First-generation physician-scientists are under-represented and need better support

[Fencer]

Unrelated to the broader discussion, but if I was NIH Director and interested in bolstering the physician scientist pathway, I would create grant mechanisms awardable to graduating MD/PhDs to establish small but longitudinal research projects throughout residency. Like enough money to hire a tech, buy materials, produce 1 high impact paper or preliminary data and be taken on as a fellow in an established, larger lab at an academic center for the duration of clinical training. Awardees would be allowed to integrate leading this project in a role more akin to that of a PI than a postdoc, but likely a bit of both, during their clinical training. Up to clinical departments and the awardee how they want to split the time / organize things.

The goal? Financial and time support to begin to produce preliminary data +/- papers for applying for a K immediately at the end of clinical training. Less time away from science, a clear recognition of the benefit physician scientists bring to science, training in the PI role while still not being complete independence, faces the reality of doing modern science in that things take much longer than they used (and at least in the wet lab it might make more sense to run a project at 50% effort for 2 years than 100% effort for 1) to in most disciplines and might bring down that "average age to R01" number,
...

Over past few years, I have submitted to several NIH RFIs a similar idea based upon my experience reviewing K99/R00 and other mechanisms. Here is part of a slide I presented at the AAMC MD/PhD section meeting in DC, in the 50th anniversary of the MSTP mechanism in 2014:

NIH:
•Incorporate summer R25 URM/DV mechanisms for EVERY MSTP and competitively MD/PhD programs (Pipeline downstream).
•Incorporate institutional 2-year Transition Career Development Award (K22) program (mixed with individual K99/R00 applications) for PSTP support for EVERY CTSAs (Pipeline downstream).
Summer Gateways --> MSTP --> PSTP --> KL2(CTSA)

Barking, barking, barking... The NIH T32 should have FUNDING and a requirement for every MSTP to develop our untap underrepresented groups such as URMs, first-generation, etc.

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[Cognimancer]

The culture part is truly difficult, but the career outlook of MD PhDs is quite a bit different than pure PhDs. There are people in this thread and on SDN who are in a much better position than me to discuss this but no research track fellow I know worry about getting a job. There aren't many careers with more stability than a MD. If after a MD PhD all you want a job with 200k salary, it's almost guaranteed. And unlike your MD-only peers you have no loans from your postgraduate training.

If by difficulty finding a job you mean specifically applying for research funding or getting a position with protected time and startup money, in my inexperienced opinion it seems not anywhere remotely as difficult for a physician scientist in an academic clinical department as it is for PhDs looking for positions in basic science departments, where competition does look fierce and each position seems to get hundred of applications. The funding rates of clinician scientist K08 at some of these NIH institutes are like, 70%...

I am glad to hear that the MD-PhD pathway offers a decent amount of opportunity. My thought experiment is to ask the following: would a graduate/post-doc at school x be a competitive candidate for a post-doc/assistant professor position at a highly similar school? If the MD-PhD programs can reliably answer yes to that question, then they have accomplished something remarkable. I will definitely do some digging in case I run into any interested students.

 

[Dormouse]

I would create grant mechanisms awardable to graduating MD/PhDs to establish small but longitudinal research projects throughout residency. Like enough money to hire a tech, buy materials, produce 1 high impact paper or preliminary data and be taken on as a fellow in an established, larger lab at an academic center for the duration of clinical training. Awardees would be allowed to integrate leading this project in a role more akin to that of a PI than a postdoc

Could not agree more that we all benefit from more funding to physician scientists, but is this different from the existing K awards and research fast-tracks that are funded by T32/R25/or whatever they're funded by these days? Are you proposing R type of funding that you would apply for as an individual in residency?

The thing is that having research type of grant that involves hiring and purchasing materials also takes administrative effort that takes away from your time to purely do research and build up your publication record. If you use the department for this, I'd imagine that you'd also have to pay overhead and lose part of your money to the university. If you mean a mechanism that allows you to start research early, I think many specialties now do have those fast-tracks that give you a little bit of time for research even in PGY1-3 years.

As to having more intellectual independence as a fellow, I think that largely has to do with a PI's management style and your relationship with the person, especially if you're not directly paid by the lab by rather by some training grant or individual fellowship. Some PIs even let their grad students largely drive research projects on their own. The title itself can be a matter of semantics.

Up to clinical departments and the awardee how they want to split the time / organize things.

And that's another issue, it's hard to negotiate this as an individual because resident schedules are largely dictated by board certification requirements and hospital admins. You often cannot take your boards without enough training hours, so doing more research too early on ends up stretching out your residency years unless some of those clinical requirements are entirely waived. This has to be something arranged for clinician scientist trainees at the administrative level.

Basically I think we should work very hard to abolish the concept of postdoc as a position.

