clinical rotations before vs. after graduate school

[specialflava]

Some programs have you do 6 months of clinical rotations before heading off to full-time grad school, while other programs wait until you're finished with the grad school portion entirely before you start clinical rotations. Does either system strike you as clearly better/worse? I'm curious as to what others think.

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[Neuronix]

This is always going to come down to opinion and I'm not sure one is clearly better. It's just like the teaching argument. Some programs require TAing and will tell you just how important it is for your future. Other programs don't require TAing and those will tell you what a waste of time it is.

I'm very glad I did 6 months of rotations before my PhD because it allowed me to settle on what residency I wanted to do. Going into clinics I wasn't sure, but the experience soured me on most of my top interests. If I went into my PhD not knowing what I wanted to do clinically, I wouldn't feel nearly as confident about merging my research interests with my clinical intersts.

Many will say "Well the goal of getting a PhD is general training". I'm not saying I disagree, but I think doing research in the future clinical area gives you a huge leg up not just for residency, but also for beyond. Then again, there's not so much of the usual cell and molecular biology in my area of interest. If you're planning going into IM, peds, or pathology (the top 3 MD/PhD specialties), all of what I said may not be so important because you can pretty much work in any cell/molecular biology lab and get the training you want.

Just between you and me (and everyone else in this forum), I'm beginning to think the best time to get a PhD is residency or post-residency. That's the logical extension of my argument anyways, and it makes alot of sense to me. But while we're on the topic, why not do the full year of clinics before getting the PhD? Oh yeah, because the drop out rate from the program will be too high. I guess the 6 month thing is a good compromise maybe?

 

[malchik]

Taking off to do a PhD in between M2 and M3, the way most programs do it, is the worst possible time. Any alternative is better. If I were designing a program, I would go with Neuronix's plan of doing it during/post-residency, or before M2. M1 stuff could be taken along with grad school classes the first year, then go and finish the PhD, then come back for M2/3/4. Some may say this means you're out of research for too long. But this is only one year more than the typical program. More to the point, it doesn't matter. If you're out of research for one year, you might as well be out for 6, you're still going to have to re-tool.

 

[greg12345]

I like doing the PhD between M2 and M3. I knew exactly what field I wanted to pursue my PhD in after M2, hence it was the best possible time for me. I like having all my clinical training in one chunk, plus it is logistically easier in my opinion and the least painful way to go about it. A PhD during or after residency is pretty crazy in my opinion b/c your clinical knowledge would seriously deteriorate, unless you did a half-day in clinic every week like fellows do. But then you are trying to keep up with 2 sets of literature, etc. If you split up M1 and M2 then taking Step 1 might be painful. The best option would be for MSTPs to be flexible and let individual students tailor when they do their PhD (e.g. after M2, after 1/2 of 3rd year is done, etc.) to best suit each individual student's needs. I can certainly see how doing 6mo of 3rd year could be helpful, but it wouldn't have been helpful for me at all.

 

[jjmack]

I agree with this model of training. I know a lot of schools are starting these programs.

Just between you and me (and everyone else in this forum), I'm beginning to think the best time to get a PhD is residency or post-residency. That's the logical extension of my argument anyways, and it makes alot of sense to me. But while we're on the topic, why not do the full year of clinics before getting the PhD? Oh yeah, because the drop out rate from the program will be too high. I guess the 6 month thing is a good compromise maybe?

 

[Neuronix]

I agree with this model of training. I know a lot of schools are starting these programs.

There are two things this pathway will need that I don't know are being met:

1) Loan forgiveness. What is really needed is full loan forgiveness for medical school. Some of the awards are $35k/year for a max of two years, but this isn't even close to the debt of many medical school graduates. It needs to be clear that after 4 years of PhD, your debt is gone, even if your debt is $250k or more.

2) Total or near total absolution of clinical responsibility during this time AND a serious, thorough PhD taking on average 4-5 years.

 

[Dr.Watson]

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[Vader]

There is no generalized "optimal" training sequence. As greg mentioned, each student has individual goals and perspectives that require individualized strategies.

That being said, I think one thing I would have done differently is to have done a clerkship before starting grad school. Done this way, you are fresh with knowledge from boards and you could ramp up quickly to 3rd-year level. Then I would try to do a half-day bi-weekly clinic, working at 3rd-year level (i.e. interviewing patients, presenting to residents/attendings, writing up notes).

Done this way, it won't be such a steep learning curve when you ultimately finish up grad school and transition to 3rd year clerkships. Plus, a half day every other week wouldn't be taking too much time away from your PhD work.

 

[hawkeey]

One of the things you might want to consider is the possibility of moonlighting during some parts of your PhD. If you done a psych or neurology rotation, you might be able to work a night shift for a few hours doing something clinical.

 

[strangeglove]

One of the things you might want to consider is the possibility of moonlighting during some parts of your PhD. If you done a psych or neurology rotation, you might be able to work a night shift for a few hours doing something clinical.

I hope you don't mean moonlighting as a medical student. Moonlighting, the way most people define it, is done by licensed physicians (i.e. passed Step 3). Of course, it is a great idea for MD-PhD students in their PhD years to keep up their clinical skills by seeing patients in the capacity of a 3rd year medical student. There are some programs that have such ongoing clinical experiences built into their curricula.

 

[PTPoeny]

In a sort of related manner, a student in my class was at a conference last weekend and there was a presentation by a guy who was presenting a plan to change step 1 and 2 CK to a combined test designed to be taken after third year. I googled and perused the AAMC and AMA websites but could only find vague references to the fact that they are "considering an overhaul" of the USMLE system not to go into place before 2012.

The student in my class said that he presented it in a manner suggesting that the change had already been approved on some level and they were just figuring out how to implement it and how to weight clinical vs. basic science knowledge. As a caveat, she could not figure out who he was or what organization he was representing. So this may be just some guys idea on how to improve medical education.

I think this would change a lot of programs to M1 then PhD then M2, 3, 4. I think this would be good for removing the time limit but it would also make it harder for people to be sure what clinical field they want to be in.

Has anyone else heard anything about this?
Any other thoughts on how it would affect MD/PhD?

 

[hawkeey]

I hope you don't mean moonlighting as a medical student. Moonlighting, the way most people define it, is done by licensed physicians (i.e. passed Step 3). Of course, it is a great idea for MD-PhD students in their PhD years to keep up their clinical skills by seeing patients in the capacity of a 3rd year medical student. There are some programs that have such ongoing clinical experiences built into their curricula.

Well moonlighting isn't specific to medicine, it's just doing another job at night than you do during the day.

I admit I'm a little fuzzy on this though, but there is apparently an opportunity for students who have completed a psych clerkship to see patients as a 3rd year medical student at the county hospital next to the medical school. I guess they are just that short-handed. As far as I can tell, the students would be doing the initial interview independently. I feel pretty good about doing a psychiatric interview and doing a mental status examination as a first year student, so this seems reasonable to me.