Tacky

Some non-physicians think physicians are overpaid. This physician disagrees, but does think that a number of specialties are way overpaid (I'm looking at you radiology, dermatology and some others--you know who you are).

After walking through a university parking lot while on a visit recently, I had these thoughts:
1. If you are in a highly paid specialty, there is no need to drive to work in a late model Ferrari. This is in bad taste in a time of great concern about health care costs.
2. Even if you feel that you need that Ferrari and need to drive it to work, you do not necessarily need vanity license plates that announce you paid for the vehicle by billing for your grossly over-compensated medical service.
3. All of the above is doubly true if you work for an academic medical center.

Part of a dying breed

The DrugMonkey blog is laden with the type of practical, career advice that I wish I had been given early on. I was thinking recently about a post from last year:

So noob, you put in one grant, it didn't get funded and you feel mopey? . . . .
It is not about what anyone else or the "typical" person has done. It is about doing whatever you possibly can do until that Notice of Grant Award arrives.
My stock advice right now is that you need to have at least one proposal going in to the NIH for each standard receipt date. If you aren't hitting it at least that hard, before you have a major award, you aren't trying. If you think you can't get out one per round.... you don't really understand your job yet. Your job is to propose studies until someone decides to give your lab some support.
My other stock advice is take a look at the payline and assume those odds apply to you. Yes, special snoflake, you.
If the payline is 10%, then you need to expect that you will have to submit at least 10 apps to have a fighting chance. Apply the noob-discount and you are probably better off hitting twice that number. It is no guarantee and sure, the PI just down the hall struck it lucky with her first Asst Prof submission to the NIH. But these are the kinds of numbers you need to start with.
Once you get rolling, one new grant and one revised grant per round should be doable. They are a month apart and a revision should be way easier. After the first few, you can start taking advantage of cutting and pasting a lot of the grant text together to get a start on the next one.

And also, in the same vein, this:

In the face of budgets which allow the funding of only a subset (a third? quarter?) of the grants which are excellent and interesting and impactful and all that jazz, review becomes variable. Meaning the difference between making it into a fundable score and just missing a fundable score takes on the appearance of chance. The only way to beat such odds is to give yourself more chances at the game. This means writing and submitting multiple applications (on different topics, of course).

And I was castigating myself: "how come I'm not doing this? I obviously need to submit more applications; why can't I find the time?"

And then it occurred to me: I was thinking this while I was writing a medical clearance letter on behalf of a patient.  And just before that, I was reading about an unusual case I saw in clinic on UpToDate. And I have my half day clinic the day after tomorrow, which, if you include associated documentation, follow-up, reading and responding to patient queries, really takes up a full day. And the month before, I was on the hospital consult service, which breaks up the day and eats up time. On top of that, I have the same responsibilities as DrugMonkey and most of his audience: stay up to date on the science literature, run a lab, write papers and, oh yes, write grant applications.

Another thing about DrugMonkey is that, as far as I can tell, he does not have kids at home. The thing about having kids is that when they're not driving you crazy--which, fortunately, tends to be more than 50% of the time--you want to spend time with them; and your spouse, also. In fact, now that I think about it, by virtue of being single, divorced or old enough to have adult kids, many (most?) of the investigators I know who are thriving in the current environment do not have kids at home.  Hmmm.

Medical students are smart. They can put two and two together: soft money salaries + historically low NIH grant success rates=job insecurity and potential for high stress.  "Fixes" for the system thus far proposed generally involve pumping more physicians into the system through training grants and lower barriers for initial R01 grant awards. Proposed measures seem to never involve increasing downstream job security. Our society idolizes youth. This includes the NIH: trainees and new investigators are loved.  Once you've been sucked into the system and you're trying to get your grants renewed, you're on your own buddy. Think the PhDs reviewing your grant applications or tenure file give a fig that you are a physician-scientist? Think again. Physicians in training--and this goes for MD-PhD students also--aren't blind: they see what is happening.

There: I've solved the puzzle of why medical students are less inclined than ever to do what I do for a living: of why predictions that physician-scientists are a "endangered species" are coming true.

Annals of ineptitude: NIH grant planning edition

Still clearing my desktop.

The April 4th issue of Science has a ten page section up front regarding the current travails of U.S. grant-funded researchers: "Chasing the Money".

