Doing core clerkships before graduate work

[vasovist]

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There's a number of institutions where MSTP students do their core clerkships before they start their graduate work - Duke and Vanderbilt come to mind (1 year preclinical) and other places like UT-Houston (3 years of medical school completed before graduate work begins).

Can any students of these programs comment on advantages/disadvantages of this route vs. the traditional preclinical phase-graduate phase-clinical phase route?

Is there better continuity with their clinical experiences during their graduate phase - for example, being able to have a more active role while shadowing physicians in their clinic or while volunteering at student-run clinics during the graduate phase? Logistically, would students of these programs have to request recommendations for residency before the graduate phase begins?

 

[Fencer]

My program has an integrated curriculum with one 8 week clerkship prior to step I and the formal beginning of graduate school. During the graduate phase, students still do once a year a non-graded specialty rotation based upon their PhD research. Then, there is an intensive 2-week boot camp in the June prior to starting their MS-3. These strategies to keep the integration between clinical experiences and scientific inquiry is not unique. Many MSTP and MD/PhD programs are adopting these ideas, or at least, that is what it seems based upon presentations and posters at the national MD/PhD directors' meetings.

 

[ratherbefishing]

There was a thread on this recently with some good comments on the different tracks. In the end, I don't think it matters all that much what order you do it in.

 

[StIGMA]

Strictly speaking about clinical training, it is better for clinical training (M3/M4) to immediately precede residency. Interrupting clinical training with a 3-5 year hiatus should intuitively be less than ideal. If you have a strong personal preference to have earlier clinical training to inform your project (such as if you are working heavily with patients), then earlier clinical training may assist your project. For most people, this is not the case.

Many programs have the model that Fencer describes- there is early introduction to clinical medicine, and the bulk of M3 follows the PhD. This is a good model.

 

[sakata8242]

We have the option here of doing up to 8 weeks of M3 rotations prior to joining the lab. A number of fellows opt for this for a couple reasons
- to stay with their classmates/friends for a little while longer;
- to get a rotation they are set on excluding from career options done and out of the way;
- this option also allows for greater scheduling flexibility when returning to 3rd year several months late into the year, which is common for MSTP fellows. Having the 2 month "cushion" can help mitigate or eliminate any "bleed over" of 3rd year clerkships into early M4 year and free up those first few months for career electives. I didn't take this option and was kicking myself when I returned to the wards as I came back 3 months late. That meant I lost 3 months of elective time before ERAS apps opened for submission.
- For fellows who do opt for this AND return to third year on time, they can usually ask to be reassigned to a rotation track that allows them to essentially finish M4 year 2 months earlier

 

[Shifty B]

- this option also allows for greater scheduling flexibility when returning to 3rd year several months late into the year, which is common for MSTP fellows. Having the 2 month "cushion" can help mitigate or eliminate any "bleed over" of 3rd year clerkships into early M4 year and free up those first few months for career electives. I didn't take this option and was kicking myself when I returned to the wards as I came back 3 months late. That meant I lost 3 months of elective time before ERAS apps opened for submission.

I've heard this argument before, but if you do clerkships before starting your full time PhD work you are delaying the start of your PhD as well. So, if you started 2 months later, you would have come back 5 months late (assuming your PhD took the same amount of full time months).

In general, I don't think it makes a whole of sense. If you come back late, you have fewer clerkships of experience than the other medical students you are being compared to, making it that much harder to get those honors which can be much needed for some specialties. That said, I don't think doing 1-2 months before starting your PhD makes any appreciable difference either way.

 

[Elixir6]

I have to agree with Shifty B on this one. Though in defense of the other argument, we all know that because people tend to procrastinate and also research is never inevitably finished (you can always do just one more experiment ) that taking two months from the beginning of the PhD is not equal to the last few months. However, if you start late your PhD late, well you will be behind. Maybe if its a mouse project, some breeding can happen during that time? I tend to think its easier to come back to the clerkships having done your PhD and matured as a person. I feel like a lot of life things happened to me during my PhD and the thick skin I've built will help me ace the clerkships in ways that I wouldn't have been able to have known a few years ago. Moreover, advice trickles down to you over the years so that you are more savvy about the clerkships than before. Also, I have tutored certain subjects and know them much better than I did even before I took Step 1.

Something good to do if your school has it might be a longitudinal clerkship in something like family medicine that can be one day a week for several months. This will help with easing back to med school.

 

[sakata8242]

I've heard this argument before, but if you do clerkships before starting your full time PhD work you are delaying the start of your PhD as well. So, if you started 2 months later, you would have come back 5 months late (assuming your PhD took the same amount of full time months).

While you may technically start your PhD later, I don't buy that you're losing any significant time towards your PhD, unless you've already made significant progress towards it in a previous rotation or as an undergrad. In which case you might even argue that you have some time to take a couple months off anyway. The first 2 months of your PhD are not particularly productive with regards towards your thesis when you're just starting your project. It's really no different than doing an extra 6 week lab rotation after 2nd year before officially joining a lab.

