A few thoughts on getting promoted

Professorship is not an accomplishment, it's an opportunity

I recently got the good news that I was promoted to Full Professor. I am grateful to have hit this milestone at the age of 39. On this occasion, I wanted to share some thoughts.

Many view promotion as accomplishment, but I see it as opportunity. It is a chance to take on ambitious and high risk projects; to work on controversial issues and oppose the status quo where it harms patients and society; to fight runaway corporate greed and the emerging, dangerous threat of groupthink.

Throughout my time in the academy, I have tried to advance scientifically rigorous, methodologically careful and fundamentally truthful arguments in our research papers, and I hope to continue this. I wish I could say I was never dissuaded from taking on a controversial topic, but we are only human, and I am sure I have been. In the future I hope to be more courageous.

Professors should have time to think, but this has been devalued. In a soft money world, I often feel like a Mary Kay salesperson—holding a job with no guaranteed income—where you are perennially hunting for open shifts or grants or teaching slots to fund yourself. I have been deeply fortunate to be grant-funded by an incredibly ambitious and visionary philanthropic organization: Arnold Ventures. At the same time, I have repeatedly seen the limitations of the NIH. That is why I agree with Adam Cifu that with each 5 years after being an associate professor, 10% of your time should be bought out by the university.

When I was a medical student, my understanding of research was limited to laboratory science. The idea that health policy and evidence based medicine could be a research focus was outside my grasp. That’s why I was initially interested in private practice. During my residency, I had the pleasure of working with Adam, as we crafted papers on medical reversal, pulmonary embolism, stress testing, and more. I learned the art and practice of medicine from many Northwestern greats: Hirschtick, Neely, Wayne, Didwania, Landsberg and many others. I read hundreds of books and papers by the giants of EBM: Sackett, Feinstein, Angell, Kassirer, Redberg, Ioannidis, Guyatt, Avorn, Kesselheim, Brett, and more. In the 17 years that followed, I have met many but not all of these virtual mentors. This is the aspect of “mentorship” we seldom discuss. How someone can deeply influence you solely through their writings. I fear we don’t discuss it enough because so few people read these days, and the culture of careerism seldom asks: how can I make myself better? but prefers to ask: why won’t others give me accolades?

During residency I expected to love cardiology, but it never clicked. Instead, H.G. Munshi, Shuo Ma, and others showed me how fascinating hematology and oncology could be. I went to the NIH with the vague idea that one could combine interest in oncology, EBM and regulatory science, and briefly contemplated working at FDA. But I quickly learned our current Oncology FDA was less committed to EBM than it was to helping for-profit companies bring products to market. Tito Fojo, Susan Bates, Barry Kramer, Sanjeev Bala, Sham Mailankody and many others at NIH influenced my thinking. My virtual mentors grew to the hundreds, as I poured through old issues of JCO, NEJM, JAMA and many others. They included Korn, Freidlin, Tannock, Sargent, Moertel, and countless others. I loved my time at NIH and was very productive there; Cifu and I finished our Reversal book in my final year.

I took my first academic job at OHSU, and made many life long friends. I spent 5 years there and published hundreds of articles. My philosophy of oncology broadly gelled in these years, and I summarized that thinking in a book (Malignant). The best part of Oregon was, of course, the students. It was easy to teach a new class, and I launched a popular course on how to read and interpret medical papers— the idea for this was completely stolen from Adam Cifu’s class, which I loved most as a student.

I had many great trainees and collaborators in these years. They are featured here. I came to love listening to podcasts, and like so many launched my own. Plenary session would become massively popular, particularly in western Europe, and lead to more collaborations than anything else I have done. Many of my OHSU friends have been guests.

My academic work and writing began to pick up steam upon moving to UCSF. Although zoom is an unbearable misery, and pales in comparison to real life interactions, for me it has helped with research. I have always had collaborators from a distance, but as the years progressed, and with the popularity of Plenary Session, it seemed more people from Europe, Canada, Latin America and beyond wanted to meet and work together. Zoom helped us run shared meetings, where we exchanged ideas with vigor. We published another 100+ articles in just 2 short years.

Meanwhile, I spent more time trying to bring evidence and sanity to covid policy. The new challenge was that liberal, left-wing politics fused with draconian restrictions— this was a bizarre marriage, as most draconian policies disproportionately harm the poor and vulnerable, but this virtue-signaling pairing ensured that the anger and vitriol would follow. Many people who prided themselves as being good “science communicators” or “popularizers” were simply in over their head as nations embarked on unprecedented, consequential and non-evidence based measures without ongoing attempts at remedy. Naturally these people relied on broken heuristics, and outsourced their thinking to their preferred political parties— something a scientist should never do.

When I decided in fellowship to give academic medicine a crack, I promised myself to only pursue things I was truly interested in, passionate about, and where I felt our work could be scientifically accurate. I hope I have stayed true to my promise. Going forward, I wish however to focus on novel insights, and avoid the mistake I see too often of repeating oneself.

Evidence based medicine has always meant different things. At one level it means using the best evidence and incorporating patient preferences in decision making. It prioritizes data over anecdote, and evidence over eminence. Myself and others tried to push EBM to also mean: clarifying when and how evidence should be generated, when drugs or devices should be debuted and embraced, and how regulatory systems and reimbursement could optimize patient interests. We have also sought to dispel the great myths of medicine: that more is always better, information has no downsides, and medicine is all powerful. To a large degree we have been successful, but we have also met fierce resistance. The same tired, worn out, illogical arguments used to battle against randomized trials for high risk devices like the Impella have been used to battle against trials for bizarre, disputed measures like cloth masking 2 year olds. It is a form of intellectual whack-a-mole.

An audience member recently asked me after a lecture: what chance does oncology have when the industry has perverted our trials, our evidence and our regulators? Why should we be optimistic? One can extend this question to a broader one: what chance does medicine have when the forces of ignorance, fear, greed and irrationality can so easily dominate the minds of people?

My answer to the audience was that medicine has been around for thousands of years, and the industry has dominated oncology just 30. And my answer to the broader question is that reason, evidence, and clarity have continually advanced on irrationality, fear and greed for the last two millennia. And so it will again.

Despite all the corruptive forces in the academy, it remains the place where novel ideas and insights can still be generated and freely advanced. Being a professor doesn’t mean that your work is done; instead, it means it has just begun. Medicine is an ancient profession that is constantly evolving and reinventing itself. The work I am interested in is how it can improve the outcomes it delivers to patients, lower the prices it charges to society, and do more things that make sense. Uncertainty is inevitable, but when we can reduce it, we have an obligation to do so.

I’m grateful to all those who supported me along the way— all the trainees who taught me more than I ever taught them— and the patients who still trust me with their care. I was abroad when I got the news. The local time was 2 AM. I took a moment to appreciate the milestone, but by the time the sun rose, I was back to work.