Nontraditional humbly seeking advice...MD/PhD vs. MD

[yonderson]

Hello all. Long time reader, first time poster here. Im humbly asking for advice from anybody who is willing to give it. Im a pre-med, almost done with pre-reqs and taking the MCAT soon. It's getting close to time for me to start getting my application affairs in order. I really CANNOT decide whether or not to go for MD/PhD or just the MD. I know Im still in undergrad, but this decision, unlike medical specialty decision, really is right around the corner. Here are my thoughts on the matter so far:

I really do want a research career, but I also want patient care. I have seen the 80/20 research/clinic figure floating around here, and I can say I definitely don't want that. I would like to keep it as close to 50/50 as possible.

If an MD can do fulfilling, innovative, effective research (both clinical and basic science), then I would prefer to just do the MD. I will start med school at age 26 (nontraditional), and seeing myself start my career in my early 40's is really hard. I would much prefer to keep it to mid to late 30's (I am neurobiology major right now and have participated in several research projects and would definitely like to do neurosurgery. If I did a PhD I would hope to study neuroscience or cancer biology and do work on neuro-oncology, etc. or maybe even spine/paralysis.)

So, any thoughts? A really big concern I have is whether or not there is a prejudice against MD only's doing research in academic medicine. Any comment on this? I just can't help but thinking it would be easier to become the editor-in-chief of a major neurosurgery journal with a PhD tacked on to the end of my name. But then again, I am totally ignorant. Also, comments on the future of NIH funding and such, and how that will affect MD's vs MD/PhD's? Again, I am really looking for a way to satisfy my research interests with an MD only, as that will lessen the length of schooling.

Sorry for the long post and THANKS SO MUCH.

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[gutonc]

If you are in any way on the fence at this point, you need to get off it on the MD only side now.

If you really want to do neurosurgery, you're looking at about 15 years between starting an MD/PhD program and finishing your residency. Factor in another 2-4 years at the Super Fellow/Adjunct/Instructor level (more or less a given in academic medicine these days if you're looking for a tenure track physician-scientist position) and all of a sudden you're pushing 45 before you get a real job.

 

[ValentinNarcisse]

Based on what you said, MD only could not be clearer. Publishing in clinical journals is a different ball game from the physician-scientist path. MD/PhD programs are built to train basic scientists, and will not prepare you better for a clinical research career.

 

[yonderson]

If you are in any way on the fence at this point, you need to get off it on the MD only side now.

If you really want to do neurosurgery, you're looking at about 15 years between starting an MD/PhD program and finishing your residency. Factor in another 2-4 years at the Super Fellow/Adjunct/Instructor level (more or less a given in academic medicine these days if you're looking for a tenure track physician-scientist position) and all of a sudden you're pushing 45 before you get a real job.

45?! Wow I was expecting something like 41-42 (7 years getting degrees, 7 year residency and 1-2 year fellowship). I was not aware of the "Super Fellow" phase. Thanks for the info. Im just curious is anybody bitter about that at all? 15 years is a really long time for training! Are all of those years completely necessary?

 

[yonderson]

Based on what you said, MD only could not be clearer. Publishing in clinical journals is a different ball game from the physician-scientist path. MD/PhD programs are built to train basic scientists, and will not prepare you better for a clinical research career.

Ok thanks! Would you mind elaborating on how publishing in clinical journals is a different ball game from the physician-scientist path?

 

[Neuronix]

Im just curious is anybody bitter about that at all? 15 years is a really long time for training! Are all of those years completely necessary?

Supply and demand. We're producing too many scientists--physician-scientists included. Very few people are willing in their mid-late 30s and 40s to keep slaving away with high hours, low salary, and few, unstable job opportunities. Thus, the potential physician-scientists go off to become physicians. Additional "training" serves to cull the supply down to the few lucky diehards for the few positions available. Is anybody bitter about it? Sure. But people just re-arrange their brains to accept whatever situation they find themselves in. Who is going to come say "Oh hi! I'm a failure and I hate how my life turned out!" Yeah. Nobody.

Also, add at least a year to the MD/PhD program. At least 8 years is the average time.

Ok thanks! Would you mind elaborating on how publishing in clinical journals is a different ball game from the physician-scientist path?

