After Fellowship

Preparation for Life After Fellowship

Robert F. Todd, III, MD, PhD

University of Michigan Medical School

“It is the Best of Times…”

Never before in the history of medical science have the opportunities for advancement in the fields of hematology and

oncology been greater.

• Sequencing of the human genome and the genomes of

relevant animal models (C elegans, Drosophila, mouse…)

• Identification of disease-specific/-related genes. Improved understanding of genetic basis of cancer predisposition/molecular pathogenesis.

• Identification of molecular targets for novel drug development (“targeted therapy”).

“…the best of times (continued)

• NIH funding doubled in past decade.

• New federal opportunities for extramural support of clinical research.

• Other federal and non-federal sources of extramural support of cancer research abound.

• Medicare (and certain other insurance vendors) to pay for cancer clinical trials.

“…the best of times (continued)

• Emergence of a robust biotechnology industry and the investment of the pharmaceutical industry in cancer drug development create opportunities for progress.

• New employment opportunities in the biotech and pharmaceutical industry.

• The market for both private practice and academic jobs in hematology/oncology is excellent (field of medical oncology is not oversaturated).

Private Practice versus Academic Career

• Personal preference (e.g., an influential role model)

• Dominant interest in patient care

• Interest in conducting research/medical education.

• Generally the purview of the academic health center.

• Limited opportunities for medical teaching and clinical research may exist in private practice.

• Compensation

ASCO Time/Activity AnalysisComparison of work activities (% of effort) by main duty:

patient care, laboratory research, and clinical research

Major Areas of Academic Research Opportunities

• Basic (laboratory-oriented) research: fundamental or applied (translational) laboratory investigation. Diverse areas of emphasis include: • Cancer Genetics (e.g., oncogenes, tumor suppressor genes, etc).• Cancer cell biology (e.g., cell cycle regulation, signal transduction,

regulation of cell death/apoptosis).• Tumor immunology (cellular and humoral immunity to cancer;

vaccines, etc).• Vascular biology, thrombosis, and hemostasis.• Cancer etiology (virology; chemical, physical, and hormonal

factors; etc).• Cancer pharmacology.

Major Areas of Academic Research Opportunities (continued)

• Clinical research: academic career that combines clinical care with clinical research• General trend toward sub-subspecialization (e.g., lung

cancer, breast cancer, thrombosis and hemostasis) (clinical investigator becomes expert in one type of cancer).

• Focus on experimental therapeutics of cancer using pharmacologic and biologic forms of therapy.

• Involves collaborations with translational scientists in academic centers or industry.

• Phase I, II, III clinical trials.• Health services/outcomes research.

Major Areas of Academic Research Opportunities (continued)

• Hybrid (laboratory/clinical investigation)

• Professionally gratifying to translate progress in the laboratory to the clinic (bench to bedside).

• Challenging for any single individual to achieve sustained progress both in the laboratory and in the clinic.

• Alternative is a highly interactive team of laboratory and patient-oriented collaborators.

Private Practice versus Academic Career (continued)

• Compensation

• Private practice generally offers higher levels of compensation as compared to academic careers.

• For basic or laboratory investigators, industry may provide greater compensation than in academia.

• Within academic health centers, market forces influence compensation: clinical investigators generally have higher salaries than laboratory scientists; bone marrow/stem cell transplanters are highly valued.

Compensation (Salary) in Academic Health Centers (by rank)

Assistant Professor

Associate Professor Professor

25th Percentile 115,313 137,423 162,675

Median 127,308 154,259 187,872

75th Percentile 157,301 170,489 214,517

90th Percentile 182,097 195,320 261,914

From the Medical Group Management Association Physician Compensation and Production Survey: 2004 Report Based on 2003 Data (5)

Compensation (Salary) in Oncology-Related Private Practice (MGMA, 2003)

From the Medical Group Management Association Physician Compensation and Production Survey: 2004 Report Based on 2003 Data (5)

Adult Hematology/Oncology

Pediatric

Hematology/Oncology

Radiation

Oncology

25th Percentile 227,273 144,927 307,928

Median 315,969 167,817 405,209

75th Percentile 530,021 189,798 524,500

90th Percentile 882,118 262,884 672,470

Finding a Job After Fellowship

• Identifying employment opportunities.

• The academic employment interview.

• Criteria for success in getting the position.

• Types of academic appointments.

• The academic offer letter.

Methods of Identifying Employment Opportunities

• Journal advertisements (e.g., J Clin Oncol, Blood, NEJM, JNCI, etc).

• ASCO/ASH websites and national meetings.

• Personal contacts.

• Mentor contacts.

The Academic Employment Interview:

How to Prepare and What to Expect

• The academic employment interview provides an opportunity for individual meetings with the unit director as well as multiple prospective faculty colleagues.

• In preparation for the interview, request advance information to include the roster of interviewers, the unit annual report or other summary information describing the professional/clinical activities of the unit, etc.

The Academic Employment Interview:

How to Prepare and What to Expect(continued)

• Develop a polished 50 minute seminar in the area of research/clinical interest.• Pay special attention to the quality of the

presentation and visual aids.• Target the presentation to an audience with

a general knowledge of the topic to be presented. Provide sufficient background information.

General Criteria for Success in Getting the Academic Position

• Evidence of broad clinical training in the desired discipline with, if necessary, focused expertise in a targeted clinical arena.

• Strong foundation for an independent scientific career as evidenced by publications and by letters of reference.

• Success in competing for initial grant support that is preferably “mobile” to the new institution (e.g., multi-year grants that are transferrable).

• Positive professional image on interview; excellent interpersonal skills.