In general, I don't think it makes a whole of sense. If you come back late, you have fewer clerkships of experience than the other medical students you are being compared to, making it that much harder to get those honors which can be much needed for some specialties. That said, I don't think doing 1-2 months before starting your PhD makes any appreciable difference either way.

The whole point is to provide more flexibility so that you are LESS LIKELY to come back late. Regardless, MSTPs are at a disadvantage anyway because of the 4-5 years in lab, not because of 1 or 2 months.

It's more about scheduling and flexibility (potentially) during 4th year, not about clinical knowledge or getting honors during 3rd year. At our institution there is no elective time until 4th year, which starts in May. That normally gives you ~4.5 months for subIs and electives for letters and career exploration before ERAS opens. Any 3rd year rotations missed because of a late return are made up at the beginning of 4th year. Potentially losing even 2 of those months as a result makes career exploration, letter hunting, and general scheduling that much more difficult and less flexible.

Choosing a split 3rd year can really only help you; there aren't that many major disadvantages. Our program has been offering this option for the last 7 years and it's been received very well.

 

[solitude]

It's more about scheduling and flexibility (potentially) during 4th year, not about clinical knowledge or getting honors during 3rd year. At our institution there is no elective time until 4th year, which starts in May. That normally gives you ~4.5 months for subIs and electives for letters and career exploration before ERAS opens. Any 3rd year rotations missed because of a late return are made up at the beginning of 4th year. Potentially losing even 2 of those months as a result makes career exploration, letter hunting, and general scheduling that much more difficult and less flexible.

Choosing a split 3rd year can really only help you; there aren't that many major disadvantages. Our program has been offering this option for the last 7 years and it's been received very well.

I am not sure what you are saying here, and there seems to be a lot of confusion in this thread. What it boils down to is that any time spent doing clerkships prior to PhD will mean more time tacked on to the end of PhD, so you end up going back late to 3rd year. I personally have never witnessed somebody do clerkships prior to the PhD and then start MS3 year at the exact same time as MD-only MS3s. There is something psychological about "having already done clerkships" that makes people drag out their PhD, so they SAVE NO TIME.

So then the issue boils down to just a few things:
1) will your experience in one or two MS3 clerkships help during your PhD? I think this one is very easy. The answer is no.

2) will starting one or two MS3 clerkships at the same time as your MD-only classmates help you at the beginning of your mini-MS3? The answer is no, because you are on an equal footing, just coming off of MS2.

3) will starting the remainder of your MS3 clerkships late, with a 3-5 year hiatus from any prior clinical experience (save half day shadowing and the like done during the PhD), help you or hurt you during the bulk of your MS3 year? This one is also easy--it hurts a lot. I hear a lot of MSTPs complain that "it's so hard to do well in MS3 because we're so far removed from MS1-2 and clinical knowledge.

Ladies and gentlemen, the solution is to start MS3 when everybody else does, and then work your ass off, reading twice as much every night when you're dead-tired, to catch up on your knowledge. If you do this, coupled with your - let's face it, superiority relative to MD-only students at studying and retaining knowledge - and your maturity, owing to age, which the members of your clinical team will appreciate, you can absolutley excel in MS3 as an MSTP. HOWEVER, if you come back 1-2 clerkships behind, it is almost impossible to pull this off. It took me two of my six clerkships before I could really shine. Had I been two clerkships behind, I would have been nearly done with MS3 before I started to pull ahead of my classmates and start raking in the Honors. As it stands now, I'm all set for AOA.

Thus, I would very strongly caution against doing any clerkships prior to starting your PhD. I would also caution very strongly against starting MS3 even one clerkship late. For some people, particularly those without the motivation to bust their ass as an MS3, it may even make sense to extend their PhD an additional 10 months so as to start MS3 on time with other students. Of course, this all presumes that you want to get Honors, etc. in MS3. If you are planning on Peds, Path, or post-doc, then it's moot.

 

[sakata8242]

I am not sure what you are saying here, and there seems to be a lot of confusion in this thread. What it boils down to is that any time spent doing clerkships prior to PhD will mean more time tacked on to the end of PhD, so you end up going back late to 3rd year. I personally have never witnessed somebody do clerkships prior to the PhD and then start MS3 year at the exact same time as MD-only MS3s.

Although you may have never personally witnessed this, it does not mean it's categorically untrue. We have had many of our MSTP fellows return ON TIME after having done 1 or 2 M3 rotations prior to starting their PhDs since this option was introduced 7 years ago. A handful have not only returned on time, but were able to adjust their M3-M4 schedules and finish their clinical requirements several months ahead of schedule, allowing them to return to lab uninterrupted prior to residency and finish up work.

