Welcome to the Clinician Researcher podcast, where academic clinicians learn the skills
to build their own research program, whether or not they have a mentor.
As clinicians, we spend a decade or more as trainees learning to take care of patients.
When we finally start our careers, we want to build research programs, but then we find
that our years of clinical training did not adequately prepare us to lead our research
program.
Through no fault of our own, we struggle to find mentors, and when we can't, we quit.
However, clinicians hold the keys to the greatest research breakthroughs.
For this reason, the Clinician Researcher podcast exists to give academic clinicians
the tools to build their own research program, whether or not they have a mentor.
Now introducing your host, Toyosi Onwuemene.
Welcome to the Clinician Researcher podcast.
I'm your host, Toyosi Onwuemene, and it is a pleasure to be talking with you today.
I'm especially excited because I have an amazing guest today on the show, Dr. Lance Okke.
Lance, welcome to the show.
Oh, thank you, Teyasi.
Thank you so much for the opportunity.
Lance, you are a clinician scientist, and I want to say that there are not many like
you, and I know we went to residency together.
I know you had clinical training like I do, and you are not PhD trained.
So how did you make it?
How did you transition from being a clinician to becoming a scientist?
Yeah, no, Teyasi, thank you again for the opportunity.
It's been now, I think I would say 12 years since this journey started, starting back
to the end of my clinical year and infectious disease fellowship in summer of 2011, somewhere
around there.
And you know, my interest in kind of HIV and cardiovascular disease, which is my area of
focus right now, came partially from the fact that I had developed an interest in HIV that
occurred probably towards the end of my residency program, but also solidified by the good opportunity
I had while I was a third year resident going to Kenya and seeing the state of HIV and HIV
epidemic.
I've been taken as inflection from kind of like massive deaths, but still high incidence,
but better control and really kind of hit this plateau of like, well, what do we do
now that we're keeping all the people that were dying five years ago alive into their
40s, 50s and 60s?
What is the next stage of epidemic look like?
And is there risk associated with continued chronic infection?
And so I came away from that 10 week rotation.
The last time I was in the scene, I was like, yes, this is a problem that I want to pursue.
And so I was able to kind of finish off a hospital stay here and then start my infectious
disease fellowship and started my clinical research career in earnest in the summer of
2012.
And at that time, you know, like I always kind of had this impression that I had an
idea, I had a focus and I thought I had like a mentoring team, but then it kind of, I found
out very early on that the mentoring team that I had didn't really have the research
infrastructure that was available and ready to support my career development.
It was just absence.
And so literally the first couple of papers I'd published were based on databases that
I abstracted the data myself, 1500 patients looking at hypertension outcomes in this group
and the use of evidence-based strategies for CBD control in that context.
And so statin use, aspirin use, and we published our paper, I'm blanking on the first journal
it was, but really this was just me going to the electronic health record and abstracting
data myself for all 1400 patients.
Whoa.
Yep.
It's a resource that was used by many after that, but it was just, I just did the work
and it wasn't anything here.
So I did it.
And that's kind of what gave me the confidence to say, you know what, like in some cases,
it's probably not the prescribed path forward, but in some cases you can make your own destiny
and you can start your program from nothing.
Fortunately, I had a division chief that was supportive and saying, you know what, if you
feel like you can use the elbow grease to kind of do it yourself and move things forward,
then do it.
And I was fortunate to kind of have that time to develop and flounder around and figure
it out.
But soon after, probably about a year into this process, my mentor moved on to another
position at another institution.
And then I was like straight out by myself on, on without no support whatsoever, no mentor
team to be seen.
And then kind of things got really, really hairy for about a year and a half afterwards.
Fortunately, I was able to make some cold calls and I found a really awesome collaborator
and mentor and now a friend of mine in population health.
I'm not sure if I should be mentioning names, but who was really, really gracious, had no
idea about HIV, but I came to him with a plan for continued retrospective studies, but also
an intervention.
It was based on his expertise in that intervention that I wrote my first, my first K proposal.
Back forward two years later after six submissions, visions and revisions and erodemas and getting
rejected.
