Not all MD/DO-PhD programs are structured in the same way. However, common among the structures out there is a period of time between the beginning of medical school training and the end, which is occupied by PhD research. After the PhD, you go back to medical school and suddenly you’re in the hospital at 4 am asking patients if they’ve pooped or you’re in clinic trying to do a physical exam on a fussy child. If you haven’t thought about or done anything clinical in years, this can certainly be a shock.
At the same time, you’re integrating with a whole new medical school class, which has been made even more difficult in the setting of COVID-19 (Calco, JCTS [2020]).
This “major chasm” that occurs during the PhD years has been historically recognized, and programs are addressing this chasm through the development of clinical continuity opportunities. However, these vary widely between programs and have not been well studied as a collective.
A few years ago, myself and some of my fellow student leaders of the American Physician Scientists Association decided to study this. The motivation began out of discussions with the Institutional Representatives of the organization. The Membership Committee did a preliminary survey. Then the Policy Committee set out to do a comprehensive survey, seeking out Institutional Review Board approval so that we could eventually publish this data for broader dissemination.
This manuscript is now available from the Journal of Clinical and Translational Science. You can read it here.
As a trainee, here are the things that are most helpful to know:
Again, there is wide variation among programs. If you haven’t started your dual-degree training, this could be something useful to ask about during your interviews.
The clinical continuity experiences rated as more efficacious were:
Standardized patient encounters
Mentored clinical experiences
Clinical skills review sessions
Preclinical courses/review sessions
Clinical volunteering
The clinical continuity experiences rated as less efficacious were:
Clinical case reviews
Clinical journal club
Medicine grand rounds
The strategies offered vary based on proximity to clinical re-entry. For example, clinical skills review sessions and preclinical/review courses were typically only offered within 8 weeks of clinical re-entry while other experiences like clinical volunteering, mentored clinical experiences, and medical grand rounds were available throughout PhD training.
We also don’t know which of these are the best to truly prepare students for the transition back. There are many outcomes that need to be assessed with respect to these experiences not just performance in clinical skills during the clerkship years but also student confidence in their knowledge and skills and overall wellbeing amongst the period of transition. I have a feeling that there is not going to be one best way to do this and it will have to be specialized to the learner.
Importantly, these clinical continuity experiences are typically voluntary and so the amount that you do during your PhD is mostly up to you. Your PhD years are the one time you will be able to have time solely dedicated to thinking about research questions so enjoy them (yes it is possible to enjoy them!) and do not distract yourself *too much* with clinical experiences or other obligations.
According to the Association of American Medical Colleges, there are 125 schools that offer MD/PhD training in the United States. There are also a few DO/PhD programs, though I could not find a comprehensive list of these.
These programs vary quite a bit. I was certainly not aware of all of the things to consider when deciding where to apply for MD/PhD training. This is just a general overview of some of the major ways programs can differ based on what I know and is by no means a comprehensive list of the variations that you’ll find.
Structure
The “assumed” structure of a MD/PhD program is what we call a 2-4-2. This means that students take the first 2 pre-clinical years of medical school, take USMLE Step 1, then take a break from medical school to complete their PhD in hopefully 4 years (sometimes more, sometimes less), and after that they return to medical school to complete their 2 clinical years.
I say the “assumed” structure because my MD/PhD program is one of those that is quite different. We begin with our PhD and progress through our PhD training on the same timeline as PhD-only students, except that we also take the first year of medical school decompressed during that time. Check out my post My MD-PhD timeline for how that worked out for me. Only after completing our PhD do we continue with our second year of medical school, take the Step 1 exam, and then go on to our 2 clinical years of medical school.
I have not heard of another school that does it quite like mine, but I have heard of one that has students take their first year of medical school all at once, then take a break for their PhD, then return to do their last 3 years like my school.
While some schools – like mine – frontload research training in their MD/PhD program, others have a structure that puts more medical training before students do their PhD. As some schools are shortening their pre-clinical curriculum to 1.5 years, students are able to complete a couple clinical clerkships to solidify their medical knowledge before transitioning to their PhD phase. Other schools have students complete the first 3 years of medical school (through their core 3rd year clerkships) before doing their PhD and returning for their 4th year of medical school.
