- Surviving and Thriving as Physicians in General Internal Medicine Fellowship in the Twenty-First Century
- Building a Research Career in General Internal Medicine
- What is an Academic General Internist?
- Academic General Internal Medicine: A Mission for the Future
- General Internal Medicine – ACP
So, I’m in my final year as an internal medicine resident, and honestly, I have no clue what I’m going to do next year. The problem is that I’m a generalist at heart – I wanna have my hands in a bit of everything. When it comes to forks in the road, choosing one pat h and cutting off the others… is hard.
So for my sake and for the sake of all the other generalists out there, Core IM and the American College of Physicians are kicking off a series looking at careers in general internal medicine, or GIM.
I’m Michael Shen, I’ll be hosting the first one. Here’s the episode.
Today’s episode is about GIM Research careers. You’re going to hear from four generalists whose research makes up a large part of what they do. I chose these stories and clips because I thought they illustrated important points about career-making – something I know very little about at this point.
I feel like a lot of people go to medical school and residency thinking they’re going to be clinicians. So how did these doctors pivot into doing research and making a career out of it? When did they know? How did they catch the research bug?
Here’s Dr. Francesca Gany who tells her story.
Gany: It was clear to me that I needed to do something to address the disparities and care that you would get based on whether you, you got admitted to the private hospital or you got admitted to Bellevue.
M: Bellevue is the oldest public hospital in New York City, the place where I train today and where Dr. Gany trained in the late 1980s.
Gany: A new group of immigrants from Senegal had just arrived in New York looking for work to support their families back home. They worked long hours peddling watches on the street. Living in a Single-room occupancy or an SRO on 27th street, which is just down the block from Bellevue. So when they were sick, that’s where they would go.
And there was a group of like 40 guys who came to the Bellevue ER, all complaining of the same sets of symptoms. It was abdominal pain, weight rating radiating around their waist to their backs and they were in a lot of distress.
M: So, by the time they’re sent to her in Primary Care Clinic, they’ve already gotten this full workup through the ER – like abdominals, barium swallows even…and it’s all negative. But they’re still in a lot of distress. And so she feels like there has to be something else going on that’s causing this mystery abdominal pain.
So she does something that we should all do in this situation – consult somebody who’s even smarter than ourselves. So she goes to her director, this guy named Mack Lipkin. Well, Dr. Lipkin is actually still the head of the primary care track that I’m in today, and he also happens to be one of the founders of the Society for General Internal Medicine.
Gany: And I talked to Mack about it and he suggested that I, um, that I enlist the aid of an anthropologist who had worked in Senegal in West Africa and that we try to find out what more was going on with the community members. And through that work going out into the community asking our patients, we found out that there was a syndrome in Senegal called Tooy. It happened when people were removed from their familiar surroundings when they were working too hard, when they didn’t have their usual support structure, which exactly describes what was going on with this group of new immigrants who were working such long hours removed from their family.
M: And she figures out what they do in Senegal to help treat it – and that’s by taking something called Kell, which is a gelatinous substance from a tree, and they would have a healer that they would talk to, and the community would come and surround them and help ease some of their work burden.
Gany: We were the healers because none of the healers had come over yet from Senegal. So we would, so I would see them in clinic, they would take some gelatinous remedies. Um, and sometimes I would get on the phone with the healer and Senegal to do a session with the guys. And one by one they got better. And I realized that if this was going on with this small immigrant community, what was going on with the other immigrant groups in New York?
M: At this point, her mentor, Dr. Lipkin, suggests that she gather a group of people to discuss immigrant health issues in NYC, nugding her in the direction of what’s basically the rest of her career. It sounds like a clear path looking back, but its fair to say, she didnt know it at the time.
Gany: And out of that formed something called the New York task force on immigrant health, which later became the center for immigrant health at Bellevue…
M: She’s now the Director of the Immigrant Health and Cancer Disparities Service at one of the biggest cancer centers in America, Memorial Sloan Kettering, which is just uptown from Bellevue. Now her research focuses on patient and community level interventions to bridge immigrants populations to the health care system and facilitate health equity. Her work revolves around language barriers to healthcare, financial barriers, food insecurity, and a bunch of systems levels stuff.
Gany: Also I’m doing research to do interventions, to try to get people better access to care and to have better health outcomes.
M: Thinking back to careers, I think it’s easy to get hung up on the fact that she’s got this really cool story, and very often I find myself asking – where’s my story? But I don’t think you need a great story in order to justify a career. I think she she tells it, and its a good one, but she tells it because it really clearly shows us what drives her.