We finally on our seventh attempt, we're able to refine it to the point where we got it.
We got funded.
Wait, wait, wait, wait, wait, wait, seven attempts.
Oh yeah.
Yeah.
I was good at summary statements summary statements.
And, and, and, but, but that to me, it was kind of like the building, the academic muscle
of kind of grantsmanship, right?
All right.
How am I going to make it better?
The fifth time when I sent this proposal in and, and I didn't take, I didn't lose heart
cause I knew my idea was a good one and one that was needed.
We just kind of kept on working on it.
And I think to me it's, it wasn't a hidden curriculum that educated me.
It was really the classic curriculum of a, of a trial and trial and error centered science
that educated me and how I kind of moved along with the scientific space from then on.
And so that's what I would say.
Wow.
Okay.
Lance, so much in your story.
The first thing I heard is your passion.
You found something you cared about and you dared to believe that you could build a research
career out of something that you cared about and you thought would be impactful.
And it sounds to me that that was a driving force and clearly you had a plan going into
your fellowship research space where many people are still just trying to figure out
what do I really like?
What do I really care about?
I wonder to what extent was that an advantage for you and what do people do if they don't
have that?
Yeah.
You know, I think it's really interesting cause I'm actually having these conversations
actively with our fellowship director right now.
It's a really interesting space about what a clinical fellowship program really is.
Is it a graduate school PhD program equivalent where you should really be kind of gearing
the availability of potential opportunities within the realm of specialty to a bunch of
like fresh PhD students and everybody tries to advertise what their lab was doing?
Or is it a postdoc program where you should actually have some level of sophistication
going into your research years or your fellowship?
I tend to think it's the latter in which we do expect a certain level of sophistication
and the goal of the fellowship program is not to kind of say, well, here are all the
potential opportunities in hematology, like choose one, but really like, okay, you've
had time to at least identify an idea and area of interest.
Let us as a fellowship program, the postdoctoral program that it really is, foster that, build
that and give you the resources to succeed in that regard.
And so in many ways it's a heavier lift in the graduate program, right?
Because the expectation is not that you're just going to walk in as a fresh PhD student
and say, oh, here are all these labs carrying on what there's regular operations.
Maybe you can pitch your code to one.
It really is the fellowship program responsibility to customize their operations to make sure
you succeed because you're exclusively a postdoc under their tutelage and the expectation is
that they drive you towards independent investigation.
So in many ways, I think that the key is that when you choose your fellowship programs and
master's in development, that you're very, very intentional to kind of look not just
at if you're a researcher, not just at, okay, is a clinical training going to be rigorous,
but who is it within that division that you can see yourself modeling your career after
to the best of your ability at the cross section of residency to researcher transition.
And then really first and foremost, base your decision on a fellowship choices based on
if you can find that person kind of division, if you can, it's not gonna be a perfect fit.
But if there's no one that's not even close to a fit to what you're doing, then that's
probably not the best program for you.
And so I would encourage residents coming up just trying to go up into this space to
really kind of be critical of how they see their mentors from our from our interest alignment
standpoint when they choose our fellowship programs.
That would be my biggest.
No, that's really good.
That's really good.
And I think that's really what you talked about about whether it's a graduate program
versus a postdoctoral program where you should come with some level of sophistication.
But the challenge is there is no research training in our clinical training.
So by the time you come to your postdoctoral program, you're not like a PhD trained person
who's pretty much been doing research for four or five years.
You literally are a clinician who's been stuck doing clinical work for at least eight years.
So to some extent, they're not sophisticated.
How can how can people become sophisticated?
Or to what extent can programs help sophisticated people?
If you can say that.
Yeah, you know, I think I think I think it's a really interesting thought to see.
I think that we underestimate the value of our clinical knowledge.
So on one end where the postdoc comes in with a lot of like basic science training in the
context of like basic science research and methodology and all that they don't have the
ability to kind of generate relevant ideas that a clinician has based on their actual
kind of touch and feeling of medical conditions and how they manifest.
And so I think there's a trade off.
