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how to fix MSTP

Discussion in 'Physician Scientists' started by gbwillner, Mar 29, 2012.

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  1. gbwillner

    gbwillner Pastafarian Moderator

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    Background: I am 12 years out from matriculating in a top-10 MSTP. I have completed a research-track residency (PSTP). I have loved my experience, yet over time I have come to realize the MSTP system is fudamentally flawed.

    Every year there are more and more funded spots. Programs take pride in the number of positions they offer. I noticed in my time that the attrition rate during training was fairly high (definitely higher than the stated averages). I also noted that upon graduation, many of my colleagues, who after years of toiling away in lab, decided to pursue clinical work only, and used their status in the MSTP to improve their standing in the match process. They had given up the notion of research all together. For those that are left in the science-bent track, residency comes, and you are swamped with clinical work. Some are able to continue research during this time (I was) but most did not. I'm sure none of this comes as a shock to any of you. Those who are still interested in research can pursue it during fellowship, or even a post-doc.

    The real eye-opener comes after residency, when real-life intervenes. By this time you are likely to have a family and other commitments. You finish your fellowship and are given an option (assuming you still want to do research)- do a 3-year post-doc with little compensation and extend your miserable semi-professional state, just to have a shot at a decent start-up package with nothing guaranteed; or go into practice making more money in 1 year than in all your residency years combined. Most prefer the second option.

    In real life no one will hire you to a significant research position because of "potential." If you want protected research time, you need to provide your own funding. Anything less than a K08 and you are not likely to get any protected research time, meaning you need a post-doc to have data to apply for grants. And those are currently dwindling. Even with a K08 you are a risk to some degree- you will be given protected time but likely few start-up funds. You really need an R01 to punch your own ticket, which are nearly impossible to get now. Meanwhile your colleagues are vacationing in Europe or sailing their yachts. Most mentors will tell you that you can't be a successful scientist devoting less than 80% of your time to it. But you can't really get that job unless you've already been successful and got grants. It's kind of a catch-22. You are basically forced to do a post-doc if you want to get a GOOD job and have a chance, meaning you'll just be older and more cynical when you finally get there. This is why the average age for the first R01 is more than 40, almost 20 years after matriculating in medical school! By the time you enter the post-Doc, you probably do have a good chance at a good job and start-up. It's because you're in the small percentage of MSTP'ers who actually made it this far, and are a prized commodity- you will provide prestige and research funds to a department at less pay with more committments.

    I'm not complaining. I have been very successful in my career thus far and my future looks bright. I just don't think any of the younger folk here know the sacrifices they are going to have to make to have a successful career as a physician-scientist. Once they see it, most will flee. I had a large MSTP class in a large MSTP program. I honestly can't think of more than a handful of people who are still going strong on research and are writing substantial grants. Most are happy to take clinical jobs and tinker with science or forget it all together. This all seems so inefficient to me.

    I guess I was wondering what other senior MSTPs/residents/fellows/attendings thought about all this, and what could be done to make it better.
  2. Gfunk6

    Gfunk6 Troublemaker Moderator Lifetime Donor

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    Background: I am 14 years out from matriculation to an MSTP and have completed residency on a research track.

    You raise some excellent points, but I do not think there are easy or universal solutions to the issues you raised. Most of the problems are extrinsic to the MSTP itself, namely:
    1. Changing life circumstances (marriage, kids, re-location)
    2. The funding environment is horrible; gutonc has some excellent posts on this topic, search SDN to learn more
    3. Physician-scientists are undercompensated, in some cases dramatically so compared to their clinical counterparts

    Within the confines of the MSTP, here are some more issues which stray graduates away from research that programs may be able to influence:
    1. Residency matches to fields where Physician Scientists are rare and clinical compensation is high (e.g. Derm, Rads, Rad Onc, Surgical Sub-specialities)
    2. Burn-out from research
    3. Lack of formal training in grantsmanship

    Some quick ideas I'd throw out are an increased emphasis on writing grants and coming up with fundable projects rather than the nitty gritty of running experiments, better mentorship of MSTP students by existing physician-scientists, and "nudging" towards more traditional residencies which are friendly to physician scientists (IM, Peds, Path).

    Of course, the ultimate measure they could implement is institute payback for those who bail out of research. But this is difficult to enforce and could dissuade otherwise good candidates.
  3. gbwillner

    gbwillner Pastafarian Moderator

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    I agree with the first paragraph. I don't think it's really possible to have poor med students repay such a huge loan. Plus, it's not usually the institution's money, and it only accounts for dropouts during the PhD years.

    The reason I really started thinking about this was kinda weird- I saw the stories running about the whistle-blower from Goldman-Sachs. The guy was sick of the toxic environment he saw, and how they were cheating their clients. After 12 years working for the company, he retired (making 500K/yr) and threw them under the bus. Then I saw that he was YOUNGER than me, and I still haven't got a real job.

    LOL.
  4. solitude

    solitude Senior Member

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    Great post and discussion. As a somewhat senior MSTP (wrapping up PhD soon), I have a somewhat different take. I believe that the entire system of science is broken. MSTP is very inefficient but it's just a small component of the overall inefficiencies present in the scientific enterprise.

    In my opinion, the incentives are all wrong. There is a moral hazard in that scientists are rewarded (in grants, jobs, salary, prestige, fame, etc.) for their papers rather than the quality of their papers. Yes, some papers are obviously bad, but many are ostensibly quite nice until you very closely interrogate the authors and discover all sorts of holes, many of which are ethically dubious. Even in the most well-intentioned scientists, the bias is ever-present and insuperable. As a consequence, it's my estimation that many if not most papers are, when you get down to it, essentially worthless.

    We have to realign the incentives. Hundreds of years ago, scientists were motivated largely by curiosity and altruism. Monetary incentives were absent as most/all were gentleman-scientists. The focus was on getting the right answer. Think Darwin locking his manuscript in the drawer for 15 years.

    It seems to me that the incentives in science are as perverse as fee-for-service in medicine. If you pay an MD to do things rather than maximize health of the patient, he will do the most number of things. But if you pay him to maximize health of the patient, he will do things most efficiently.

    How to realign the incentives for science? I don't know. If I were omnipotent, the first thing I would do is axe about 75% of scientists, to cut the fat. This could easily be accomplished by mandatory retirement age (a la Britain), capping number of NIH grants per investigator, precluding PIs from paying postdocs off of NIH grants, and slashing training grants.

    Then, cut the overhead costs. How many quarterly e-mails do you get about nominations for the Chancellor's Award for ____? You realize administrators are just sitting around making up these committees, spearheading nominations, ruling on this stuff, and hobnobbing at receptions? They all make way more than hardworking postdocs I can promise you that. IUCAC is largely a waste. IRBs are of course, needlessly complex. NIH grants have so much needless paperwork I want to pull a Santorum and barf in my mouth.

    Once I've cut the number of scientists and the overhead, there are a lot fewer nincompoops and a lot more money to go around. Now, this relieves a lot of pressure and lifestyle improves, but I still haven't realigned incentives to maximize quality of the science. To do this, I promote large-scale collaboration. I'm talking everybody who's working in an area (say, chromatin remodeling) shares all of their data, both positive and negative data, on a daily or weekly basis. That removes a lot of the redundancy and inefficiency and enables fields to move faster. Of course this makes it more difficult to assess authorship contributions. That's fine because I abolish listed authorship of papers. Things become more like the Physics collaborations, where there is a Consortium of authors who publish hundreds of papers together. Except I would get rid of the Consortium and the enumeration of those authors altogether, and just have it authored by "Science Community, 2012". Of course there would have to be an executive committee and a tiered system of some sort to delegate authority for writing the manuscript, etc. etc. But removing authorship removes the perverse incentives for people to publish papers rather than maximize the quality of the science.

    So what happens to the prestigious postdoc fellowships, the endowed professorships and the Nobels? Who cares? They fade away. Those do incentivize scientists, but for the wrong reasons and they lead to bad science.

    Obviously, this is a pipe dream. But if you could fix science, you solve the financial and lifestyle impediments to keeping MSTPs in the fold.
    nutate likes this.
  5. echod

    echod Junior Member

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    Isn't it better to enter a specialty with good compensation so that physican-scientists can generate enough salary to support ourselves with 1-2 days of work? This way we would have the rest of the week to do research even if there were no external salary supplementation. I'd imagine that it'd be harder in lower paying specialties because more time needs to be spent in the clinics to support ourselves if there weren't other sources of salary support.
  6. sluox

    sluox Copier

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    Define "support ourselves". In psychiatry, you can make 100k with 10 hours a week in private practice, but this is not necessarily enough for the kind of life style you want.
  7. sluox

    sluox Copier

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    I agree with the above that there's probably something not quite right with the way biomedical research is structured as it is right now, and we should make some effort in reforming it somehow. The pipeline is a bit "leaky", and maybe we can do something about that.