Gany: I think my biggest lesson from all of that was something that Mack really, um, kind of inspired me, which was to follow my passion and to really do what you love and what drives you because when you do what you love you do the best job at it.
M: I was actually talking about this with the creator of Core IM, Dr. Shreya Trivedi, and she put it really well. She linked it back to the question of “how do you catch the research bug?”, basically, she says: “you follow what bugs you!” … that’s exactly what Dr. Gany did. She followed a line of questioning through to the end.
And I think our next story illustrates that you don’t have to know where you end up in order to start. The voice you’ll hear is of Dr. Joseph Ravenell, who is the Director of Diversity in Research at the Perlmutter Cancer Center.
Origins & Mentorship
M: He’s best known for studying disparities in healthcare for black men in America. His research actually takes place in an unconventional setting – the barbershop. He basically found that when barbers offered blood pressure checks along with their haircuts, their customers had better controlled blood pressures. In his 2016 TED Talk, says the barbershop as a safe haven for black men, where they can openly discuss all kinds of topics including their health.
I really wanted to know how he ended up in this line of research and it turns out he started doing community-based work before he even knew that he was doing it.
Ravenell: So, uh, it’s important to know that I am the son of two ministers. Um, and so, um, I’m what’s called a PK or a preacher’s kid. Uh, and so I, uh, grew up in church and basically was tagging along with my parents as the minister to people with a whole set of needs.
M: Many of the times he went to visit sick church members in their homes and attend to their spiritual needs. Sometimes he’d find himself going to hospitals.
Ravenell: Um, they probably had different rules back then about, um, kids being allowed to just show up on a hospital ward. But, the one thing that I learned fairly quickly was that, um, I did not like hospitals very much.
M: But, he says, taking care of people appealed to him.
Ravenell: And so I figured out very quickly that I was not cut out for the cloth, so to speak, but did see healthcare as it as a ministry in, in of itself. So I, uh, from day one, the day that I decided that I wanted to be a doctor, knew that I wanted to do a primary care.
M: And so he goes to medical school. In the summer after his first year, he starts feeling that pressure to do a research project.
Ravenell: But I knew at that time already that I hated bench research, like hate with a passion. But, I had the good fortune of meeting a mentor as I was, uh, coming out of the Dean’s office, this African American man with just incredible presence who kind of walks into the main lobby of our science building and as, the kind of unicorn that he was, um, at my medical school, I felt compelled to introduce to, to introduce myself to him. Uh, and at the time found that he had just finished a Robert Wood Johnson clinical scholars program and he had an interest in figuring out why black men underutilized, uh, primary healthcare.
M: And he asked him if he wanted to be involved in his research. Dr. Ravenell says yes and that summer he and two other med students basically figure out by themselves how to do a qualitative research study.
Ravenell: We ran 10 focus groups. We recruited for them, we moderated them, and we ultimately, uh, transcribed and analyzed them all within this, this one summer. The 10 focus groups were all basically different subgroups of, uh, black men, uh, younger men, older men, church-going men, HIV positive men… Essentially trying to figure out what they think about health and what barriers they have trying to access healthcare.
M: They found that the black men they talked to had a very broad view of health that included more than just a good blood pressure, having a controlled blood sugar, or not being overweight.
Ravenell: But it included things like being able to live in a safe neighborhood where you have access to healthy food where you can actually commune with your neighbors and get to know them. And so it was really my first introduction to kind of the social determinants of, of health, uh, talking to those men. Um, and in that experience I also realized my love for talking to adults. And having a front row seat to their lives.
And this was so eye opening to me because at that time i had no idea that you could do research and it could involve people as opposed to mice and rats. So I was like…wow! RESEARCH!
M: I kind of wish I had the same enthusiasm about research earlier in my journey. But if his story shows me anything, it’s that you never really know where that beginning actually is. And that’s why, the longer I spend producing this episode, the more I feel like careers are made in retrospect. When you look back to his roots ministering to his community, his current research makes so much sense.
Ravenell: I wanted to essentially create a career where I could reproduce that feeling of being on the front row, of figuring out how all these components of peoples lives affect their health.
M: And it turns out that the study that he did that summer – the results actually made their way to the Chicago city government.
Ravenell: They were so compelled by the findings that they actually gave us funding to open up a black mens clinic.
M: They named the clinic Project Brotherhood and it took into account many of the things they found in their study.