You know, the post is a little post with has been and of course, there's dimensions for
kind of comparison there, right?
Like so if it's a really heavy basic science PhD lab, like super molecular, super granular,
whatever, then of course, you as a clinician coming into that environment, have a whole
a really, really steep curve to climb.
Whereas for someone that's going to come into my research program, all I require is that
they have some work and knowledge of HIV and epidemiology coming in to that and what they
don't have where the gaps exist, you fill in your skill sets kind of like make sure
you kind of you're up and running.
So I consider writing that fellowships are not fellowship programs or research years
are really your opportunity to kind of like build your skills in the context of the career
that you're trying to generate, watching how your PI operates and filling in the skills
that you don't have to kind of reset level sophistication.
It's not like let me see if I'm interested in in crypto caucus or basic biochemistry
or or whole genome sequencing.
It's literally like, here's here's a restricted set.
You've you've expressed this interest, how can we kind of fill in those skill sets and
what you need to kind of take it and go and you know, if that time is literally that you're
spending two years in a lab, spending those two years learning those methodologies that
the postdocs the PhD postdocs had coming in, then that's that's valid, right?
That is absolutely valid.
And that's what you should be doing for that entire two years, the hope that eventually,
in a two to four year time frame, you feel that you've you're on an accelerated curriculum,
but one that's that's empowered and driven by the fact that you had clinical context
walking into that wet lab and going.
And so it's not going to be like a PhD student that comes off the street is like, I'm taking
my clinical expertise, emerging kind of methodology and whatever in molecular genetics or whatever
the field may be.
And I expect that because I had some prerequisite of expertise going into that, that this path
of sophistication should be accelerated and the time that the fellowship researchers give
you.
So and we know for that, especially in the basic sciences, two years may not be enough.
It might be three, four.
But the advice obviously is just to take as long as you need to go because that's your
last.
I like it.
So okay.
What I'm hearing so when you talk about that level of sophistication, I think it doesn't
come naturally and it doesn't come easily.
And it's definitely not part of our training, right, because going through medical school,
there's a curriculum.
You're you're going to follow the curriculum.
There's not like your own curriculum that you create.
Maybe you take an elective or two.
You're going through residency.
It's the same thing.
You're kind of just like sheep going through the whole process.
And so where do you develop that level?
I mean, I get what you're saying.
It's like you're a clinician.
You know where the problems are and you know what's interesting to you.
And I think where people start is why well, who is the superstar mentor? and how can I
you know, build my career around this mentor?
And what you're talking about is flipping the script and saying, No, no, no.
Who am I?
What do I want to do?
And what are the resources around to support me?
That's not on.
That's not a common way of thinking.
Yeah, it's not a common way of thinking.
I think is one that that I think probably is most beneficial to you, right?
It's like you need to just have a really clear interest.
It's actually a you know, I serve as associate fellowship director for the ID program.
It's actually for me and evaluative criterion for the fellows that were getting is like,
tell me who you are, right?
Tell me who you are and tell me how you're looking based on who you are on where who
you want to work with going forward.
Yeah, you only know so many of the details of the people to factor in our division.
But if you know who you are well enough, you can figure out and be strategic of how you
fit align your interests with existing resources in most places.
But I mean, I think I think the key is tell me who you are.
And and and be very thoughtful.
Of course, with the guidance of going up, going on as junior fellowship years about
what skills you need to get to get to their level, what are the skill sets you need, because
that's where the fellowship is right is filling in those gaps based on your interest and then
letting you I agree, it hasn't been the traditional way that things are are done.
But I think in many ways, it's unless unless we we kind of foster that level of ingenuity
back that we're building kind of like isolated research trees of like, oh, this is the Jones
line of investigators and everyone is in 1975.
We're kind of Austrian, like independent investigators, then it has to be the approach is like, what
is this make it happen?
Because somehow they did.
Yeah, yes.
No, I love it.
It's not you're not building a clone army.
And somehow, sometimes the prevailing model is the clone army.
I'm a superstar success.
Come be like me.
And there's a lot of that.