It's very hard for researchers to publish well in the biomedical sciences if they're new though... Science is supposed to be judged entirely by merit but often who you are associated with matters. The "clout" of a well regarded postdoc advisor can help with early career grants, perception of your work by reviewers, and having access to their network. How do you feel about eliminating the PhD and only doing a postdoc as a MD, if medical school is paid for?

 

[Dormouse]

would a graduate/post-doc at school x be a competitive candidate for a post-doc/assistant professor position at a highly similar school?

There are people who would be much more knowledgeable than me on this but if you're asking about academic clinical assistant professor positions, then I'd think absolutely guaranteed for all but the most competitive specialties. Most of those people do not have PhDs, and those positions are not all that competitive because "normal" MDs do not want to stay in academia where salaries are quite a bit lower. From there, whether or not you can do research depends on your ability to get money and fund it yourself. The bottleneck is more in getting grants, and having the time and support early on that would allow you to do that.

 

[Dormouse]

Barking, barking, barking... The NIH T32 should have FUNDING and a requirement for every MSTP to develop our untap underrepresented groups such as URMs, first-generation, etc.

Appreciate the sentiment very much but what's most crucial is more readily available access to paid research opportunities and career advising early in high school and undergrad, such as the summer gateway programs you proposed. It is very difficult to do well in MD PhD programs without extensive prior research experiences. The lack of first-gen students is not something MSTP programs alone can resolve. Feels like there's already a very small pool of first-gen and URM applicants that all the programs are fighting over.

We need time and experience to become familiar with the culture of academia, which as many have pointed already out, can be rather exploitative and difficult to navigate, especially if you're a woman or URM. Some PIs see their grad students and postdocs mainly as sources of labor, to extract as much from as possible. Those who "punch down" on trainees know to pick on students who are perceived as weaker or outsiders and those people are rarely ever held accountable. Increasing the representation of disadvantaged students in MD PhD programs also means having the administrative and advising capacity to support students once they're in the program.

 

[MD-PhD-NonTrad]

Feels like there's already a very small pool of first-gen and URM applicants that all the programs are fighting over.

Are you able to elaborate on the demand for first-Gen applicants? I am first gen, and reading through this thread has really been eye opening for the dichotomies present, however I haven’t really felt I have been under-prepared for this pathway. Granted, I have had to go out of my way to get where I am and I still have not been through the publication process, but I certainly feel prepared.

 

[Dormouse]

Sorry I really should have said URM, I'm not sure if there is any formal effort by NIH yet to increase first-gen MD PhD students, though of course that information is available on your applications and programs can see and use it if they so choose to judge your accomplishments in its context. I don't want to dox myself since it's a small world but I definitely felt under-prepared during my PhD, and wish that I knew many things that I do now.

 

[Med201821]

Nature Medicine article:

First-generation physician-scientists are under-represented and need better support - Nature Medicine

First-generation students, whose parents do not have baccalaureate degrees, are less likely to apply to MD-PhD programs than to MD programs, which has led to a worrying lack of diversity among physician-scientists.

www.nature.com

"First-generation students, whose parents do not have baccalaureate degrees, are less likely to apply to MD-PhD programs than to MD programs, which has led to a worrying lack of diversity among physician-scientists.
Physician-scientists occupy a unique and important space that bridges scientific research and medical practice, and many have expressed concern that physician-scientists are an endangered species, with a dwindling pool of interested future researchers1,2,3,4. Indeed, the number of MD-PhD applicants in the USA has remained stagnant from 2012, when there were 1,853 applicants, to 2020, when there were 1,825. Meanwhile, applications to medical school have steadily increased during the same time period, from 45,266 to 53,030 (refs. 5,6). Is this because the traditional pool of applicants—those who have adequate advising and probably do not come from minority identities—has reached saturation? If so, there is a pressing need to recruit students who do not fit the traditional mold into the physician-scientist career path...
... ...

According to data from the Association of American Medical Colleges, a total of 666 first-generation students matriculated into MD-PhD programs between 2012 and 2020, compared with a total of 5,461 matriculants during this period5. The total enrollment increased from 5,010 to 5,830, while the representation of first-generation applicants and matriculants remained unchanged across the same 9-year period14,15. The ‘first-generation indicator’, a more recent designation created by the Association of American Medical Colleges in 2018 to identify applications by first-generation students, was used by 11% of MD-PhD program applicants and 8% of matriculants in the 2020–2021 academic year16,17. The gap between applicants and matriculants was greatest for first-generation students, relative to that of students whose parents have degrees. We conclude that first-generation students are under-represented among applicants to MD-PhD programs, and that these students do less well during admissions, as evident by the applicant-to-matriculant ratio (Fig. 1).

