Borges, Nicole J. PhD; Navarro, Anita M. MEd; Grover, Amelia MD; Hoban, J. Dennis EdD
Medicine has different pathways in which physicians pursue their vocation. Historically, private practice, industry, the military, and academia have been common paths. Recently, physicians' academic careers have received increased attention in the literature as medicine and academic health centers evolve and change.1–3 During the past 20 years, enormous pressure on academic physicians to generate more of their salary through patient care has occurred, thus reducing time for research and/or teaching. Also, during this era, the number of tenure-track faculty positions has declined.4 Medical schools currently are confronted with physician workforce issues, including expected retirements of the baby boomer generation of physicians and an increase in part-time schedules for younger physicians.
Concerns expressed about academic medicine's future5–7 and viability as a career path for future generations of physicians generate questions regarding why physicians choose academic medicine.
Our attempt to answer these questions (stated below) led to a review of the literature on physicians' selection of an academic medicine career. We examined the literature to identify factors, revealed by research, that have influenced physicians to choose an academic path. Specifically, we sought to find answers to the following questions:
* What are the reasons physicians choose to enter academic medicine?
* At what point in a physician's career is the decision to work in an academic setting made?
* Are there common factors that predict academic career choice across medical specialties?
* Do the reasons for entering academic medicine vary among specialties?
Answering these questions is important to faculty recruitment and retention in the current climate. These answers could also assist faculty in advising medical students about career options, including academic medicine, in a more informed way.
Data sources and criteria for inclusion of studies
In the fall of 2006, we searched the PubMed database for articles published from 1960 to 2006 using the term career academic medicine. This search resulted in 1,411 articles. In reviewing the list, we decided to confine the review to articles from journals in the United States because of the unique aspects of this country's medical education system. Articles outside this parameter were eliminated, leaving 1,161 articles in the database. Because of changes in clinical practice brought on by a number of factors (e.g., Medicare/Medicaid reimbursements, managed care) and their lasting effects on the culture of medicine, the database was further limited to articles published in the 20-year period of 1986 to 2006. This limit decreased the articles in the database to 1,132. Despite these parameters, we did retain in the database certain articles considered seminal or relevant although they had been published outside the United States or before 1986.
The approach to synthesis
Two of us (J.H., N.B.) reviewed the titles of the articles in the database to determine specific relevance to the research questions. Articles determined to be nonrelevant because of their titles were eliminated, further decreasing the database to 921 articles. The article abstracts were then reviewed and additional articles were deemed nonrelevant and eliminated. The database at this stage of the review process contained 480 relevant articles. Three of us (J.H., N.B., A.N.) again reviewed the article titles but this time to identify themes by which to categorize the articles. After themes were identified, we three coded the articles according to the themes (see Table 1).
Articles were coded for multiple themes if appropriate. Any questions between the three of us about the coding of an article were discussed and resolved. The articles in each theme were then assigned to one of us (J.H., N.B., A.N., or A.G.) as the primary reviewer. We each read our assigned articles to determine how each article's theme was relevant and/or important to answering the overall research question, “How, when, and why do physicians choose an academic career in medicine?” After reading, each primary reviewer distributed to the rest of us those articles that he or she considered important and/or seminal, and also distributed additional pertinent articles found in the reference list from the articles he or she read, along with a summary of his or her reading. At this point, the database contained 320 articles. After all of us reviewed and discussed the summaries and articles, we reached a consensus for each theme group of articles regarding highly relevant and important articles to include in the final summaries for each theme. The total number of highly relevant and important articles from all summaries combined was 41. The summaries were then revised and reviewed by all authors.
Below is a synthesis, by themes, of our findings from the literature review. In the heading of each section below, after the theme name, we state the number of relevant and important articles used for the synthesis.
Opinion and editorial pieces (n = 1)*
Editorials, opinion pieces, and published speeches from our literature review comment on the decline of academic physicians, especially in particular specialty areas. Their authors offer potential strategies and recommendations for attracting medical students and residents to academia; however, very little empirical support for these recommendations was articulated in these articles. Neilson's8 suggestion for medical school admission committees to include more than 10% of students who are inclined to become medical scientists may be worthy of further discussion and exploration. However, research-based information that would assist with identifying such applicants was not included. At the very least, the opinion pieces and editorials identified do recognize the workforce issues, but the central questions of this study were not answered in this category of literature.
