If you could go back, would you still do the PhD?

[QVequalsQED]

I am nearing the end of my doctoral years now. I find that as I get closer to the end, I regret having done the PhD. For all the work that I have put into this, I am not sure I see the benefit. What is it that I can do that a MD with a research fellowship (before or after residency) cannot do? Sure, the MD may struggle in the initial years to establish an independent lab, but frankly so will I. For goodness sake, I am going to be years out from the lab (because of clinical years and residency). How does this help me become an independent scientist any faster? Even if it does, isn't the difference negligible? A matter of just a few years?

People have tried to console me lately with the idea that I will be more competitive for residency positions than my fellow MD-only applicants. But, I am not sure that there is any advantage that I will receive for doing my PhD when it comes to residency applications. In fact, some residency directors have given seminars at our program to let us know that the larger publication quantity of MD/PhDs is not compared on a one-to-one basis to the MD-only cohort. What this means is that MD/PhDs are compared to other MD/PhDs while MDs are compared to other MDs, in this regard. This makes logical sense, but also means that any perceived advantages I had compared to my MD-only classmates are non-existent.

I am also frustrated by the career-path being presented to me. When I started, I was under the impression that the 50-50 model for physician-scientists was possible. While there may be some individuals who accomplish this, it is evident to me now that many faculty are actually pushing us toward a 80 (research)-20 (clinic) or 100 (research)-0 (clinic) model. My years doing the PhD have convinced me that I absolutely do not want to pursue this route. If anything, I am leaning towards a 20 (research)-80 (clinic) model. I don't want my career beholden to the whims of the federal budget process. I also flatly enjoy patient interaction.

The frustrating thing is that I still enjoy science and I am excited by the process of discovery. I am naturally a curious individual and I don't think that will ever waiver. I just don't want to to have my paycheck depend on it. I hate to say it, but it almost feels like I want to do research as a hobby and to satisfy my curiosity. I still believe that there are branches of research that only physicians can do. Clinical research and translating ideas from the bedside to bench are examples of such. But my training has not been in this, as is the case for most MD/PhDs. We are trained as basic science PhDs first and foremost. In this aspect, the MD-only physician scientists may even have a leg up on us.

I just don't know. Maybe I will change my mind when I have been away from research. Right now, I am in the thick of things and everything maybe seems darker than it actually is. But for all the reasons above, and more, I keep asking myself, "Why the hell did I do this?"

Does anyone else ever feel like this?

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[solitude]

Does anyone else ever feel like this?

Every day.

I'm not sure if you are new, but there have been a lot of good threads lately about this very topic (one in particular entitled something along the lines of "how to fix mstp"). You may find them helpful.

You articulated your reasons well. I agree with many of them, though not all. I too am about to graduate from the PhD and head back to med school. Despite MANY frustrations, in the end, I feel that doing the PhD has been worthwhile for me, because until you do one, you simply cannot understand how knowledge is discovered/"made". From a philosophical perspective, as a fellow very naturally curious person, I've found this first-hand knowledge to be very personally important. Will I end up "using" the PhD professionally? Probably not, as I too am leaning towards the 20-80 model. Would an MD-fellowship path have gotten me there? Maybe, but it's my opinion that MD-fellows never truly understand how hard research is. I have not yet met one--they always rise above the fray a bit, and on the strength of their MD connections can get a job without the true slog that is a PhD.

But I digress. Points being:

1) I do think you will be more competitive for residency, provided that you perform well in med school and are interested in academic residencies. An academic residency does not consign you to academic career tracks only. Lot of good info on here from prior threads (search Neuronix's posts in particular)

2) if you're frustrated by the career paths, ignore the ones that are "presented to you". Just do what you want to do. If that's 80-20, 20-80, 50-50, 100-0, 0-100, who cares. Pick what you want to do and just do it. You are not beholden to the dictates of the NIH mavens. There is no shame in a clinical career, or even an industry job for that matter. Most of the academics who deride private practice, clinical, and industry types are just bitter that they don't make as much money. Seriously, a strong argument against staying in academia (and basic science in particular) is: do you really want to spend the rest of your life around these people? I don't.