    Nevertheless, there is an underlying philosophical problem that is the undercurrent, even though you explicitly disavow it. No matter what you do with the system it's unlikely that you'll EVER catch up to an investment banker in terms of renumeration. But I don't see how this is a reason for kvetching. This is a choice that you've made, and I'm assuming that back in college when you applied you know full well that you won't make as much money as your compatriots who went into banking. So I'm not really sure exactly what you are looking for in a "real job"?

    Is it $$? But a T32/K08 fellow likely gets paid more than an associate professor in the humanities even without counting additional clinical revenue. Or is it that you are actually having financial pressure from daily expenses? Or your significant other is complaining that you aren't making enough?

    Is it prestige? Does anybody outside of science/medicine actually cares that you are a fellow and not an attending?

    Is it independence? But being a postdoc likely allows you to do whatever science you want to do anyway.

    Basically you are saying, I wish I was in banking, and that guy didn't seem like he was as smart as I was, and what makes him deserve the millions that he made. I wish I was making as much money as he is, except I want to do what I'm doing now. Yes, we all wish we won the lottery.

    What I'm saying is, as much as you or anyone else thinks your degrees and trainings are worth, at the end of the day it's useful to be a little less narcissistic. If you aren't happy with what you are making, go into something else. If you are stuck and can't figure things out, get therapy. You ask what can be done to make it better--sure there are things that you can do to the system, but there are also things that you can do to yourself: change your perspective.
    Last edited: Mar 29, 2012
  8. gbwillner

    gbwillner Pastafarian Moderator

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    Actually, no. The "higher" paying specialties generate a lot of revenue by doing clinical work, not dinking around in a lab. Although there are exceptions, from what I've seen it's more difficult to do research in these specialties. You get paid (and the department gets paid) for you to be in the OR or whatever... so you never get enough time to be successful.
  9. gbwillner

    gbwillner Pastafarian Moderator

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    No, I don't think that's at all what I'm saying. I DON'T wish to be an investment banker. I'm actually HAPPY where I am. Do I wish I made more money? Who doesn't? It's hard supporting a family on a fellow's salary. It's silly to compare our salaries to what other professions make. It would be insanely stupid to change careers, or compare myself to a humanities professor. My point with the Goldman Sachs guy is he is retiring and I'm still in training, not yet to the point of earning wages for any services I provide. It made me feel old, not necessarily jealous of his money bags.
    The money issue is not with other careers- it is with your peers. The temptations for rewards (cashing in) are too great for most to stay in research. Loving research means hardship most seem to want to live without, despite wanting to continue research careers. Most of my friends who stopped their research careers after residency did not do it because they didn't like it (as opposed to those who drop out during their PhDs), they did it because life was too difficult to fight for table scaps while they had a pot of gold they could basically reach out and take (i.e., private practice).
  10. Fencer

    Fencer MD/PhD Director

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    There are a lot of important points in this discussion. Some of you know pieces of my story too. Almost 25 years ago (in July) I began my graduate research and now direct a MD/PhD program. As I read about the career dilemmas of the OP, I remember experiencing similar financial pressures, expectations, etc. The real question is whether you would be happier doing something else. In my personal world, we (as a family unit) were able to pursue an academic career but I made compromises such as declining a faculty position at a top 10 institution. That decision resulted in some challenges but other opportunities. I also have seen ups and downs of funding rates but also the progressive increased accountability of faculty time in departments. Funding might improve in the future (VA funding rates are still in the 20%+), but the increased accountability of faculty time is not going to reverse. We will adapt, and the incentives for clinician scientist careers will remodel. The pipeline is leaky but not entirely broken. I agree with the idea that MD/PhDs might actively participate in Team Science. Read "The Vanishing Physician Scientist".

    A couple of clarifications. The number of institutions with MSTP awards has grown but the actual number of NIH funded MSTP positions has not increased since 1992. However, Institutions (MSTP and non-MSTP) have increased the overall number of funded MD/PhD slots using endowments and other sources. Keep in mind that the MD/PhD class entering in 2011 remains at 3.3% of the MD entering class (633 of 19,230 AAMC FACTS).
  11. SBR249

    SBR249

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    Just a clarification that I believe the NIH has added a few more MSTP slots but only to facilitate the establishment of the OxCam program/NIH GPP so that these students do not take up existing MSTP slots at participating institutions.

    Also, are you saying that for newly funded MSTPs like Maryland and OSU, their slots were reallocated from existing programs?
  12. sluox

    sluox Copier

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    I don't understand why it would be "insanely stupid" to compare yourself to a humanities professor. You are trying to be a professor, aren't you?

    I don't see how other academics (and more explicitly, other basic scientists) at your university aren't your "peers". Or for that matter, professionals working for other non-profit organizations. How much money do you think an average string theorist makes? I'm sure he's way smarter than you. I don't see Einstein complaining I could make a lot of money running a hedge fund, because oh, all my friends are going to wall street. Your entire argument makes NO sense. And it's not like a career doing basic science research is any more similar to a career in private practice than a career doing investment banking. Really.

    You made a DECISION. It's your life. If you want to make more money, get a different job. You KNOW that you will NEVER make as much as a pure private practice physician, no matter how "the system" is twisted and haggled. You are "happy" with your job, except you want to get paid a lot more. Everything you've said thus far that showed nothing but envy--despite your constant and deliberate disavowing thereof. Your complaints about the system are really just an outlet for your envy. I would recommend actually making some friends outside of medicine.
    Last edited: Mar 29, 2012
  13. Fencer

    Fencer MD/PhD Director

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    OxCam slots are technically not MSTP slots, but supplemental T32 slots to the main MSTP earned by each OxCam awardee (just as F30s) funding the last 2 years of the MD program.

    MSTP slots have not increased in number, but they have been re-distributed. This trend is likely to continue placing pressure in the very large MSTP programs, who fortunately tend to have large institutional endowments.

    Another trend of interest chiming in solitude's reconstruction post is that there are 60 CTSAs and 44 MSTPs. There are 40 institutions with MSTP and CTSA, 17 with MD/PhD program (non-MSTP) and CTSA, and only 1 CTSA without a MD/PhD program. The other 2 CTSA institutions are Rockefeller and Scripps, each of them affiliated with institutions having MSTP and CTSA. The only 4 MSTP with no CTSA are UVa, Baylor, MD and Stony Brook. Why this institutional relationship between MD/PhD program (MSTP or not) and CTSA is important? Precisely to bridge the gaps between mentoring clinician scientists at all stages of development... creating a culture of inquiry and research at all levels (bench, clinical, health care outcomes and community).
  14. SBR249

    SBR249

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    You can also do OxCam as a Track 1 student which lets candidates move through MSTP just like a regular student (and on the same schedule) and get funded for all 4 years of med school through the supplemental MSTP T32 slots.

    Nevertheless, I think many institutions refuse to participate in OxCam despite supplemental funding because they do not have the financial resources to support another slot for a student who won't be working in one of their labs.
  15. Fencer

    Fencer MD/PhD Director

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    Sluox, I disagree with your criticism. It takes a lot of guts to describe this issue, and furthermore, we all have had (or will experience) periods of doubts when second guessing our career choices. It's human. I have been offered at least twice and even three times my salary if I go out to a practice mill giving up research. I could not enjoy that and I have what I need...
  16. StIGMA

    StIGMA aspiring MD/PhD!

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    I disagree with singling out gbwillner for targeting physician-scientist renumeration. He has a valid perspective that a major aspect of physician-scientist egress is due to the steep monetary divide between purely clinical versus physician-scientist careers. Who cares if gbwillner is happy with his job as a scientist if it does not afford his family (or any other MD/PhD) the lifestyle that would make that family satisfied. It seems like to those with family (or aging/poor parents, chronic/expensive health concerns, disabled children, etc.), focusing solely on the individual is myopic. You can't deride him as envious without knowing his prevailing life pressures.