Clincial research involves mostly treating patients and publishing on what you did. You can write some protocols about how you might tweak the clinical pathway or compare two possible "standards of care", but that requires minimal extra training and support. Basic science requires several years of additional training to design the necessary experiments outside of the clinic.

 

[yonderson]

Clincial research involves mostly treating patients and publishing on what you did. You can write some protocols about how you might tweak the clinical pathway or compare two possible "standards of care", but that requires minimal extra training and support. Basic science requires several years of additional training to design the necessary experiments outside of the clinic.

Also I guess my math was wrong before. I was expecting 15 years, but I was not expecting the 19-20 years it would take. My dilemma is I really want to do some basic science research (I think), but not at the cost of a good clinic workload and Im really not sure I want to train until 45. What are some examples of basic science vs. clinical research in specific fields like neurosurgery? Or other surgical specialties? I guess Im trying to get a tangible view of the difference in basic science and clinical research.

 

[yonderson]

http://journals.lww.com/neurosurger...ously_Unidentified_Mechanism_of_Immune.9.aspx

I guess this would be considered basic science research? Could I participate in stuff like this with just an MD? It appears the authors only have MD's, but will there be less opportunity in the future for MD's only to participate in this type of research as physician-scientists become more mainstream?

 

[Neuronix]

I have seen the 80/20 research/clinic figure floating around here, and I can say I definitely don't want that. I would like to keep it as close to 50/50 as possible.

If you want to do serious research that requires a PhD, you need to do it most of the time. 50/50 doesn't cut it. MD/PhD programs are designed to create basic scientists. To get the grants to conduct basic science, you will compete with 100% research PhDs. Your MD gives you minimal advantage over them in getting grants. Thus, you have to be as close to 100% in the lab as possible. The reality is that you end up 100% lab and 40% clinical. A desire to be 50% in the clinics is not considered reasonable by those who are or want to be basic researchers.

If your goal is to run clinical trials or do other patient outcomes research, 50/50 is more reasonable. A PhD is not required for that type of research.

If an MD can do fulfilling, innovative, effective research (both clinical and basic science), then I would prefer to just do the MD.

MDs can do effective basic science research, however they require several years of dedicated training to become proficient in the techniques for their areas of research. Integrating MD training with PhD training is one way of doing that. There are two possible advantages to this approach: it takes massive medical school debt off the table, and trains you from day one in how to leverage both positions to become a physician-scientist. However, pursuing a PhD before med school or during residency or doing several years of research without obtaining a PhD are all reasonable alternative pathways.

would definitely like to do neurosurgery.

You have no idea whether you want to do neurosurgery residency until you've (sort of) lived that life as a medical student. Keep your future flexible and open at this point. Even if you pursue MD/PhD, you may end up in neurology, psychiatry, radiation oncology, or anything else.

prejudice against MD only's doing research in academic medicine.

There is not. There's probably more prejudice against MD/PhDs practicing medicine in academic medicine

I just can't help but thinking it would be easier to become the editor-in-chief of a major neurosurgery journal with a PhD tacked on to the end of my name. But then again, I am totally ignorant.

Why do you want to be editor-in-chief of a major neurosurgery journal??? Regardless, having a PhD is irrelevant for that.

I am really looking for a way to satisfy my research interests with an MD only, as that will lessen the length of schooling.

If you want to conduct serious, basic research, you need to take the years out of your training to get the skills to do that research. There are no shortcuts.

My dilemma is I really want to do some basic science research (I think), but not at the cost of a good clinic workload and Im really not sure I want to train until 45.

How much undergraduate experience in research do you have? You should know (i.e. not I think) by now if you have enough experience. If you want a basic research career, that's fine. But the only way to do that is to dedicate yourself to the research a majority of the time when you complete training. You can't be a "part-time" principal investigator for basic research in today's world. You can dabble in research on the side or perform clinical research part-time, but again these do not require a PhD, and would be a waste of years of your life and resources used to train you.

What are some examples of basic science vs. clinical research in specific fields like neurosurgery? Or other surgical specialties? I guess Im trying to get a tangible view of the difference in basic science and clinical research.

http://www.undergraduateresearch.osu.edu/nutsandbolts/biomedical_research.html

http://journals.lww.com/neurosurger...ously_Unidentified_Mechanism_of_Immune.9.aspx

I guess this would be considered basic science research? Could I participate in stuff like this with just an MD? It appears the authors only have MD's, but will there be less opportunity in the future for MD's only to participate in this type of research as physician-scientists become more mainstream?

