Are surgery and MD/PhD incompatible?

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.

xnfs93hy

Full Member
10+ Year Member
15+ Year Member
Joined
Jun 24, 2008
Messages
2,243
Reaction score
85
I'm interested in pursuing both. I do not know which field of surgery I want to pursue at this time, and probably won't know until I take the USMLE Step 1 and receive my scores. My core question is whether obtaining an MD and a PhD and going for a surgical residency is really compatible. If some residents or attendings can chime in on this, I'd really appreciate it. Thanks.

Members don't see this ad.
 
It's good that you are waiting until you take Step 1 to decide which subfield of surgery you are interested in. Actually, I'd suggest that you wait until you complete third year of medical school, which is probably 7-10 years out from where you are now, to really decide which residency to choose.

MD/PhD's pursue surgery, although it is uncommon, unfavored, and makes a majority research career even more difficult.
 
  • Like
Reactions: 1 user
Members don't see this ad :)
Is it possible? Yes. Just not very probable if you plan to continue doing basic research. And if you're looking to do more clinical research (such as outcomes, which is common in surgery), you're probably better off getting a clinical research MS instead of a PhD.
 
  • Like
Reactions: 1 user
Most academic surgery residencies value research; many require or highly encourage protected research time during residency. If you think you're going to be doing experiments in the lab and doing liver transplants on the weekend as an attending, think again. But some of our best attendings are MD/PhDs who have contributed significantly to their fields and manage their own labs.
 
  • Like
Reactions: 1 user
Most academic surgery residencies value research; many require or highly encourage protected research time during residency. If you think you're going to be doing experiments in the lab and doing liver transplants on the weekend as an attending, think again. But some of our best attendings are MD/PhDs who have contributed significantly to their fields and manage their own labs.

This is along the lines of what I was thinking. I'd like to learn about my patients and be able to take what I learned from my clinical practice back to my laboratory and research it.
 
I am puzzled why/how surgery can value basic science research so much. From my perspective, the unique contribution a surgeon would make would be extremely translational (e.g. a new biomaterial for CABG or valve replacement, biological matrices for wound healing, etc.). Anyone - PhD only, non-proceduralist (e.g. internist), OR surgeon can tackle the scientific underpinnings of the medical management of surgical disease. So why are the surgeons wasting time in a niche potentially occupied by others (do we really need a surgeon doing research on finding alternatives to tacrolimus or cyclosporine in rat models of transplantation?) when they could focus on translational research that only they can test in the OR?
 
It comes down to math, IMHO. Surgeon salaries are pretty high. Any protected time you will have must at some point be paid for by your funding. It is highly unlikely you will ever get enough funding to pay for a significant percentage of your time if you expect to get paid like your peers.

This is beyond the fact that your department pays you to be in the OR to raise revenues for the department, not tinker in lab. They will hire PhDs to run labs for the surgery department to do basic science. Of course, clinical research is probably expected at all top tier academic surgery programs.

That being said, there are some surgery/basic scientists out there- but they are quite rare. My (speculative) guess is that 95% of MD/PhDs who go into surgery specialties goo 100% clinical, either because of internal or extrinsic forces.
 
I might regret this, but I'm gonna chime in to add my pre-intern perspective. I got a lot of push-back being MSTP applying going into gen surg. But I liked internal med and I loved being in the OR, and clinically, this was the best compromise. I was made to understand that when I finish, I might not get protected research time. But I'd rather come up with novel ways to get my lab going than do something that I hate clinically-- especially now when there are no 80/20 TT jobs available anymore.

A lot of premeds believe as jefgreen does, that what surgeons learn in their clinical practice can be taken back and studied in the lab and then later translated. It sounds a bit naive, but I also believe it's true. I've often used the example of Judah Folkman to explain this-- as a surgeon, he noticed during his operations that tumors were highly vascularized. He then went on to propose that angiogenesis was a critical phenomenon in the progression of cancer and the rest is history.

