COMMENTARY

'Making Room' for a New Generation of Medical Leaders

Vinay Prasad, MD, MPH

Disclosures

September 05, 2019

With fall medical meetings on the horizon, we are set once again to enter "awards season" in medicine. There have been, and will be, countless ceremonies and dozens of press releases heralding the achievements of luminary physicians. Some esteemed academics may be receiving their fourth, fifth, or even tenth lifetime award.

While no one would underestimate or diminish the achievement of great physician-scientists, these ceremonies often leave me, at best, thinking that there must be a better way to promote leaders in medicine and, at worst, rolling my eyes at the self-congratulatory theater.

We continue to see concerning trends for junior researchers in medicine. The median age of an R01 grant recipient is climbing and is now 40-plus years old.[1] Prominent positions in medicine (eg, division director, chair, dean) are routinely held by physicians who have been a full professor for 20 or 30 years. Editorial boards and conference panels often feature faculty who have held the rank of professor for 20 years or more. Of course, this phenomenon is in part due to the fact that doctors often do not assume their first "real job" until they are in their 30s. That said, despite the late start, it is not unusual to encounter faculty with 30-, 40-, or even 50-year careers in their "real job."

I want to be very clear. I believe that as long as they are of sound mind, individuals should be free to work as long as they choose. At the same time, given limited opportunities in academic medicine and the need to cultivate the next generation of leaders, I propose that distinguished faculty voluntarily embrace an attitude of "making room" for the next generation.

As a faculty member in my mid-30s, it would be natural to think that I have an inherent conflict of interest here. But I want to assure the reader that the particular path I am on is so atypical—perhaps ill-advised, even—that there is no one ahead of me to stand in my way.

Here I suggest 10 voluntary actions that would "make room" for junior physicians. I propose that any faculty member who has held the rank of professor for more than 10 years strongly consider adopting these. Please note that I am careful to define distinguished faculty not by age, but by years holding the full professor title.

1. Do not accept invited editorials (unless your mentee is first author). After 10 years of being a full professor, faculty should decline invited editorials. These papers are a platform to showcase the thinking and writing of an individual. They should be increasingly offered to junior faculty who are not yet well known. If a distinguished faculty member accepts such a role, he or she should demand that the first author be a junior physician and partner with one.

2. Accept only one lifetime achievement award. For the select faculty who are heralded by the community, one lifetime achievement award is great. Decline the second or third award made by a sister professional association or at an international conference. After 10-plus years as a professor, perhaps consider letting one of your colleagues have a chance to be honored. You might even suggest that a hitherto unrewarded mid-career faculty member receive the prize.

3. Decline to run a center or lead a new program. When a university announces that, "due to a surprising act of philanthropy," they are opening a new center for medical science and are calling for applications for an inaugural director, don't apply. Let the opportunity go to someone earlier in their career who has not yet had a chance to develop his or her vision.

4. Limit yourself to two R01 grants. A few years ago, the National Institutes of Health floated a proposal to cap the number of major grants an individual could receive. This was based on data that extra funding was subject to the law of diminishing returns, but the proposal was not enacted in the face of bitter opposition.[2] But that doesn't mean that one could not enforce one's own standard and voluntarily limit oneself to two R01 grants. This would free up grants for colleagues as well as junior scientists.

5. Do not be first author on your papers. Over time, forgo being corresponding author, and finally, further on, don't be an author at all. After a decade of being a full professor, one simply does not need to publish more papers. Instead, one might devote time to guiding junior faculty, with the goal of eventually helping them step out of the shadow. This happens best when the distinguished faculty member becomes an advisor on projects rather than senior author. Some may retort, "But what if it is my idea and I did most of the work?" I would humbly suggest spending time developing your ability to guide someone through a project rather than seeking to do everything yourself.

6. Don't drag down junior faculty. On social media and in editorials, I frequently see distinguished faculty harping on petty matters, often toward junior faculty. Some examples include complaining that a decades-old paper was not cited in a recent analysis; obsessing over a tangential point or figure in a paper and thus missing the big picture; or complaining too loudly when a new result contradicts work that your team or lab has done. In all of these cases, distinguished faculty would do well to not sweat the small stuff. This is also the advice that any good public relations rep would give.

For faculty who have reached the point of personal financial independence, having saved enough money to maintain their lifestyle for the remainder of their life, there are a few additional steps that could be taken:

7. Decline or donate all honoraria or prize money. Ask conference organizers to use the money to invite a junior colleague or to put toward the young investigators program. Alternatively, one might ask that these funds be donated to a high-quality charity, such as Oxfam or Save the Children.

8. Voluntarily limit your term as chief, director, chairman, or dean to 10 years. Organizations may benefit from different ideas or a different approach, and limiting one's time in these (often extra-paying) jobs is easy if you are financially secure. Limit your term and groom a junior colleague to take over when you finish.

9. Consider a part-time position. Could some portion of your salary (often high due to many years in the position) be used to recruit a junior person as you transition into a part-time role?

10. Decline invited travel opportunities. Use your savings to go on vacations, but decline conference organizers' offers to pay for your travel. Ask them to instead invite a junior person whom you admire.

Making room for the next generation should not be seen as an affront to the many diverse contributions of a wiser and senior generation but instead as part of the inevitable transitions of life. At a time when many trends in medicine further delay and limit professional opportunities, perhaps we should consider "making room" a voluntary strategy, a professional philosophy, and an ethical course of action.

Follow Vinay Prasad on Twitter: @VPrasadMDMPH

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