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Alternative Career: Clinician-Teacher

Patrick C. Alguire, MD, FACP
Director, Education and Career Development

As a result of the changing practice environment, medical schools and community-teaching hospitals are now looking for large numbers of clinician-teachers to see patients (generate income) and to teach students and residents. Most of these positions are for generalists. Young physicians interested in these positions join academic or community centers with the idea of dividing their time between clinical practice and teaching on the wards and in the clinic. For many physicians just completing residency training, this seems like the ideal job. This article highlights the important career aspects of clinician-teachers and provides suggestions on how to evaluation such opportunities.

Typically, a clinician-teacher is expected to teach and see patients. Some institutions expect some research or scholarly productivity as part of the overall effort. The exact amount of time devoted to each varies with the institution, but generally the need for patient care outweighs the need for teachers and researchers. Nevertheless, you need to determine how you wish to spend your time and negotiate these expectations. If research or scholarly activity is part of the job description, define precisely what type of work is expected, what type of productivity measures will be applied, and what amount of time (if any) is set-aside for these activities.

Most clinician-teachers are granted an academic title but are rarely granted tenure. This means that the role of clinician-teacher is not as secure as other, more traditional academic tracts. Typically, the contract will provide for a limited number of years of job security (for example, three years) with an opportunity to renew the contract at the end of that time. This opportunity will be based upon your performance, as a teacher, sometimes as a researcher, and in terms of clinical productivity. Of the three, your ability to generate your salary in clinical income is usually judged as the most important.

According to the Report on Medical School Faculty Salaries 2006-2007 released by the Association of American Medical Colleges, the 2007 median salary data for U.S. medical school faculty in General Internal Medicine are:

Instructor: $135,000
Assistant Professor: $142,000
Associate Professor: $160,000
Professor: $197,000

However, as noted above, most new physicians receive compensation not from salary alone, but from a combination of salary and clinical productivity. In general, contracts that are more heavily weighted toward the salary component provide a more dependable income, but there is no incentive to see extra patients or work harder. On the other hand, a contract that is heavily weighted toward a productivity arrangement has the potential for greater earnings. However, contracts with a large productivity component may have important shortcomings that deserve careful attention. For example, how is productivity defined? Is it related to patients seen, billings, or collections? If related to collections, how efficient is the institution's collection system? What percent of the gross billings are they able to collect? Are the collections "taxed" in any way? At some institutions, fees are deducted from your collections to defray the cost of the clinical operation. You may be required to pay a share of the clinic the overhead, your malpractice insurance, and equipment needs such as beepers, cell phones, white coats, and so on. With this in mind, one good strategy is to check with the current clinician-teachers to determine if they are able to "make" their productivity allotment each year. If not, try and determine why not.

For many young physicians, the role of clinician-teacher is enjoyable. With time divided between clinic and hospital, teaching, and "private practice," the days are varied and exciting. Generally, the concerns of running a practice and its associated paperwork are someone else's responsibility. The salary is competitive and the benefits often exceed what is found in private practice. However, there are some downsides as well. The following paragraphs address the commonly encountered problems and suggestions to overcome them.

Teaching is a skill that is not inherent, but is learned. Since part of your performance assessment includes your teaching ability as evaluated by your students and residents, you will want to maximize your teaching skills. To this end, you might inquire about the availability of faculty development courses in order to increase your chances of success. Specifically, you may wish to negotiate professional time to attend these courses since they are integral to your job.

Another problem faced by many clinician-teachers is having enough time to meet their practice, research, and teaching obligations. Typically, as you mature in your job, time is slowly eroded away by department requirements to attend meetings, join committees, and take on extra responsibilities such as interviewing student or resident applicants. Often, the extra time for these unforeseen activities is subtracted from your clinical practice time, impacting your earnings. Be aware of these "hidden obligations." Speak with other clinician-teachers at the institution and determine to what extent this will pose a threat to your income, retention, or promotion. Based upon these conversations, negotiate up front the amount of time you will devote to these activities.

Clinician-teachers fill a relatively new academic role. Because of this, many medical schools lack experience in appropriately evaluating the quality of their clinician-teachers for the purposes of promotion. Therefore, it is important to ask about the criteria for promotion before you sign the contract. Do explicit criteria with obtainable, objective measures exist? Does the institution have examples of clinician-teachers that have been promoted? Does the proportion of promotions for clinician-teachers approach that of the tenure track academic physicians? What are the consequences of not being promoted? What will the institution do to support your effort to become promoted?

For more information about clinician-teachers and available opportunities contact the Society for General Internal Medicine.

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