A Clinician Scientist attending answering questions

[Fencer]

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[happygoluck]

I will be joining a program after being out of school for four years.

Although there was a brief discussion regarding matriculation age and MD/PhD Programs -- I want to know your perspective on what limitations this may bring (if any..?). Basically, what kinds of difficulties/limitations can one expect as a 'late-bloomer' and how can one best prepare for those (mental, physical,social) obstacles?

I realize four years out may not be that old to start, but I'm noticing people my age already going on to residencies... and cannot help but feel a little behind? Think it would also benefit others that may feel like they're in a similar position -- would welcome anyone's thoughts...

 

[tiedyeddog]

Any words of wisdom you can give on raising a family and keeping a marriage healthy during this process? Did you have any pressure from your family to go into private practice for the big(ger) bucks?

 

[LaEsponja]

Do you have any personal experience with DO/PhDs?

I'm also a non-trad and believe I may have found my niche with this path, but have reservations about starting so "late" as I will be 29 upon matriculation.
Thanks for answering questions- this thread is amazing!

 

[Fencer]

... discussion regarding matriculation age and MD/PhD Programs -- I want to know your perspective on what limitations this may bring (if any..?). Basically, what kinds of difficulties/limitations can one expect as a 'late-bloomer' and how can one best prepare for those (mental, physical,social) obstacles?
.... I'm noticing people my age already going on to residencies... and cannot help but feel a little behind? Think it would also benefit others that may feel like they're in a similar position -- would welcome anyone's thoughts...

The professional lifetime expectancy for a MD/PhD student enrolling now is about 12-15 years of training followed by 28-35 years of faculty career. Most MD/PhD students entering a class this summer would be 22-25 years of age. That means that expected age for 1st faculty appointment would be at age 34-40. Expected retirement would be 68-72.

Pursuing and staying as a practicing clinician scientist requires passion for doing science but also a clear realization that your lifetime income will be spread out over those 28-35 years of practice. In addition, during the first 10-12 of those years, your salary will be below the NIH cap. As programs get measured by the number of graduates in academia (i.e.: academic retention of their students), the calculation that is made by program directors is that older individuals will have a lesser incentive to stay in science or academia.

Having said that, when I was chief resident (at 33), one of my junior residents was a 52 yo woman who eventually became a primary practitioner at age 55. She was a very fine resident, but clearly academic medicine was not going to recoup her medical studies.

 

[Fencer]

Any words of wisdom you can give on raising a family and keeping a marriage healthy during this process? Did you have any pressure from your family to go into private practice for the big(ger) bucks?

You have to be very open about the time demands of your studies and research. We had to compromise many times. I was one of the soccer coaches of my kids, and it was difficult. Right now, I have 2 private college tuitions, and I am losing rather than earning money. Overall, you need to be incredibly efficient with time and money. Live within your means. I am not a neurosurgeon, this is the career that I chose. I am concerned about when I will be able to trade cars, repair the house, etc., but I wake up thinking all of wonderful things that I need to do today. I love it!

Communicate with your partner. It becomes more stressful if you don't.

 

[Fencer]

29 is not too late... You have had other experiences of value, but given your age, focus, focus, focus... You should try getting your PhD in 3 years, or 4 at the most.

DO/PhD, no experience, but 2 of my best clinical fellows were non-traditional DOs (one was also an astronaut).

 

[tiedyeddog]

Frist off, I want to say thanks so much for doing this. This thread has been just amazing for me.

Can you comment on the time to completion vs. amount of work done during the PhD years? Did you have a set amount of years you really wanted to spend on your PhD (like three or four years) or were you more set on publishing great data in great journals?

What's the best efficiency between those two factors? Much better to stay another year or two and add two or three more first authors to your name before heading back to third year?

I guess, in essence, my question is what is a good PhD and how much does it help later on when gunning for faculty positions?

 

[Fencer]

Papers is what counts... The Dean does not know your science, but knows how to count papers. However, the Dean recognizes very well High Impact Journals (Science, Nature, Cell, PNAS, etc.).

It is a tricky balance for sure. If you are certain that you will get 3 more papers staying in the lab for 1 more year, keep riding the wave. If it is uncertain, you might want to keep the shorter route. In the big picture, an extra year is almost nothing and it will ensure a higher appeal for residency and faculty positions (as long as you got 1 more good paper). You should also use your background/significance for a review.

 

[bored]

do you focus your career on your job to help people? or on your job as a researcher?
also, is the research type mostly applied research (ie drug related) or are there clinicians that have the ability to carry out basic research?