    Perhaps a substantial financial increase after residency and before assistant professor (the post-doc/ K08/etc level for physician-scientists) phase would encourage more of us to stay the path. Making 50k in my late 30's is not desirable and is not viable for me, personally. It would be great if clinical departments could 'share' revenue amonst all faculty so that research and clinical salaries were more on par.
  17. gbwillner

    gbwillner Pastafarian Moderator

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    I enjoy my profession and could not see myself doing anything else. I am simply stating why so few of us make it this far. I'm not at all sure why you see me as just envious of what others do or that I wish I had done something else with my life. Northing could be further from the truth. As I said, I've been very successful so far and am sharing my observations of what we go through in this process, which I beleive is flawed. I don't know why you have an issue with me considering my peers other clinicians or physician-scientists. I guess according to you, NEARLY EVERY MSTP'er is an idiot whiner who should have gone into investment banking since most will ineviatbly realize they don't make enough money and will give up basic science at some point, which by the way, was only PART of the problem (the others include the ridiculous amount of time it takes to finish training). Also, you probably don't hear Einstein complaning about making enough money because you don't know him and he's f*cking dead.

    The REALITY is that day care costs ~$15K/year per kid. The REALITY is that you're likely to be 35-40 before you're even in position to become assistant professor. While you can do research you are interested in as a fellow or post-doc, you're not really in control because it's not your lab. The REALITY is that, from start to finish, to become a physician scientist takes a LOT longer than people realize, and you will be in training from the MSTP, to residency, to fellowship, to post-doc before you get a real job (which is why I brought up the Goldman Sachs guy- he was retired in less time than I was in training). The REALITY is that getting a good fellowship or post-doc makes no guarantees about securing a real job doing what you want. So while your colleagues are secured in their employment out of residency, you have no idea where you will end up in 5 years. Will you be productive enough your institution will hire you? Will you get a grant and shop around for the best deal? Will you get dumped and scramble for a clinical spot somewhere, where your time in research serves as a liability since you have less experience than your peers? The POINT is that it is excessively difficult to stay the course and become a physician-scientist, and once out of residency, those who bail do so for very valid professional and financial reasons that could be avoided with a better system. But for some reason you just dismiss this all and would tell these folks to get in a time machine and un-do the last 15 years of their lives.

    I do have an idea about what I would do to make the system better, but I wanted to give everyone a chance to share their ideas or concerns before I said what it was, so this thread wouldn't turn into a criticism of one idea.
    Last edited: Mar 30, 2012
  18. justgo

    justgo

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    I'm almost loathe to respond to this, because I think there are a lot of problems with the MD/PhD route, because I will be starting a program next year (with 11 yrs experience in academic research though), and because I am sure my response will not be favorably viewed here.

    But, it seems that the issue with MD/PhD compensation here is one presented in terms of compensation needed to have a career and have a family. 50k per year is plenty enough to live extremely well anywhere in the US as a single person (maybe your won't have marble in your bathroom, but who needs that? Nice ceramic is just fine, especially considering the few hours you will spend in your house!). But yes, the costs of maintaining a career and having children is exorbitant.

    As a woman starting out, I have seen this, and as a consequence I have made a choice. Starting an MD/PhD program means for me that I will not have children, unless I happen to marry someone with vast disposable income and then I will likely be biologically incapable due to age. This is ok. I made this choice....and actually thought about the consequences of the program I joined before I joined it (and am still thinking about the monetary ramifications of Harvard vs. WashU vs. XXX program).

    I think the real issue is that we are accepting students when they have no clear view of what the career will be, and no understanding of the sacrifices necessary. People do MD/PhD almost BECAUSE they want to do research but don't want the hardships associated in the cultural vernacular with a PhD, starving scientist, track. This is false, but we don't tell them that until much later on (well, at least not outside of SDN).

    We as a society need to get away from this idea of super-parents, and that "you can have it all". You can't. Having certain things means sacrificing others. Also, though the path is long, entering students should have sufficient experience in the field to know the difficulties that arise at the end of the paved path, or they should not be allowed to enter. It does no good to have a bunch of children entering programs who will not end up in research.

    We have increased retirement age, but have yet to do anything about thinking to change the antiquated time scale to being a "professional". There is a lot more to learn than there was 100 years ago, it takes a long time to know it.

    This is not meant to be an attack on any posters or their life choices, and is only one perspective, but I honestly feel that the biggest problem is that we are accepting too many students not suited to the realities of their futures (and maybe too many students period). Instead of asking meaningless questions like "would you chose the MD or the PhD" (to which there is really only ONE response if you truly want to be a physician scientist), we should be asking truly deep and probing questions like "have you thought about how you plan to carry the financial burden of a salary that will not top 50k before you are forty? How will you do it?"

    I think the issue is that a lot of folks in the field presently did not think about these questions and don't have answers themselves...so we just proliferate a bad system. Really, MD/PhD is a 90%+ life commitment....I think we should tell students that, and expect them to know it.
  19. Gfunk6

    Gfunk6 Troublemaker Moderator Lifetime Donor

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    Nice discussion we have going.

    Most MD/PhD matriculants are in their early to mid-20s. It is very difficult to answer questions about theoretical events 10-15 years in the future. People change, situations change, attitudes change.

    When I started my MD/PhD program I was DIE HARD about pursuing a physician scientist career. This continued through all eight years of the program. I married my spouse ~ year six. When I was applying for residencies I was DIE HARD about pursuing a physician scientist career and tried my best to gravitate towards programs that would allow this. I matched to a top research program and even abbreviated my clinical training to get more lab time. During my PGY-4 my daughter was born.

    When it came time to apply for faculty positions I was DIE HARD about getting a physician scientist position. Sadly they were highly limited in the year that I applied, so I loosened my restrictions a bit to go for a more translational/clinical type of faculty position.

    In the end, I was forced to make a choice. I could move to the middle of nowhere, have a great career and probably would have been productive academically . . . but my family would have been miserable. Alternatively, I could compromise my research career, take a more clinically friendly job, and keep my family happy.

    This is a tough decision that only you can make. I agonized over this for a month, I was miserable. I talked to my Chair, my faculty, other residents, my family and eventually I chose the clinical job.

    Now I've never been happier and have never looked back.
    Chemistry Cat 3.0 likes this.
  20. Spacedman

    Spacedman amateur vibeologist

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    This is what has helped me stay in research. I'm 12 yrs out from matriculating in an MSTP, and I'm on the tail end of a research-track anesthesiology residency. It won't surprise most of you if I say I'm in the extreme minority of people pursuing a majority-science career in my field. I'm also realizing my ultimate success and my field's longevity depend on attracting and retaining MSTPs. oh, and i have full-on family which i'm currently supporting. A few observations:

    - most people with dual degrees whom I meet in the OR (surgical subspecialties & anesthesia) are done with research. as other have pointed out, this probably reflects a mix of research burnout, changing interests over a (long) training period, and financial pressures pushing people to primarily clinical careers.

    - my field has a dismal per capita NIH funding rate, which (duh) most likely stems from the very high differential pay for OR based time vs grant supported time.

    - the most important factors allowing me to continue research during residency and convincing me to accept a postdoc/fellowship post-residency are 1) a chair who strongly advocates for developing physician scientists and protecting us from excessive clinical obligations, and 2) $$$. I think it's worth noticing that the very thing that makes my clinical specialty less research-oriented (huge clinical revenue) has subsidized my ability to stay in research. Again, I think this is almost entirely due to my chair's vision for the department, and the larger institution's strong research focus.

    For the MSTPs that have made it into residency and are looking at another 5-7 years of dog$hit pay while finishing their training, I have to wonder if a salary bump would dampen attrition. I'm not talking about huge sums of money, maybe 125-150% of PGYx.

    I agree that a significant chunk of the issue (for me) comes down to money, but you sound like someone without kids or debt. $15K per year per kid is an underestimate in my town, and I'm accruing some pretty impressive debt during my spouse's training. Think about it for a second: either don't have kids til your 40 or agree with your spouse that only one of you gets to have an academic career. I feel like this is a pretty common situation for MSTPs who have already come a long way in training.
  21. gbwillner

    gbwillner Pastafarian Moderator

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    One other point I didn't address earlier...

    It's not all-or-nothing with research. While almost all MSTPers will eventually bail on running their own labs, lots will join a clinical academic departments with a little protected time. There they can dabble in small translational projects or be part of larger funded studies. I wouldn't consider that a total loss, but your real opportunities are pretty limited in those roles. Others will rarely go into industry, where you can continue research in a very proctored setting.

    I also wanted to give a few eamples of what happened to a couple of my closest friends who finished MSTP around the same time as me. Yes, these are anecdotal.

    Friend 1- dead set on continuing research with a PhD in genetics. Went into RadOnc at a top residency program with built-in research time. Found out well into the program that the type of research he was allowed to do had to be centered on radiation therapy, which he was not as interested in. Found out he would have little protected time in academic settings. Decided to go into private practice.