Issues and obstacles (n = 9)
For every reason that could engender the choice of academic medicine, there seems to be a barrier preventing a physician from entering academic medicine. The literature identifies many different obstacles deterring physicians from academic careers, as early as at the residency level. Alpert and Coles9 identified competition for funding, long hours of patient care, administrative demands, and heavy teaching schedules as deterrents to entering a career in academic medicine. Reasons identified by Ley and Rosenberg10 include decreased availability of grant funding, less pay, debt, years of training, and uncertainty of success. Studies by Neacy and colleagues11 and Leonard and Ellsbury12 suggest that interest in academic medicine among residents may wane after the initial year of training. This may be especially true of women, who may suffer more stress as the program goes on.12
In addition to these general studies, specialties such as dermatology and surgery have identified barriers to entering their fields. Several studies13–15 examined academic dermatology in particular. Reck and colleagues13 identified bureaucracy, salary differential/financial, lack of effective mentoring, role modeling, and guidance, and location/practice environment as reasons contributing to loss of interest. Rubenstein and colleagues14 also studied dermatology residents and suggested the following as factors deterring such residents from academics: less awareness of academic positions and more awareness of clinical opportunities among residents, not having sufficient resources for establishing a research program, concerns about grant support, salary differentials, time considerations, work–life balance for women in academia, and insufficient mentoring. Furthermore, Prystowsky's15 study cited concerns by dermatology residents that included financial issues, length of training, and obtaining funding for research. In that study, almost all dermatology residents indicated that they entered dermatology with an intention to pursue a career in academic medicine. When asked about their future plans, 77% of the residents surveyed indicated that they would be in academic medicine five years after residency. In an article on academic surgery, Sonnad and Colletti16 identified seven primary reasons for leaving academic surgery: uncertainty of external funding, sense of isolation, unsupportive atmosphere, stress, conflicts with family responsibilities, salary, and excessive clinical workloads. Factors negatively influencing residents in other specialties were also described in the literature. Salary expectations, funding, academic competitiveness, and administrative and family responsibilities were among the factors cited by pediatric residents.17
Although common themes emerge in this category, the generalizability of these findings across specialties has yet to be established, suggesting further research is warranted. Also, although these barriers have been identified, it is not clear whether removing these obstacles will, itself, result in more physicians pursuing academic medicine. Several of these obstacles emerged as separate categories in this review and warrant further explanation.
Financial considerations (n = 3)
Whereas salary and issues regarding research funding were often cited as obstacles to choosing the academic path, the literature describing the role that personal debt and other financial considerations play in the choice of an academic career presented findings that seem highly inconclusive and even contradictory. Fox18 indicated that there is little research on the effects of debt and other variables on the choice of academic career. He suggests that debt does have some influence on this decision and also that the more distinguished the physician's medical school, the more likely the physician was to pursue an academic career. Whether this is true across specialties seems less clear. One study that focused on neurology suggested that indebtedness may play a role in deterring residents from entering academic neurology.19 In our opinion, more studies are needed to advance the understanding of the personal debt and financial factors that relate to physicians' choice of academic medicine. This is especially important as medical student indebtedness continues to rise. In terms of managing indebtedness, government programs set up to repay medical school debt when graduates seek research training do exist and were described in the literature.20
Role models and mentoring (n = 3)
Another obstacle identified in the literature is the lack of role models and mentors. Our review of articles on mentoring confirmed the lack of mentoring and role models for careers in academic medicine. Cain and colleagues21 surveyed perceptions of nearly 5,000 residents and approximately 1,000 fellows in obstetrics–gynecology and found inadequate mentoring in that field for careers in academic medicine. Neumayer and colleagues7 reported a survey of the membership of the Association of Women Surgeons. Although considered essential for female medical students, the authors noted that successful surgical female role models and mentors had been lacking in the respondents' experiences. In surgery, women want to be mentored by successful surgery academicians, but there are so few of them at the present time that this is difficult to achieve.
Although formal mentoring programs for women in academic medicine do exist,22 many of these programs are geared toward leadership development or other skills and interests, such as choosing a generalist career, learning practice management, and legislative advocacy, not choosing academic medicine as a career path. These various types of mentoring programs have been described in the literature; our review of the mentoring literature, however, revealed a lack of mentoring programs specifically for students and residents who express an interest in exploring academic medicine as a career path. Furthermore, the literature articulates formalized programs for mentoring physicians who desire a research focus but fewer programs for academic physicians who would like to have a teaching focus.
Role models also contribute to career decisions, allowing a trainee to imagine the role model's career as his or her own. “The absence of any role models during the formative years of career differentiation has been cited by medical students as an important factor in the disproportionately low numbers of women choosing surgical disciplines.”7 Our review also uncovered this negative impact of the lack of role modeling, especially the lack of women and minority role models in academic medicine. In our opinion, what remains to be explored is the unanswered question, “If mentoring support and the number of role models both increase, will these influence a physician to choose academic medicine?”