Ravenell: And so that was really where I was bitten by the research bug, that through a career in research that you can have an impact on more than just the patients sitting in front of you in your office.
M: And there’s another part to his story that I think is worth highlighting, which is…that you never know who you’re gonna bump into along the way – and it really matters. There’s a lot of times where I feel like I don’t know who to talk to for guidance. What if Dr. Ravenell hadn’t run into that mentor outside of the Dean’s office?
And so I’d be remiss if I didn’t talk about the utter importance of representation in medicine, especially in our current political and social climate. The pandemic highlights the fact that Black Americans experience some of the worst health outcomes. And while they make up 13% of the US population, only 6% of doctors are black. And you realize that this problem is circular when black faculty members say that a lack of mentorship and sponsorship, racist work environments, and a lack of antiracist policies factor into a high attrition rate of black faculty in academic medicine.
It was important in Dr. Ravenell’s story to find someone who he saw himself in and create a career where he could reproduce a feeling he loved — of talking to people and making an impact for the black community. That “northstar” is so important because the truth is that research careers can be really tough. And that’s where Dr. Melanie Jay is going to take us next. She’s going to talk about some of the practical topics and roadbumps that you encounter in research careers.
Jay: My husband thinks I’m crazy. He’s like, well, how many grants do you write for every one you get are like, why are you doing all this? Couldn’t if you went into industry, get like, you know, why don’t you get Bill Gates to fund you? You know? Or like, why, why are you doing this?
M: Dr. Jay is an obesity and nutrition researcher. She co-directs NYU’s Comprehensive Program on Obesity. Her research is funded by a few big RO1 grants — which is no small feat; these are large grants that people dream of getting — but she says started out not only outside of the research arena, but also late to the game.
Jay: I hadn’t had any publications had not done any research before residency. A lot of people who go into research kind of have been grooming themselves or being groomed to do research the whole time and entering residency. I did not have the bandwidth to do a lot of research until my third year and chief year, and so I had a lot of catching up to do.
M: So after her chief year, she took a faculty role working full time as a Clinician Educator at one of the clinics affiliated with her institution. And while she loved seeing patients as a primary care doctor, she wanted to carve out more time for her own research interests.
But there’s a problem: institutions and hospitals prefer to compensate doctors for patient care aka clinical time, at least until you can prove your worth as something else. So Dr. Jay was told that her research time would have to come out of her allotted precepting and admin time – which is essentially all the time outside of patient care when she can run cases with residents and follow up on her own patient’s lab results.
This is something that a lot of people in academic medicine face – the battle for what’s called protected time — the time you can use to shape your own schedule and pursue the things you’re interested in, like obesity research, in Dr. Jay’s case.
Jay: So I was kind of starting to find it very frustrating and very difficult to try to, to do the clinic, but try to study it and try to do academic, uh, research. And I was finding it very difficult. And, and, and at the same time I had a very difficult pregnancy I didnt know if the babies were going to survive. And luckily everything turned out well. I had twin boys and I was on bed rest for about 15 weeks.
And I had gotten advice way back that I needed to do a fellowship to really get protected time and mentorship and more credentials to really learn how to do research and also have the credentials that people want to give you money to do research. And so I actually left and took a major pay cut.
Being in a research fellowship is a lot more flexible than, than having seen patients every, you know, 20 to 30 minutes. From there, I really learned the ropes and was able to build upon a research career.
M: And that fight for protected time doesn’t end there. When you become a clinician researcher, you have to Buy Out time to do research. And that’s when grants come in…
Jay: After I did my fellowship I was able to piece together some funding while I was trying to write a career development award…
M: Career development awards are grants that are available through organizations like the NIH and the VA. As an example, the NIH offers K awards, which support junior investigators by funding maybe 75% of their salary for up to five years. This is money to do research, but more importantly, it’s freedom and flexibility.
Jay: So you can really get your foot in the door and they’re very competitive, but they’re really important to get as a signal that you can do this.
M: And to speak to Dr. Jay’s accomplishments, she ends up getting her K award and then two R01 awards – which is like the next step up- but…the journey continues to be an uphill battle…
Jay: So you’re never always there, you’re always having to keep going. And thinking okay well maybe I’ll try this direction or what will happen if I don’t get funding maybe I’ll go back to clinic or maybe I’ll decide whether I wanna like take a pay cut and try to keep up my protected time.
M: And not only that, you have to face a lot of rejection.