The NIH funding situation has been getting progressively worse over the past few years. Meanwhile, over the years, the NIH has kept coming up with new schemes to direct funds to new investigators in order to pump fresh blood into the system.

Now, read the following excerpt from the lead article:

• The agency makes it easier for new investigators to get funding, for example, but it doesn't know how they fare 5 years out, when their first big grant is up for renewal. "We want to make sure we're not setting them up for failure," says Sally Rockey, NIH's deputy director for extramural research. The agency plans to start tracking these people, to gauge whether they're headed for dire straits.

Now read it again.

Note the words "plans to start." Plans. To. Start. Plans to start. Now? Now?(!) 

Two things: 1) when starting a program, it's good to think through the outcomes beforehand. Especially when your enticing people into a career and investing heavily in them. Especially when their livelihood while pursuing that career is dependent on your organization. Similarly, it's good to try to ascertain results/outcomes in as timely a fashion as possible. 2) Sally Rockey and her colleagues should read "Chasing the Money" in the April 4th edition of Science as well as the many other articles out there about the current funding environment. They might learn something. Why would these new investigators not be headed for dire straits?

File this away under the NIH subsection of government ineptitude. 

Clearing my desktop part 2. Medicine-the ABIM piles on

Two recent articles of interest concern medicine, and specifically how burdens unrelated to patient care continue to accumulate in a cruel fashion.  I want to highlight one quotation from each article. These quotations perfectly echo my sentiments about one particular new aggravation .

The first article can be found here.  The following quotation is in regard to one new initrusion that I and many, many of my colleagues find outrageous. The American Board of Internal Medicine (ABIM) continues to ratchet up the monetary and time burden of recertification with no evidence that anyone, aside from the ABIM itself, will benefit: 

• doctors also face board recertification in the various medical specialties that has become time-consuming, expensive, imposing and a convenient method for our specialty societies and boards to make money."

The second article--also dealing with new cruelties inflicted on physicians who would rather just be providing patient care--is here.  And here is the quotation: 

• Almost comically, the response of medical leadership—their solution— is to call for more physician testing. In fact, the American Board of Internal Medicine (ABIM)—in its own act of hostage-taking—has decided that in addition to being tested every ten years, doctors must comply with new, costly, "two year milestones." For many physicians, if they don't comply be the end of this month, the ABIM will advertise the doctor's "lack of compliance" on their website. 

Physicians would not be up in arms about these dictates from the ABIM if there were any shred of solid evidence that they improved patient outcomes. But there isn't. There is just yet more intrusion on the schedule, budget and sanity of physicians; yet more paperwork.

Clearing my desktop part 1. Science-the broken research funding system.

I have not written here for a while. Some of the key problems with the biomedical research enterprise that I have been thinking about of late have been described by prominent scientists in widely-circulated articles. What I would have written--at least regarding the descriptions of the problems, if not the solutions--would have been redundant.

Here is an example of one of these articles (in the op-ed section of the Wall Street Journal). Regarding the authors' description of the problems with grant review, I can only say "amen."  (The article, unfortunately, may be behind the Journal's paywall.)

Here is another example. Again, regarding the overview provided and the descriptions of the problems with the current system of research funding: "amen."

Whew, another three sentences written . . . I deserve a little break

Pro . . .cras. . .tin. . .ation

I do a lot of interesting reading while I'm in the midst of grant writing. The number of sentences I can write before "needing" a break is inversely proportional to the time remaining before the deadline, starting at about three and increasing exponentially beginning a few days before the deadline. If not for grant and manuscript writing, my knowledge of history, philosophy, Consumer Reports ratings of refrigerators, the 10 best places to retire, the 10 worse things to say on a first date, the Freedom-class littoral combat ship and Amazon.com's selection of V-neck undershirts would be infinitely smaller.

Recently, I ironically found myself reading this on my iPad, having stumbled upon this article while lounging on the living room couch, surfing the net and diligently avoiding completing a grant application due the next day. The article, "Why Writers Are the Worse Procrastinators," was strangely reassuring. I'm a professional writer in a way. Here I have been beating myself up about my chronic procrastination, but it turns out that, if you're a writer, it just comes with the territory.