It almost never makes sense to purposely drag out the PhD 10 months longer if you're ABD just to return "on time", and I dare you to find me an MSTP director who would disagree. That's an even greater opportunity cost than coming back to M3 year a few months late and having to work a little harder than your new classmates. There are other considerations to M3-M4 year, especially for MSTP fellows, than just Honors and AOA, and our graduates match strongly with and without full honors/AOA; but that may be somewhat specific to our program..

I don't buy that coming back 1-2 months late in M3 year as an MSTP places you in any more disadvantage than if you came back on time from a clinical knoweldge/grade standpoint. Yes, you might be done with half of M3 year before you start "raking in the Honors", but when you end up making up the months you missed at the beginning of your 4th year, with a new crop of M3s, you're pretty much guaranteed honors anyway. Or at least you should be.

You are dwelling on the incorrect assumption that doing this kind of split M3 year is categorically harmful. Experience at our program demonstrates otherwise.

 

[vasovist]

I apologize for not being clear in my questions.

I am at an institution where I am required to do my entire MS3 year before starting my PhD. I don't have the option of doing only one 8 week clerkship before starting my PhD, as Fencer mentioned and what seems to be a more typical model across MD/PhD programs.

That being said, can other students who have followed this route (doing all of their core clerkships before starting their PhD) comment on their experiences and provide any strategies for keeping up with their clinical experiences during their PhD?

 

[ratherbefishing]

I

Ladies and gentlemen, the solution is to start MS3 when everybody else does, and then work your ass off, reading twice as much every night when you're dead-tired, to catch up on your knowledge. If you do this, coupled with your - let's face it, superiority relative to MD-only students at studying and retaining knowledge - and your maturity, owing to age, which the members of your clinical team will appreciate, you can absolutley excel in MS3 as an MSTP. .

You make it sound so easy.

 

[Shifty B]

If you have to do your entire MS3 year before your PhD, that's different sort of beast. You should be able to do well on your grades and it will be fun to do MS3 with your classmates. You will have to work harder in your MS4 year to reacclimatize yourself to the world of clinical medicine, whereas many people can just phone that year in.

But to the points above.

1) Clinical clerkships have a very steep learning curve, because half of your grade is how well you play the game. Someone who has done 3 clerkships already easily has an advantage in this regard. Plus, when you get to the shelf exam, a lot of the knowledge depends on stuff from other clerkships, which makes it harder to do well if you haven't had, say, internal medicine. It is a distinct advantage to go back when the MS3 year starts. Now, if you do 1-2 clerkships before your PhD and still go back when the MS3 starts, then that's great, because you have more time for electives or research during those years. But that's not a given, because in fact, you did start your PhD a couple months later than you would have.

2) A corollary to #1, and perhaps more important. Do not underestimate the importance of getting as many honors as possible. For more competitive specialties and competitive institutions in all specialties, your grades/AOA are the second most important part of your application (after only USMLE). Time and again, I've seen brilliant researchers passed over for people with a little research and outstanding scores/grades. 90% of the time, my institution will take an MD only with all honors/AOA and 1 paper over an MD/PhD with a mix of high pass/pass and 10 papers.

None of this is to say you can't have success with either option. Of course you can. But to maximize your success you need good papers during your PhD, a great step score, and the most honors possible.

 

[Neuronix]

2) A corollary to #1, and perhaps more important. Do not underestimate the importance of getting as many honors as possible. For more competitive specialties and competitive institutions in all specialties, your grades/AOA are the second most important part of your application (after only USMLE). Time and again, I've seen brilliant researchers passed over for people with a little research and outstanding scores/grades. 90% of the time, my institution will take an MD only with all honors/AOA and 1 paper over an MD/PhD with a mix of high pass/pass and 10 papers.

Glad you're back. I could have used you in this thread 😉 http://forums.studentdoctor.net/thr...ances-read-before-asking-for-md-phds.1069371/

I've been staying out of this thread because I don't have a strong opinion either way. It was really hard coming back to third year with a bunch of people who had been in clinics for 9 months. But then again, it was nice getting some clinical experience before the PhD. Then again, it was still difficult adapting to my sub-I in part because IM was so long ago.

 

[Shifty B]

Glad you're back. I could have used you in this thread 😉 http://forums.studentdoctor.net/thr...ances-read-before-asking-for-md-phds.1069371/

I try to keep tabs on the entire internet, but it's hard to always know when you're needed!

I think on average, doing clerkships before PhD is not likely to be of much benefit. It could probably be helpful if that flexibility pays off for you when you need to come back, but could be harmful if being a few months behind your fellow MS3s harms your grades (the single most important thing). On average, probably a wash. If it were me, I would not do clerkships before the MS3, but that's just me.

Since I started on these forums a long time ago, I've had the luxury of seeing the inner workings of a lot of these things in a relatively competitive field (radiology). If I could go back and give an MS2 MSTP any advice, it would be (in order of importance)

1. Try to ace step 1
2. Try to get all honors
3. If given a choice between returning from your PhD and staying extra time to get more/better papers, go back to medical school