When the editors of this series asked me to describe my career path and a typical day in my life as a physician-scientist, I initially thought that it would be a straightforward assignment. But after reflecting on my career, and the careers of my many physician-scientist colleagues, I realized that there are as many different paths as there are individuals, and many more "days in the life." Nevertheless, I will describe the course of my career here, pausing to reflect on my decisions and to offer some advice to those of you who have chosen to pursue the truly wonderful and unique career of the physician-scientist.
As a student in the University of Iowa Medical Scientist Training Program (MSTP), the first major decision I had to make was the choice of the thesis lab. I was interested in human genetics, but somehow, through received advice or through my own sensibilities, I decided to seek out the best genetics training lab, regardless of whether the focus was on human genetics or some other sort. I suppose I also considered other aspects of this decision that have been so beautifully described by Skip Brass in an accompanying article .
Research in the lab I joined dealt with the genetics of protozoan parasites, which was a particularly hot area of biology at the time. As I neared the end of the research phase of my training, I became increasingly interested in the immunologic aspects of tropical diseases, particularly in the possibility that infection with the American trypanosome induces autoimmune myocarditis. I decided to spend a fourth year in the lab, partly because I had several projects that could be brought to fruition with another year of research, and partly because being a senior graduate student with responsibility for nothing but benchwork is one of the most enjoyable times of life, or should be.
In the end, the additional research papers that resulted from the extra year in the lab opened an additional and unexpected career possibility (see below). Because the Iowa MSTP had no M4 year (the fourth year of medical school) and required that we complete a 9-week clerkship before the research phase, I had to decide on a clinical specialty before returning for the nine remaining months of clinical training, so that I could arrange the clerkship schedule accordingly. My research interests led me to consider clinical infectious diseases (preceded by medicine or pediatrics) or clinical microbiology (preceded by clinical pathology).
I chose the clinical pathology/microbiology path because I believed it was the quickest route to clinical competency and back to the bench, and also because it offered the most time for research. While I have no misgivings about this decision, I now consider it to have been somewhat short-sighted. Pathology is a terrific specialty that is very well suited for scientists, but I have many colleagues in clinical specialty areas who have equally satisfying combined careers with ample protected time for research.
Research Residency Training
I interviewed at a number of the top clinical pathology residency programs and had already decided to pursue the one that had the most strength in immunology, and autoimmunity in particular, when an unexpected opportunity arose. I received an invitation to interview for a position at Northwestern University, and to give a seminar. I had been an undergraduate at Northwestern, and my college research advisor, who had just written a dozen or so letters of recommendation in support of my residency applications, had discussed my career goals with Northwestern's chair of pathology.
Northwestern had a particular strength in autoimmune disease research, and my visit included interviews with the investigators who worked in that area. At the end of the 2-day interview process, I was offered a unique opportunity to develop an independent molecular parasitology laboratory, while simultaneously pursuing residency training in clinical pathology and postdoctoral research in autoimmunity, in a flexible manner, over a five-year period.
With the encouragement of my former advisors and the chair of pathology at Iowa, I decided to take this nontraditional path. I spent the first year setting up the lab, applying for grants, and training my first students. During the next 4 years I completed the clinical pathology core rotations a few months at a time and gained experience in immunology through hands-on experimentation and by advising students jointly with my immunologist colleague. In 1995, at the end of the 5 years, I had completed residency training, my lab was a going enterprise, and I had gained some experience in autoimmunity research, although the vast majority of our papers were still in the area of molecular and cellular parasitology. It should be emphasized that this course was only possible because the research in my independent lab was initially a direct extension of my PhD research.
Was Northwestern the right decision? The course I took has its advantages, but there have been trade-offs. First, although the immunology research in my lab has expanded considerably during the subsequent 8 years, there is no doubt that I would have emerged from a traditional postdoc with a stronger foundation in immunology. If I had gone that other route, I would most likely be studying basic mechanisms of immunity rather than applying them to the study of infectious and autoimmune disease models. My clinical skills would likely be more refined as well. On the other hand, my career has progressed more rapidly than it would have had I taken that other route.
The keys to whatever success I have enjoyed will open doors for anyone. I had excellent mentors who advised me on virtually every aspect of my career development: choosing my thesis lab, deciding to come to Northwestern, management of start-up funds, becoming a good research advisor, grantsmanship, choice of clinical subspecialty, time management, and so on. I also have had extremely supportive department chairs over the years who, for example, provided additional start-up funds as my lab expanded and did not allow me to put my salary support in the budgets of my first grants (which left more money in those grants to pay for research). Importantly, I sought out advice and did not wait passively to be advised.