3) I too enjoy the process of discovery. That's why a 20-80 job in academia is appealing. You can see the interesting cases to get the intellectual stimulation and also get the satisfaction of patient interaction. Also, you can satisfy your curiosity in other ways. Me, I read a lot, both widely in science, and in many other fields. Sometimes I waste hours on wikipedia. It's a lot more satisfying than pipetting small amounts of colorless liquids for hours.

4) even if you never use your PhD again, hopefully you feel confident enough in your findings that you can always look back and say, "I contributed X to the body of knowledge". Personally, I think that's pretty cool.

You may change your mind. Maybe I will change my mind. Maybe the NIH will discover a pile of money and funding will change. Who knows. Just make sure you make decisions for yourself rather than conforming to the standard "track" and what others around you want you to do. And don't forget to sleep enough, work out, pursue your hobbies, and build meaningful personal relationships. The rest will fall into place.

 

[Vader]

I agree with many of the sentiments above. What is especially hard is that this gets even worse during residency and there is even less incentive to go back to research during and after residency for another few years of work that is probably unrelated to what you did during the PhD years. I am at the end of my residency and will be doing a fellowship. However, I am not excited about the prospects of going back to bench research during or after fellowship, particularly since K awards now depend on not only having preliminary results but actually having published a paper or two. I am not interested in spending 3-5 additional years after residency trying to get a K award and then additional years after that trying to get my first R01. I realized that starting my "independent" research career at age 40 (if and only if I am lucky) would really only give me a handful of good years, while in the mean time sacrificing my family life and aspects of my career that I enjoy like taking care of patients.

 

[gbwillner]

I agree with many of the sentiments above. What is especially hard is that this gets even worse during residency and there is even less incentive to go back to research during and after residency for another few years of work that is probably unrelated to what you did during the PhD years. I am at the end of my residency and will be doing a fellowship. However, I am not excited about the prospects of going back to bench research during or after fellowship, particularly since K awards now depend on not only having preliminary results but actually having published a paper or two. I am not interested in spending 3-5 additional years after residency trying to get a K award and then additional years after that trying to get my first R01. I realized that starting my "independent" research career at age 40 (if and only if I am lucky) would really only give me a handful of good years, while in the mean time sacrificing my family life and aspects of my career that I enjoy like taking care of patients.

VADER- long time no see...

Interesting to see how our careers are shaping up, huh? What you stated above was the entire reason behind my "how to fix MSTP" post last year. reality changes for us as we get older, and the real world intervenes with our youthful idealizations of what we want to do with our lives. The physician-scientist track is still available- but the amount of work necessary to achieve it is ever-growing. And we are not living longer. And funding is decreasing. Basically, you have to be borderline insane to continue it at this point. I guess I am still that insane, but have been tempted to the "dark side" many, many times. Specifically when all my friends have basically given up at this point.

I hope to finish my Post doc in the next year or so (I gave myself a max of 1.5 years) and take an academic job that will be somewhere between 50-50 and 80-20.

You can get there with less effort but, either A: you will not get the time/space required to be successful, or B: you will not get the start-up necessary to be successful. Personally, I am seeking a $1M startup. That's 1.5-2 years post-doc, a few decent papers, and a few grants. If I wanted 50-50/70-30 with less cash (like $200K), I could have probably gotten that without the post-doc. At a not-top institution, where my chances of success would have been far less.

 

[dl2dp2]

I realized that starting my "independent" research career at age 40 (if and only if I am lucky) would really only give me a handful of good years, while in the mean time sacrificing my family life and aspects of my career that I enjoy like taking care of patients.

It's really surprising to see someone like you to say this.

 

[curiousgeo]

Just out of curiosity, which schools are all of you attending / did you graduate from?

I am curious if the attitudes are different at different schools (because of different quality of organization, oversight, mentorship, etc.)