 

[Fencer]

I do 25% bench (animal models of disease - physiology, anatomy, molecular), 10% clinical research (health care outcomes, trials, clinical observations), 40% clinical care (clinic, diagnosis, procedures), 25% teaching/admin. Not your usual clinician scientist person. In my 15+ year career as attending, I have been 75% research / 25% clinical, but for the most part 50/50. Now, as I said before, this is highly inefficient, but I love doing that mixture (and they have kept paying and promoting me!)

 

[98md]

@ Fencer, Currently, I am an junior in engineering at a top 10 school considering a MD/PhD program. I have 39 MCAT and a 3.7. I am also a 18 yr old female who wants to start a MD/PHD program right after UG. Ended up junior due to grade skips etc. I have a solid research experience in tissue engineering for three years in a single lab now. Will be published before I am done with UG. I have other research experiences in summers that include immunology, vaccine research etc. I am looking for your advice on the following,
1.% female in MD/PhD is a lot lower than MD only. Is there a reason for this?
2. Are there any unique roadblocks for females as a Physician scientist or MD/PhD student?
3. Are there programs that are more receptive to females than others?
4. Any general advice that you might have would be very appreciated.

Thanks

 

[erikreinertsen]

I do 25% bench (animal models of disease - physiology, anatomy, molecular), 10% clinical research (health care outcomes, trials, clinical observations), 40% clinical care (clinic, diagnosis, procedures), 25% teaching/admin. Not your usual clinician scientist person. In my 15+ year career as attending, I have been 75% research / 25% clinical, but for the most part 50/50. Now, as I said before, this is highly inefficient, but I love doing that mixture (and they have kept paying and promoting me!)

I apologize in advance for this being a vague question, but how would you define efficiency, and on that note, success? Surely an MD/PhD that devoted 100% of his time to bench research would achieve more in the lab. Likewise, a pure clinician could help more patients than one split between lab and clinic. But the ideal of the MD/PhD is that a synergy exists between these two realms.

To me, an inefficient MD/PhD means out of balance, and not fully realizing this ideal, e.g. patient care is too demanding to allow for sufficient research on relevant disease, or research is taking up too much time to maintain clinical skills / relevance.

While I realize "to each their own", why would you love your current inefficient setup if it is not allowing you to attain maximum results, help the most patients, and progress furtherest scientifically? Long question short, why do you have things the way they are? What would you change?

Also, is it usual for MD/PhDs to receive some sort of exposure to clinical research throughout their program? I feel like the emphasis of most journal clubs is on rigorous bench research, and clinical case conferences are on mechanisms of disease and individual cases rather than topics like study design and statistics.

 

[Fencer]

The hard drive of my laptop got corrupted a little over 2 weeks ago. Our University requires an arcane encrypting software that makes them unusable. I fortunately had kept my image file that was last saved at the end of April. I only lost 2 weeks of work/documents/etc, enough for significant disruption. Getting back to answer some of your questions and PMs ...

 

[Fencer]

...
I am looking for your advice on the following,
1.% female in MD/PhD is a lot lower than MD only. Is there a reason for this?
2. Are there any unique roadblocks for females as a Physician scientist or MD/PhD student?
3. Are there programs that are more receptive to females than others?
4. Any general advice that you might have would be very appreciated.

98md,
Congratulations on your academic achievements!
1) A MD/PhD career requires a greater "time commitment" from students. Whereas women are over 50% of MD matriculants, they only constitute close to 40% of MD/PhD matriculants. Perhaps, because of this greater time commitment (i.e.:MD/PhD training plus the required subsequent GME and/or post-doct training) some women might foresee conflicts with their own "biological clock". There are MD/PhD programs that have better and more supportive environments for women, but the most important person is the support of your partner/spouse and family. Our program has a 54% women with 8 babies. In general, those MD/PhD students who are mothers and fathers are more driven and have better time-management skills (they must!).
2) Yes, there are perceived and a few real roadblocks along the way. There is a great chapter on the book "The Vanishing Clinician Scientist" written by women clinician scientist for women in training. The major issue is expectations to be equal in productivity, committee and clinical service, while there is a societal and sometimes personal need to play a major role raising a family. Diversity means that we are different, and that we bring different perspectives to the table. Institutions are adapting, creating better support networks for women, but still there is a lot to be done. Fortunately, there are support groups that mentor women through these challenges.
3) Yes. Talk to students when you interview, but specifically ask about female students with children. Those will be the most perceptive students because they keep testing those support networks. PM me.
4) You are going to have many choices.