You linked to a *commentary* on a research publication found here: http://www.ncbi.nlm.nih.gov/pubmed/25136121. The first and last authors of that article are both PhDs. If you put in several years of research training and dedicate yourself to the lab 80%+ of the time, you could be the first or last author on a publication like this. If you become a mostly clinical neurosurgeon, you can contribute samples to the research being performed, but you won't actually be running the experiments.

Alternatively, you could comment on the research performed by others such as in the article you linked. I.e. You don't have to be a chef to be a food critic. Similarly, you don't need a PhD to comment on the clinical relevance of someone else's research. But you do need a PhD (or PhD level research background, i.e. years of dedicated training) to run the lab where these experiments take place.

 

[yonderson]

Ok, I guess its probably MD only, then. I definitely don't want to research more than 50 percent of the time. Thank you everybody for your help. I will keep always my eyes open for new info, of course, but this has been very helpful.

 

[gonogo]

That 'super fellow' phase mentioned above is somewhat an exaggeration. Your more plausible timeline would be something like 8 years MD/PhD + 7 years residency + 1 year fellowship. No one I know in neurosurgery does more than 1 year of fellowship. You can integrate significant research during your residency, most places would allow you a full year during your 5th or 6th year (although you'll likely still need to take call and have other clinical duties). The typical MD/PhD in neurosurgery is not done until age 37-39, so you'll be a few years older than the average. Most MD/PhDs decide to go for shorter residencies, and certainly less clinically and time demanding ones. Your interests may as well change once you're in med school.

 

[yonderson]

That 'super fellow' phase mentioned above is somewhat an exaggeration. Your more plausible timeline would be something like 8 years MD/PhD + 7 years residency + 1 year fellowship. No one I know in neurosurgery does more than 1 year of fellowship. You can integrate significant research during your residency, most places would allow you a full year during your 5th or 6th year (although you'll likely still need to take call and have other clinical duties). The typical MD/PhD in neurosurgery is not done until age 37-39, so you'll be a few years older than the average. Most MD/PhDs decide to go for shorter residencies, and certainly less clinically and time demanding ones. Your interests may as well change once you're in med school.

Interesting. Do you know how it would work if you decide to get your PhD in something because you are thinking of a certain specialty, but when you get to rotations you decide you're going to do something different so you have a PhD that may not have anything to do with your chosen specialty? Like (I'm assuming, perhaps incorrectly, that these are fairly unrelated) if you get a PhD in cancer biology wanting to do neurological oncology, but then end up going into cardiology, what good does the PhD do? Or if your PhD is in biomedical engineering and you choose a specialty with hardly any procedures?

 

[MooseMan3]

Yonderson, this is a really important question for MD/PhDs, and you will hear different things from different people. I am currently considering this question very intensely as I decided which MSTP to matriculate at next fall. Hopefully other senior members will provide their perspectives. Broadly speaking, there are two ways you can look at it:

A) The "changing fields is not a problem" stance. Basically, the point is that you don't need to have your clinical specialty defined before your PhD. Biomedical research skills are transferable from field to field, and the most important part of PhD training is learning how to think and do science. Many people will advise you to choose solely on having a great mentor and an exciting project for your PhD, and not worry too much about a specific topic/field.

Rationale:
1) Easy to apply various experimental techniques from one system to another. (This varies, see below)
2) It varies from program to program, but in the standard 2-4-2 model of MSTP training, you do not have much clerkship experience to base your choice of thesis lab on. Tons of students change their mind about clinical specialty when they enter the 3rd year clerkships and begin to see what life would be like as a practicing physician in that specialty. So that type of "cancer biology PhD goes into cardiology" probably does happen quite a bit anyway.
3) Some of the most popular MSTP specialties (IM, Ped, Path) have pretty broad options for sub-specialization, and you can go in many different directions based on your evolving clinical interests. Then once you sub-specialize, you can dig in again for 1-3 (or longer...) years in a sustained research experience.
4) After clinical specialization, you can now apply your scientific skills and techniques (maybe) to your specific clinical interests, and this will be the launching point of your career. The research you do during your PhD will NOT form the basis of your career, as you will be away from science for 5-8 years during the last 2 years of medical school and then 3-5 years during residency.