I believe that there is a growing appreciation among surgeons for surgeon-scientists. There are a number of them I've met on the interview trail who have multiple RO1s (still rare compared to IM, Path, Neuro etc for example). It's not reflected in preferential recruitment of MD-PhDs into all surgical subspecialties yet, but it might in the future. Who knows? I thought there was just a shortage of MD-PhD applicants, and it's totally understandable. The lifestyle and length of time it takes to train seem to be a major deterrents. After all, why spend 5-9 years in clinical training when you can get back to the lab after only 3-4? And as gbwillner pointed out, many never make it back to doing research.

As for the research that surgeons do, let's narrow it down to transplantation. Yes, it seems silly to be dicking around with tacrolimus vs cyclosporine in rats when there are plenty of PhD only basic scientists who can do that. But I haven't met any transplantation surgeon-scientists who do just that kind of research. The ones I talked to are trying to solve uniquely surgical problems like optimizing the condition of the organ prior to transplantation-- whether it's to prevent tissue damage during cold ischemia or avoiding cold ischemia altogether, or expanding the selection of organs that can be transplanted etc. Then there's the pipe dream of tissue engineering. None of these can be safely translated (and performed on humans) at this point and a lot of these studies are still done on animal models. I'd argue that the best scientist to do these studies is a surgeon.
 
  • Like
Reactions: 2 users
It comes down to math, IMHO. Surgeon salaries are pretty high. Any protected time you will have must at some point be paid for by your funding. It is highly unlikely you will ever get enough funding to pay for a significant percentage of your time if you expect to get paid like your peers.

This is beyond the fact that your department pays you to be in the OR to raise revenues for the department, not tinker in lab. They will hire PhDs to run labs for the surgery department to do basic science. Of course, clinical research is probably expected at all top tier academic surgery programs.

This is the simple mathematics of it. If you want a salary of $250k/year and you want to be in the lab 80% of the time, you're expected to bring in 80% of $250k = $200k in salary support from grants. The more serious departments might support someone's salary for about three years to bring in that level of funding. That's not enough time, but it's out there. There are some nuances to that, but that's how the numbers roughly breakdown. Meanwhile, for $50k/year, a department can buy a post-doc and for $80k/year they can buy an assistant professor who will be in the lab 100% of the time. So that's 2-3 assistant professor PhDs vs. the department supporting a surgeon's academic salary to go do serious research.

If you can bring in a million a year in grants, of which $200k+ pays your salary, great, you can write your own ticket to most institutions. But in the current funding envrionment, that's very uncommon among anyone who graduated a MD/PhD program in the past 15 years. You could still insist on doing 80% research without that level of funding. There are a few places that will let you--for a salary more on the order of $100k/year (i.e. like a PhD only assistant professor). There are various post-doc/fellowship/instructor positions out there. But the question always is, who is willing to take on the time and risk for the uncertain future of you needing to bring in that $1M/year down the road to be more than an instructor and bring in a sustained salary comparable to your clinical peers. That level of funding is very uncommon in the current funding environment, and will require significant risk and time investment to get the protected time necessary.

The mathematics is significantly altered for a pediatrics faculty who earns on the order of 60-80k/year and cannot significantly move above that salary. Still, there are plenty of other issues there like field saturation, the ever present lack of funding to stay within research, and the inability to earn a high income after all that training if they do decide not to continuing pursuing research.

That being said, there are some surgery/basic scientists out there- but they are quite rare. My (speculative) guess is that 95% of MD/PhDs who go into surgery specialties goo 100% clinical, either because of internal or extrinsic forces.

The Brass 2010 data shows 27% of MD/PhD surgeons in private practice. My guess is that on the order of 70% are probably in academic practice. I disagree with the assertion that they are "100%" clinical. They are probably 80% clinical, in academic teaching positions requiring clinical research, with minimal to no funding doing work that did not require a PhD. However, that data is not reported. This is most of the research that goes on within most specialties, including surgery, as a resident and beyond. This is one of those things that the starry eyed med students and pre-meds don't get. As a resident, research allows you a few things. It gives you a break from the hellish intensity that is surgery residency. It gives the program a pool of residents to grab from if a resident has to go out for some reason like illness or pregnancy. It gives the resident time to study for exams and other things. The types of studies done during that "research" time is typically not PhD level work. However, if you worked hard and had the right mentors it's possible to pull a K08 out of it and go on to try to become a physician-scientist. It's just exceedingly rare, even among the MD/PhDs who are designed for it. If there was some degree of certainty that the research career would be worthwhile (i.e. more funding and a high chance at funding), more institutions would push their MD/PhD residents this way and give them good faculty jobs designed for research. But it just isn't there.