There’s pros and cons to all of these approaches. I liked doing more research first so that I could approach my medical training from a research perspective. Now that I’ve done more medical training, I feel like it also would have been nice to have at least the first 2 years of medical school done before doing my PhD so that I could approach my research from a more clinical perspective. This is why it is important to research all of the schools you’re considering and, importantly, try to talk to students at those schools to find out what they think about their program. Regardless, all of these should, on average, take 8 years to complete.
Size
MD/PhD programs also dramatically differ by size. So, depending on where you go, you may or may not be part of a large community of students going through the same challenge of being both a medical student and graduate student. Of the 125 schools on the AAMC list, some of these have quite large MD/PhD programs. For example, Washington University in St. Louis has approximately 200 MD/PhD students. On the other hand, some of the schools listed only have a listed option for students to do a MD/PhD training without any listed students in the program on their webpage.
I began in a cohort of 10 MD/PhD students. At the time, my program had 120+ students overall and had been training MD/PhD students since the 1970s (so we had a large alumni network). I enjoyed having this larger community. With 125 students in the M1 class, it meant that there was at least a few other people in the room who understood the challenges of balancing MD and PhD training. We have had yearly retreats to facilitate community building and collaboration across the campus. These have slowly shrunk in size due to our campus of our college of medicine closing down, but our sense of community remains. I’m in the last graduating class from our campus, and all 12 of us are MD/PhD students, which is a quite unique experience.
This is so important. Medical training is ridiculously expensive and committing to the extra years of research training cuts away at your years where you can make actual attending physician-level money. Luckily, *most* MD/PhD programs that I’m aware of offer tuition waivers to relieve the burden of medical school debt. However, I have heard of at least one program where students are responsible for a portion of their medical school tuition.
Importantly, all programs should provide a stipend for all years of training. Usually, these are similar to the stipends of normal PhD students, so somewhere around $20,000-$30,000 for the year (this depends on the school, department, and cost of living in the area). Some programs have a Medical Scientist Training Program (MSTP) grant, which they use to fund their students and provide a stipend throughout the entirety of their MD/PhD training. People often use “MSTP” as an equivalent of the term “MD/PhD program”, but there are only 50 schools with this funding status. So, these terms are NOT the same (as a non-MSTP MD/PhD student, this is definitely a pet peeve).
Other programs rely on different funding mechanisms to support their students. For example, my program provides a stipend while we’re in our medical school years, but during our PhD years, we are funded like any other PhD student. This means if our advisors are able to afford a research assistant appointment for us, then we get our stipend that way. Otherwise, we have to work as teaching assistants on top of doing our research to get our stipend. PhD programs often have teaching as a requirement for getting a PhD, so this was fine for me though I did have to do more than my department required. Some MD/PhD programs waive these teaching requirements.
Another funding option that MD/PhD students are encouraged to apply for is the Ruth L. Kirchstein Individual Predoctoral National Research Service Award (NRSA). The F30 award is specifically for MD/PhD and other Dual Degree Fellowships. There is also a F31 award for predoctoral students but not specifically those also completing a medical degree. Note that these are funded by the National Institutes of Health and are only available for U.S. citizens or permanent residents. I was fortunate to be awarded a F30 grant and will hopefully be able to write more about these awards in another post and will update with a link when it is published.
Other things to consider
Is the program in an area of the country that you want to live? Are there people doing research there that you’d want to work with (see my post How to pick a research lab)? How good are the hospitals that you’ll train at? Are there opportunities to experience rural/urban health? Do they effectively promote diversity and inclusion in their program/at their campus? Do students feel like the administration listens to them?
Featured photo: Adapted from @MDPhDToBe on Instagram
This was originally shared on www.almostdocs.com (which no longer exists???)While I thought I had re-published all of my important articles from that site last year, I guess I missed this one. 🤷🏻♀️ Please note that I wrote this in 2014!!!
Whether you’re a pre-med who wants to build your resume for medical school, a medical student who wants to fill a free summer, or a graduate student, you’re probably going to be doing research. Before you jump in to trying to join a research group, I am here to warn you that not every research environment is equal (as I’ve learned the hard way, which sort of makes me an expert so you probably heed my warning). If you do it right, there is a lot to consider when finding a research advisor that is best for you, which is ultimately what’s important.
