The Pros and Cons of Academic Medicine

In 2022 I made the transition from fellow to attending.  With that upgrade came an endless stream of paperwork regarding contracts, duty hours, rules and regulations.  Given my family’s current location (and the fact that my wife is already on faculty) we decided to stay put.  As such, I stayed on faculty at the program where I completed fellowship.  Therefore, both my wife and I are academic attendings at the same hospital.  We spent countless nights discussing the pros and cons of academic medicine as we considered my career choices.  There is an opportunity cost that must be considered when deciding to stay in academic medicine.  All of this got me thinking I should put my thoughts on paper.  Here are some factors worth considering when deciding if a career in academia is right for you!

The ‘pros’ of academic medicine

As part of the ‘feedback sandwich’ often utilized to provide trainee critique, I too will start by discussing the benefits of choosing a career in academic medicine. 

Flexible hours

First and foremost, let’s discuss employment hours.  This will commonly be the referenced reason for staying academic.  In a profession plagued by burnout, our medical community is looking to optimize work hours. 

Medicine has, for decades, been associated with grueling hours.  Only recently have we seen changes in duty hour requirements.  This has not quite changed the medical culture, but it does appear to be slowly having an effect.  That said, many programs across the country (and many specialties for that matter) continue to have 80–100-hour work weeks. This leaves little time to recover.  This drives stress, poor sleep, and ultimately burnout. 

Many physicians exit residency or fellowship with PTSD…seriously.  For the past three years (or more) they have been overworked, underpaid, and traumatized by their work-life balance.  Because of this, many seek to prioritize quality of life over reimbursement.  This has become abundantly clear in a post-COVID era.

Enter academic medicine…

What academic medicine offers is a reprieve from significant work hours and the benefit of multiple layers of shared responsibility.  At many academic institutions, you will work alongside medical students, interns, residents, fellows, and mid-level providers; all participating in patient care.  This creates freedom as the attending on service.  Much of an academic attending’s role is to assist in providing appropriate patient care while trainee’s accumulate experience.  With these fail-safes in place, academic attendings are often able to round later and leave earlier given the cohort of colleagues they can lean on.  This flexibility is enticing for individuals with children, dependent loved ones, etc. 

Protected time

Another benefit of academic medicine involves the breakdown of clinical hours as it pertains to your contractual time.  One incentive often utilized for promotions is ‘protected time.’  Protected time can often be synonymous with ‘buy-down’ time or ‘administrative’ time.  All of these are fancy ways of saying ‘instead of increasing your salary, we will decrease the number of clinical hours you have to work for equal pay.’  The time that is ‘bought down’ represents the quantity of clinical shifts needed to maintain your salary.  This time free of clinical obligations is often assigned to division leadership responsibilities, educational requirements, research, etc.  However, as long as you demonstrate utilization of this time, it is generally not closely scrutinized. 

Non-clinical time can be vital as it doesn’t compromise salary and provides a sense of freedom for your schedule. 

Specialists at your fingertips

Another benefit, especially from a medico-legal standpoint, is that academic institutions often house the majority of specialists and subspecialists.  This can be helpful as you are able to utilize experts more readily. 

There is a saying I use in the ICU… ‘Load the boat!’  When the ship is sinking…load the boat!  It spawns from a tendency to recruit all other intelligent minds if a patient is deteriorating, especially if I don’t completely grasp the etiology.  In academia, I find it refreshing to call on colleagues I trust, in all specialties, asking for help.  The ability to be in an academic center, with physicians on the cutting edge of medicine, can truly help patient care and calm the mind. 

Feeling supported by your institutions is critical for a physician, but being surrounded by other professionals offers personal and professional benefits. 

Support for other academic endeavors

With the absence of substantial pay raises comes the advent of other avenues for incentivization.  Often in lock-step with academic advancement comes a prioritization of continued personal education.  Master’s in business, master’s in public health, master’s in hospital administration…all of these can bolster your competitiveness of promotion.  Where academic institutions may be hesitant to negotiate a pay raise, they are often eager to foot the bill for continued education. 

If you aspire to further education, these can often be great negotiating terms as it pertains to advancement.  Completion of degrees can also drive candidacy for advancement!  Double whammy!

Quality of life

I will put quality of life under ‘pros’ because with academia comes flexibility. With flexibility comes improved quality of life.  We touched on this earlier. 

Now, an argument can be made that a salary bump can drive quality of life improvements too.  I have written about this before.  In a previous post I wrote how buying back your time is a way to exchange money for free time.  In this instance, a salary increase can correlate to buying power as it pertains to freedom.  However, overwhelmingly, academia offers freedom of one’s time (both clinically and non-clinically) that private practice (usually) cannot.  In an era where work-life balance is driving burnout, academia offers freedom on the job.  The opportunities afforded with this freedom are (in my opinion) the primary incentive driving physicians into academic careers.    