Academic physicians as teachers and/or researchers (n = 5)
The literature indicated a great debate regarding the question, “Can academic physicians still be ‘triple threats’—oriented to patient care, teaching, and research—and do all three successfully in the current environment?” Often, individuals interested in academic medicine pursue their careers either as teachers (referred to in the literature as clinical-educators) or as researchers (physician–scientists), with patient care as part of both dichotomous roles.
Training as an MD–PhD is a common path for individuals interested in a career as a physician–scientist. Specific programs have been described pertaining to the career development of the physician–scientist.23 Fang and Meyer24 support the assertion that research training at the medical student level leads to training of physician–scientists. They specifically mention how participating in a research program increases the likelihood of pursuing a research career. Publishing research as a student or resident and/or having an MD–PhD tend to correlate with choosing academic medicine.23,25–26 It is unclear whether physicians are doing research to secure a position at an academic health center or whether conducting research leads them to enter academic medicine.
Donnelly and colleagues27 conducted a study to identify characteristics of physicians who choose academic careers. Findings from their study suggest that individuals interested in pursuing academic medicine have an interest in teaching, not research. It is our observation that although there appear to be a number of programs established to produce physician–scientists, what seem to be lacking are programs to produce physician–teachers. It is unclear from the literature if these interests are more commonly combined or mutually exclusive. The literature does point to having either interest as a reason for choosing an academic path.
Publication and research activities (n = 6)
Research focused on the discovery of new information in the basic sciences or in clinical treatment has traditionally been a cornerstone of an academic career and of academic health centers. Research activities that one engages in as a medical student or resident with respect to pursuing a career in academic medicine were mentioned in the literature. Chevalier28 states, “The evolution of an academic medical career is a gradual process often beginning well before residency.” Because of this evolutionary process, programs have been developed to help inspire both medical students and residents to pursue traditional research.
The influence of research experience at the medical student level has been studied, and there is consensus among articles that programs and opportunities to foster research should be included in medical schools because of the influence that these experiences have on student interest in pursuing careers in academic medicine and research.29 Solomon and colleagues30 evaluated the impact of medical student research on the development of interest in academics using students involved in National Institutes of Health-sponsored research programs. Their research suggests that exposure to research as a medical student fosters interest in research and careers in academic medicine. Specific programs for training medical students in research were also described by others.31,32
Exposure to research was also suggested to be important during residency training.17,28 Unfamiliarity with research was discussed by Chevalier28 as a reason residents may not choose careers in academic pediatrics. He suggested that residents be invited to participate in research and that research should be included in residency programs with appropriate mentoring, financial support, and time for research provided. Like Chevalier's study,28 Ledley and Lovejoy's17 article focused on pediatric residents. These authors also suggested that research experience during residency helps foster interest in research.
Although traditional research clearly seems associated with academic career choice, the literature was void of studies evaluating exposure to research in teaching and education. In our opinion, this is also a critical aspect of academic health centers that has largely been ignored.
Gender (n = 2)
At the beginning of the 21st century, women entered medical school at approximately the same rates as men. During the 1980s, women entered academic medicine at higher than expected rates,33 but historical, cultural, and social barriers may limit women's full potential in academia.34 “Work from top academic institutions in the U.S. indicates that unless clear steps are taken to improve recruitment and retention of women in academics, no significant changes in gender distribution in medical school faculty are expected throughout the entire twenty-first century.”34
Out of 60 articles in this category, only two contributed to answering this study's questions. The 58 remaining articles in our review focused on women's advancement in academic medicine but did not fully explore our central questions. Of the two pertinent articles, the work of Brown and colleagues35 and Leonard and Ellsbury12 described differences between men and women in academic medicine. For example, women physicians choose their careers because of the perceived quality of life, earnings potential, and organizational reward. They are less likely than men to identify role models for professional–personal balance. Also, for female physicians, achieving national recognition and being viewed as a leader are less important than for male physicians. Academic medicine's intellectual challenge is equally important to women and men. It seems, then, that with the exception of appreciating academic medicine's intellectual challenge, women and men choose academic medicine for different reasons. Based on the articles reviewed, further investigation is necessary to determine ways of changing academic medicine's environment to enhance career satisfaction and success for both women and men.