B) The "don't waste your time doing irrelevant grunt work in the basic sciences" stance. Essentially the opposite of the first position, some would argue that physician-scientists would be better off doing their PhD once their clinical field is completely defined. The "learning to do science as a process" approach sounds great, but the reality is that the workflow of science is often greater than 60-70% experimental time. You can't learn a lot about the process if you take on a project that was pre-designed by the PI and/or post-docs in the lab and requires 10 hrs/day of benchwork. If you don't end up staying near that field for your clinical specialty, you really will waste a lot of time.

Neuronix already mentioned that you can do a PhD during/after residency, and I have talked to numerous MD-only physician-scientists at top 10 schools who advocate this approach (during MSTP interviews... LOL). The obvious huge disadvantage to this pathway (which was traditionally the only pathway) is the financial debt you will go into during medical school. Further, this debt will continue to accrue as you move through the many years of PGY and post-doc. It is a LONG time to be in debt and not earning attending salary... Especially with the difficulties of a research career, you might be tempted to forego a physician-scientist career due to the higher salary and better lifestyle of a clinical career. Note that this is also a major concern at this career stage for MD-PhDs, but the idea is that they don't have the debt of their MD-only counterparts and are more likely to stay involved in research.

Another way would be to complete your 3rd year clerkships, then do your PhD before heading into back 4th year (this is part of the new curriculum at UW-Madison). This route makes a lot of sense to tons of people, but I really doubt that many programs will adopt this structure into the MSTP... the attrition rate would skyrocket!! Imagine if you had already gotten 3 years of free tuition + stipend and could bail and finish in one year... Other programs (Penn, Columbia, Cornell...) have a 1.5 yr pre-clinical curriculum and will have you do ~1/2 a year of clerkships before heading into your PhD.

Rationale:
1) Residency directors probably won't care too much if you publish in field-specific journals that they do not recognize or know of. If your research is relevant to their field, that should help your application. Unfortunately, it seems that MD-only students who come in with a year or less of field-specific clinical research (which is much faster to do, and much easier to publish) will have a significant advantage over MD-PhD students that spent years working on basic science projects in a distant field. Neuronix has posted extensively about this.
2) Depending on your bench research to clinical field transition, your skills can be extremely valuable or extremely worthless. If you did a PhD in structural biology, you can probably apply that to any clinical field. You wouldn't have a problem moving to field X and studying the structure of new and interesting protein Z. However, if you did your PhD in neuroscience with techniques like electrophysiology, those skills are extremely field-specific and labor-intensive. They probably won't serve you well if you decide you want to be an oncologist working on mechanisms of hematopoietic differentiation. Gaining expertise in a field that is at least peripherally related to where you want to be clinically is arguably a huge advantage.
3) If you have a good idea of what your clinical field will be during your PhD, that gives you the ability to select a mentor who is well established and respected in that field. It allows you to spend some time networking at conferences, and understanding what the dynamics of your field's politics are- who are the leaders, where are the best places for residency in your field, etc... Science is actually a pretty small and political world. These things could help you in the match.
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Well that's about all I can think of for now. Elders of the community, please correct me where I'm wrong! There is obviously no "right" way to structure the training. I am a bit older (will be 26 upon matriculating) and already have a lot of research experience, so I am very wary of spending too much time during the PhD that won't be useful towards my career. My plan to maximize the utility of the PhD is:

- Do as much shadowing during the first two years as possible (I have 2-3 fields I could see myself in at the moment), to hopefully narrow things down a bit.
- Rotate in labs with substantially different flavors (to keep options open as my clinical interests solidify)
- Choose labs/projects that are interdisciplinary. Ideally, I'll be able to find multiple fields of biology represented. E.g. immunology of Neuro-oncology, neuro-immunology of neurodegeneration, cancer-immunology, etc... To me, this keeps the science more interesting anyway!
- Work on a project that has some component of bioinformatics/systems biology. Computational and statistical skills are highly sought after and easily transferable to most fields. I really wish my undergraduate advising office had told me this a long time ago, as I would have spent more time acquiring some of these skills during college.