 

[Neuronix]

Just out of curiosity, which schools are all of you attending / did you graduate from?

I am curious if the attitudes are different at different schools (because of different quality of organization, oversight, mentorship, etc.)

I agree with the above sentiments, and I don't think I'll offend anyone by saying we all come from top programs and diverse clinical specialties. The frustration with a research-based career is very common among our generation of MD/PhDs. Clinical revenue contraints and extremely competitive research funding envionments have made starting a new research career require extreme sacrifices.

I hate the question "if you could go back, would you still do the PhD?" I can't go back. It was the right decision for me at the time. Though now due to the negatives already expressed above, I suspect I'm heading into a mostly clinical practice, perhaps private practice.

 

[curiousgeo]

I agree with the above sentiments, and I don't think I'll offend anyone by saying we all come from top programs and diverse clinical specialties. The frustration with a research-based career is very common among our generation of MD/PhDs. Clinical revenue contraints and extremely competitive research funding envionments have made starting a new research career require extreme sacrifices.

I hate the question "if you could go back, would you still do the PhD?" I can't go back. It was the right decision for me at the time. Though now due to the negatives already expressed above, I suspect I'm heading into a mostly clinical practice, perhaps private practice.

Thanks for your response. I definitely have no experience with this, so I hope you don't mind if I ask a follow up question.

The term "top program" seems vague. From my vantage point (college student interested in MD/PhD), any funded MSTP program is a "top program." However, could it be that there exist very real differences within these programs? Could it be that the very top, research-heavy schools like Harvard, Stanford and Johns Hopkins, produce more successful physician-scientists for whatever reason (resources, faculty, self-selecting students)?

I know everyone is concerned about anonymity but I would like to know if the people here unsatisfied with the route are from these elite institutions. (Sorry, I don't mean to be rude, I just am genuinely curious).

 

[kfre2435]

I agree with the above sentiments, and I don't think I'll offend anyone by saying we all come from top programs and diverse clinical specialties. The frustration with a research-based career is very common among our generation of MD/PhDs. Clinical revenue contraints and extremely competitive research funding envionments have made starting a new research career require extreme sacrifices.

I hate the question "if you could go back, would you still do the PhD?" I can't go back. It was the right decision for me at the time. Though now due to the negatives already expressed above, I suspect I'm heading into a mostly clinical practice, perhaps private practice.

This is discouraging to read as a prospective student. I hope to apply next cycle, but honestly have no idea whether to apply MD-only or MD/PhD now. I only know that I want to do research, and I want to be a physician. I will not allow myself to do one without the other. These posts make me constantly reconsider and bring up more questions than answers:

Are the opinions on SDN representative of MSTPers everywhere? I appreciate the wealth of knowledge on here, but perhaps it lends to itself to the more disenfranchised.
Is the PhD worth the work and years? Will it help in my future career/lifestyle choice?
Would I be better following the MD-residency-fellowship route? What about money?
Can I afford to be 35 (at best) and starting my career? How much does it depend upon mindset? What if I want to pursue surgery as my speciality? Will I ever see my family?
Will I even get in?

There are only hard questions and no easy answer to any of them. It is enough to make your head spin.

 

[mercaptovizadeh]

Thanks for your response. I definitely have no experience with this, so I hope you don't mind if I ask a follow up question.

The term "top program" seems vague. From my vantage point (college student interested in MD/PhD), any funded MSTP program is a "top program." However, could it be that there exist very real differences within these programs? Could it be that the very top, research-heavy schools like Harvard, Stanford and Johns Hopkins, produce more successful physician-scientists for whatever reason (resources, faculty, self-selecting students)?

I know everyone is concerned about anonymity but I would like to know if the people here unsatisfied with the route are from these elite institutions. (Sorry, I don't mean to be rude, I just am genuinely curious).

Well, the people who have responded so far ARE from research heavy places, like Penn and UCSF, so your question is answered, if only in anecdotal fashion.