Career development/career choice (n = 8)
The literature regarding this theme suggests that programs directly related to the preparation of physicians to be researchers/scientists (federally and privately funded) are very successful at producing academic physicians. (There are currently 43 National Institute Medical Scientist Training Programs—see http://www.nigms.nih.gov/Training/InstPredoc/PredocInst-MSTP.htm.) Additionally, it seems that research-intensive medical schools also have a strong record of producing academic physicians. The literature also suggests that other types of medical schools may attract medical students who enter academic medicine because of their desire to be part of the educational process, as described by Donnelly and colleagues.27 Other aspects of careers in academic medicine described in the literature include being in academic medicine as a clinical educator36 or working as a part-time academic.37 Preparation for the role of teacher was described by Markus and colleagues.38
Regarding how physicians choose their career path, whereas family medicine physician–educators indicated choosing this career path because they like teaching, for most of them the decision was serendipitous.39 Mentoring seems to play an important role in career decision making and influences the decision to be an academic physician.40 Factors associated with an interest in academic medicine include research participation during medical school, residency training program length, being a first-year resident, and better perception of overall academic skills preparation.11 Straus et al2 suggested that career choice in academic medicine is associated with completion of medical school with a graduate degree or fellowship and publication of research in medical school or residency. A desire to teach, conduct research, and find intellectual stimulation and challenge may also be important in deciding to pursue academic medicine.
Other topics addressed in the literature related to career development include job satisfaction, advancement and promotion criteria, recruiting, and compensation. A summary of these areas was not included in this review because these topics pertain to careers in academic medicine after entering the field (whereas the current review focused on themes associated with choosing this career path).
Values (n = 4)
A person's values, the important principles in living one's life, play a defining role in career decisions. Values may be different for students, residents, fellows, junior faculty, and senior faculty and can change for individuals over a lifetime. The current review attempted to identify the values important to the choice to pursue a career in academic medicine. Three types of values were mentioned in the articles we reviewed: the value of the individual, of the groups with which one associates, and of one's generation.
The values associated with an individual working in academic medicine were not well defined or explored. Only one personal value, intellectual stimulation, clearly emerged across many specialties as a reason to pursue academic medicine.41 The articles indicated that this is a key value primarily manifested in research activities. Academic medicine as a whole does promote scientific inquiry: “The pursuit of knowledge is one of the defining attributes of human beings that separates us from other living creatures, and physicians working in academic centers enjoy a special opportunity to engage and develop the inquisitive side of their nature.”42 To our disappointment, the literature did not strongly elucidate the personal values involved in the academic career decision to the extent expected.
Our reading of the articles for this theme led us to surmise that the institutional values that academic medicine espouses for generating new knowledge and translating that knowledge to the next generation can attract physicians to work in academic medicine. The traditional organizational values of research, teaching, and patient care seem to be at odds with one another, primarily because of the current funding structures and the pressures to generate income for both research and clinical enterprises. The literature seems to indicate that institutional values are conveyed to individuals in a variety of ways, including hiring, support, and advancement as well as admissions, curriculum and structure, and time in training. How these translate into personal choices remains unclear.
Individual values can be at odds with organizational values, especially in terms of generational differences. Bickel and Brown1 delineated differences in baby boomers' and Generation X's approaches to personal and work–life balance, mentoring, affiliation, and career advancement, and they offered strategies for the generations to relate to one another as they work together in academic health centers. One study evaluated the ratio of growth and attrition of faculty in academics and found that in younger generations the ratio of those starting to depart to those who remain is decreasing.43 The same study showed that there was great variation in this kind of ratio related to the orthopedic subspecialty, and the exact implications of this finding are unclear. These articles made clear that generational values differ and can affect the decision to enter and remain in academic medicine.
The literature offered little in terms of understanding the role of generational, institutional, and personal values in the decision to enter academic medicine. This review revealed a void in the literature regarding how values affect the personal decision of how, when, and why physicians choose academic medicine. Articles were also limited in that they often focus on one medical school, residency program, or specialty. The most insightful articles were national studies undertaken by specialty societies or groups. Further clarification of the values underlying the choice of entering academic medicine will be key in the future. Generational differences present a critical tension in the workplace and, from our review, do not seem to be well studied in the context of academic medicine.