The last thing I'm thinking about I'm not so sure of, which is trying to do clerkships in the 2-3 fields I am interested in before starting the PhD. This would probably be easy to do at any of the schools with a 1.5 yr pre-clinical curriculum, and it is becoming more common for students to do 1-2 clerkships before PhD even at schools with the traditional 2-4-2. The benefits seem to be that seeing the wards might drastically shift me towards 1 of my 2-3 fields if all other things are equal as far as thesis labs. Another benefit would be the ability to spend a day here or there in the clinic of that specialty during the PhD years, improving/maintaining those clinical skills and hopefully being much better prepared for Sub-I / away rotations. However, the downside of this approach seems to be that these clerkships would necessarily be your first clerkships, and you might not get great grades. I have heard some program directors specifically advise students to save your "anticipated specialty" clerkships until after you have completed your PhD and been back on the wards for some time. So I am unsure about this one. Thoughts??

Yonderson, sorry for the thread hi-jack at the end, but hopefully most of this is relevant to your question.

 

[Ariodant]

2) Depending on your bench research to clinical field transition, your skills can be extremely valuable or extremely worthless. If you did a PhD in structural biology, you can probably apply that to any clinical field. You wouldn't have a problem moving to field X and studying the structure of new and interesting protein Z. However, if you did your PhD in neuroscience with techniques like electrophysiology, those skills are extremely field-specific and labor-intensive. They probably won't serve you well if you decide you want to be an oncologist working on mechanisms of hematopoietic differentiation. Gaining expertise in a field that is at least peripherally related to where you want to be clinically is arguably a huge advantage.

Patching is an extreme example. Most experimental techniques are not as complex/finicky as E-phys, and can be learnt in one month or less. Besides, after leaving your thesis lab, your skills get rusty very quickly. Technical proficiency is not the point of a PhD training, and plenty of PhDs switch fields in postdoc. I even know some MD/PhDs that went to do a postdoc/fellowship in a different field. Don't worry about techniques, your ability to complete projects, publish papers and obtain funding determines your success.

 

[MooseMan3]

Yeah, I used e-phys as an extreme example (although I do know MD/PhD students who are primarily focusing on this for their thesis). There is certainly variability from field to field, but I agree that the technical skills are not the most important thing to get hung up on.

Of course the things you mentioned (publishing/obtaining funding) are the most important. I'm not trying to make the case that whatever field you do your PhD in will automatically be what you have to spend the rest of your career on. Of course people can successfully switch fields, and many PI's "re-invent" themselves over the course of their career. Within the context of short-term as far as PhD-residency-early career transitions, it does seem that there are significant advantages to staying in a relatively similar field.

With regards to obtaining funding though, don't you think someone competing for a K award (or with a K award and seeking first R01) has a much stronger chance of getting funded if
1) They have a demonstrated track record of success in studying biological system X (the current grant is now on a different topic within the same system X)
2) They have a demonstrated track record of success in applying technique Y (which you propose to use in your grant)
3) They have connections with big names in the field (letters of support, possibly even listed as collaborators on the grant, or direct contacts within the residing NIH funding agency)?

 

[Neuronix]

Most experimental techniques are not as complex/finicky as E-phys, and can be learnt in one month or less.

I respectfully disagree. I have never worked in e-phys, but I have worked in several other experimental technique labs. In my PhD area of research, it takes a year or more to get proficient at what we do.

Besides, after leaving your thesis lab, your skills get rusty very quickly.

They do, but they come back. You are also considered an expert in that area, even if you are no longer able to perform the experiments yourself.

Technical proficiency is not the point of a PhD training, and plenty of PhDs switch fields in postdoc.

IMNSHO, the goal of MD/PhD and residency should be to train you so that you don't *need* a post-doc. You may have a research heavy fellowship for example, but you should not be spending 5 years in post-doc. Your fellowship also needs to be quite productive. You can't spend years in the lab 100% of the time letting your clinical skills atrophy while sitting in a post-doc or instructor position spinning your wheels into your 40s. The earlier your spinning wheels can gain traction, the better off you're going to be.

I even know some MD/PhDs that went to do a postdoc/fellowship in a different field. Don't worry about techniques, your ability to complete projects, publish papers and obtain funding determines your success.

There are many anecdotes out there. My anecdote is that I see a legion of MD/PhDs in their mid to late-30s without stable research-oriented academic jobs who are going to 80-100% clinical jobs. You should try to line yourself up as well as possible to get yourself the career you want. Doing a PhD related to your future clinical area isn't mandatory, but I argue that it makes it easier for you to get the residency you want and do the research in your field faster so that you can get the job and the grants you want.

