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.

Q. 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, I can imagine that this would be hard for programs to achieve because the ends of each spectrum can look very different.

Q: Why do you think the number is so low?

JR: 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.

SC: 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. 

Q: How could this number be increased?

JR: 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.

Q: 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…

Q:  How important is salary in determining whether fellows stay in academics?

JR: 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.

6 Responses to “Beyond Fellowship: Academia or Private Practice?”

  1. Micah Eimer, MD says:

    I don’t think that this question can be answered without first defining what constitutes “academics”. A doctor who generates his own income by seeing patients, reading tests and making rounds in the hospital is in “private practice” – right? What if that same doctor did the same thing but was employed by the University? Is that doctor now in “academics”? All that is different is the name on the lab coat.

    Is it teaching of trainees that differentiates academics from private practice? Some of the best teaching I ever got was from affiliated physicians. I also know lots of private practice docs that publish frequently, attend/lead conferences and are respected thought leaders.

    The only real difference that I can see is that true academics receive grant money to support research activities. Using this definition, my conservative estimate is that <1% of medical graduates go into "academics".

    Those of us in private practice have realized that the "academic centers" do not have a monopoly on academics.

    My advice to graduating fellows – be as academic as you want to be.

  2. Eric Osborn, MD, PhD says:

    not sure that exposure to private practice would entrain more interest or not, maybe just the opposite, but would certainly show what the “other side” is to those that pusue this direction in ways other than just the monetary gains.

    Competing interests pertaining specifically to this post, comment, or both:

  3. Saurav Chatterjee, MD says:

    Also often times the world of Academia seems quite restricted in its outlook in that the same institutions and individuals get awarded and receive grants while other meritorius ideas lose steam…..not to say that the individuals/institutions donot merit their success….however sometimes maybe others outside of the restricted circle of research illuminati may deserve a success……….Case in point-look at the YIA awardees of the major American meetings and NIH grants for the last year.

    Competing interests pertaining specifically to this post, comment, or both:

  4. Micah, thanks for addressing the exact definition of “academics”- not an easy task. Throughout our training with our limited exposure to “private practice”, residents and fellows obtain little insight into the large volume of scientific literature being produced outside of the university setting. Similarly we are not exposed to the patient load associated with private practice, which by most reports is larger in volume than what it is in academics (although there are plenty of exceptions to this from either side of the aisle). So I think Eric is right- for some, more exposure to private practice may serve as a deterrent.

  5. This is an interesting discussion. I think it all comes down to what incentives there are to pursue academia or private practice. Academia may not be what truly excites some physicians to get out of bed in the morning and put in a full day’s work, while some physicians love doing research and like much less the clinical time they have to put in. I think by the time that an individual finishes residency, they should know where their interests lie – whether it is to pursue a private practice life or academic career. With that known, one can choose a fellowship more geared toward such. The Kaiser fellowship programs and Cedars Sinai program come to mind (as a Californian) but I’m sure there are a huge number of great “clinical” fellowship spots that are not rigorous academic appointments.

    Competing interests pertaining specifically to this post, comment, or both:

  6. Great Q and A and very interesting comments that follow!
    I have a couple of thoughts
    1) When we think about a 20% figure for fellows starting in academics, we have to realize that many, if not most, fellowships are predominantly clinical programs and do not really provide an academic option for their trainees.
    2) I’d be interested to know what proportion of those that enter an “academic” fellowship intended to go into academics when they started fellowship, and changed their mind for the reasons described above. As a cynical program director, I am convinced that most fellow applicants lie about their true intent during the interview process! They believe (rightly so!) that they have to demonstrate an academic intent to get a top fellowship spot.
    3) To keep fellows in academics, we have to be able to provide the job opportunities when the fellows finish. This is a huge issue in many programs, where budget cuts and shrinking clinical volume have led to slowed (or no) growth in faculty size.
    4) Micah’s point is really important–but equally so for academic jobs as practice jobs. I think we do fellows a disservice by suggesting that there are only one or two models for success in academic careers. If you take a young person, and tell them that the only way they can succeed is to be indepedently NIH funded, it’s no surprise that this is terrifying and by default they will choose what they are comfortable with. In truth, as Micah says, even in the most “academic” of academic centers, there are many different models of success, from pure clinicians, to clinician educators, administrators, and the “traditional” physician scientist. Fellow need to be told that academics can accomodate a huge variety of career goals, and also allows these to change over time.