Jay: We’ve put in so many grants this year and, and they’ve, none of them have come through, you know, and it’s a lot of work every time. It’s a lot of rejection. I have people submitting papers and two days later, they get a rejection and I’m just like, I’m so glad they rejected us so quickly. Cause then we can just like, turn it around instead of waiting three months and getting rejected.
M: And she tells me this horrifying story about this grant she once wrote.
Jay: So I wrote a good proposal and actually got a good score. So I was like waiting … I figured I was gonna get it and um I didn’t hear anything and then and finally like I called the project officer and I was like you know everyone else has gotten their paperwork and she calls me back as I was walking to the subway. She’s like well I think the reviewers were too nice to you and so we’ve decided not to give them to you were going to give it to someone more deserving. And this is like years of work. And I was like wait what? What? You know? What do you mean I didn’t deserve it. I felt like crying, I was trying not to start crying on the sidewalk. I was really pissed and upset.
So like I’m so used to rejection that I can just be like, that’s so good. We just, we found out now we can like do something else. So, to do research, you have to not have people’s rejection of your ideas, of your writing, of anything, um like get to you.
M: So, at this point I’ve realized that research definitely has its pain points. And it makes me wonder what keeps people going in this field, and what do you have to do to become a successful researcher?
The Path of many fellowships
Schwartz: When I sit down with a fellow, when I sit down with a new faculty member…
M: This is Dr. Mark Schwartz, who’s actually Dr. Jay’s former mentor and the program director of her GIM research fellowship.
Schwartz: …I tell people that to be successful what they need to do is to craft a body of work that people will understand to some extent what box you fit in. Um, uh, they need to provide a compelling history of a sustained commitment to an idea, um, that they’re advancing the science in an area because of that more funding and more success as a researcher, because which is writing science for money.
M: When I first heard him say this – boiling it down to “writing science for money”, it made me feel like this was some kind of business venture, which is not how I like to think about research that benefits health, but in hearing about the real world of research, I get it – selling your idea, selling your passion, is part of fighting for what you believe is meaningful.
Schwartz: You need to be able to sell your ideas to people who will pay you to do the work that you want to do to solve the problems that matter. And I realized that early on, when I, at my first grant, it was such a huge opportunity to be able to carve out that time. Now I had a good chunk of my time that I could devote to thinking and reading and writing and, and doing the science. that autonomy is a real privilege as a, as an academic. And it was sort of addicting.
M: But while he recommends what sounds like a straightforward, strategic approach to careers, he admits that his own experience was not typical.
Schwartz: I was not particularly strategic, um, growing up as a junior year as a fellow or a new faculty member. Um, I advise people to be strategic now. And, I think I need to start by acknowledging that, um, I do this and have done this as a, as a white man of privilege. My own path has been anything, but the kinds of recommendations I’m sorry, I typically make to people to be successful now. Um, so, uh, so I think that’s important as a caveat.
M: In particular, he talks about his career path as a path of many fellowships. He doesn’t mean fellowship like a formal fellowship, but rather fellowship with air quotes around it. Phases of learning in his life. And this is an idea that to me, being the generalist that I am, sounds really really interesting!
Schwartz: I think it, uh, this opportunity to do multiple fellowships in one’s, life and career is not completely unique to general internal medicine. Of course but there is something about being a generalist, uh, where my job is to be a super learner all the time. To, um, pull things together, synthesize and learn new things quickly.
To focus on learning physical exam skills, to, uh, focus on, uh, my educational skills. Later on in my career, I, um, took on, um, health policy, as a associate professor at the time and spent a year in Washington through a program funded by the Robert Wood Johnson foundation, the health policy fellowship. being, um, part of the professional staff on the ways and means committee in the US house in 2009 and 10 when we passed the affordable care act. I’ve also done sort of health services, research and, you know, dove into deep learning. and now in my sixties, I’m doing my first clinical drug randomized drug trials in the COVID era. So I’ve done many fellowships over my career.
And the truth is it’s only makes sense in retrospect. I remember seeing a just unbelievable grand rounds presentation when I was a junior faculty member. And I went up to the person afterwards and I said, how did you do that? How did you build such a beautiful logical, rational sequence of studies that led you to this place? And he said, what? I just said that it’s only obvious in retrospect.
M: I love this idea of careers really only making sense when you look back in time. Because when you hear about successful researchers, there’s kind of this fallacy at play – you see only the success, and it obscures the all the failures that led them there.
Schwartz: I want to talk a little bit about my failure CV. Mmm. Uh, because I, I don’t think we do that enough.
