality mentoring.
: How could this number be increased?
I’d expect that providing dedicated time during fellowship for uninterrupted research would produce the highest yield. However, that typically extends training, which is already seen by many as too long. Also, there may be some selection bias, as the fellows who do these two- to three-year research programs are presumably the ones most interested in academics . And there is only so long that we can stretch out our training before reality settles in and we need to start earning a salary.
SC: I have no choice but to agree with
John , since I’m now finishing up what will be my third year of dedicated research time – as an overall fifth-year fellow! One can take all the courses in the world, but nothing replaces the hands-on experience of spending large, dedicated amounts of time working on research projects under the right type of mentorship. The issue is that it does take time. Most of the people I know who are moving into academic positions out of fellowship have spent a solid two, three, or more years doing clinical, translational, or basic research – regardless of whether or not they had a bunch of experience or even PhD training prior to cardiology fellowship (science is changing that quickly). I wonder if this reality should be made more clear to fellows entering cardiology and, perhaps, if there should be different tracks for people depending on their career preferences – if they happen to be aware of their preferences that early on.
: Could programs better prepare their fellows for private practice?
JR: If we could spend more time in private-practice settings
that would be beneficial; however, I am not sure how that would work out from an ACGME perspective. I suspect that developing more familiarity would likely increase the number of graduates going into private practice (although I have no data to support my suspicion).
SC: I can imagine several things that could
help better prepare fellows for private practice, such as seminars on providing quality care in a high-volume setting, managing a practice as a well-run business, appropriate billing practices, human-resources management, maintaining certification, continuing medical education, and probably many more areas that I don’t know much about. As far as helping fellows figure out what type of career is right for them, wouldn’t it be great to get a bunch of private practitioners and academicians (and people who have careers that are something in between) together to talk to first- and second-year fellows about their jobs, what they like, what they dislike, and what they would do differently if they could? Maybe we could do something like that online, though I realize that’s another topic altogether…
: How important is salary in determining whether fellows stay in academics?
It is likely a major factor, but at least some literature suggests it is not the sole deciding issue. At least in this study of medical students regarding their career choice, the most important aspects were educational experiences, the nature of patient care, and lifestyle. Whether we can extrapolate these data all the way to graduating fellows, I am unsure.
SC: I bet it becomes a more important factor
as people get further into their training, as loans accumulate, and they start to build families. It is at this point that I see people around my level of training start to rethink their decision to pursue an academic career. It’s sort of like “the daycare test” – they look at the cost of daycare and then decide that things will be okay the way they are, that things will hopefully get better soon, or that there now needs to be a major change in plan.