    Friend 2- dead set on doing a mostly research career. got into a PSTP program in IM, with a fellowship in oncology. Built-in research time was given, he was very productive. Got 3 grants from private institutions. Looked for academic jobs. Lack of K award meant no significant start-up package would be given (<200K). Options: 1- Post-doc (as instructor ~$80K). 2. Asst. Prof 80/20 clinical making ~$140K; could "buy" more protected time with research funding (this makes it impossible to be successful, IMHO). 3. Private practice ($400K). Guess which one he took?????

    Friend 3- Genetics PhD, went to a top pathology program and wanted to continue his research career. After residency got a competitive dermpath fellowship. Still wanted to do research. Joined an academic institution. Got a 50/50 protected time job, but no start-up (he did get space). Was told he could "buy" more protected time. He is currently struggling to get funding to support a technician.

    In my residency program, we usually get 3 MSTPers/year, all who claim to want to continue research. in the past 5 years, only 2 have gone on to do full-time research (or propose to do so). Most do a subspecialy fellowship and join an academic department in clinical track or go into private practice.
  22. sluox

    sluox Copier

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    While it might be hard to swallow that there is an element of "envy" in the entire discussion, I maintain my position that the question that "why so few of us make it this far" is really a combination of both internal and external factors. I agree that the external factors can be attributed to a poor funding environment, unsupportive department chairs, poor relative renumeration, family pressures, etc. However, I urge all of you (as I did) to carefully examine what are the *internal* impetus and barriers to becoming a physician scientist.

    Again, none of you are able to answer the most basic question, which is, why is it that you have "financial pressure" to "send your child to a 15k day care", and yet someone who's equally qualified educationally and intellectually get paid LESS than you do nevertheless may or may not have the same set of complaints. Let's think about this logically. Clearly there are physician scientists who AREN'T miserable. Clearly there are humanities professors who AREN'T miserable. Clearly the reason that one may or may not be miserable isn't clearly causal to external variables! Or perhaps it's a lack of ability to COPE with the external stressors that's the issue.

    On the other hand, there clearly are people who make a lot of money who are miserable. So I really don't see the logic that paying physician scientists more at this or that time is really going to solve the situation of *perceived* career dissatisfaction.

    Before you rush to criticize me for singling anyone out, I urge you to reflect on the fact that there MAY BE at least some parts this dissatisfaction that has nothing to do with the system but everything to do with who you are and what you want. And I urge you to reflect on the fact that perhaps the most efficient way to fix that is to gain more perspective.

    Along these lines, I think at a systems level, providing systematic and sustained career guidance and mentorship, so that trainees and early career physician scientists not only know what to expect but also have a place to vent and be encouraged, is probably much more important than dumping salary into the system. This would also include peer mentorship.

    Personally I disagree with your assertion that being physician scientist (as opposed to being a pure clinician) puts a dramatically heftier financial burden on your family, except under very specific circumstances. I also disagree with the idea that seeing other people making more money makes me more likely to want to jump ship. It actually makes it easier to take risks knowing that if it doesn't work out the alternative could only be better.

    I also disagree with another above poster that going into MD/PhD and becoming a physician scientist as a woman would automatically exclude you from a rewarding family life. I think it's a terrible terrible stereotype and a horrible misconception that a lot of women have. It may be a bit more difficult. You may have to take a hit here and there, but it is entirely possible. I've seen it. You can make it happen.

    Again, I just want to stress that while it is true that being a physician scientist leads to certain sacrifices in life, it is NOT true that you will not be able to have a really nice comfortable upper middle class life if you so chose to have it. These words like "hardship" and "biologically incapable of having children" are simply ridiculous! Sure it's difficult, but it's not like we are being sold into slavery. What we go through does not compare at all to what would genuinely qualify as "hardship." Please, resist the hyperboles--it's actually quite offensive. And I would encourage all the women out there including the poster above that having a child during both medical school and residency is ENTIRELY possible, and your employer CANNOT fire you for being pregnant. Talk to people at your institution and make it happen.
    Last edited: Mar 30, 2012
  23. gbwillner

    gbwillner Pastafarian Moderator

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    I totally agree with this as well. Probably the only reason I'm still in it as well- a great department with a forward-thinking chairman, who allows you to do 100% protected research time as instructor. Most are not so lucky.

    HOWEVER, I think the bottom line is the government (and these institutions) spend so much money and time training us, it is a waste if we bail once our training is over. I can understand people who drop during the PhD- they just don't care for science as much as they thought, or are entranced by clinical medicine. No big loss. But it serves no purpose for people to abandon their path at the end of training because the options are not feasable at that point.....

    What I would do if I was the MSTP Emperor:

    I would cut 1/2 of all MSTP spots. I would then take the money I saved from the MSTP program and use it to fund graduates of residency programs who went through the program as research funds. Let's say each graduating resident was given $200-$500K from this fund towards start-up costs- you would be much less of a liability to whatever clinical department hired you- probably they would fight over you since they got to keep the overhead costs. You could then start at the Asst. Prof. level, meaning there would not be as much of a financial incetive to bail on the research track. You would have to have a minimum 80% protected time. I would also take some of this money and funnel it back to the MSTP programs who were most successful at getting their students to their final destination. That's it in a nutshell, the specifics could be discussed later.
    Last edited: Mar 30, 2012
  24. sluox

    sluox Copier

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    I'm not really sure what this example supposedly illustrates. I know someone in exactly the same situation who decided to do the $140k job. I think it's pretty clear what this individual choses depends very much on what's INTERNAL to him.

    Statistically, MSTP has been extremely SUCCESSFUL in bringing in people with clinical training to basic and translational research. You need to calculate the effect of having the PhD on a possible future in research -> use Bayes theorem. And I'm pretty sure that effect is huge. Your inference is erroneous because you didn't take into account the high prior odds that an MD would tend to go into clinical practice.
  25. sluox

    sluox Copier

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    Again, this makes no sense to me. I know RESIDENTS who have two children on ONE salary who manage. And I live in the most expensive locale in the country. Something's messed up in your personal finances. Assuming a typical situation of two resident's salary of at least 100-120k a year, I just don't see how this cannot support a family in any geographical location in the country, especially when the children are young. And once they are old, you'll be making 100-150k a year each as academics. And if 200k a year of family income isn't enough for you, when the average family in the US is making 60k...something is BADLY wrong.
    Last edited: Mar 30, 2012
  26. gbwillner

    gbwillner Pastafarian Moderator

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    Dude, no one said physician scientists are "miserable"- more like they have lots of challenges, and one of them is the temptation of "cashing in" (which most will take at some point). And most of the criticism is actually coming from you.

    But you're right though- it's all about perspective. I don't HAVE to pay the $15K/yr/kid day care costs from the ritzy university-provided and discounted service- I'm sure I could kidnap a migrant worker and force them to provide care for me for pennies on the dollar. You're also right that physician scientists do not actually have heftier financial burdens than their clinical counterparts. $50K/yr probably goes just as far for a family of four in East St. Louis, IL as $400K/yr does in Greenwich, CT.

    You should take you message of perspective and wait by the revolving door of MSTPers fleeing basic science research, and remind them they are all just envious, and should just reflect on that for a while. Tell them they just need better mentorship, not the cushy and secure lifestyle they are about to receive.
  27. mercaptovizadeh

    mercaptovizadeh ἀλώπηξ

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    I'm nearing the end of my PhD, and I think a little reflection on history might do us credit.

    1.) Support. If you look at the great scientists of history, most were either "gentlemen" or relied on patronage. Patronage, which amounted to free reign to publish their scientific theories and funds to drive their research. And most importantly, patronage generally came from people who didn't dabble much in science.

    Most of today's scientists are fighting for funding which will be issued at the decision of their peers, i.e. competitors or cronies, many of whom are entrenched in a particular understanding of the subject matter and favor material within that vein and disfavor stuff outside of it.

    2.) Technical dominance/obstruction. Science is different today from what it was like 200 or 300 years ago. Back then, very simple instruments could help one or a few individuals discover fundamental phenomena and develop theories to explain them.

    Today, the equipment and assays are becoming more demanding, requiring in depth knowledge by the investigator or extensive collaborations with many other individuals. Yet research - rather than being question focused and delocalized - continues to be driven by strong self-aggrandizing personalities who mix up the science with their desire for recognition and prestige.

    There's also an issue of bureaucratization. I or the lab tech have lost countless hours - days even - dealing with IACUC protocol crap, IRBs, radiation safety forms, chemical hygiene, EHS, DEA, etc. They've given us grief (i.e. refused to allow it) about wanting to do a repeat experiment on 24 mice. This is absurd and a waste of time.