He then went on to propose that angiogenesis was a critical phenomenon in the progression of cancer and the rest is history.

When I was an undergrad, some PIs were telling me that bevacizumab would be the "cure for cancer". Fifteen years later and it has demonstrated only a modest improvement in survival in a few tumor types. Though at on the order of $100,000/year, it has made a lot of people a lot of money. This is where the funding for my med onc peers is coming from these days--trials of $120k/year+ agents that extend progression free survival or overall survival by a month or two. It's bad for society to only fund studies that are essentially all investments in future pharma company profits and not funded for the overall good of society, but it's one of the few pathways these days to bring in funding to actually do serious clinical trial work.
 
  • Like
Reactions: 1 user
This is the simple mathematics of it. If you want a salary of $250k/year and you want to be in the lab 80% of the time, you're expected to bring in 80% of $250k = $200k in salary support from grants. The more serious departments might support someone's salary for about three years to bring in that level of funding. That's not enough time, but it's out there. There are some nuances to that, but that's how the numbers roughly breakdown. Meanwhile, for $50k/year, a department can buy a post-doc and for $80k/year they can buy an assistant professor who will be in the lab 100% of the time. So that's 2-3 assistant professor PhDs vs. the department supporting a surgeon's academic salary to go do serious research.

If you can bring in a million a year in grants, of which $200k+ pays your salary, great, you can write your own ticket to most institutions. But in the current funding envrionment, that's very uncommon among anyone who graduated a MD/PhD program in the past 15 years. You could still insist on doing 80% research without that level of funding. There are a few places that will let you--for a salary more on the order of $100k/year (i.e. like a PhD only assistant professor). There are various post-doc/fellowship/instructor positions out there. But the question always is, who is willing to take on the time and risk for the uncertain future of you needing to bring in that $1M/year down the road to be more than an instructor and bring in a sustained salary comparable to your clinical peers. That level of funding is very uncommon in the current funding environment, and will require significant risk and time investment to get the protected time necessary.

The Brass 2010 data shows 27% of MD/PhD surgeons in private practice. My guess is that on the order of 70% are probably in academic practice. I disagree with the assertion that they are "100%" clinical. They are probably 80% clinical, in academic teaching positions requiring clinical research, with minimal to no funding doing work that did not require a PhD. However, that data is not reported. This is most of the research that goes on within most specialties, including surgery, as a resident and beyond. This is one of those things that the starry eyed med students and pre-meds don't get. As a resident, research allows you a few things. It gives you a break from the hellish intensity that is surgery residency. It gives the program a pool of residents to grab from if a resident has to go out for some reason like illness or pregnancy. It gives the resident time to study for exams and other things. The types of studies done during that "research" time is typically not PhD level work. However, if you worked hard and had the right mentors it's possible to pull a K08 out of it and go on to try to become a physician-scientist. It's just exceedingly rare, even among the MD/PhDs who are designed for it. If there was some degree of certainty that the research career would be worthwhile (i.e. more funding and a high chance at funding), more institutions would push their MD/PhD residents this way and give them good faculty jobs designed for research. But it just isn't there.

As always, your posts are well-reasoned and cogent Neuronix. I've been reading your posts and blog for some time now and I factored in the valuable insight you shared into my decision to pursue surgery. And it's not as ironic as it sounds. When I first started out, I was a starry-eyed med student who wanted to follow in the footsteps of my PI, likely the last batch of MSTs who got the coveted 80/20 TT job. After shadowing him a few times and listening to him occasionally complain about his few weeks of consult duties, I realized I also did not like the field as a clinical job. By the time I came back from the PhD, I was in a panic. I did not love any non-surgical specialty that had an obvious link to the kind of research I had been doing-- and it ran the gamut from IM, neurology, path, even radiology and derm. I wrote off surgery initially because I thought they're just a bunch of highly trained clinical technicians who do nothing but outcomes research. I was very very wrong. There are a great number of interesting basic to translational science projects in various surgical subspecialties. A number of MSTs I know go into something like plastics (eg nerve regeneration), transplantation (eg reperfusion injuries or immunomodulation to combat rejection), acute & critical care (eg sepsis), neurosurgery (eg tissue engineering to replace dura), optho (stem cell or gene therapy cures for blindness) or even ortho (eg cartilage renewal/repair). Sure, they're not so deep down basic as yeast cell cycle/genetics etc, but who's to say they're not worth doing? And I agree, most surgical residents likely do not use the "research years" to generate fantastic basic science post-doc work. But I've seen it done by some very motivated MD-PhD's. In short, surgery and an MD-PhD aren't necessarily incompatible.

