For MD-PhD graduates, do you feel like you have enough time to do really good research?

[CrayonShinChan]

I recently interviewed a MD-PhD professor from a very prestigious institution, he does a pretty typical 80-20 research-clinical split for his career. While he had an impressive academic track record, I can't help but feel like his research wasn't as top-notch as I expected compared to some PhD professors I interviewed in the same department, and his students receive less mentorship because he's always busy. So I am wondering if splitting time between clinics and research makes it harder to really be the best in either field.

For me personally, although I have a genuine interest in practicing medicine as well as research, if I have to choose one, I would go with research. And I want to try to be the best in one thing more than being ok in both things.

So realistically speaking, I'd like to ask current physician-scientists in this forum, do you feel like your clinical practices and your research are actually synergistic to each other or they are distracting each other. I understand that national surveys say that most MD-PhD graduates go into research, but I am not clear on how good their research is, compared to their PhD counterparts given that most of them will spend less than a full time job in lab.


TL; DR:
1. In a realistic world (with time constraint etc) , is MD and PhD really synergistic or are they distracting each other from becoming the best possible in respective field? Let's say I will follow the traditional 80:20 split and my research field is something very clinically-relevant like cancer (with MD in something related to oncology)

Thank you!

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[Lucca]

well you dont get your MD "in" anything, you differentiate clinically following medical school. If you wanted to do adult heme/onc you would do 3 years of IM + 3 years of Heme/Onc fellowship, roughly, following the MD/PhD.

Considering there are physician scientists (with PhDs or not) winning the Nobel Prize on a yearly to semi-yearly basis, it is self-evident that it is possible for a physician scientist to be a leader in their field and, indeed, many are even if they don't have a Nobel . Many physician scientists will choose to move to 100% research effort if the opportunity arises and from that point forward their job description is ostensibly identical to a PhD-"only" scientist in their field. Many will go through the entire grueling pipeline and end up performing close to no research by the end of it.

You should check out this paper looking at the career outcomes of MD/PhD program graduates:

JCI Insight - The national MD-PhD program outcomes study: Relationships between medical specialty, training duration, research effort, and career paths

insight.jci.org

Here are some figures relevant to your question. First, % of graduates in full-time academic jobs by clinical specialty.

Second, % of MD/PhD graduates reporting >50% FTE devoted to research by clinical specialty on the left and on the right you can see more closely what proportion of graduates in each specialty report what % FTE devoted to research.

Here's both of those figures and average time to first position after graduating medical school for all the IM subspecialties specifically.

I'll let more senior members of this board provide their professional perspective on your question but you should at least be aware of these trends. It should be fairly uncontroversial to add, however, that an average MD/PhD graduate is far more likely to be in the position to perform *any* level of independent research than a PhD-"only" graduate given the current labor market and funding climate. Even as someone who loves science I couldn't recommend someone do a PhD if their only goal is to be a PI at an academic institution, but would certainly recommend the PhD-"only" path to someone who is primarily interested in research (whether they be a PI or not, academics or industry, etc.), not interested in practicing medicine, and has a good enough track record to be competitive for a top PhD program in their field.

Also any discussions of chances of ending up with X career outcome is going to be highly dependent on things that nobody can possibly know. You want to be a heme/onc physician scientist working on cancer research? NCI paylines this past year for R01s were about ~8% and heme/onc / cancer research is probably one of the fields with the highest number of physician-scientists within it so competition is steep. You want to be a neurologist working on Alzheimer's? NIA and NINDS paylines are 2-2.5X those of the NCI and while neurology also has many MD/PhDs the field is far less saturated so chances overall that you'll get an opportunity to even attempt to be anywhere in your field, much less at the top, are likely higher. What will these variables look like 15 years from now when you're out of training, assuming you start medical school next year? Nobody knows.

 

[tortuga87]

You are seeing that trend because you are comparing an average PhD graduate and an average MD/PhD graduate at the senior level. In that case, the average PhD wins for sure because he/she had to go through stiffer competition to get to that position. Aka survivorship bias.

If you instead compare the average PhD graduate to the average MD/PhD graduate starting from the time of degree completion then, over the long term, the average MD/PhD has more time to do research and therefore publishes research of better quality. But this is mostly just because the comparable PhD graduate usually leaves research sooner or goes into industry and stops publishing.