    3.) Knowledge overload. Given so many scientists and labs, knowledge is being expanded at a greater and greater pace. This creates two problems:

    a.) individuals are being required to assimilate ever-greater quantities of information and integrate it so as to better formulate their own ideas and understand the data; the individual's intrinsic capacity for this hasn't improved at all. If anything, scientists have less time to read broadly because they are dealing with the microdetails of their field all the time.

    b.) lots of incorrect information/data is being put out there (including entire well-developed models, not phlogiston/spontaneous generation type nonsense), which lead science down incorrect paths and require threshing out at the individual level, followed by debunking (which requires higher and higher standards of experimental rigor (see the technical point in 2) the more entrenched the models are).

    In other words, the science of the textbooks, the elegant little experiments we read about in our college textbooks that proved that DNA was the genetic material and not protein, or that calculated the charge/mass ratio of the electron, or demonstrated electromagnetic induction....that's all over.

    Science itself has changed. The new "successful" scientist of our generation must read copious amounts of material related to the field and broadly outside of it. This provides the fertile germs for hypothesis/theory development. He or she must be very talented at socializing/networking with his colleagues (who will give him money) and must write well and persuasively. His or her name and lab must be marketed, show up in Science and Nature and Cell and PNAS. "Sexy" science is a plus, it's no longer enough to merely have consistent and well-conceived and -controlled experiments. He or she must be very technically adept, planting roots into a variety of collaborations and/or taking on new techniques and approaches as soon as they come out (as methods are dominating science today, I see how my mentor, who's perhaps 10-15 years off from the 'current trend' in techniques, is no longer getting funding).

    And in the midst of all this, who has time to also see their family and friends, see patients in clinic, and take the odd vacation?

    The 'have it all' dream (or is it nightmare?) was a lie.
  28. gbwillner

    gbwillner Pastafarian Moderator

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    Not everyone is married to another physician. Some are married to grad students. Some are single parents. This is a pretty myopic view, IMHO.
  29. gbwillner

    gbwillner Pastafarian Moderator

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  30. Spacedman

    Spacedman amateur vibeologist

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    dude. read again. i AM a RESIDENT with TWO CHILDREN on ONE SALARY accumulating school debt on my spouses behalf. i ALSO live in one of the most expensive locales in this country (also a choice). i am managing. I am not miserable. I am overall pretty happy with the way things are going. i made a decision (with my family) to do things this way and postpone higher paying opportunities. let me guess, you live in NYC with your SO, no kids, shoebox apt, eat ramen noodles every night. now, add a 2 year old, see if your perspective changes a bit. mine did.

    i can also understand why other MD/PhDs in this situation would NOT make this same decision, and I think it's a loss to academic medicine to lose otherwise motivated people during the "bridge years" between MSTP and faculty.

    btw, a little childcare math: 15k a year (a steal), is ~300/wk. that's $7.50/hr for a 40hr week. i don't know any residents working 40 hours a week. yes, if i had a 9-5 job i could probably vet a bunch of non-state accredited at-home day cares run by people whom i only know by their craigslist references. didn't work out.
    Last edited: Mar 30, 2012
  31. Fencer

    Fencer MD/PhD Director

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    I agree with everything but the 1/2 of all MSTP spots. A proposal that has been made is that the number of F30s need to be increased at the expense of MSTP spots. The MSTP designation is about certifying the mentoring process with minor funds to support the infrastructure benefiting MD/PhD programs. F30s are competitive, and certainly a program with MSTP will have strong environment, but for many small areas, a non-MSTP program might be a better location/environment for a particular student.

    Regarding the use of funds for PSTP (postdoctoral/residency) and CTSA (instructor/assistant prof), there is no question. I strongly agree. That is one of the reasons is brought up the issue of accountability of faculty time as a barrier/opportunity to truly preserve protected time.

    Let's stop the name calling... This is a great discussion that is sorely needed.
  32. gbwillner

    gbwillner Pastafarian Moderator

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    I don't WANT to cut spots... but money don't grow on trees. I do think this may force programs to do a better job at identifying long-term success in their candidates. When I applied, I had done research since high school, and was a NIH pre-IRTA for a year. I thought that was necessary for the admissions process. Once I matriculated, I met people who's experience was a summer or two of research only. I would bet that people without significant research are less likely to know what they are getting themselves into... I maybe would increase the required research time BEFORE committing to the program. It's worth considering, at least.
  33. justgo

    justgo

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    I don't really want to spend a lot of time on this peripheral point....but again, it is a question of thinking a person can "have it all". This is just not true. There are a lot of women scientists who have children, of course, but I would venture from conversing with many of them that their definition of motherhood shifted as they went through the process. I know based on being an aunt to academic children that if you are considering only the fiances of it, it is extremely expensive to provide full-time child care for children, and one parent leaving a 100k+ job to be "stay at home" can actually loosen the financial belt. That was the side I was addressing in my comment, the finances....not a moral discussion about motherhood and science. However, as a women, a lot of the reproductive responsibility will fall on my shoulders, so it is important that I know my stance starting this program.

    It is a matter of defining priorities and determining how good a job they are willing to do on any one particular activity. Parenthood was not something I was willing to only dedicate 30 or less percent of my time to, therefore, no-go for me.

    As to "biologically incapable of having children", trainees need to be realistic. If you start at the average ages in mid 20's it is highly probable to be 14 years give or take until one starts fighting for a stable faculty position. This already puts a women into tenuous territory...biologically. If you wait until your tenure clock starts or until you have tenure, well then my quoted statement holds quite well. Mid to late 40s is a difficult time biologically to reproduce leaning towards incapacity. We all know that. Add in any familial difficulties and a woman might spend more time as a patient than seeing patients (if they have 80/20 split that is!) to put a bun in the oven. This discussion leaves wide open the door for adopting a child or two when I or anyone else feels 100% capable of providing financial and other care....this can be done without changing career trajectory or sacrificing education milestones.

    My arguments were about financial capacity. During the years of fecundity a women on the MD/PhD path does not make enough to support a child and continue her career without some external input. My particular case is just that, particular.

    We need to stop lying about the difficulties and maybe people, women included, will start to really weigh their priorities seriously from the outset. I already know the career I want is different from what others tell me to aim for. I'm ok with my plan to live happily in the "middle of nowhere" and do what I love. It's all a balance, but certain natural imperatives just don't budge.

    Just want to clear that up.

    As to the rest of this discussion, its helpful, but I feel like money should not be the key point under discussion. There are fundamental problems in that I think very few faculty or PDs at "top" programs can really describe what the point of MD/PhD is (or any research for that matter) except the trite prestige driven arguments of no worth. We've got to start thinking about the reality of it all and if there is a real reason for this distinct (and long) path, which I believe there is, find a way to 1) Recruit the right people and the correct number of people, 2) Guarantee that few are lost along the way, 3) Ensure these people keep doing what they were trained to do. Right now we are investing a lot in without a lot of return and I think this is just a symptom of the lack of focus around the idea of why we need the MD/PhD scientist (beyond it looking good).
  34. justgo

    justgo

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    And the situation remains the same today, and it is still just as depressing for us applicants who are truly prepared. What is even more depressing is the obvious bias of some programs towards young students with the bare minimum of research experience needed to check their boxes. Additionally, I really did not appreciate several experiences where I literally had to sit in a faculty members office and justify (though I am within age norms) having stuck with a research program and getting 4 publications in top journals, versus going straight into a program after undergrad (when I already had 5 years in the lab). It all worked out for me (accepted everywhere I interviewed), but applicants that are a little less "**** you" than I am, probably would not have performed as well under grilling.

    I think programs struggle to fill their spots with qualified applicants, and there is competition for "flashy" applicants, not necessarily for the applicants who are really going to become physician-scientists and know what that means. They want to be able to fill press releases and flash names on grants. Its not really a game driven by the outcome of producing scientist as much as it is a game driven by the outcome of producing prestige....my impression at many programs.
  35. Chrome19

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    I carry out research at a top 10 medical school, and most of my friends in the final years of the PhD phase of the MSTP program are definitely backing out of science, but they don't tell this to the program. One of my friend's project just never worked, and his PI had to help him scramble for something safe/small so he could get a PhD in time. He published a small paper and he's out now. (For comparison, a straight PhD student in the same lab is entering her eighth year in the Fall and still doesn't know when she will graduate.) Another MSTP guy almost done with his PhD did pretty good work, but then after going through the pain of his project and looking at the future, he decided he is not cut out for science.

    I have realized basic research is very difficult, and institutional or bureaucratic policies won't change that reality. And I think science is made even more difficult by competition for grants, space in journals, promotion, tenure, relatively low pay, politics, etc. It's extremely understandable to see why people decide to move on to other career paths. I don't think most undergraduates (even those with research experience) understand how challenging the path they face.

