Academic internal medicine as a physician career choice

I received a wonderful inquisitive e-mail from a 1st year medical student.  He aspires to an academic internal medicine career and, as a non-traditional student with an MPH, has realistic goals.  He asks:

What scares me is the prospect of going into a relatively low-paying specialty in such a non-lucrative practice environment with such massive educational debt.  Are there any other challenges to going into internal medicine that are unique to the academic practice setting?

I must preface my response by saying that at this stage of my career I do not have any major financial issues.  However, when I entered academic medicine I did take a lower paying job than if I had gone into practice.  I did it for “flow“.

In retrospect, I could not be happier with my career choices.  From the 3rd year of medical school I loved teaching and learning internal medicine.  During my career I have dabbled in research and written many paper.  I have gravitated towards administrative positions but have always kept a clear rule that I will not take any job that removes me from ward attending.  When making rounds I find flow. From the Wikipedia entry:

According to Csíkszentmihályi, flow is completely focused motivation. It is a single-minded immersion and represents perhaps the ultimate in harnessing the emotions in the service of performing and learning. In flow the emotions are not just contained and channeled, but positive, energized, and aligned with the task at hand. To be caught in the ennui of depression or the agitation of anxiety is to be barred from flow. The hallmark of flow is a feeling of spontaneous joy, even rapture, while performing a task.

Colloquial terms for this or similar mental states include: to be on the ball, in the zone, in the groove, or keeping your head in the game.

During this career I have counseled many students.  I regularly tell them that “flow” trumps salary.  Daniel Pink’s recent book Drive tells us that after we make sufficient salary (and academicians make sufficient salary) we need more internal motivation.  We prefer to work in an environment that exists at sync with our values and our desires.

I hope to meet this student and have some long discussions about his career.  I hope he will find his flow and not focus too much on the money.  I wish we did not charge so much for medical school.  His e-mail reveals much about medical education, the economics of medicine, and the hidden curriculum.

Robert Centor is an internal medicine physician who blogs at DB’s Medical Rants.

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  • Frank Drackman

    Thats the great thing about Anesthesia, NO rounds, oh they have “Grand” rounds, but its not really rounding, just someone reading 80 Powerpoint slides.
    Once took a patient from the MICU for an ex-lap, came back 90 minutes later, and the Medicine Team was STILL rounding on the same patient…


  • anonymous

    I am an academic general internist and full time faculty for over a decade. Thus, in practice for some time, but started my career much later than Dr. Centor. I went into academics for “flow”, knowing quite well that as a generalist I would not make as much as a specialist, and as an academician, I would make much less than in private practice. However, two things have happened. First, salaries are so bad, that I can barely make ends meet. My kids go to public school, we almost never eat out, I don’t drive a fancy car, etc. I never thought in a million years that I would struggle financially as a physician. Second, the clinical pressures have increased substantially. Outpatient academic internists see twice the amount of patients and have double the paper work than when I was a student making this decision.
    Though I LOVE my job, and would hate to leave, if I knew what I know now, I am not sure I would have made the same decision.
    As a role model, it is important that you encourage students to go into internal medicine and espouse the values of academics. However, do not discount this student’s very real concerns. If your spouse is a lawyer, then academic medicine is a great choice. If you are supporting a family on one salarly and high loan debt, not so much.

  • anonymous

    if you started academic life with the financial burden of this medical student, you might still have major financial issues at this stage of your career. i do not think it is necessarily that easy to be successful in academics, finances aside. i find for general internists, the research available to them may be highly competitive and the young attendings forced to do more and more clinical work. some centers won’t consider you seriously, even with an mph, unless you do a general internal medicine fellowship, whatever that is. i would say unique is a special word and that i find it unlikely that unique situations truly exist with regards to a career in academic medicine– however there certainly are unique opportunities that may satisfy one in both academic and private practice. beware the sharks!

  • andymc

    Think about this aspect. Will he be fulfilled knowing the positions he is training young MDs for (outpatient internal medicine) might not be filled by them at all. Most IM residents , as we well know, avoid outpatient IM like the plaque for hospitalist spots or fellowships. Most of the ones he trains in his IM clinic will end up doing very little if any clinic time at all. If his training and teaching is in an inpatient setting, this won’t be the case with future hospitalists, but the outpatient internist seems to be a dying breed..

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