GME Funding Cuts

DhPDM said:

Obviously, the number of residency spots is already limited, does anyone know the stats on md/phd's who end up not matching into the specialty that they did their phd in?

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See the NRMP publication "Charting Outcomes in the Match". There are releases based on data from 2011, 2009, 2007, 2005 at: http://www.nrmp.org/data/historicalreports.html. The data includes numbers of PhDs that did not match overall and by first choice specialty.

I am planning on doing the phd in a very competitive field and would hate to not match into a residency related to my phd.

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The real problem currently is that medical schools are opening and expanding class sizes while the number of residency positions has held mostly flat. Currently, IMGs are feeling the squeeze as their match rates fall, but AMGs feel this as increased competition in every measured factor of competitiveness. I wrote a paper about this, and am in the process of trying to get it accepted.

Any other thoughts on how this new budget plan may affect md/phd students?

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My concern is not that the overall number of residency positions will fall (though it could happen), but more that the number of residency positions will not increase while medical school positions increase, further increasing competition. As I've repeatedly stated, the most important things for all applicants, including MD/PhDs, is class rank and step scores, and they've been rising very quickly for ALL specialties, and may continue to do so. The conventional wisdom for MD/PhDs has been to "take it easy" and your MD/PhD will get you whatever residency you want, but this is not true.

Once you are in residency, the programs may have less money per resident for training. This may translate into less protected research time as programs use their residents to generate more clinical revenue by doing more clinical work. This would make it even harder to build the CV to obtain a mostly research faculty position, further lengthening training time. Obama's proposed budget also leaves the NIH budget flat, which further drags on the terrible funding environment for biomedical research.

DhPDM said:

Is it true that slots are not being cut? My assumption was that cutting funding added pressure to the residency programs to cut slots as well.

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My understanding is that the number of positions is controlled by the specialty boards. The question is whether those positions the residency programs are approved for will be funded 1:1. The other possibility is that programs will be approved for more positions, fill those positions, and just take less money from the government per resident. My thought is that programs will simply stretch their funding more thin if the GME budget is stagnant or falls. I just can't see many programs removing residency positions entirely. That said, what we've been seeing in the Transitional Year world is that TYs aren't as clinical revenue generating as categorical residents or fellows or even just IM or surgical prelims, and so TY programs have been falling by the wayside. I have certainly used my TY time to work on several research projects as well as perform electives that my categorical programs requires, thus giving me more research time as a categorical. I do not feel this would have been possible in an IM prelim.

I would consider persuing a less specialized thesis project if my chances of matching into a residency related to my research were cut in half. I'm just trying to be practical and plan ahead.

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I think you should name that specialty and backups of interest, frankly. I recommend those thinking about rad onc vs. med onc to just do rad onc research. It's not that competitive to get a good IM position and transition into med onc as an MD/PhD, but it's extremely competitive to get that rad onc spot. Meanwhile, rad onc mostly only cares about rad onc research. But for surgical subspecialties, surgical subspecialty research may not be very impressive to IM if that's your backup. Though, I'd still probably recommend you aim high and know your med school performance is most important.

I don't personally know of any md/phds that didnt match into their top choice specialty, but I was curious if these stats are available.

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I know several. We had four MD/PhDs not match in one year--one went on to not match a second time and went to post-doc, one switched specialty, another matched prelim and moved into categorical, and I'm not sure what happened to the fourth. What we really don't know is how many MD/PhDs were talked out of applying to their top choice specialty because it's thought they couldn't match in it. I know several of those too, but they would never admit it outside of close personal friends, and there is of course no such data. That said, the PhD can only help you match to academic programs, just do well in med school on top of it.

gbwillner said:

Only problem with that is that it may be hard to be successful as an investigator if you are not that interested in the research.

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Obviously that is true. I would never tell someone to go do research they're not interested in. This is the case of someone trying to decide between different areas of oncology. If this is the case, then they would have interest in rad onc.

A lot of Rad Onc research can be very limiting and not too creative. OK, maybe I don't have the best personal experience, but of my 3 MD/PhD friends who when into RadOnc, only 1 even considers doing research anymore. The reasons they gave for giving up on the research path was that they felt that the only kind of research they were allowed to do was boring. Plus, why be bored in academia for $200K, when you can get a job in PP out of training that pays more than twice that?

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I take some offense to the idea that my research is limited and non-creative. I used to hear it for my work in radiology research as well. I also used to hear nonsense like it's too hard to get it published in mainstream, big name journals. Personally, I find running gel after gel to look at random protein interactions to be boring and non-creative. I have always found what I do to be incredibly interesting and challenging, and would be happy to share details of that in private.

Conversely, I know several people who have gone into the traditional MD/PhD fields and have little interest in research. That said, why live on anecdotes, when we can see the data from Brass et al. See table 3: http://journals.lww.com/academicmed..._PhD_Programs_Meeting_Their_Goals__An.35.aspx
Radiation Oncology has a higher percentage of graduates in academics than internal medicine and is really in same tier as other MD/PhD stalwarts like psychiatry, neurology, and pediatrics.

As for the argument about whether it's worth it to turn down a 2-fold increase in salary to stay in academics, I agree. It's a challenge. Why should you stay in academics fighting for very limited funding, accepting less vacation time, more hours, less job stability, and much less pay?

To avoid temption, should you restrict yourself to a crappy job market by going into a specialty where you have no private practice options to limit your own temptations? I would argue that you should have a good clinical backup in case you decide you don't want to do research down the road or your funding dries up. But this is a personal decision. I find it silly to avoid specialties where you may have a lucrative career in private practice because you might choose that over a research-based career. There are many research-based positions available in radiation oncology as well as a research-residency track called the Holman Pathway, if you choose to work for them.

In the end, all specialties should be chosen based on interest. I am a physics, tech-oriented person, and for me I chose the most high tech, physics oriented specialty I could. No matter what specialty in medicine you choose, there will be research opportunities if you decide the sacrifices for a physician-scientist career are worth it for you.