Speaking for myself, still in MS3 and increasingly aware of what's going on in terms of funding, I think the MD/PhD is great for 1.) learning how to do some sort of basic science biomedical research; 2.) getting a free medical education; 3.) lending you an unusually high degree of economic security should you desire to pursue some sort of research career (by virtue of the MD to fall back on). In and of itself it is NOT a great system for 1.) getting into a top residency; 2.) getting an academic tenure-track position at a great institution. It's just part of your application (alongside step exam scores, clinical rotation grades, and LORs, all of which are arguably more important than a PhD) and it's just one tiny milestone in shaping an academic research career (with connections, "who you know," clinical training, postdoctoral training, mentors, etc. being more important down the line).

If you go into the MD/PhD knowing what it can do for you, it's a great program. If you think it's your golden ticket to competitive and prestigious residency and an academic research career down the line, you are deluding yourself and setting yourself up for failure.

 

[Neuronix]

The term "top program" seems vague. From my vantage point (college student interested in MD/PhD), any funded MSTP program is a "top program." However, could it be that there exist very real differences within these programs? Could it be that the very top, research-heavy schools like Harvard, Stanford and Johns Hopkins, produce more successful physician-scientists for whatever reason (resources, faculty, self-selecting students)?

I think any funded MSTP program being a top program is a reasonable approach. I did do my MD/PhD at a so called "elite" institution. However, you have to be careful with these "elite" institutions. The level of mentorship and supervision is different at these programs, and can lead to significant differences in things like average graduation time. That said, I think where I went did have an excellent level of mentorship and supervision.

This is discouraging to read as a prospective student. I hope to apply next cycle, but honestly have no idea whether to apply MD-only or MD/PhD now. I only know that I want to do research, and I want to be a physician. I will not allow myself to do one without the other. These posts make me constantly reconsider and bring up more questions than answers:

The question is whether you want to do basic science. If you want to spend a minority of your time performing mostly unfunded clinical research, like most academic physicians, this is not much of an issue. However, you don't need a PhD to do that.

If you do want to have a basic science career, you have to train longer after the MD/PhD program, accept a much lower salary, go wherever you can find a job, and have an inherently unstable career compared to your clinical or mostly clinical colleagues. It's really that simple. Even if you think you're willing to do that, you don't really know how you'll feel in your 30s when you're in your early 20s. You may not be successful despite being smart and hard working. Funding might get better, in which case the bar for becoming a new physician-scientist will be lower, or it might get worse, in which case the bar will become higher.

If you hear all that and you're still willing to give it a shot, go for it.

Are the opinions on SDN representative of MSTPers everywhere?

No. You are clearly hearing from a handful of students and graduates among tens of thousands of students and graduates.

I appreciate the wealth of knowledge on here, but perhaps it lends to itself to the more disenfranchised.

When you interview you will meet almost nothing but first years, the applicants turn a deaf ear to anything that isn't "rah" "rah" "rah" (if anything, real info seems to be frowned upon by most applicants), and the faculty are all the most successful of MD/PhD graduates. It's a positive feedback cycle. What you hear on here is a more representative sample of reality. But, it does not reflect all the attitudes out there.

 

[dl2dp2]

I think you are not thinking about this in the right framework. You are too fixated in "I have to do both research and medicine, how do I get there?" I would emphasize the journey part of the training. The NIH MSTP is thought of as the crown jewel of medical research education in the US, if not the world. Since its start, numerous prominent researchers spanning the spectrum of basic to clinical research have come out of this program. A couple have won the Nobel. Many are HHMIs. Many have made seminal discoveries. Many are heads of clinical trials at university or pharma research divisions. Many are private practice physicians enjoying excellent quality of life in subspecialties that are both rewarding and remunerative. The per capita return of MSTP appears to be quite high, which is why it has been expanded in size since the 90s. Nevertheless, what you END UP becoming is only partially determined by your training pathway, and more to do with your personal talent, effort, luck, mentorship, lifestyle choices, and a variety of other factors.