    I personally think you just have to really really really love research (that is, very strong passion/fire in the belly), and be quite masochistic, to continue with it. In addition, it has to be seen from an all-or-nothing perspective.

    By the way, I know a female HHMI investigator (straight PhD) with two kids. I often see her walking towards the garage with her two non-rambunctious kids anywhere from 5-7pm.
  36. Neuronix

    Neuronix Super Corgi Away! Administrator SDN Senior Moderator SDN Advisor

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    I think this is a great thread. I hope we can keep it civil without name calling or personal attacks. Everyone is entitled to an opinion on this. I think our opinions here in SDN are fairly one sided. i.e. we're the zealots. Those who left the physician-scientist dream don't come here. But, even as zealots many of us are fairly conflicted. I know I am. Many of us really believed once in what we are doing, and many of us are having a hard time rectifying our choices and our insecurities with our past beliefs and reality as we see it individually. Are we strong enough? Are we getting what we "deserve"? Is it worth it? So relax on each other. We're on the same ship.

    My first point would be that people don't go into MD/PhD for all the right reasons. You can know why you're doing MD/PhD, and you can come on here to SDN, and say all you want about how the physician-scientist world is amazing. But if you're doing MD/PhD for the money, or for the prestige, or because your parents are pushing you to become a physician-scientist, you're not going to stick with it. You're also going to be one of the countless MD/PhDs who never post on this forum. Everyone seems to want to go to the top medical school and the top residency program. Many people are willing to use MD/PhD to get themselves there. Anyone can bluff their way into an MD/PhD program. It doesn't mean they're going to stick with it in the long run. As much as people say the money shouldn't be an issue for applying MD/PhD, it's a huge issue. A free ride to a top medical school? When faculty members at my internship program hear where I did my MD/PhD program, they want to know all about how to get their own children a spot. This is regardless of whether their children are interested in the MD/PhD pathway.

    This brings up a second, related issue. With the MD-only cohort out there, many will also do research, often as a year out, in order to try to get the most prestigious residency positions with the best research. They soak up research-oriented residency positions from the most research interested MD/PhDs. Thus, MD/PhDs often do not have priority even when attempting to gain research residency positions. Residency program directors tend to be mostly or only clinicians who don't care much about research, but would rather get the most mileage out of their residents with the least issues. Thus, research track residencies are limited, protected research time during residency is limited, and the places with the best opportunities are soaked up by MDs who think they might some day want to do *academics*, but really have little interest in serious research. Everyone believes (and to some extent it's true), that going to a top residency will get you the best private practice jobs with the most money as well. This is of course regardless of the prestige that going to a top residency program makes you feel for yourself. As long as step scores and grades are the most important thing to these residency programs, MD/PhDs are lost right off the bat because they're not getting access to the institutions (or even specialties) where they want to be and should be training.

    Even among top residency programs, residents often don't get the protected time they need to head into a research career. Many are loathe to support research track programs, and instead burden their residents with high amounts of clinical work so that they don't have time to do serious research. They push this off to fellowship, making the training pathway to be a physician-scientist that much longer and more difficult.

    Third, people change. Even if you are dead set on becoming a physician-scientist at the age of 23, it doesn't mean you will be at 30, 35, or 40. Life happens. Interests and priorities change. You might find that during your clinical years of medicine and residency that you want to be a clinician most of the time. Or the opposite, you might find that you hate clinical medicine and only want to be a researcher. You might find, as I did, that you loved research but the daily frustration with trying to get your research approved, funded, and published simply aren't worth it. You might also find that you have interests outside the hospital. It's much easier to find balance as a physician than as a physician-scientist, and so if you're not completely fulfilled by being a physician-scientist, you may not want to stay with it. But again, you can't know this at 22.

    This thread also assumes that people don't suffer terrible setbacks in their training that are out of their control. They do. We've put a lot of emphasis here on the transition from MD/PhD graduate to faculty, but the pipeline leaks at all levels. Some students have a terrible time during their PhD training or their MD training for various reasons that might be out of their control. MD/PhD training certainly is not perfect. Some people are pushed to the breaking point during MD/PhD or residency, and don't want to go back there. Were they simply not strong or dedicated enough? Or is the bar too high?

    Fourth, as many in this thread have pointed out, there are tremendous disincentives for physician-scientists to be scientists as opposed to clinicians. I think this topic deserves some background information about the academic world. Because to pre-meds and MD/PhD students, academics means *research*. But in the real world academics means a whole spectrum from clinical only to research only and everything in between. This is why in the Brass outcomes data (http://journals.lww.com/academicmed..._PhD_Programs_Meeting_Their_Goals__An.35.aspx), when you look at MD/PhDs within academics 13% are not doing research at all, and of those doing research 34% do research less than 50% of the time.

    This is the reality of the job market as I have seen it. I am a lowly resident, but I am perking my ears up to find out about job opportunities within my field within research and without. I'm in the same field as gfunk, and what I've found is similar to what he's reporting. If you want to do serious research, you need to be willing to go anywhere that job is available. You need to be willing to devote much more time to training to get that job, a much lower salary within that job, and be willing to be uncertain and likely to move again, possibly several times during your career. And when we talk about lower salaries, even within "academics" the spread is over a 2-fold difference. When you consider private practice, multiply the salary by another 2. It takes a tremendous amount of dedication to be willing to go wherever the job is, whenever the job might be available, accept far less money for doing so, and accept the instability inherent in the research career. After your 13+ years of post-graduation training, isn't it time to live the best life you can? You can say that living on 150k/year at 60-80 hours a week affords a decent life, but working 40-60 hours a week to make 300k/year looks awfully appealing after all those years of being at the bottom and working very hard for very little.

    Even within academics, there are few chairs willing to support researchers. The MD/PhD field is incredibly saturated here. The idea of getting even a startup package is laughable. So you will be expected to bring in your own salary within 3 years, with a 10% funding rate, or be moved to clinical or fired.

    What gets me is that, yes I'm in a procedural field. But, I frankly don't think this is any better in the less procedural fields. My observation is simply that the clinical world in non-procedural fields is much worse. The salary spread is not that great. And while my MD/PhD program director used to say things like "There is a tremendous shortage of physician-scientists", the reality was that the departments at my medical school were often on hiring freezes. There is a tremendous shortage of grant funding, and that is what needs to resume to make physician scientists. There are a large number of terminal fellows and junior faculty out there in academics who are fighting to actually become faculty, stuck with low salary. But in certain specialties, the difference in pay isn't that great (say $80-100k vs 150k) vs. in others (say $80-100k vs 300k). So does that mean you should lock yourself into a position in a specialty with less clinical prospects so your temptation is lower? I'd argue no.

    Thus, if I could change things:

    1) Should MSTP even exist? If so, even in a better funding environment you need to accept on the order of 25%-50% attrition from a physician-scientist career due to improper selection of candidates, training issues that MD/PhDs suffer that push them away from the combined pathway, and personal/life changes.

    If MD/PhD shouldn't exist, maybe we should all be on MD with loan repayment programs. It's one thing to choose MD/PhD at the age of 30, and a different thing at 22.

    I'm not advocating necessarily for either of these, just putting it out there. It is common sentiment among graduates not on this board that the idea of putting a 23 year old through very expensive combined training for a career they will establish at 35 is ridiculous. They can't possibly know what they've signed up for.

    2) More funding for physician-scientists. It seems obvious, but we're suffering for a lot of reasons. Departments aren't willing to support us because we don't bring in the revenue. We're self-selecting ourselves out of the pool because the opportunities aren't there for us. Residency programs are even getting as fatigued as the trainees of training physician-scientists. The sentiment becomes: "why should I let you out of clinical duties when you're not likely to become a mostly research anyway?" It's a vicious reinforcing cycle. Instead, if there was more funding specifically for physician-scientist faculty, a lot of these problems would ease. I'm afraid that just a small increase in research funding in general will do little to help us, as the PhDs fight tooth and nail to get at it.

    3) Lower the bar. This is in part a side effect of the funding environment, I think. But, honestly MD/PhD programs should average 7 years, and should never take longer than 8 except in exceptional circumstances. Research residency programs should favor MD/PhDs and provide protected research time and a clear bridge to faculty positions without an extended post-residency or post-fellowship limbo. This is a very gradual effect, but I'd speculate that compared to 20 years ago, the MD/PhD training is 1.5 years longer and the residencies and fellowships are 1-2 years longer. The funding is much harder to obtain, making the career much harder to sustain once you're doing with all that extra time training. Remember the old adage to pace yourself for the long path? You can't. Not when you need to honor most things and score very high on your step 1 and 2 to get the good residency, just to get abused in PhD and in the good residency to put out more to keep the whole enterprise afloat. To me, it seems that MD training is tougher, PhD training is tougher, and thus doing both is 2x tougher.