If the thought of picking a research advisor makes you feel a little like this:
Then this list of considerations is for you.
1. What area of research do you want to be in?
First things first, you need to narrow down your options. Often this will be in your major or graduate program area, so hopefully you’ve already had a chance to reflect on this. Do you want to do biology or engineering or anthropology? Whatever it is, look for professors who are doing research in that area.
2. Does your personality fit with that of the Primary Investigator (PI)?
Before asking to join a lab, it is essential that you reach out to the PI (or the professor in charge of the lab, for those who do not know). Talk to them about their research and the lab environment and by doing so, try to gauge how well you would work together. The PI will be your primary advisor in the lab and you need to make sure that you will be able to work with them and be successful.
3. How involved is the PI in their students?
Some PIs expect a detailed schedule of their students’ work and oversee it closely while others lay back and don’t keep a close watch on their students at all. Of course these are the extremes, but you will find PIs along a whole spectrum of involvement. Depending on your work ethic and confidence, one extreme or the other may be better for you. It is important to understand how you work to understand what you’re looking for in a PI. Remember, if a PI is more laid back, you will have to be more driven and independent to get the work done. On the other hand, if you’re more independent, a PI that sort of hovers will be quite frustrating.
Also, ask the students in the lab about the PI. You may find out even more information to sway your decision (such as if the PI has a short temper – true story).
4. How much do students have control of their own project?
This related to #3 and mostly pertains to those students in graduate school. To become an independent researcher (as is the goal of graduate school), you need practice planning your own research. If your PI doesn’t let you do much of the planning, you won’t get this experience and you might get stuck doing work that you do not want to do.
5. Do students get adequate guidance?
How often do students in the lab meet with the PI? Are there regularly scheduled individual meetings? Do they have to present regularly at group meeting? Does the PI have an open door policy? Is the PI always traveling? Are there senior scientists, post docs, or senior grad students in the lab that can provide guidance as well? Research is based on mentorship and you need a mentor that will be available to you.If you’re new to research, especially, figure out whom you will be working with and if you will be able to work well with them. Will they be a strong supporter of your development as a researcher?
6. How large is the lab?
A large lab may mean getting lost within the students and not having adequate access to the PI, but it also means having lots of students to rely on and work with as well as greater resources. A small lab likely means a more personal environment but possibly less equipment. Will a small lab be adequate for the research that you would want to do? How personal of an experience do you want?
7. Do you get along with the students?
You will likely be spending most of your time with the other students in the lab rather than the PI. It is quite important that you will be able to get along with them otherwise working in the lab may not be the greatest experience. How close are the students? Are there cliques? Does your personality fit within the group? Do they like to chat? Do they like to chat so much that it affects work time? Do they hang out outside of lab? Being social and working well together is great. Being too social and not getting enough work done is not so great.
8. Will they pay you?
Oh, the ever so important issue – money. As a novice to research, it is often expected that at least initially you will be volunteering in the lab. Perhaps if the PI has enough money, they will be able to pay you eventually, which is an important thing to figure out early on. For graduate students, this will determine whether you will have to do additional outside work to make your money.
9. If you’re a grad student, will you have to TA?
Going along with #8, the usual way for graduate students to earn their stipend other than being paid by their PI is to serve as a teaching assistant. Of course, this takes away time for doing research, which is what you’re there to do (unless you’re an awesome person who also likes to teach!) Many programs require at least some TA experience, but depending on the PI’s funding level you may need to do more than required. Also, if you’re not comfortable with teaching/have no interest in doing it, you also may not want to join a lab that will require it for your pay.
10. How well funded is the lab?
Money isn’t just essential for your pay; it is essential for the research. Does the PI have enough money to do the work that you will be doing or will you be restricted by funds? This can likely affect your success in the lab if you cannot do the work that you need to do to get results.
10. How much time is expected from you?
Does the PI want 10 hours a week or 70 hours a week? Do they not care about the time as long as you get the work done? Do they require you to work on weekends? Most of us try to have lives outside of lab, so this is an incredibly important consideration and the required time can vary drastically.