 

[Fencer]

...

While I realize "to each their own", why would you love your current inefficient setup if it is not allowing you to attain maximum results, help the most patients, and progress furtherest scientifically? Long question short, why do you have things the way they are? What would you change?

Also, is it usual for MD/PhDs to receive some sort of exposure to clinical research throughout their program? I feel like the emphasis of most journal clubs is on rigorous bench research, and clinical case conferences are on mechanisms of disease and individual cases rather than topics like study design and statistics.

I use the term inefficient or efficient in regards to scientific or clinical productivity (i.e.: publications vs patients). At the lower level of abstraction, the easily measurable is number of those, not so much quality. Your point is very sophisticated... I could argue that it is better to have 20 publications with 100 citations each, rather than 100 publications with 20 citations each. Citations are one easily measurable unit of research quality, by it is far from ideal. The example of 20/100 vs 100/20 might be interpreted as an example for "this synergy" between bench and bedside vs incremental knowledge from bench scientists. Clinical excellence is even harder to measure. Is it number of patients or RVUs, claims/lawsuits per physician, waiting list time for your clinic, inclusion in the Physician list of US News & World Report, or being name Fellow of your professional society. Ideally it would be about clinical or research outcomes.

Regarding your second question, it is not common to get clinical exposure during graduate years of training in a MD/PhD program. In my program, last year, we required one half-day per week of clinic for 10 weeks during the Spring semester of their PhD training. The universal response from the PhD mentors was not enthusiastic at onset. After the first Spring when we did that, the PhD mentors change 180 degrees. They felt that their MD/PhD students were more driven and had a greater sense of purpose after that small clinical experience.

 

[erikreinertsen]

Fencer, thanks for the detailed response! I hope things are okay with your laptop.

EDIT: Elaboration on my second point - I meant moreso clinical research than just clinical experience. I'd love to have some clinic time but I think some understanding of clinical trial design and execution would be valuable for MD/PhD training, right?

 

[Fencer]

Fencer, thanks for the detailed response! I hope things are okay with your laptop.

EDIT: Elaboration on my second point - I meant moreso clinical research than just clinical experience. I'd love to have some clinic time but I think some understanding of clinical trial design and execution would be valuable for MD/PhD training, right?

An excellent point. The science for serious clinical research is not taught in traditional bench PhDs. Clinical trial statistics and design are different. One development sponsored by NIH is an alignment of MSTPs and CTSAs. CTSAs are creating courses, certificates, Master's and even PhD's in Translational science (TS). These educational offerings are been recently added as optional experiences to the MD/PhD programs in CTSA institutions. In my program, you can add a certificate of TS, which amounts to 12 credit hour courses (along the 7-8 years of training) or pursue a formal PhD track in TS. In the past, most MD/PhD graduates learnt about the science of clinical research during their residencies or fellowships. In my view, the average MD/PhD graduate should come out with 4-6 pubs: 2-3 bench original 1st authors, 1 review (background/significance of thesis), and 1-2 clinical research projects during MS 3-4. That is a diversified scientific portfolio.

 

[StIGMA]

In my view, the average MD/PhD graduate should come out with 4-6 pubs: 2-3 bench original 1st authors, 1 review (background/significance of thesis), and 1-2 clinical research projects during MS 3-4. That is a diversified scientific portfolio.

How many publications in each category is typical? If you pubmed the names of MD/PhD graduates among top programs, you may find a significant number of students do not have even a single first author paper. I certainly have not noticed 2-3 first author basic science papers as the norm- maybe 1-2 students per year in a 10 student program accomplish this 'average' goal, while the majority have 0-1 first author publications. Do a significant proportion of graduates finish without a single first author pub from the PhD, and if so, how common is this?

 

[Fencer]

How many publications in each category is typical? If you pubmed the names of MD/PhD graduates among top programs, you may find a significant number of students do not have even a single first author paper. I certainly have not noticed 2-3 first author basic science papers as the norm- maybe 1-2 students per year in a 10 student program accomplish this 'average' goal, while the majority have 0-1 first author publications. Do a significant proportion of graduates finish without a single first author pub from the PhD, and if so, how common is this?