Much of my training occurred before the advent of online grant submission. Evidence that a lot of my colleagues were fellow procrastinators? Scientists and administrative assistants waiting eagerly by the FedEx pickup box to ensure pickup 5 PM on the day before major grant deadlines. Common knowledge in the local biomedical science community about where to take FedEx packages for the very last after-hours drop-off (I seem to remember that it was at the airport FedEx office). True story: when I was in training, my lab's Principal Investigator missed the last FedEx and UPS pickups the day before a major NIH grant was due. I remember the frantic copying and stapling: even more panicked than usual the day before grants were due. The PI's solution: buy a ticket for a transcontinental  flight that very night to Washington DC, put a postdoctoral fellow on the plane with the application (and all 14 copies, or whatever it was back then) in hand, and send him off to hand-deliver the application to the NIH.

A tip for those of you whose procrastination leads to self-flagellation and misery: read this essay on Structured Procrastination by John Perry, emeritus professor of philosophy at Stanford, and his follow-on book, The Art of Procrastination: A Guide to Effective Dawdling, Lollygagging and Postponing.  They're both witty, easy reads and, importantly, many people (including me) find that Perry's way of looking at procrastination makes a huge difference in how they think about their procrastination and themselves. My only slight concern is that maybe these writings have lulled me into too much complacency about my procrastination and have perhaps forestalled my eventual self-"cure."

For my benefit

This post is for my benefit.  You may want to skip over it.

Due to the current funding environment, my job is a bit more stressful than I originally anticipated.  I am what is know in the business as a "triple threat": researcher, clinician, teacher. "Triple threats" may be a dying breed; there is some debate about that.  I have a lot on my plate. I don't claim to be alone or exceptional in that regard.

Things I need to remember when I feel stressed or when I am stewing over some job-related issue (if I sound like Stuart Smalley, I didn't intend it) :

It's too easy to focus on the "minus" column and overlook the pluses.

I am at home in two different worlds: I can function in a basic research environment as well as any PhD, and I can walk into a hospital or medical clinic and be mistaken for a pure clinician. MD-PhDs are plentiful at top medical schools. It is easy to forget that being both a fully qualified MD and a PhD-level researcher might be seen as impressive outside the medical school campus.  At least my parents are impressed.

Being a physician is a pretty big responsibility. Hey, some people do it full time and even make a career of it. I guess I should keep this in mind when I compare myself to straight basic research PhDs.

I can help diagnose and treat people who are ill. I am privileged to be able to do so. This also greatly helps in framing research questions.

David Brooks says " . . .  I tell kids if you have a great career and a crappy marriage, you will be miserable. If you have a crappy career and a great marriage, you’ll be happy."  I have a good marriage (to the fetching Mrs. Grantslave). I should count myself lucky.

I don't think my kids are going to laying on a psychiatrist's couch when they're adults and complaining about me.  I've been fortunate to have had the desire and the  flexibility in scheduling to be an involved, not bad father.  When I'm very old, I think I would have regretted the time I didn't spend with my kids more than the one extra grant application I didn't have time to write.

I have made contributions to our encyclopedia of knowledge about how the body works. For some reason, this is satisfying.  I have to remind myself that this is something I very much wanted to do when I was a naive kid.

Every predoctoral trainee that has come through my laboratory--both graduate students and students spending a couple of years in the lab before going to medical school--has had solid first-author papers.  This has not been the case with other, bigger, better funded laboratories that I am familiar with.

I have used the public's money efficiently and always keep in mind that I am spending tax dollars taken from the earnings of the supermarket manager just barely in the middle class or the tow truck driver just scraping by or spending funds donated by the earnest, well-meaning walk-a-thon participant.

I just looked at the blog CaliforniaStemCellReport, so I have to throw this in:
I have never and would never personally fight for the passage of a state proposition that would force residents of my state to pay specifically for my research, willingly or not. I would not grossly exaggerate the potential for near-term benefits of my research in order to influence 55% the residents of my state to vote for a law that would also forcibly extract money (as bonds are paid off) from the other 45% who perhaps felt they had better uses for their money.  Public funding of biomedical research is essential. I am strongly in favor.  But  I wouldn't become a huckster in order to coerce funding targeted specifically to my laboratory, which of course I think is highly valuable and meritorious of funding.