11. How long does it normally take for students in the lab to complete their degree/publish a paper?
Being published is a major measure for the success of a researcher. If you want to publish as an undergrad or a medical student, it is important to try to feel out the chance that you would get published from your work in the time that you have. If you are a grad student, you want to make sure that you will be able to publish in an adequate amount of time since you usually need to publish to get your degree.
12. Where does the lab normally publish?
Not every research journal is equal. Some hold much more prestige than others and many people look at where people publish as a marker of their success not just if they publish. If this is important to you, look to the PI’s papers and see where they tend to publish. It is important to note that often publishing in the top journals requires much more data, which means it likely takes longer to produce a paper for journals of that caliber, so that might also be a deterrent.
13. What is the specific research topic in the lab?
Finally, we’ve reached the topic that many make a mistake by considering too greatly. Sure you picked a field of research in your first consideration, but you haven’t yet considered the exact topic in the lab. There’s a reason – it honestly isn’t that important as a trainee. If you’re going to be doing research as your career, then you’ll have more freedom to study what you want, but as a trainee, the most important thing is becoming skilled as a researcher. Maybe you want to study RNA splicing in liver development but you end up studying signaling pathways in neurogenesis. Guess what, you’re still doing research and getting the experience that you need to move on to the next step in your career path. Picking a broad topic within your field of choice – such as cancer like me – can be a good idea as a basis for your career, but don’t pick a specific area that restricts your choice of labs, which may make it harder to find a lab that fulfills the other considerations.
Now with this guide, go forth and find a research lab that is best for you and discover great things!
“Why MD/PhD?” is probably the most frequently asked question that I somehow haven’t appropriately addressed yet on my blog. I have multiple drafts of posts that go back years that I never felt were ready for the world. I’m changing that now.
To answer this question, I must first answer another –
Why become a physician-scientist?
The general goal of MD/PhD programs is to train physician-scientists, but that is not the only way to become a physician-scientist.
The general definition of physician-scientists is that they are medical doctors who are also trained to do research and typically spend the majority of their time doing so. These medical doctors could have a MD or DO degree, or a MBBS degree if they trained internationally. They do not necessarily have to do residency training and become a licensed practicing physician. They also may or may not have a PhD. They can also get sufficient training during residency/fellowship or another post-doctoral research experience that would prepare them to become an independent researcher. And as team-based research is coming in to prominence, they may also not necessarily spend the majority of their time during research or it may be difficult to distinguish their clinical and research time if they’re involved in clinical research.
Whichever way you approach this career path, it’s a long road. So why do people do it? One reason is that the physician-scientist is uniquely positioned to effectively answer questions that arise in the clinic. For example, say you’re an astute physician who noticed a family with high levels of cholesterol in their blood and are more likely to have heart attacks at a young age. You ask whether the cholesterol is high because 1) more of it is being produced or 2) because it’s not being taken up by cells. You decide to take a sample of their cells and grow them outside a body. By treating these cells and a non-affected person’s cells with a labeled cholesterol-containing lipoprotein, you find that the affected cells do not take up cholesterol like the non-affected cells. Therefore, the cholesterol cannot provide feedback to the cell to tell it to stop making even more cholesterol! 😱 There must be something on the cell surface that is responsible for taking up cholesterol that is missing from the affected patient. Turns out, this something was the low-density lipoprotein (LDL) receptor (LDLR).
The physician-scientists in this case were Joe Goldstein and Michael Brown, who ultimately won the Nobel Prize for their work on cholesterol. Their findings were the first to show a biological process called receptor-mediated endocytosis, but they were also instrumental in showing how statins work to reduce cholesterol levels in the blood. Statins are now taken by more than 30 million people worldwide to reduce their risk of heart attacks. Neither of these physician-scientists have a PhD, but both did fellowship training in biochemical genetics at the National Institutes of Health where they had some clinical responsibility while also training in basic science.