But really, it's it's helping people foster their independence is already something that
you're excited about.
How do we help you grow that?
Because you're going to grow it well.
And this is a hard journey.
You submitted seven times.
It's not the kind of thing you want to keep resubmitting something you don't care about.
And many times I do feel like many young people are stuck in that in that place.
The junior faculty are stuck in that place.
Now I want I want you to speak about this whole concept of knowing yourself knowing
what you want, because you took a year and did a hospitalist fellowship.
Like what I'm hearing is that you don't want people coming to your fellowship program starry
eyed saying I'm not really sure what I want to do.
That's not going to fly.
Yeah, I would say that's a fair characterization.
Honestly, I say that, but our program is probably more forgiving in that regard than many other
in the country.
Right.
And that they're actually I remember when I was interviewing for ID fellowships at a
number of places, I interviewed widely across the country.
They actually asked the question straight up.
Who are you going to work with when you get here?
Now I personally think that's a little bit extreme.
I never framed a question that way.
But I do say, what are your interests, and let us do the work of trying to align you
with the best person based on your interest.
What we don't want to do is give you like 15 options and say, Okay, well, you know,
you have 15 options of all the things you can do in infectious diseases.
And I don't know what I want to do.
And then all of a sudden, between 4048 weeks of continuous clinical medicine, you're in
July one of your second year, you're supposed to figure it out magic.
Like, what are your decisions being based off of?
If, if, if, if, if we're not giving you a time to kind of think and so, in my opinion,
that thinking should have happened slowly, but longitudinally over a long period of time,
whether it be like two years prior or whatever.
And if it is, it also is okay to say if that's not your path, and that's not how you accompany
things, how you process things, and that's okay, too.
I mean, I think there are many fine clinician educators out there, right?
There are many fine people that have actually kind of figured it out like two months before
and says I run around transplant ID, and now I want to study after jillis for the rest
of my life, if that's the case, and that's great.
I will say that is is rare.
That's typically what happens, and we should I feel that there's a little bit of a, we
have a responsibility to our trainees to let them know that the likelihood of them figuring
out their life and research in the two months leading up to when you have to make a decision
on July 1st or their second year fellowship is is highly unlike that that was that thread
that narrative should be.
Sure.
So it's almost like right now.
We are dependent on the chemistry.
You see if as you're seeing patients, there'll be chemistry between you and a certain population,
and then you'll know that this is a population you're working with.
What you're talking about is forgetting the romance chemistry that may may help you figure
it out and just being thoughtful, being thoughtful about what you care about and how the resources
of the institution potentially could support you.
And if that means taking time off to figure it out, it is important, but it really takes
time to think.
And when you're in the midst of your clinical training, you are so busy clinically, you
may not have that space to think and coming to these decisions, take thought, they take
time they take space.
And you should be thinking about how do you create the space to be able to make a good
informed decision.
Absolutely.
And I think I think the reason why there has to be longitudinal choices, think about he
went through this process.
You start from when you're an intern and take that time period consecutively.
If in case of internal medicine, to the time you the day you finish your clinical fellowship,
right.
And now you're about four or five years in and out, all of a sudden, it was to be a research,
you supposed to have a research plan.
What I would encourage is that you have to be thoughtful of the small steps along the
way that kind of gear you towards that interest all the way through because you're not going
to have two weeks to just kind of sit back and kind of strategize, okay, here's my life
now, but the but the journey is actually meant interested in many ways in that thread, right
of like, here's where I started.
Here's how I was interested in hematology.
Then I did some extra around hematology.
I really, really liked it.
And then I was like, well, hmm, this sickle cell clinic is kind of cool.
I'm going to do a little bit more of that.
And then I got to hematology fellowship and like, okay, well, here are the aspects of
sickle cell that I'm really interested in.
And so let me try to find a program that have people kind of doing that.
I may not know all the answers right now, but I like sickle cell.
And I like this aspect of patient centered sickle cell research.
I'm going to do that.
And then you get to somewhere that where someone's doing that and boom, like, in a way you go,
but it's not going to be a epiphany.
