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
MSTP funded dual degree-granting institutions and about 75 additional
M.D.-Ph.D. programs funded through other means. Currently, 500 of the
physicians (3%) graduating each year
receive dual degrees.
What is the M.D.-Ph.D. program?
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
institutions, but the average length of study is 8 years and designs are
- an initial 2 years of preclinical/basic science coursework, in which some courses are taken for credit in the graduate school
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?
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
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.
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).
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?
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.
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.
are significant differences among various programs and careful
examination of the programs and self-examination of one’s goals and
commitments are required.
- The Association of American Medical Colleges (AAMC) website maintains a list of M.D.-Ph.D. programs in the United States and Canada along with a wealth of other information.
- A complete listing of institutions offering Medical Scientist Training Programs (MSTP) is maintained by the National Institute of General Medical Sciences (NIGMS).