Frankly, the more senior I get, the more I look at things this way. The whole world is stacked against us. Once we finish that MD/PhD training, we are fighting an uphill battle to keep doing research for the rest of our lives. Any one misstep makes it harder or impossible to proceed. The more you can strategize your research career and let go of anything that interests you outside that career, the better your odds are going to be of success. If this doesn't appeal to you, and if you're sane it shouldn't, don't do MD/PhD.

 

[Ariodant]

I respectfully disagree. I have never worked in e-phys, but I have worked in several other experimental technique labs. In my PhD area of research, it takes a year or more to get proficient at what we do.
They do, but they come back. You are also considered an expert in that area, even if you are no longer able to perform the experiments yourself.
IMNSHO, the goal of MD/PhD and residency should be to train you so that you don't *need* a post-doc. You may have a research heavy fellowship for example, but you should not be spending 5 years in post-doc. Your fellowship also needs to be quite productive. You can't spend years in the lab 100% of the time letting your clinical skills atrophy while sitting in a post-doc or instructor position spinning your wheels into your 40s. The earlier your spinning wheels can gain traction, the better off you're going to be.
There are many anecdotes out there. My anecdote is that I see a legion of MD/PhDs in their mid to late-30s without stable research-oriented academic jobs who are going to 80-100% clinical jobs. You should try to line yourself up as well as possible to get yourself the career you want. Doing a PhD related to your future clinical area isn't mandatory, but I argue that it makes it easier for you to get the residency you want and do the research in your field faster so that you can get the job and the grants you want.
Frankly, the more senior I get, the more I look at things this way. The whole world is stacked against us. Once we finish that MD/PhD training, we are fighting an uphill battle to keep doing research for the rest of our lives. Any one misstep makes it harder or impossible to proceed. The more you can strategize your research career and let go of anything that interests you outside that career, the better your odds are going to be of success. If this doesn't appeal to you, and if you're sane it shouldn't, don't do MD/PhD.

Most people don't study neurophysiology or radiology, and many techniques are not exclusive to one field, just saying. I'm a big proponent of following the path of least resistance and lining everything up to maximize chance of success. But if someone did the 2-4-2 pathway and changed their clinical interest after M3, they are not automatically at a disadvantage. The person I know who switched field is thriving and happy.

By postdoc, I meant fellowship/clinical instructor for MD/PhDs. The length varies with your success at getting a K. Most I know are 3-4 years, but I've seen longer ones. I must be the glass-half-full type, because although I agree it's disappointing to spend ~ 10yrs (counting undergrad) in research only to do 100% clinical, at least you can do clinical. The PhDs, on the other hand...

I just finished my PhD, and I'm certainly more pessimistic than before I started. I don't know if the world is stacked against us, but at least Congress is. If the funding situation deteriorates at the current rate, by the time I finish residency I may very well join the legion of MD/PhDs in your anecdote. It's not what the NIH wants to see, but the NIH has done little to change the trend. Given their stagnant budget, I don't entirely blame them.

 

[Fencer]

Neurophysiology and patch clamping are techniques that take years to master, and are techniques that are not going to go away.

Despite the doom-day forecasts, there are several major factors:

• PhD only training programs are decreasing enrollment - right-sizing future research workforce.
• Overall the national class of MD/PhD program enrollment is stable - no national increases or decreases.
• We still are spending over 30 billion dollars per year in NIH sponsored research plus over 15 from other funding sources.
• Current research faculty (tenured or not) are under greater pressures because: a) it is harder to get research grants, b) there are decreased cross-subsidies to support research, and c) increased accountability for research faculty (must produce substantial amount of salary from research or "else").
• Current PI workforce is getting older (crushing a group of people coming out from fellowship) but eventually will be phasing out (not fast enough for some) - you could blame statins and aspirin for keeping their brains/hearts working for longer .
• Opportunities will remain be available for some (but not all) resilient clinician-scientists, particularly in institutions with CTSA grants, which provide for mentoring programs to increase your likelihood of success.

 

[yonderson]

What about dental school? Just kidding. But seriously all this info is great. I am definitely thinking MD only just because I want to practice medicine more than be in the lab.