Career Development as a Faculty Member
Since completing my official training (though I will always be "training" in one thing or another) my research program has continued to develop, and my clinical responsibilities have become narrower. My clinical responsibilities now include part-time direction of a hospital molecular genetics lab that specializes in the diagnosis of human genetic diseases and hematologic malignancies--a return to my early research interest in human genetics.
The most significant change in my professional life came shortly after I completed my residency training in 1995. The medical school dean had gotten to know me over the years and asked me to consider becoming director of the Northwestern MSTP. The lab was doing well, my clinical duties were minimal, and I had become quite involved in mentoring MSTP students and research-oriented medical students and residents. I agreed to accept the position and have directed the program now for more than 8 years. This responsibility is among my most gratifying. This new duty did have its costs, however: My lab published seven papers in 1995, none in 1996, and only one in 1997. It took me several years to successfully integrate these new administrative responsibilities into a professional life already filled with research, clinical, and teaching duties.
A Day in the Life ...
It is impossible to describe a typical day in my life because no day is the same as any other. I am certain that this is true for all physician-scientists. My activities fall into four categories which, over the course of a year, break down, roughly, as follows:
Research (65%). Benchwork (rare but enjoyable); advising graduate students and postdocs; preparing and reviewing manuscripts and grant proposals (including review of MSTP training grant applications); attending seminars, symposia, retreats, and conferences; discussing research with colleagues; presenting research seminars; organizing laboratory courses; parasitology field work; and reading (unfortunately, the activity which is both the most precious and the hardest to protect).
Clinical (5%). Part-time (5 to 6 weeks per year) direction of the clinical diagnostic microbiology lab and occasional involvement in clinical parasitology cases.
Teaching (10%). Mycology and parasitology lectures and small-group pathology case sessions for second-year medical students; mycology and parasitology lectures to graduate students; advanced microbial pathogenesis paper discussion sessions for graduate students; participation in PhD qualifying examinations and thesis committees.
Administration (20%). Direction of the MSTP; service on various departmental, medical school, and university committees; faculty recruitment.
Although I enjoy (almost) all of these activities, the single most gratifying has to be the involvement in the research activities of my lab and the mentorship of my own students and postdocs. The most challenging aspect of combining these duties is finding protected time for my own professional writing (editing papers, writing grants, reviewing manuscripts and grant applications, and preparing seminars). Since there is a nonstop parade of students through my office during the day, serious writing is usually relegated to the weekend and wee hours.
A final point: Not only does this mix of activities change each day, it changes during the course of an academic year, grant cycle, etc. Most important, the overall mix changes during the course of a career. It is common for those whose research takes off to begin their academic careers with an afternoon clinic and 2 months of service per year and end up with 1 month only or even no clinical responsibilities.
There is much good advice in the accompanying articles, but if I might offer some of my own it would be as follows:
You can combine biomedical research and clinical medicine while also having plenty of time for a rich and rewarding personal life. Those who tell you otherwise likely have not found the keys to making it happen. Find successful physician-scientist role models and emulate them. Speak with those who have not been able to successfully combine research and medicine and find out why they were not able to do so. Be active, not passive, in seeking advice and guidance. Keep your research strong. As I mentioned above, your personal mix of activities will evolve over time. The goal is to remain in control of these decisions, and the best way to stay in control is to sustain a strong, well-funded research program. High-quality research publications and ample grant support are key commodities in academic medicine, and you will effectively be a "free agent" if you have a solid research portfolio. Make career decisions for the right reasons. Don Ganem addresses this issue very well in his article  about the choice of residency programs. The same basic approach can be applied to all your decisions.
You can combine biomedical research and clinical medicine while also having plenty of time for a rich and rewarding personal life. Those who tell you otherwise likely have not found the keys to making it happen.
Find successful physician-scientist role models and emulate them. Speak with those who have not been able to successfully combine research and medicine and find out why they were not able to do so. Be active, not passive, in seeking advice and guidance.
Keep your research strong. As I mentioned above, your personal mix of activities will evolve over time. The goal is to remain in control of these decisions, and the best way to stay in control is to sustain a strong, well-funded research program. High-quality research publications and ample grant support are key commodities in academic medicine, and you will effectively be a "free agent" if you have a solid research portfolio.
Make career decisions for the right reasons. Don Ganem addresses this issue very well in his article  about the choice of residency programs. The same basic approach can be applied to all your decisions.