This is looking back, 5 years after graduation. Many students begin projects that eventually get published while they are in residency. Bottom line, that is the idealized graduate. You are correct that many students graduate with one or no publications. Their work is done and they (and their program) have a time clock ticking. However, if they intend to move up into science, they eventually wrap up their publications that led to their PhD thesis. Personally, I published my last paper with a small portion of PhD work 10 years later (however, that was my 12th paper related to my PhD thesis, and there was substantial amount done post-PhD).

 

[RagingBeauty]

Great information, Fencer! Thanks for sharing your experience.

 

[erikreinertsen]

In my view, the average MD/PhD graduate should come out with 4-6 pubs: 2-3 bench original 1st authors, 1 review (background/significance of thesis), and 1-2 clinical research projects during MS 3-4. That is a diversified scientific portfolio.

And also an admirable goal to strive for, at least on paper. Not that you can fully control how successful your projects are... but would you suggest MD/PhD students get involved with a clinical project on the side of (but preferably relevant to) the main bench work? I feel like this is an obvious and necessary thing but not really mandatory in most programs.

 

[KevAquarius]

Hi Fencer! Would you encourage MD/PhD graduates to specialize in a field of medicine? Do you think this would make for a more effective physician scientist?

 

[Fencer]

Hi Fencer! Would you encourage MD/PhD graduates to specialize in a field of medicine? Do you think this would make for a more effective physician scientist?

Absolutely... the most effective physician scientists (as determined by translational measures - bench to bedside to bench) are those who study mechanisms of disease at the bench and bedside. Diabetologist clinically and at the lab, Cancer biologist, etc. In my case, it is Epilepsy.

 

[Underarchiever]

The current funding situation makes a MD/PHD a high risk investment. I see majority of the young physician scientists struggling in our department. Even the seasoned PIs lose their RO1 renewals. It is tough to advise people geting into this trap: Half the pay of private practice, and far-off the hope of tenured.

I have to point out that most employers or study sections will only look at the first author papers if you look for your first job or first grant. The others are more or less CV stretchers.

 

[Fencer]

Although you are an attending, you might be missing the time perspective that I have. Over the past 25+ years, I have seen other times when people were discouraged because of poor funding. Forward to today, our economy is not looking good and jobs (within academia or outside in private practice) are scarce. Practices are fearful due to health care reimbursement declines, and academic centers no longer subsidize research from clinical revenue. Inflation adjusted earnings are going to be less no matter where you are. Are you investing, getting loans to push for MD school, or are you getting a subsidized MD PhD education with a PhD in 3-4 years. Even after graduation, professional life expectancy is over 30 years. Do you want to do/work doing what makes you happy, or is that pursuing the buck (Wall Street is better than Medicine for this purpose)?

 

[Underarchiever]

When I look back at those fellow residents with MD/PHD 30 years ago from a top 5 training program in the country, majority of them have fared quite poorly. None become RO1 funded investigators. They are just practicing medicine in academic centers, doing routine clinical work, and have no lab. I don't know what they do is different from the private practice. When somebody's career path is stagnant, I don't know how he/she could be happy. Worst of all, I also find some bright physician scientists at the time not geting tenure, being forced out, and complelely disapppearing from the medical literature world. Those guys were so involved in research and specialized, their clinical skill is simply not up for private practice.

That said. I do think MD/PHD training having an edge over MD only, especially for increasingly evidence-based medicine in the next 20 or 30 years. You are so upbeat on physician scientist track. I just need to balance the atmosphere a little bit and inject some cold reality here.

 

[Fencer]

I have enjoyed the ride so much, and have been promoted, tenured, and remain funded. Although I got offered jobs at a top 5 medical school, I decided on joining schools in the 40 - 60 (out of 136 schools) over the last 20 years. I disagree with your point on MD/PhDs not having an edge over MDs. In fact, as you might be aware the age to 1st R01 is same for both groups, and the number of MDs applying are diminishing while MD/PhD are raising. Furthermore, if I am a chair and will be committing my scarce resources for 3 years to support a young assistant professor, I would favor a MD/PhD over a MD. MDs are being hired to support the clinical mission of the departments. As greater accountability for time is been implemented, MDs trying to do bench are facing tougher challenges. I am not saying this is easy, but it can be a very enjoyable ride.

 

[flyers]

I pm'ed you Fencer

 

[Underarchiever]

Fencer, please read my post carefully. I said clearly that MD/PHD has an edge over MD-only in evidence based medicine. Geting a RO1 is probably not sufficient to gain tenure in top 5 medical schools. They demand leading role in science. Since the bar is set very high, many good people fail in these institutes. Indeed, taking a job in a lower rank school is a good decision since they are less pushy.