    This goes back to #1, should MD/PhD exist? If so, should we demand everything out of them we demand out of MDs and PhDs only? What kind of life are we thus giving to our physician scientists? Is it worth it? People can choose it if they like. But I certainly don't blame anyone for choosing otherwise.
  37. Shifty B

    Shifty B

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    This is a quite interesting discussion indeed, and I think it reflects a lot of the realities out there. I don't think most people are interested in money ONLY, but when it adds up with the other factors it becomes a huge deal.

    That is, by the time you get to the end of your PhD, most people have experienced the frustrations of science: the bureaucracies, the endless grant submit/reject/submit/reject cycle, the pressure to publish at all costs. Once the shine is off of the academic research world, then it sure seems a lot less appealing.

    Then, you get to the end of your residency, and are faced with 2 options:

    1) continue to pursue predominantly basic science. lower pay, and depending on your previous experiences, perhaps more frustrating, harder and longer hours, and much more delayed gratification.

    - or -

    2) give up some or all of your efforts toward research to make more money, have more time to spend with your family, and have a job that you potentially find more rewarding. In many cases, clinical medicine is much more rewarding because the feedback is much more instantaneous.

    So, unless you're one of these people who can ONLY be happy doing basic science, #2 starts to look a whole lot better.

    I would try to address one of the points that was brought up earlier by more than one poster. I too think the whole system is broken, and I don't mean the MSTP system. I think all of science is broken for the most part, predominantly because of the way funding is allocated. Multiple groups compete to do the same work, which is frequently duplicated and inefficient. Money is concentrated not on the basis of which ideas are the best, but rather on the basis of whether you've been funded before and published before. But this becomes a whole catch-22 because whether or not you can publish also depends on what funding you have and whether you've been published before.

    Plus there are too many PhD positions across the country. You think MD/PhD graduates have it bad, look at where PhD graduates end up. Many bail immediately and end up in industry or unrelated jobs entirely. The ones remaining in academics either languish as postdocs or research associates indefinitely. Others will leave and become instructors at liberal arts schools. It's pretty bleak for all but the most successful.

    I would propose something much more dramatic, which is to reduce the number of all PhD spots (including md/phd) by half. A lot of that money can be redirected towards educational efforts at the undergraduate and masters level science and engineering degrees, training those people who will ultimately end up as instructors and working in industry anyway. It would be much cheaper and more efficient and go a long way towards narrowing the gap between engineering/science education from China/India and here.

    Whether or not you restructure MSTP training is then a separate discussion. Perhaps I agree with making everyone pay for medical school and then giving those who choose to do prolonged research during and after residency loan forgiveness? I don't know.
  38. sluox

    sluox Copier

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    I find this unpalatable and kind of offensive. I'm not really sure what you are saying, but you certainly don't have to live in Greenwich.

    I don't see your point at all. So you are managing and you are overall very happy with the way things are going. So then what? I mean exactly as you said, clearly whatever pathway that provided you with the situation that you are in now WORKED.

    Obviously I understand people who decided against a career in science. I understand people who decided to become an investment banker. Or a hooker. Or whatever. I just don't know what's the logic behind all this kvetching over things that you have very little control over. If you are happy, why do you think the system is broken? If you aren't happy, then do something about it.

    I think it's interesting that people who actually end up in clinical medicine and laugh all the way to the bank don't kvetch nearly as much as people who stay in science. If you hate it so much why not just change your job? Oh no, that would be "insanely stupid", and "I've been doing research since I was a toddler", and "I'm actually very happy and everything's going great." Gimme a break here. Let's be honest. You hate it. You want to make 300k doing science. You want to send your child to private day care in Greenwich and schmooze with people who can buy your whole family. I'm saying it's not possible. Face the reality. The world does not revolve around you. People manage with 60k and a load of student loans and two kids ALL THE TIME. And you know what, you are not a superior human being just because you have five letters behind your name. The sooner you make peace with this the better.
  39. h e r o

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    Great thread. Another problem I see is that MSTPs are kind of "half-assed." I think the concept of this program where MD/PhDs are trained is good, but the implementation is flawed and dare I say even lazy. The existing structures at universities are the graduate school and medical school. MSTPs are simply grafting those two existing structures into a strange hybrid.

    If there is going to be something like the MSTP offered then there needs to be a unique MSTP track, an accelerated track. I am talking about a 6-7 year MD/PhD track, not this 8, 9, 10 year garbage.

    Phase 1:
    3-4 years of PhD work

    Phase 2:
    3 years of medical school: 1 year of accelerated basic sciences + 2 years of clinical training. Regional institutions may be selected to host all the MSTP students in that particular region for the accelerated basic science year, and the students return to their home institutions for the clinical years.

    This is just a rough proposal of something that might work, but whatever the case I think the NIH needs to decide whether or not MSTPs are worth it and to either go all the way with truly specialized programs, or not at all and just let research-oriented MDs pursue it on a different path.
  40. justgo

    justgo

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    So, this comes out very similar to the Duke MSTP program. Not entirely due to anything "unique" but because their MD is 1 preclinical, 1 clinical core clerkships, 1 research, 1 electives/interviews etc. Thus MSTP students do years 1 and 2 along with the MDers then move into 3-4 years of research then cap with one year clinical.

    I take it this means I should chose Duke! Clearly the best. :p

    I would counter the poster's plan by noting that doing some clinical before research allows tailored research directives and a more mature approach to science. Thus I think this schema could really work well with Neuronix's idea about loan repayment plans. Perhaps students could elect to join research track (resembling Duke's program) or clinical track (classic 2-2 breakdown programs) for the MD (either at separate institutions or at the same institution) with the understanding that loans acquired for Medical School would not accrue interest until the end their "training" (exact point debatable), with loan repayment of a certain percentage if the student finishes the PhD, and with a higher percentage once the student reaches other milestones on the road to a "research career".

    This would be ROUGH, and few would chose to have huge loans hanging over their heads this long, but maybe it really would encourage people to think before entering the program and not think of MD/PhD as a "free ride" to prestige and marble countertops.
  41. h e r o

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    I remember hearing the bolded statement frequently on the interview trail especially at places that had from 6 months to up to a year of clinicals before the research year so maybe I underestimated the value in that. What do you think of Vanderbilt's clinical track?

    https://medschool.vanderbilt.edu/mstp/cit
  42. Fencer

    Fencer MD/PhD Director

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    This is not a unique program. There are about 15 other institutions with Clinical Investigation PhD tracks available as part of their CTSA training programs.

    We need people who do research at all of these levels. For some it is very appealing career to take a molecule, design and conduct the clinical trials, go thru the regulatory approval, and then do post-marketing clinical research. It does make sense to do a MS-3 to face clinical arenas prior to pursuing this PhD track.
  43. Shifty B

    Shifty B

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    I think in order to make post MD research more feasible for many markedly may be interested, it has become somewhat more lucrative. I was taking a look at the Vanderbilt site, and I think that second pathway that they have his somewhat interesting. However, the choices that someone would face after having completed a residency are going to be even more bleak than already described. You will have potentially just have finished a residency, with the potential to get a clinical job making 200k dollars or more versus going back to a lab and participating in some sort of low paying apprenticeship.

    In order for post-residency research to make any economic sense, their salaries have to be in the same ballpark as the clinical options to be even remotely interesting. I think this is part of the problem right now. There is an paucity of relatively decent paying research jobs for people who have much more earning potential as clinicians. I think if people finishing fellowship could find jobs doing research and making 75% of what their clinical colleagues were making, then I think a lot more people would do it.

    There is a huge difference between a 25% discrepancy in salary (150k vs 200k) and a 60% discrepancy (80k vs 200k). Once the difference is that great, many people who don't find themselves primarily motivated by money will start to make choices based on salary.

    One thing that could make research more (relatively) lucrative is a decrease in salaries for clinicians, which is likely to happen in the next 20 years anyway.
  44. r1oid

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    This is one of the more interesting discussions I've seen in a while. I'll give my two cents as a soon to be 4th year finished with PhD. Hearing some of the things the +10 yr outers are saying is heartening b/c I am feeling a lot of what they said they went through.

    1. I too am a bit disappointed in the number of my program mates who have decided to go pure clinical, even more so at some of them who had this intention from day one. No personal judgment, a lot of them are great people and "like" doing science, but they don't love it like I think some of us do. On the other end of that spectrum one guy had to be convinced to finish the program rather than postdoc after his PhD b/c he knew after 2nd year that he did not want to do any clinical medicine.