Although there are virtually no conclusive answers to the research questions guiding this inquiry, our literature review revealed a wealth of studies (both including and in addition to the 41 relevant studies we reviewed) related to the questions and a number of seemingly important variables that could be useful in the further quest to find answers. For example, essential to understanding the decision to enter into a career in academic medicine are values. They include the values of the individual, the values of the educational organizations in which individuals train, and the values of groups to which individuals belong. Unfortunately, we found that personal values were not well defined in the literature with the exception of intellectual stimulation. It seems that the institutional values supporting the generation of knowledge or the translation of knowledge to practice may attract individuals to a career as a physician–scientist. It is less clear that institutions emphasize teaching and educational development to attract individuals to seek an academic career as a clinician–educator. In fact, there seems to be great tension regarding how to best structure the academic health center to achieve the missions of research, teaching, and patient care. Finally, the values of the groups to which potential academic physicians belong may have powerful influence. Two such groups were gender and generation. Gender was the topic of numerous studies in this review; generational issues seem to be of increasing importance as we learn more about the distinct values of different generations. Conceptually, it makes sense that values play an important role in the decision to enter academic medicine, but the role of values has not been well established in the literature.
This literature review also identified factors that seem to be associated with academic medicine career choice, including research-oriented programs, gender, and mentors and role models. Special programs (federally and privately funded) to produce physician–scientists seem to be successful. Special programs to produce clinician–educators are less apparent in the literature. Research-intensive medical schools seem to predictably produce more academic physicians than non-research-intensive institutions. There does seem to be a strong possibility that research experience in medical school or residency plays some role in deciding on an academic career. There is some evidence that research experience is important for research careers in academic medicine. What the literature could not tell us is whether the same is true for the academic physician who chooses academic medicine with the main intention of teaching.
Although the topics of mentoring and role modeling are frequently found in the literature, our readings revealed a lack of mentoring programs specifically for students and residents who express an interest in exploring academic medicine as a career path. Clearly, the development and evaluation of mentoring programs to specifically help develop and foster such interests among our future physicians should be established.
Numerous obstacles to academic medicine were mentioned in the literature. They include loss of interest in academic careers during residency as residents learn about factors associated with academic careers in medicine, such as salary differential, lack of availability of grant funding, uncertainty about success, and the number of years of additional training. The generalizability of these findings, however, has not been established, suggesting that further research is needed.
Although debt is often suggested as a barrier to choosing an academic career, the best that can be said is that for some people in some specialties this may be the case. Nonetheless, some specialties have worked to try to use medical school debt reduction as a way of attracting trainees into research careers. But, this review indicated that there is very little research that links medical school debt levels to the decision to enter academic medicine.
In conclusion, although our questions remain essentially unanswered, this review has allowed us to uncover areas in which rigorous and complex research efforts are needed. Given this void, we advocate finding a structured way to understand who enters academic medicine and their reasons. We propose a call to action by various professional groups and organizations, including the Association of American Medical Colleges (AAMC), members of the Society of Directors of Research in Medical Education (SDRME), as well as medical schools, the National Institutes of Health, and other publicly and privately funding granting agencies to study questions about academic medicine career choice. Because the AAMC espouses the mission of “preparing physicians and scientists to meet the nation's evolving needs”44 and sees the national picture, it seems well positioned to assist in this call to action. Its various professional development groups and offices, including the Center for Workforce Studies, Women in Medicine, Group on Faculty Affairs, Group on Student Affairs, Group on Educational Affairs, and Careers in Medicine, seem like natural partners in investigating our central questions, especially those pertinent to the gender, financial, issues and obstacles concerns that we uncovered in the literature. The SDRME, with its promotion of collaboration between schools, on research topics, also seems positioned to facilitate multischool studies on this topic. Multischool studies on values, role modeling/mentoring, and career development/selection would be particularly informative. In addition, the National Institutes of Health Office of Research on Women's Health, is committed to the development of “opportunities for and supports recruitment, retention, reentry, and advancement of women in biomedical careers.”45 Currently, as members of the faculty at our respective medical schools, we are working together on a qualitative study that has been funded recently by the Joan F. Giambalvo Memorial Scholarship, which is supported through a program of the American Medical Association Foundation and the American Medical Association Women Physicians Congress, to further understand the reasons women choose academic medicine as a career path. As the evidence of physician shortages increases, and universities face predicted faculty retirements, working together to understand physician career decisions espousing this research agenda could prove critical to academic medicine's future.
We dedicate this article to our dear mentor, colleague, and friend, J. Dennis Hoban. Denny formed the research team for this study and was an integral part of the team until he passed away unexpectedly while this article was in its final stages of submission for publication. Denny devoted his career to medical education research and scholarship and to mentoring students and faculty. He is dearly missed, and we are grateful to have worked together with him on this study. As with so many who knew him, his presence lives on with us each day.
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* For the sake of simplicity in reporting our findings, we classified “opinion and editorial pieces” as one of the nine themes on academic medicine careers that we found in the literature, even though it is not a theme but, instead, a category of articles. Cited Here...