Basically - if you do an MD/PhD, then you will never feel like you have enough time for research. You will not be able to do the best research you can do because of the additional clinic time constraint. The clinic is demanding af. So, if you did a PhD and stuck it out for the same number of years as an MD/PhD, your research will generally be of better quality and quantity because you will devote more of your time to research.

 

[CheGuevaraMD]

I think we don't talk enough about the economics of research enough, so here's my take:

First, what is scientific research? In its purest form, science is just an endeavor to categorize and understand the world around us, and in that sense, it is much like art. However, in biomedicine, there is a strong ideological push to not only understand the world, but to change it. After all, the field is a fusion of biology and medicine.

Second, changing the world, through the identification of new diseases, invention of new therapeutics, etc. is generally a good thing, but it is costly. In that sense, biomedical research is an investment. We want to cure all cancers, but at what cost? Further, most academic research is long term research, in that the benefits of the investment are likely not to be realized for years or even decades. This means, conventionally, that investing in long term research is unprofitable. A funder must believe that it will benefit in the long term, or that the funding is purely charitable.

Third, the unprofitability of long term research rules out a lot of potential funders in the modern era. Most for profit firms are only concerned with quarterly profits, and for whatever reason, most of the modern super elite are not interested in creating endowments to fund research for the next century.

Fourth, that leaves one major player who can benefit from long term research: the government. In the US, the federal government is the major funder of academic biomedical research, mostly through the National Institutes of Health (NIH). Now, why has NIH spending declined in recent years? Well, all federal spending outside of entitlements (Medicare, Medicaid and Social Security), has declined since the 80s (with a small bump after the recession).

Fifth, why has federal science spending declined? Spending on entitlements has exploded. Healthcare costs in the US are out of control and as a major insurer (via Medicare), the federal government spent 18% of its budget in FY18, vs. 16% on all other discretionary spending (including all science spending).

Sixth, why do we care about this? MD-PhDs can take advantage of the fact the the government underfunds science and overfunds Medicare, by cross-subsidizing their work. They can work clinically, and it helps pay for the salary that they can't make up in NIH or other grant funding. Unfortunately, receiving reimbursement from Medicare requires actual clinical work, so MD-PhDs must spend time and energy on the clinic that will compete against their research efforts.

Seventh, how do PhDs succeed? They face the same funding climate, but (1) there is some selection bias at the top, and (2) they benefit highly from the overpriced tuition at most US universities and medical schools. Student debt is privately held, and profitable, so even though it is mostly held by the federal government, it isn't a part of the budget. Student debt is about 7% of GDP, which allows universities to support otherwise mostly unprofitable PhDs.

Eighth, that's it -- science is generally poorly funded, so MD-PhDs and PhDs must use some other means to support their career. MD-PhDs typically work like contractors in clinical work -- reimbursement is fee-for-service, rather than salary -- while PhDs are salaried employees that receive compensation for all of their work, no matter how much time is spent on any task. PhDs famously expend very little effort in teaching and service, and shift that extra time to research. The salaried employee model benefits PhDs in a time when much research is done for free or is only partially funded. PhDs can fudge their time, while MD-PhDs must physically be in clinic.

 

[CrayonShinChan]

These are some really practical advice and insights, really appreciate them!!

 

[dl2dp2]

You are seeing that trend because you are comparing an average PhD graduate and an average MD/PhD graduate at the senior level. In that case, the average PhD wins for sure because he/she had to go through stiffer competition to get to that position. Aka survivorship bias.

This is the correct answer.

Also, the poster's sampling is biased in other ways. In general, MD/PhDs in basic science departments are not top dogs for a variety of reasons. But MDs and/or MD/PhDs absolutely ARE top dogs in clinical departments. Nobel prizes, especially recently, have been split between basic and translational/clinical, so in the 60/s70 (aka the "molecular biology revolution") the emphasis and prestige associated with pure basic work have somewhat subsided IMO. There is also for sure a long term trend in funding as they drop in the basic science side more.

In more applied domains, people with MDs, as a rule, occupy more "prestigious" administrative positions. Typically global lead for clinical development or medical affairs in biopharmaceuticals has an MD. Division chiefs, department heads and deans of medical schools are typically MDs. Anytime a project has a large bottleneck in interfacing with patients in any way, typically the showrunner is an MD. People who run large disease-focused U grants are typically MDs. Senior management in biotech and buyers (i.e. PE/VC) are overrepresented by MDs for a variety of reasons.