It is important to note that not all physician-scientists are biologists like Brown and Goldstein. While this is a more traditional area of focus for physician-scientists, a physician-scientist can specialize in virtually any area of research. For example, my MD/PhD program has trained a remarkably diverse set of physician-scientists with research areas from engineering to neuroscience and biochemistry to anthropology and music. They can also be found in all medical specialties from surgery to internal medicine to psychiatry. The important thing is that whatever research area they pursue, ideally the physician-scientist would focus their research on a question related to human health.
There is a need for more diversity and inclusion in the physician-scientist workforce. Here is a paper that I co-wrote calling for a more broad discussion of diversity in the workforce that goes beyond gender and ethnicity: Diversity and the Next Generation Physician-Scientist.
But really, why MD/PhD?
Since I’ve just told you that physician-scientists do not need both a MD and PhD, let’s get back to the question at hand – “Why MD/PhD?” To fully answer this question, there’s a couple other FAQs to answer:
If you want to do research, why do the MD? You can most certainly do research without the MD. You can even do research that is quite clinically oriented and you can collaborate with MDs to get patient samples. So why the MD? From how I see it, the MD lets you take your research one step further and get direct input from the clinic. Maybe you’re trained as a pathologist and built a skillset reading histology during your clinical training so that you don’t have to collaborate with a pathologist for your research. Or maybe you’re practicing as a pathologist and you find something novel in the patient slides you’re looking at that you can investigate further in your lab. Maybe you shift your research focus from how to kill cancer cells to studying how cancer/cancer treatment causes nausea or other side effects because your patients frequently cite that as a major influence on their daily quality of life. Or, at a more fundamental level, you simply want to care for patients as part of your career because it brings fulfillment and meaning to your life. 🙌 These are just some examples how training as a physician can complement a research career.
If you don’t need a PhD to be a physician-scientist, why do the PhD? A majority of physician-scientists do not have a PhD. Unfortunately, this is subset of physician-scientists that is facing the largest decline. Training in a PhD program provides rigorous and structured research training that is not included in the basic medicine curriculum. Typically, this is the only time of one’s career development that is solely dedicated to research. In any other case, there will be clinical and/or teaching duties that distract from the research at hand. Many fellowship and some residency programs encourage research, and by having a PhD in advance, you are more likely to hit the ground running. There is a large learning curve that often gets overlooked regarding topics such as experimental design, statistics, etc. – aka the responsible conduct of research – that are barely discussed in med school. Doing a PhD gives you time to develop your critical thinking skills and understanding of these areas.
With some of my MD/PhD classmates in 2015 (📷: UIUC Medical Scholars Program)
So why did I decide to do MD/PhD?
I had always thought I had to choose between a career in research and a career in medicine – I initially chose the former. I felt that the ultimate contribution I would like to make in the world was the creation of new knowledge, preferably knowledge that would have a somewhat direct link to improving human health. Then I found out about MD/PhD programs and the opportunity to combine research and medical careers, which was exactly what I was looking for, largely for the reasons described above.
While my research and clinical interests have evolved, my ultimate approach to my career remains quite similar. I wrote in my MD/PhD personal statement that I wanted to study cancer. My course led me to liver cancer then to liver disease and metabolism more broadly. Writing this as I begin my 8th year as a MD/PhD student and 3rd year of medical school, I know that I want to both practice medicine and do research, but I still do not know exactly how I want my career to look. Will I do more basic research like my PhD? Will I do more clinical research? Will I be more involved in advocacy and healthcare leadership? Only time will tell. Nonetheless, I am confident that the MD/PhD path was right for me and will prepare me for whichever direction my career takes me.
Featured photo: Physician-scientist and Nobel Laureate Eric Kandel (center) with some cool physician-scientist trainees (📷: American Physician Scientists Association)
The purpose of this blog is to share personal accounts of MD/PhD training, and I’m excited to expand the perspectives presented here with guests posts. This post is by Alex Yang, who also contributed the blog’s first guest post.
Keeping it Real: How to Excel in Graduate School
Alex Yang, PhD
As I am writing this piece, I have just finished my PhD years, and I am awaiting to start clerkships in medical school as soon as I’m able. Although challenging, my PhD years have been extremely rewarding. I was able to share my work in an international conference in Colorado, receive my own F30 NIH funding, publish a first-author manuscript in Nature Metabolism, and make lifelong friends. Some of you might be interested in graduate school, pursuing graduate school, or currently in graduate school right now. I want to personally share with you my top three tips for success for all of you.
