Career Advice

Lately, a lot of people in the mental health field have been asking me for career advice. Their question: “Where can I have the most impact?” Other than saying, “Don’t do what I did”, I’m not sure what to recommend. I’ve had one of those non-linear careers that looks like professional ADHD. Training in psychiatry and psychoanalysis followed by clinical research, basic science research in academia, public service at NIH, private sector at Alphabet and five start-ups, with a finale that is a mix of unpaid board service, farming, and grandparenthood. I’d like to say there was a throughline here, but the changes have been driven mostly by curiosity, opportunity, and sometimes failure. Every five to ten years I seemed to be starting over. Yes, changing careers was exciting but also a forcing function for humility and frugality. For the first twenty years, I talked a lot about impact, but I worried a lot about money. Later when I was paid more, I worried about impact.

In truth, I don’t know how to offer career advice today because the careers are all changing. For most of my career I was a basic scientist or an investor in science working at NIH. Until recently, NIH was scientific nirvana. The intramural program supported high risk research without the requirements of grant funding, teaching, or administrative service that dog scientists in universities. The extramural program, nearly 90% of the NIH budget, was the largest investor in biomedical science in the world – far bigger than any venture capital firm or philanthropy. For the last few decades, my mantra was, “You want impact, go to the NIH.” And the corollary, “You want income, don’t go into public service.”

Today, the NIH is reeling from lay-offs, threatened budget cuts, and HHS leadership that is frankly hostile to the public servants who have made this agency scientific nirvana. In 2025, I don’t think this is the ideal place to have impact. That could change. Congress continues to support NIH, brilliant people are riding out the storm, and even with significant cuts, NIH will have the capital to fund great science. But in the fall of 2025, I would not recommend a young scientist launch a career at NIH or CDC or FDA.

But it is not only the NIH that has changed. Academic medicine is also struggling. The University of California receives more than $17 billion each year in federal support (including $9.9 billion in Medicare and Medicaid funding, $5.7 billion for research and program support, and $1.7 billion in student financial aid). Much of that funding is newly at risk. And the situation at other top research universities may be even more dire. It’s never been easy to build a scientific career in a college or university. With recent attacks on some of our best research universities and threats to federal funding, it’s never been harder.

To be clear, the recent changes are just the latest shifts in a decades long decline. Academic research has become increasingly, well, academic. Impact is measured too often by journal citations, promotion, and maybe a better parking place. Many academic scientists live in a bubble, ignorant or dismissive of public health needs. In mental health, academic scientists have focused on larger, more expensive studies to find smaller, less actionable results. No one asks key questions: “Will this change practice?” “Can this scale?” And maybe most important, “If the findings are positive, who is going to pay for this?” In American healthcare, payment is essential for adoption. Experience in mental healthcare (in contrast to obesity and cancer), teaches us that most breakthroughs that increase costs will never make it to patients.

If public service and academia are not the best homes for impact, what about the private sector? Twenty years ago, the mental health private sector basically meant Pharma. Then most Pharma companies left the mental health space to focus on immunology, oncology, and other areas with better molecular targets. Today the private sector includes over 300 start-ups fueled by $12B in venture capital, large tech companies with deep investments in behavior and cognition, and a cohort of new non-profits supported by philanthropy. The entrepreneurial psychiatric resident who in the past would have launched a private practice, today is advising Microsoft or joining a start-up. And today, even Pharma is coming back to psychiatry, based on products developed in start-ups like Karuna and Gilgamesh.

So, should we be encouraging our best and brightest to pursue careers in start-ups and tech companies? Maybe. More than 90% of start-ups fail. Those that succeed often change directions to catch a market distant from the original scientific premise. And the pressures of venture funding with ROI demands and short time horizons often outweigh the mission of public health impact. If academic research is, well, academic; the private sector is, well, a business, with success measured by the economic value of the company. Yes, impact is measured by scale but more precisely by revenue. In a fee-for-service healthcare system, great products are only great if they generate sufficient revenue.

So, what’s the answer? Public service, academic research, or private sector? As I said at the outset, I really don’t know that there is an answer. And the answer changes depending on stage. Just out of training, go where you can get experience and create a social network. Later, if you love teaching, go to a university. If you are entrepreneurial with a high tolerance for risk, try a start-up. If you care deeply about patients, focus on that.

I started out by saying, “Don’t do what I did.” I’ll finish by suggesting that maybe with all the uncertainty (and potential) for innovation to transform mental healthcare, a non-linear path is inevitable. In my day, focus and persistence were key. Today, flexibility and adaptability are more essential. Follow your curiosity, look out for opportunity, and learn from failure. At least, that worked for me.