It's not and it's not but it was because of the lack of time we have to decompress and
strategize and I think the earlier we tell folks to kind of actually have this longitudinal
evolution over time that occurs in small increments over the course of those four years leading
up to your first day of clinical clinical research fellowship, I think is key.
I mean, in many ways, it's scary because you're like, well, you're making big decisions.
You're making big, such big life decisions with no time to decompress and strategize.
Right.
And in many ways, that's true.
I mean, it's always been my problem with going back to medical school, how do you decide
medicine or surgery or pediatrics or OBGYN based on what information and all of a sudden
midway through your third year, you have to start to make decisions of how you're going
to spend the rest of your life with a surgeon or as a medicine doc or a pediatrician based
on what information did you make that decision?
However, we make those and from those decisions anyway.
So I think the same applies here where it's like literally like taking that time, the
small little time you get with the small increments over time to really kind of find out where
you're landing and then come to that point in time.
And maybe maybe for the rare few of us to have that epiphany, that's good for you.
But I think that's not the typical path and one that we should expect to expect in most
cases.
Sure.
So what I'm hearing is more we've got to cultivate the interest over time and foster people really
thinking about what is it that they really want to do.
Okay, so I want to go back to the seven applications you did for a career development award.
At what point along that journey did you want to quit and what kept you going?
Yeah, I am very internally motivated.
So to me, it was always like I'm just gonna I'm stubborn, I'm just gonna prove I can do
it.
And it was it was it was my it wasn't the pressure from others.
It wasn't like the fear of failure.
I'm just wired where it's like, I'm gonna get I'm just gonna ram this thing through
one way or the other.
And so I can't really say that I ever felt like within because I had it in my head that
you know, this is a good idea.
I want to prove to myself that I can do this.
And so and so I'm gonna do it.
You know, the times if there's a time where I felt like quitting, or I felt like lost
enough words, like maybe I should be doing something different.
It was actually when my mentor left in early 2004.
So my beginning my third year of clinical fellowship, and I was like, yeah, this is
like there's really no clear path forward here.
But you know, I kind of embrace that challenge and say, Okay, well, let's just at the worst
case in the worst case.
And, and here's where I always is probably insensitive to the to the experiences a lot
of people.
In many cases, we're, we're, we're blessed, we're fortunate to have such a high ceiling
as a highly trained medical professional.
What is truly the fear of failure here is not like the person out on the street working
40 hours a week for $15 an hour at the loser job there potentially on the street, I can't
make their rent at worst.
At worst, you get a clinical job somewhere, and your family will be fine, and you'll earn
whatever money.
You'll do what you want to do for the rest of your life, but at least you're financially
secure.
So, to me, like, I was like, you know, if I'll just do this, they tell me I can't do
it anymore.
It comes, still have a pretty good job somewhere.
I can't complain that much.
So yeah, I wasn't really driven by that fear of failure or, and I think a lot of it in
many ways too, was that I've never really completely tied my identity, love, esteem
to this work.
Like, this work I enjoy is work I care about, but fundamentally, I know that there are many
other things I can be doing.
I just choose to do this, and if it doesn't work, you go do something else.
I'm not a failure, so to speak.
Oh, wow.
I love that.
It's a fundamental faith in yourself and your ability to move work forward.
It's also recognizing that you'll be okay if it doesn't work out, and it's worth doing
as long as you can do it, and it sounds like you enjoy doing it, and therefore you did
it.
And I love that because it's really about really loving the work that we do and not
doing work just because somebody gifted it to you, which is a different, you know, you
come at it differently, you interact with the work differently as well.
So I really appreciate that you talked about that.
One thing you alluded to is the finances, and I want to speak to that because Dr. Lance,
okay, you're doing all this awesome research work and resubmitting and submitting the K,
how are you making ends meet?
Yeah, you know, it's an interesting question to see.
I, you know, and there are many ways my thoughts can go on that.
But I will say this, that it is difficult, it is interesting, it is sobering to know
that, you know, I could kind of drop all these extra hours of work that I'm doing right in
these grants and actually go make more money in private practice or wherever, right?