I’ve worked with fellows to say, okay, great. You got to rejection, let’s move on. Um, before, before the sets tomorrow, let’s hit send on that to another journal. That’s a skin that gets thickened over time. Um, I had, I had a year, it’d be four or five years ago where I wrote 10 grants and got zero. Um, that happens to senior successful researchers. And it’s absolutely part of the game. And it has, it is hard. It has gotten harder.
M: But there are a few tips he gives for aspiring researchers. The first is to get involved with the larger community.
Schwartz: I would go to ACP every year. I’d go to SGIM every year.
M: The conferences for the American College of Physicians and the Society for General Internal Medicine.
Schwartz: … and ACP would nourish my clinical soul and SGIM would nourish my academic soul. You may have, may have already experienced this as a, as junior people. You go to these meetings. Oh my God. That’s so and so, or, Oh my God, they just wrote a paper in the New England Journal of Medicine and you could just go up and talk to them and get their taking, their advice on things. Um, and so, I found that that community, um, of, uh, academic scholars, researchers, educators has become such a valuable touch point for me. But that’s also very important way to cope with the vicissitudes of, of rejections and failures, because there’s a whole big world of people going through it with you.
M: He also recommends doing GIM fellowship if you’re serious about research.
Schwartz: We all probably have people around us who have, they’ve been successful in research without doing a research fellowship without getting a ton of mentoring, but there are few and rare. I think the most vital thing has to bake into your life as early as possible the opportunity to dive deep in a research fellowship. And what it gives you are three things. One is that it gives you the fallow time to, uh, go down the rabbit holes and read and read and write and rewrite and rewrite. And you have the time to do that. The second thing is that it gives you formal education to build your methodological muscle and your chops, um, because you need to be able to understand the processes and the had to do it right to do it rigorous. And the third is it gives you a network of colleagues and mentors and over time mentoring is critical. The most successful people are the ones who find environments where mentoring is a value where they will have a person or hopefully a committee, a team of people who are devoted to them who will show them tough love, who will call them on their shit and help them connect socially and connect academically and push them to stay true to their commitments.
M: So, one of the things I found most poignant in listening to all of these stories is that there’s always an underlying drive. Even for an academic with many hats like Dr. Schwartz, he says his drive is quite simple:
Schwartz: I still wear a stethoscope one day a week at the VA and that informs everything else I do. That’s the most central part of who I am as a professional and everything else. My education work, my mentoring, my research always goes back to that.
M: And I saw a similar thread in each of our speakers – in Dr. Gany’s commitment to working with immigrant communities rooted in her residency experience, in Dr. Ravenell’s focus on bringing healthcare directly to his community, a habit not so much picked up as ascribed to him in his ministerial upbringing. And as for Dr. Jay –
Jay: I went to college and I thought maybe I’d be a psychologist. And I took all these behavioral science courses and then I went to medical school, but now I’m back to doing behavioral science stuff and I’m collaborating with psychologists doing motivational signs, you know?
M: She actually started her career in psychology – and ended up on a completely different path but now works with psychologists to create motivational interventions to address obesity.
Jay: And so, you know, these things that you spend time on kind of circle back and, and still stay relevant.
M: Just like Dr. Jay, I’d say that none of the routes that our speakers took to get where they are now were predictable. But in listening to them, I did pick up some common concepts for aspiring researchers, including: the importance of mentorship and community, the ubiquity and utter normalcy of failure and rejection, and the value of being able to write “science for money” and to obtain that precious protected time.
But in the end, what I found most inspiring, and relieving, is that there are different paths to the same summit. And the thing that drives you up that mountain is a commitment to topics that you’re interested in. Letting those passions drive the career decisions we make is critical. Hopefully, the summit we ultimately find is a career with work that fulfills us.
This show was partly recorded during a Proud to be GIM career panel, with additional interviews by myself and Dr. Shreya Trivedi. A big thanks to Drs. Francesa Gany, Joseph Ravenell, Melanie Jay, and Mark Schwartz for sharing their stories, experiences, and insights.
Stay tuned for our next Careers episode.
And for Dr. Jay, she tells me what she liked:
Jay: I actually find the process of being able to come up with ideas and be able to realize those ideas and the amount of impact i could make in one clinic is different than the impact you could have if you can make some discoveries or processes that can be taught to other people. You know I get to mentor people. I get to have people on my teams. I get, I get to think about ideas. We get to problem. We get to implement them. We get to write about them. It’s very entrepreneurial. You can you know, I can basically determine how I spend my time on a given day, so that part I love.
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