The ‘cons’ of academic medicine

We are now to the ‘meat’ of the feedback sandwich.  For as many positives to academia as there seem…there remain some substantial negatives.  The majority of them apply to reimbursement, but not all. 

Less pay

I don’t need to tell you this. It is common knowledge that no matter the geographic location in the US, academic physicians make less than their private practice counterparts. 

Data from a 2016 survey found that physicians working in academia make about 13% less.  This can vary significantly by specialty however.  For example, in this study gastroenterologists make 41% less choosing careers in academia.  Don’t believe me…check out this data from Doximity. 

For those primarily incentivized by the size of their paycheck, academic careers may be a tough pill to swallow.  However, as a caveat, I would often look to see what your reimbursement is per hour. 

Now for a brief story…

View your reimbursement through a ‘per hour’ lens

When I started to consider my career choices I sat down with a mentor of mine.  This individual graduated from the same fellowship as I, years prior.  After graduation he was employed by our town’s largest private practice, working there for approximately 3 years.  He ultimately transitioned back to academia.  When asked why, he blamed reimbursement and work hours.  He said that, yes, he was paid more to work in private practice.   Unfortunately, his weeks were usually 80-100 hour work weeks.  The money was good, but he had no time to spend it!  He was too busy carrying call, covering ICUs, seeing consults and staffing clinic. 

One night he sat down and reviewed his current reimbursement on a ‘per hour’ basis.  He discovered that he was making less than he would in academia when viewed this way.  Annually, he made substantially more, but should he work the hours of his academic colleagues he would make more ‘per hour.’  His salary would be less, but his hours would be substantially less. 

Less negotiating potential and less monetary incentives

I should start by saying that this factor is not ubiquitous.  Many academic institutions are actually very receptive to contract negotiation…but expecting a significant salary hike is unlikely.  If you approach an academic contract with hopes of negotiating private practice pay, you are likely to be disappointed.  Generally academic institutions utilize non-financial means for incentives (see above).  Often these include protected time, the ability to tailor a clinic to fit your expertise, or expedited advancement through a tenured track. 

Sign-on bonuses, relocation stipends, annual or RVU bonuses, all of these you will find with regularity in non-academic positions.  The benefits of these large ‘chunks-of-change’ pertain to limited stipulations on how this money is spent.  This means you can accept that relocation stipend, accept that sign-on bonus, and put a large portion directly towards your financial goals…like paying down debt! 

In my experience, academic institutions do offer monetary incentives. However, academic offers pale in comparison to their private counterparts in size and frequency.  No matter your career, ask about these contractual incentives, just don’t hold lofty expectations for academic careers.

Convoluted promotional process

The promotional process in academia is often tied to research, educational, and administrative milestones.  Promotions rarely correlate with a significant pay raise.  There are usually a number of conditions that must be met to be considered for promotion.  Commonly, there is a time criterion that must be met to be considered for promotion as well.  It is possible that you achieve every milestone asked of you, and it still be ‘too early in your career’ for advancement.  For physicians that pursue education or clinical care in academia, this can pose a barrier to receiving routine promotion as these avenues make it harder to justify.

One size does not fit all

Before we end things, I think it important to note that the decision to pursue academia is not ‘all or nothing.’  There are loads of different institutional models.  True, there are complete private and academic locations, but there are also hybrid models…with hybrid pay!  I have visited multiple institutions keeping a hand in education while providing predominantly non-academic level reimbursement.  Some options may allow you to ‘have your cake and eat it too!’

Another aspect to always keep in mind is candidacy for Public Service Loan Forgiveness (PSLF). I did not include this in either the pros or the cons section as it belongs in neither. Pursuing PSLF is primarily a choice related to the individual. Your personal finances, candidacy, and debt aversion will all factor into your decision to pursue PSLF or not. Institutions in academia as well as the community can both qualify as sites for PSLF. You just have to do your research!

Take home points

When deciding on a career path, the decision to pursue academic medicine can be challenging.  There are many pros and cons to a career in academia.  As it applies to personal finance, the tradeoff often lies between reimbursement and quality of life.  These carry varying levels of importance with different individuals.  Understanding your comfort with reimbursement and income potential can prove difficult.  However, remember there are a plethora of alternative incentives that can mean the difference between physician burnout or benefit!

If you take anything away from this article, take this:  There is not a ‘one size fits all’ model.  Go out of your way to listen to other’s seeking work-life balance.  Calculate expected reimbursement and view that revenue through multiple lenses, including by the hour.  Lastly, and most importantly, take the time to reflect inwardly.  What is important to you?  Is money the end-all-be-all, or is it more control over your time?  Whatever it is, finding the answers to these questions will influence the happiness you find with your contract, your career, and your life.  As always…

Stay motivated,

The Motivated M.D.

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