1. Choosing a mentor
I think the number one decision that influences your success in graduate school is choosing the right mentor for you. While it is true that the right mentor is different for everyone, there are some general rules you should follow in my experience to choose the right one for you. Depending on the department, there are minimum number of rotations to do before you commit to a lab. I strongly suggest you take up all of the rotations even if you feel strongly about one lab. It will increase your experiences as a scientist, and even if you don’t end up joining the lab, it can open doors for future collaborations as well.
When the time comes to make a decision, there are a lot of factors that might end up crossing your mind: environment, personnel, funding, and the actual science. While different people might have differing opinions, I strongly suggest prioritizing the lab environment and funding of the lab over the actual science in the lab. A PhD is challenging enough as it is. Don’t make it even harder on yourself joining a lab struggling to fund itself even if the science interests you the most. You are not bound by the subject matter that you study during your PhD. Most people I know enter another subject matter as a post-doc. What is important is that you receive the best training under the best environment possible as a PhD student. So, if it comes down to it, choose the environment over the science. Who knows? You might fall in love with the science like I did over time. I was not initially interested in adipocyte biology. Over the years though, I cannot imagine researching anything else besides adipocytes.
2. Work on multiple projects at once
For MD-PhD students and even normal PhD students, time is of the essence. We all hear horror stories of 6-8 years PhDs. That’s not ideal for any graduate student. While some circumstances are unavoidable, there are things directly under your control. We all know the failure rate of science is extremely high. Probably 95-99 % of science is failure. What we can do to hedge ourselves against failure is to work on multiple projects at once. Even if one fails, you have others going at the same time. This might be extremely hard to do and to balance your time, but it’ll be worth it when the failures start to mount.
For me personally, I was able to finish my PhD in 3.5 years. Even for a MD-PhD student, that’s relatively quick. I was extremely lucky to do so of course. However, luck favors the prepared. In the beginning, I worked on 3 different projects simultaneously. One project completely failed, another project was slowed by mass spectrometry difficulties, and my third project evolved into my thesis. As a result of diversifying my projects and not sticking to one project, I was able to find a project that successfully worked and was able to graduate quickly.
3. Be aware of your mental health
Science is hard. Failure is not easy to accept, yet we fail everyday as scientists. Compound the failure you experience in lab with the failure you might experience in your personal life and that can result in mental hardships. Graduate students are 3-6x more likely to experience depression and anxiety compared the general population. It’s time to address the problem and end the stigma of mental health problems. Mental health is your health. If you are feeling burned out, tell your mentor and seek professional health as hard as it might be.
For me personally, despite my successes in graduate school, I experienced symptoms of depression and anxiety during the last 6 months of my graduate school as I worked on my thesis. The stress of writing a review paper, finishing my experiments, writing my thesis, and preparing to defend compounded with my own personal problems. I started to feel burned out and had to seek professional help. Today, I am glad to say I’ve recovered and look forward to my future. I am mentally healthy now, and I owe that to the professionals that helped me through it. If you are struggling, don’t hesitate to seek out help.
These are my top tips for you to succeed in graduate school. Every journey is different, but if you take these tips at heart, I think it will truly make your experience in graduate school better. If you want more advice, Hanna and I are more than welcome to answer any questions and give you advice. We are both active on Twitter she is @MDPhDtoBe and mine is @MDPhDinProgress. Since we are both interested in hepatology, class of 2022, and have such similar account names, I consider her my Twitter twin. It has been an honor to contribute to her blog not once but now twice. Don’t be afraid to reach out to us!
About Alex
I’m a 7th year MD/PhD student at Wayne State University studying genetic mechanisms of fatty liver disease. In my spare time I like to cook, exercise, play video games, and write. Check me out on twitter @MDPhDinProgress.
Thank you, thank you, thank youuuuu to all of the absolutely amazing people who helped me reach this huge goal, including but not limited to my PhD advisor, my labmates, my family, my partner, my friends, and my cats. 😸
Hanna Erickson, MD, PHD 