Is it tempting?
Not really, because I mean, I enjoy my work.
And I mean, everything looks seems monotonous.
All the other options seem pretty monotonous to me where I don't have my intellectual,
academic creativity as a driver of what I do every day when I wake up in the morning.
That is a loss.
It's not failure, but it's a loss if you don't have that in your life anymore.
And so in many ways, as a researcher, you've made a decision that you're going to take
the institutional discount on your earnings, just so that you can preserve your academic
creativity as a driving force of the work that you do every day.
Whether that's right or wrong, I think is really open for question.
Now, of course, I'm biased one way versus the other.
But in many ways, I've, I guess, come to terms with it that, you know, at least I don't have
to round C24 patients every waking day of my life, because that would be really, really
tough for me.
And so I say this is a privilege, Jackson, that I get to do the work that I enjoy.
And every day that I get to do this work is a privilege.
And if it might sell, you're going to be docked partially because of it, then so be it.
I think fundamentally, though, in terms of value added for what we do as researchers,
as scientists, the entire system is completely wrong, right?
But we know the realities of how institutions are compensated and how health systems make
their money.
And so unfortunately, this is probably a reality of being a researcher that will face for the
duration of our careers, but hopefully I'm wrong.
I love that.
I think what I hear undergirding that is that I love my work.
I like to do this work.
And the value it brings to me is worth the cost, because it costs you to do this work.
But you don't look at it as a cost.
You look at it as what you're enjoying.
And I just think it's really refreshing and beautiful because I feel like in medicine,
there's so much of I got to do this, I got to do this.
This is an obligation.
This is what I got to do, and which is fine.
You feel like you have to do it, but you get to a point in your career.
And that's usually in making that transition from fellowship to faculty, where you don't
have to just do whatever, where you get to choose.
And you should choose a thing that matters to you.
Yeah, I love it.
Thank you for sharing that.
All right, we have come to the end of the show.
And I want to ask you, what final thing have we left unsaid that somebody needs to hear,
especially someone who's thinking, but I don't know, I don't know what I want to do with
my life.
This research thing sounds cool.
What advice would you have?
What I would say to OC and thank you so much again for the opportunity is this that I want
to anchor on that last point that I made about the privilege of being able to use your ingenuity
and your creativity to drive the work that you care about.
The researcher, the scientists in many ways, it has the privilege and is unique within
our realm of clinical medicine of being able to do that.
Right.
And so to me, no matter how difficult it is with NIH fund rates and like what are the
how far on what are the award rates for each institution and how hard is it to get your
kid or how hard is it to make a transition.
I know why I choose this work.
And it's because of what I said, which is I get to use my ingenuity, my creativity to
do work that I care about.
And as long as that's the driving force for my work that I've devoted my professional
life to do, then I think I'll be OK.
And I want I hope that that because I mean, I think I really truly believe that once you
kind of abandon that opportunity with with your professional choices early in your career,
it's really hard to go back to it.
And so I hope that for trainees, for fellows listening to this, they don't abandon, they
don't forfeit that privilege of using your creativity to drive your work.
Like it's the it's the mandate of the researcher, the scientist and one that's that's available
to all who graduated medical school.
I want to look into careers in academia, which if you forfeit it only if you want to.
And if you do think about it before you do and think about what wakes you up in the morning.
And so that's why I do what I do.
And I had a pay cut pay cut nonetheless.
But I'm thankful to have the ability and privilege to do it.
Oh, that's so awesome.
Lance, thank you so much.
Thank you for being on the show.
Yeah.
Thank you, Tersi.
All right, everyone.
You heard Lance.
This is this this work is is it's meaningful.
It's fun.
We get to use our creativity.
We get to do amazing things and make impact at the same time.
And if you want to, you absolutely can and definitely believe in yourself and do what
it takes to to fill the gaps that you have.
All right.
It's been a pleasure talking to you all.
I look forward to talking with you again the next time.
Thanks for listening to this episode of the Clinician Researcher podcast, where academic
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