Types of Academic Appointments

• Tenure track • The concept of “tenure” may have different

definitions at different institutions. • At most medical schools tenure does not

mean lifetime job security at full salary.• At some medical schools tenure is restricted

to laboratory-oriented faculty.

Types of Academic Appointments(continued)

• Clinical/educator track

• At many schools this track is targeted to the appointment of faculty whose major responsibility is clinical care and medical education. There may or may not be an expectation to pursue clinical investigation.

• Clinical track faculty generally have renewable academic appointments without a long term (tenure) employment obligation.

• At some institutions, clinical track faculty may be full time employees of the academic health system or, alternatively, the full time employees of affiliated hospitals, who serve as volunteer teaching faculty.

The Academic Offer LetterWhat to Expect and How to EvaluateLaboratory-oriented physician scientist (assistant

professor level)• Independent laboratory space: generally 500-1,000 sq. ft.

depending upon experience of the individual and resources available.

• Independent office space.• Laboratory start-up funding.

• Amount dependent upon resources required to pursue the individual’s laboratory research ($200-500,000).

• Start-up funding is used to purchase equipment, supplies, recharge rates for shared core facilities, hire technical support: sufficient to run a small laboratory operation for 2-3 years pending success in receipt of extramural support.


professor level) (continued)

• Availability of “protected time”: generally 75-80% exclusive of clinical and educational responsibilities.

• Protected time guaranteed for 2-3 years pending acquisition of independent extramural salary support.

• Competitive salary and benefits.

• Letter should indicate criteria for merit raises/bonuses and other factors that may influence the salary.

• Terms of the appointment with criteria for achieving tenure/reappointment.


professor level) (continued)

• Ancillary support: availability of secretarial/ administrative (e.g., grant management) support.

• Availability of senior mentor.• A junior faculty member will continue to

benefit from the availability of one or more senior faculty mentors to ensure the individual’s successful career development.

The Academic Offer Letter: What to Expect and How to EvaluateThe patient-oriented clinical investigator

• The availability of patients (with relevant diseases) to serve as potential human volunteers in clinical research studies.

• Clinical effort should be targeted to the research area (versus nonacademic clinical service).

The Academic Offer Letter: What to Expect and How to Evaluate

The patient-oriented clinical investigator(continued)

• Availability of relevant laboratory/clinical collaborators.

• Availability of ancillary services critical to clinical research (e.g., radiology, clinical laboratory, etc.).

• Availability of support personnel.

• Secretarial/administrative support.

• Physician extender support (which may be critical to provide technical support for clinical research studies).

• Data management personnel.



• Availability of senior mentor (just as critical for the career development of a clinical investigator as for a basic laboratory investigator).

• Clearly stated protected time to pursue academic efforts and criteria for maintaining protected time (e.g., expectations for extramural support, etc.).

• Clearly stated terms/type of appointment with criteria for tenure (if applicable) and reappointment.



• Competitive compensation/benefit package• Criteria for achieving merit salary increases/

bonuses.• Productivity criteria affecting level of salary.

• Availability of core facilities .• e.g., clinical research center.• Biostatistical support.• Availability of assay laboratories.

PRIVATE PRACTICE

• Fellowship preparation.• Types of practices.• The private practice offer letter.

• Opportunities for career advancement.

Preparation for a Career in Private Practice

• Scope/breadth of training experience.• Need to be skilled “generalist”.• Training in medical oncology is essential

given the volume of patients with malignant diseases relative to those with non-malignant hematopoietic disorders.

• Training in benign hematology (e.g., thrombosis/ hemostasis) provides greatest flexibility for employment opportunities.

Preparation for a Career in Private Practice (continued)

• Clinical research experience is valuable training for private practice.• Opportunities to conduct clinical research may

exist in certain private practice settings.• Community Clinical Oncology Programs

(CCOP)• Contract Research Organizations (CROs)

Preparation for a Career in Private Practice (continued)

• Clinical research experience is valuable (cont)

– Helpful in critical evaluation of new therapies

The private practitioner must be able to critically evaluate the experimental basis for new/emerging therapies since

the difference between established vs “cutting edge” therapies is often blurred!

Types of Private Practice Opportunities

• Solo practice (!)• Subspecialty Group: group of practitioners who

practice medical oncology +/- hematology.• Single specialty networks (e.g., U.S. Oncology).

• Multi-specialty group (including HMO): one or more hematology/oncology practitioners in a group practice with other subspecialists.

Types of Private Practice Opportunities(continued)

• Independent; hospital-based; university-affiliated

• Independent responsible for both revenues and expenses of practice.

• Hospital-based; university-affiliated; receives salary from hospital or academic health center which may cover practice overhead.

• Opportunities to conduct teaching; clinical research?

• Academic appointment (generally volunteer teaching faculty)?

Private Practice Offer Letter: What to Expect and How to Evaluate

• Compensation/benefits (generally start as probationary employee).

• Criteria for raises/bonuses/profit-sharing.• Anticipated workload.

• Ambulatory clinic hours.• Hospital rounding responsibilities.• On-call time.

• Level of ancillary support.• Nursing personnel to deliver chemotherapy.• Physician extender support.

Private Practice Offer Letter: What to Expect and How to Evaluate

• Time for professional development (e.g., attendance at professional meetings).

• Requirement for hospital appointment/privileges.

• Terms for achieving partnership in practice.

• When (1-3 years)?

• How much to buy a percentage of practice (repaying practice for its upfront investment in salary, benefits, and overhead)?

• Terms of payment (pre-tax salary differential, loan, etc.).

SUMMARY

“It is the Best of Times…” to pursue careers in Oncology and Hematology practice and research.

Never before in the history of medical science have the opportunities to advance these fields been greater.

Advice: Decide basic career goals and then PREPARE

for future success.

Health & Medicine

After Fellowship