In contrast, for medical-school matriculants, the percentage of first-generation enrollees is double that for MD-PhD enrollees, and a lower proportion of students have parents with graduate degrees18. Differences between MD-PhD and MD-only applicants and matriculants suggest there are real and perceived barriers to matriculation into MD-PhD program, relative to those for MD programs, that exacerbate the under-representation of first-generation students among MD-PhD trainees.

The observations noted above are best understood in the context of intersecting identities. First-generation status often converges with other identities under-represented in science and medicine, including minority race and ethnicity and lower socioeconomic status19,20. These identities are also under-represented in MD-PhD programs. 64% of MD-PhD applicants and 71% of matriculants in 2020 had parents with a master’s degree or higher5. Over 40% of matriculants in the past 9 years have had at least one parent with a doctoral degree5. Nationwide, the majority of medical students came from households with incomes in the top quintile (greater than $120,000 per year), and over 20% of the students’ households had incomes in the top 5% (ref. 21). Among MD-PhD students, 41% of applicants and 49% of matriculants came from families with a household income of $100,000 or greater, with no substantial changes between 2014 and 2020. Only 9% of applicants and 6% of matriculants had childhood household incomes in the lowest quintile (less than $25,000 per year)22."

Looks like Nature is getting 'Woke'.

Disclaimer: Am a first generation baccalaureate recipient and current M4. But probably don't fit the mold of what this author was really referring to when they refer to "First-generation students".

 

[LadyDustyBlue]

Looks like Nature is getting 'Woke'.

Disclaimer: Am a first generation baccalaureate recipient and current M4. But probably don't fit the mold of what this author was really referring to when they refer to "First-generation students".

Certainly, academia could use an update or expansion of the definition of “1st-generation” students. But as it is, I think it’s more dependent on the institution you’re applying to, or getting funding from. I’d assume applications to scholarships are clearer on this, but it’s a little less clear for say, some universities.

For me, I’d have to put in extra effort for the latter, or assume as much. Also, I would hope that people in my boat or similar look far and wide. You never know what you qualify for. Don’t lose your fighting spirit, just because they don’t know how to define us, non-trads & 1st-gen folks! 🤓

 

[Med201821]

Certainly, academia could use an update or expansion of the definition of “1st-generation” students.

Hmm. I would not have thought the definition needed revision. Seems self explanatory to me.

I was more commenting on what I thought to be subtle (maybe not so subtle) socio-political undertones of the article.

 

[Fencer]

Here is the article that was in peer-review with a 4-year dataset of applicants and matriculants regarding First-Generation MD/PhD students:
Association Between Socioeconomic Background and MD-PhD Program Matriculation

Nguyen, M., Mason, H.R., Barrie, U. et al. Association Between Socioeconomic Background and MD-PhD Program Matriculation. J GEN INTERN MED (2021). https://doi.org/10.1007/s11606-021-06962-8 (early online)

Key finding:
"First-generation college graduates were significantly under-represented in MD-PhD programs compared to their continuing-generation peers. Although first-generation college graduates were as likely as continuing-generation peers to consider pursuing an MD-PhD prior to matriculation, they were 30% less likely to enroll in MD-PhD programs. This finding persisted after controlling for MCAT scores and prior research experiences, which prior research has found to be associated with MD-PhD program matriculation, suggesting that there were other barriers to matriculating into an MD-PhD program for first-generation college graduates. Notably, we found that all students with premedical loans were less likely to consider MD-PhD training, suggesting that financial barriers may be a significant constraint on the physician-scientist pipeline."

Caveat: de-identified data from the AAMC for 91,987 medical school matriculants between academic years 2007–2008 and 2011–2012.

PDF article - https://link.springer.com/content/pdf/10.1007/s11606-021-06962-8.pdf

 

[SurfingDoctor]

None of that seems terribly surprising. Its also the same reason that there are "physician shortages" despite the increase number of schools and graduates. If you are poorer or have debt, the fastest path to becoming debt free and earning money is the most likely path when choosing a career path early on.

This probably all speaks more to the cost and burden of education in this country than anything specific about MD-PhD programs. But there has been a grand inertia to addressing the former so...

 

[MD-PhD-NonTrad]

they were 30% less likely to enroll in MD-PhD programs.

With this in mind, are MD/PhD programs more cautious of admitting first generation students given the higher likelihood of deferral to MD only?

 

[love2chis]

With this in mind, are MD/PhD programs more cautious of admitting first generation students given the higher likelihood of deferral to MD only?

Not a PD, but I believe it's actually opposite, PDs love 1st gen. they love to show off how many 1st gen they admitted.

 

[Fencer]

Every program has different policies, however, first-generation students of low SES have been included into the NIH definition of Diversity. Thus, they are pursued actively by MSTPs. Several MSTPs have had a successful track record mentoring these students. In my program, I can't recall a class without a First-Gen trainee in the past decade.