I have not encountered any surgeon who does 80/20. In fact, a lot seem to manage it with minimal or without any protected research time, whatsoever. I've asked around and they do have neat ways of getting things done (which I won't get into). Point is, if you wanna do basic science research and you're an MD-PhD going into surgery, you can expect a great deal of hardship. Or be prepared for the outcomes others have already mentioned: give up basic science, give up your personal life or make far less money than your peers. I think we can all agree on that.

Neuronix, you made me realize that there are no 80/20 jobs available. And that made me factor in how happy I'd be doing the clinical portion of my work more heavily. I can't get away with the same decision that my PI did. He could tolerate a clinical field he did not love because he only has to do it 20% of the time. I don't have the same luxury. And since there are no 80/20 jobs available in surgery, or anywhere, it made choosing surgery easier.

When I was an undergrad, some PIs were telling me that bevacizumab would be the "cure for cancer". Fifteen years later and it has demonstrated only a modest improvement in survival in a few tumor types. Though at on the order of $100,000/year, it has made a lot of people a lot of money. This is where the funding for my med onc peers is coming from these days--trials of $120k/year+ agents that extend progression free survival or overall survival by a month or two. It's bad for society to only fund studies that are essentially all investments in future pharma company profits and not funded for the overall good of society, but it's one of the few pathways these days to bring in funding to actually do serious clinical trial work.

That's an interesting tangent. To be fair, you can hardly blame Folkman for bevacizumab. That was Roche/Genentech who developed and marketed it. I might have glossed over the story of cancer angiogenesis and assumed everyone knew everything about it. But I never meant to imply it was the "cure for cancer". I like to think of anti-angiogenesis as just another weapon-generating strategy we developed in the desperate arms race against cancer. It's a nice option to have and it was worth trying. In defense of one of my scientific idols, there are a great number of treatment ideas that came out of Folkman's lab-- including the repurposing of thalidomide (yeah, horrible old cheap drug for morning sickness that caused phocomelia in babies) for multiple myeloma.

But yeah, pharma profiteering is icky and it's sad that scientists are so strapped for funding, it's the one of the few ways to get any research going.
 
I have not encountered any surgeon who does 80/20. In fact, a lot seem to manage it with minimal or without any protected research time, whatsoever.

Well thank you for the compliments. This is what I was alluding to before. Most of academics involves mostly clinical positions. That is true in all specialties. These positions do not require, and often don't utilize, a PhD. So when you talk to MD/PhD zealots, they will downplay these positions but still say it's better than private practice.

Neuronix, you made me realize that there are no 80/20 jobs available.

I never said that. In fact my last post states the opposite.

You could still insist on doing 80% research without that level of funding. There are a few places that will let you

Nevertheless, I agree that you should practice in the clinical specialty you enjoy. I dont think you should pick just based on perceived research friendliness. You need to enjoy the clinical aspect no matter what you do if you stay a physician. Residency would be awful without that ;).

And since there are no 80/20 jobs available in surgery, or anywhere, it made choosing surgery easier.

Again, I have never written that. What we're often debating here is whether it's less possible to do research in surgery than other specialties. Many in the MD/PhD community think IM, peds, path, neuro, psych and maybe a few others are the only viable ways to launch physician-scientist careers. I would argue that thinking is untrue because it is incredibly hard to bring in significant funding no matter what you do nowadays. In any case, there are no data to show which MSTPs are more successful based on specialty choice. I.e. Nobody has shown for MD/PhDs who does the most basic research or gets the most funding broken down by specialty.
 
  • Like
Reactions: 4 users
Top