    2. If I was MSTP king (since we are playing this game and I was thinking about it the other day). I would make MSTP like the military or NHSC scholarships but not as harsh. The funding is as it is now but the cost of your MD part is held as an interest free "loan". If you end up not doing clinical or basic science research you pay that loan back on a schedule assuming you are making the big bucks like all your other pure practitioners. If you do research then you do four years of 80%+ time and your loan is forgiven. I think this way you at least recoup some of the money and put it towards the pot to support the people in the 80% time.

    3. To distill the sentiments above on this matter my wife told me the other day, "During the worst weeks you had during your PhD you were still a brighter person than the best weeks of your 3rd year of med school." I was kind of shocked to hear this and when asked to elaborate she said brighter = happier, more interested, just brighter.

    4. The money for family stuff is big on my mind these days. I actually found myself crunching numbers on what the different fields path v peds v IM would mean for my family. I've been asking around about which ones better support academic positions etc... its kind of stressful, lots of grown up stuff.

    5. The only thing I've got figured out so far is that basic science makes me so happy that those around me can see it even when I can't. I keep trying to remind myself of that and make decisions with that as a general north star.
  45. Fencer

    Fencer MD/PhD Director

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    As a clinician scientist, money will work out itself as long as you keep putting your best effort on your next project, grant, paper, etc. There will be bad projects, grants, or paper submissions, but if you truly are "brighter" and happier doing this, I hope you keep to your north star. Rewards will come eventually, perhaps, later than sooner, but they do...

    After 25 years from starting graduate science work, I can't change what I do or like to do, and I don't want to either.
  46. Jorje286

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    I more or less agree with sluox. Science is not an easy career to pick and you have to be ready for making sacrifices. I don't see much in whining and complaining how you can go for that 400k paying job and it's oh so tempting but you don't. Ultimately, you're fighting to get a bucket load of tax dollars so you can run crazy ideas that no one has thought of doing before. WHY do you think that should come easy? Bottom point, if you like it enough you will stick with it. It's not like you'll be dying of cold and hunger, and a 70k salary won't stop you from pursuing something you are truly passionate about and something you are doing completely for the sake of it - and imo being a successful scientist requires this sort of dedication.
  47. Habari

    Habari Senior Member

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    .
    Last edited: Apr 2, 2012
  48. miz

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    I don't think that that's what the OP was saying. Are you being serious? If so, I think it's disrespectful to imply that a person is being self-centered and greedy for not wanting to have a 60k/yr salary, student loans, and kids, and be working as hard as they can while having a lot of uncertainty as to whether they can get a job which will allow them to do research. I believe you are suggesting that people who are unhappy with this situation should quit their jobs and enter private practice. But this is one of the problems that we are trying to address- why people who love research but are unhappy with their compensation quit and enter clinical jobs to improve their lifestyles. To our perspective, logistical problems should not be the primary reason for attrition from the MSTP research career path.
    This thread isn't here because people like to complain about their jobs. It's here so that we can address problems and as future administrators and scientists, potentially offer solutions. There is a serious problem that the MD/PhD pathway has a lot of attrition due to financial and other constraints, and we are talking about how to fix that problem. The first step is to identify the details of the problem.


    I will also second Justgo on the financial difficulties of having children. Either you pay the 15k day care or someone stays home with the kids. The timing is also difficult. A typical trainee will be 22-30 during training (one period where she can give birth), then 30-34 or 36 during residency (to my understanding, you cannot readily take off time during residency for pregnancy- I'm sure there are rare exceptions though). Past age 34 the risks associated with having a first child increase dramatically. 34-40, trying for tenure; 40- tenure and you can have your children, if you still can.

    Women do have children while trying for tenure, and they do have children during residency, but there are professional risks involved in doing so. I'll probably take the professional risk, but it certainly isn't because I don't value my career. It's because I don't have any other choice if I want to have biological kids. I am willing to work hard to 'have it all'- but I think I should be allowed to be upfront about the difficulties of doing so without being accused of complaining or whining. If you call it whining, you're trivializing a serious and legitimate burden. Also, if I don't talk about it, how would anyone not in my situation know and understand? I can't expect someone to accommodate my pregnancy unless they understand my reasons for becoming pregnant.

    For this reason I think your commentary could be framed more respectfully, sluox: previous commentators aren't whining, they are pointing out real issues. Calling it whining can appear dismissive of their concerns and opinions. I hope that we will continue to have a productive and interesting discussion here.

    Edited to say that the number of people who are posting about their fulfillment and job satisfaction makes me happy!
    Last edited: Apr 2, 2012
  49. sluox

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    While we can agree to disagree in what constitutes "respectful" and "not respectful" on anonymous internet forums, the point of my post is that most people out there focus on the external reasons for people who love research but quit to enter clinical jobs and ignore internal reasons. I would make the argument that it's the internal reason that makes the biggest reason in the end. In fact, I have NEVER met someone who really "love" research but quit a career as a physician scientist because of money. And I genuinely believe that addressing only the external factors and not addressing the internal factors would not, in the end, be helpful to either the system at large or individuals working through the system.


    While I don't necessarily want to continue to be sarcastic about it, there is a HUGE element of "complain about our jobs" in this thread. Unless you commit to spending significant amount of time in terms of lobbying, advocacy and administration, financial and logistical constraints in career are basically not alterable factors. Let me give you another example, say I really LOVE being a teacher, but decided that because teachers don't make any money, I am going to go into investment banking. You are saying, let's figure out why it is that teachers don't have money--oh yes, let's not even get started on the attrition rates of teachers in the country--and see if we can fix it. Good luck with that. Clearly, this is a problem that is much greater than the teachers themselves and has to do with the overall supply and demand and profit and market and funding and taxation etc etc and unless you attempt to address these larger issues, this is again nothing more than kvetching.

    On the other hand, if you were to find some kind of psychosocial outlet, may it be psychotherapy or art or family or religion or whatever else, it might make these concerns much easier to cope with without having any unrealistic changes at the institutional level. While what I'm suggesting at face value might be somewhat abrasive and even strange, finding personal and emotional support may be the most helpful, and what i'm saying is that without being able to alter financially in any significant way, this is something that would actually be helpful that the MSTPs could provide.

    Look, I fully understand the difficulties and the often very real guilt and stress that's involved in making a decision in terms of timing and financial capacity in raising children. However, what I cannot accept is the idea that THIS career, in any particular way, is MORE demanding on women (or men) than many other careers out there that some of us would choose in the first place, and hence if that's the case it makes the case that it's not the CAREER that's the issue, it's how to properly balance a difficult and demanding career with a family AT LARGE that's the question. There is a difference between "whining" and "negotiating" and eliciting changes for things that deserve improvement. But in order to know that difference you have to know what you want, what you can expect to get (not that 400k salary that your clinical counterpart is expecting), and who are the players involved. Are you going to take a hit in terms career of having a baby during residency? Very unlikely. Are some people going to resent you for it? Maybe. Are you still going to have a baby? You will sue their ass off if they don't let you.

    And just to add more to your reassurances, I've seen QUITE A FEW emerging young female investigators who have a family, a husband, a successful career and children and are HAPPY. It's doable. Don't let ANYBODY tell you it's not possible. If you don't believe me I can put you in touch with some of them.

    What I'm criticizing, mostly, is this attitude that somehow people who are less academically accomplished (and poorer, and, implicitly, ethnic and culturally different from us) are some how having LESS demanding lives and don't have deal with as much in terms of work and family, and thus whatever we do is somehow HARDER than what the rest of society also has to deal with, and that you HAVE to have the lifestyle of rich doctors who make 400k, and that you "deserve" it, and that the fact that you can't have this is the fault of the institution that trained you. While I'm not dismissive to a particular individual's unhappiness, I am not at all convinced that the problem is existing at the level of the institution. The institution has problems, but the ones that are articulated, to me, are a lot of times the problems of the individual, and require addressing at an individual level via directed negotiation with the institution, individualized and specific psychological and career guidance/planning etc., and not necessarily at the level of the institution.
    Last edited: Apr 2, 2012
  50. miz

    miz

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    I agree that many of these problems are those that people of all socioeconomic levels face, and that the problem may be at a higher level than at the institution. I certainly believe that I can balance a difficult career with having a family (in fact, I think that I would be happier doing so than I would be with a less demanding career or without a family).
    I think that we might all agree that it would be optimal if MSTP graduates were paid enough to not have to worry about keeping their families solvent. One of the problems is that salaries seem to be fairly uniform across the board, while living costs vary wildly. Another problem is that many research universities are located in areas with high living expenses.
    One thing that the institutions I've seen have done a great job of doing is legitimizing and welcoming those who have children during the training period. That is something that is absolutely doable on the institutional level.

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