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Science Careers Blog

July 14, 2010

The M.D.-Ph.D. Track: The Triathlon of Medical Research Training

As the practice of medicine and the delivery of health care over the last half-century has grown in complexity and content, training to be a practicing physician has gone from being analogous to a cross-country track event to a virtual marathon in time, effort, and expense. With the explosion of knowledge and technical complexity in the biological sciences, M.D.-Ph.D. candidates preparing for a life of medical research are found in a triathlon by comparison. Those who cross the finish line are well equipped to take on the challenges of being a physician-scientist.

Based on personal involvement within my own institution, discussion with program directors, and interaction with M.D.-Ph.D. program graduates, I will present a brief overview of this challenging pathway to a science career.

Why was the M.D.-Ph.D. program created?

Until the 1960s, advances in medical science were most often made by physicians striving to solve medical problems. In 1964, James Shannon, the director of the National Institutes of Health (NIH) convinced Congress that a program was needed to fund in parallel the training of students in M.D. and Ph.D. programs to provide the level of knowledge and skill needed for the future. Thus, the Medical Scientist Training Program (MSTP) was born.

Today, NIH, through the National Institute of General Medical Sciences (NIGMS), spends $42 million in grants that fund both the institutions and faculty involved in the training and provide stipends for students at the level of about $21,000. There are 45 MSTP funded dual degree-granting institutions and about 75 additional M.D.-Ph.D. programs funded through other means. Currently, 500 of the 16,000 physicians (3%) graduating each year receive dual degrees.

What is the M.D.-Ph.D. program?

Joint M.D.-Ph.D. programs are designed to train physician-scientists (a.k.a. research physicians and physician investigators) to work effectively at the interface between science and medicine. The specifics vary among different institutions, but the average length of study is 8 years and designs are generally similar:

  • an initial 2 years of preclinical/basic science coursework, in which some courses are taken for credit in the graduate school
  • approximately 6 months of clinical clerkships preparing students for participation in longitudinal care clinics during graduate school
  • about 4 years of graduate coursework and research culminating in research dissertation and thesis defense while bridging activities in clinical clerkship and other medical school activities
  • finally, 1 and a half years of remaining clinical clerkships and medical school classes.

Who is it for?


The Association of American Medical Colleges (AAMC) offers this advice to potential applicants:  ". . . One feature that seems common to all committed M.D.-Ph.D. applicants is a depth of passion for treating today's patients as a physician and tomorrow's patients as a research scientist uncovering the mechanisms underlying disease. The career is inspiring but also filled with challenges and frustrations. . . . The passion to solve a patient's struggles and to crack the code of a disease's cause carries the physician-scientist through the challenges."

As this quote suggests, the M.D.-Ph.D. pathway is for people who are passionate and determined to improve human health.

What are the advantages of the M.D.-Ph.D. program?

The program facilitates comprehensive and organized research training while in medical school. It is not possible to get equivalent training as a medical student alone without completing an extended postdoctoral fellowship after medical training, which would entail even more time and greater cost. The M.D.-Ph.D. candidate enjoys a wide choice of biomedical laboratory disciplines to choose from, including cell biology, biochemistry, genetics, immunology, pharmacology, physiology, neuroscience, and biomedical engineering. At some institutions, the trainee can also choose graduate work outside of the laboratory, including disciplines in areas such as computational biology, economics, epidemiology, health care policy, anthropology, sociology, or the history of medicine.

The two degrees confer assurance of competency as both a physician and researcher and potentially offer a competitive edge in securing an academic leadership position and research funding. The two degrees also offer career choices and something of an occupational safety net as compared to having either the M.D. or Ph.D. alone. A recent study demonstrated that M.D.-Ph.D. recipients have lower educational debt, higher receipt of medical school scholarships and grants, and greater planned career involvement in research compared to the regular M.D. student (Andriole DA, Whelan AJ, Jeffe DB. Characteristics and career intentions of the emerging MD/PhD workforce. JAMA. 2008; 300 (10): 1165-1173).

What are the problems associated with the M.D.-Ph.D. track?

Positions in M.D.-Ph.D. programs are highly competitive. The ratio of applicants to positions is on the order of 20 to 1. Competitive applicants must be straight "A" students -- or close to it -- in their undergraduate work, have high Medical College Admission Test (MCAT) scores, strong research experience as an undergraduate, and the ability to interview well.

The greatest drawback in choosing the M.D.-Ph.D. track relates to the fact that at age 20 or 21, applicants are called upon to make a critical decision affecting 8 years of concentrated effort for a career that won't begin until they're in their early 30s (taking into account an additional 2 or 3 years of residency training). In this interim, one's interests and ambitions may change and the trainee may accumulate a spouse or significant other, children, responsibilities, and educational debts that lead them to change to a different career path.  This is, without a doubt, the main reason that about a quarter of trainees (per the Andriole study cited above) fail to complete the program (although almost all of them continue with their M.D. training). 

Unfortunately, no reliable database exists to track what successful M.D.-Ph.D. graduates do with their careers, as opposed to what their original intent was, nor is data available comparing the long term success of M.D.-Ph.D. to Ph.D.s in obtaining funding.

My own experience as a clinical chair has been that less than 25% of M.D.-Ph.D. graduates (from a variety of institutions) who took a residency in our department and expressed an intention of making research a part of their careers, were so engaged 5 years after completion of their residency. However, a graduate survey of the University of Wisconsin Medical Scientist Training Program indicated a much higher percentage continuing as physician-scientists. Programs vary considerably in the mentoring and support given to M.D.-Ph.D. trainees and this impacts the commitment and determination trainees have in the long haul. For a good discussion regarding selection of an M.D.-Ph.D. program, see Skip Brass's excellent Science Careers article, "Perspective: Three Crucial Questions When Applying to M.D.-Ph.D. Programs."

What are the research careers of successful graduates like?

For those who complete the training and maintain their passion for an investigative career in medicine, opportunities abound. Although general data is not available, Deane Mosher, director of the University of Wisconsin Medical Scientist Training Program, states that about 85% of students complete the training, with graduates equally divided between those trained in basic science and those prepared for a translational role (intermediate between basic science and clinical research). Less than 3% have gone into full-time clinical practice. Here, as in other medical scientist training programs, the expectation that graduates will provide major contributions to medical science and become leaders of academic medicine is clearly being realized.

Conclusions

  • The M.D.-Ph.D. training program is long and rigorous, but it is the most effective and dependable pathway to a career as a physician-scientist.
  • Admission to this program is highly competitive and "staying the course" requires passion and determination.
  • While it offers great opportunities for those who successfully complete training, about 1 in 4 trainees are unable to do so.
  • There are significant differences among various programs and careful examination of the programs and self-examination of one's goals and commitments are required.

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