The main reason to do MDPhD, to me, is the wide range of options and experiences that you are afforded as a trainee and the unique broad and translational perspective. But there's no concrete, credentialing advantage. I think a lot of premeds are mired in the mindset of what's most prestigious and what's most advantageous for goals A, B, C. That mindset is the #1 thing that needs to go. Research is a random walk. Find what interests you and pursue that, balancing priorities in your life and optimize your utility, and don't worry about what you might end up becoming.

There is a lot of internalizing of guilt and inadequacy in MSTP graduates who end up in non-research careers, especially non-academic careers. But I think if after balancing priorities in your life, such as family and life style, which are legit, and you come to a rational conclusion that this makes the most sense to you, there's not at all a failure on your part. Certainly as a community I don't think there should be an assignment of fault if this happens. Is it true that having one vs. another career pathway is more or less friendly for a specific lifestyle? This is a question that has no scientific answer and depends on the individual trying to ask it.

 

[StIGMA]

I'm currently around half-way through the PhD, in the thick of my dissertation research. I never seriously considered dropping the PhD (athough the thought crossed my mind in the few months after Step 1 when I didn't yet have a project).

To the current applicants, I'll say I agree completely with mercaptovizadeh and sluox.

If I was going to only pursue one degree, it would have been the MD, so I'll speak to that:
If you desire the PhD, if you want to spend 3-5 of the next 8 years of your life performing research, if you want to learn how to make discoveries and make them yourself, then pursue the PhD. It does not matter whether you intend to run a lab or pursue research after you graduate- you barely know anything about what that is like at this point. But you should know whether you want to pursue the PhD. Is it something you will regret, or is it something you will regret not doing? For me, it is something I wanted and still want to do. I enjoy going to lab everyday and working reasonably long hours (although I certainly don't feel this optimistic every month!).

You can have all the questions of what you will be doing at 35 in the back of your mind, if it will be worth it or not, if you want to postpone being a medical doctor for another 3-4 years, etc., but if you will regret not doing the PhD, then quite simply it is a reasonable pathway for you, and you are not making a terrible decision (except maybe financially compared to gunning straight for private practice!). I may or may not do research in the future, but I won't regret the PhD even if I never do research again (my PI and I are on the same page that I will graduate from the PhD so I'll finish the program in 7 years- if it was 8 or 9, I'd feel different as the investment of my time would be that much longer). If you are so apprehensive about the PhD and prospects of research going into the program, guess how you will feel when things are actually difficult- and I'd say to ask yourself whether or not you truly regret not doing the PhD. If you are more apprehensive about doing the PhD then not doing it- then don't do it! You will have plently of opportunities to do research without making such a significant investment of your time.

 

[kfre2435]

Thank you all for your very candid responses. They certainly help.

 

[QofQuimica]

My background is different from the MSTP folks because I did separate degrees and took time off to boot. Because of this, I will be well into my 40s by the time I finish my post-graduate training. (Lolz at those who think 35 is "old.") I'm not at all a proponent of the PhD-to-MD pathway, and in hindsight, it is easy to say that I should have done a combined program. But I have to agree with those who are saying that they felt like the PhD was "worth it" in and of itself. Not that grad school can't be frustrating, but as Neuro said, it was the right choice for me at the time. I was not serious about going to medical school when I was in college, and I would not have been going for the right reasons even if I had gone.

Ultimately what it all comes down to is how you define "worth it," which gets into the question of whether you are getting a PhD for the right reasons. Intellectual curiosity is a right reason. Wanting to get the skills and know-how to do bench science is a right reason. In general, getting a PhD for its own sake and not because you think it will get you something unrelated is a right reason. But most of the "practical" reasons for getting a PhD won't ultimately pan out, and you'll end up disappointed if any of those is your main motivation. In terms of finances, you'll likely work more and earn less as an MD/PhD than you would have as an MD if you're in an academic job. In terms of getting a good residency, the PhD is possibly going to pigeon hole you to some degree, because why would an academically oriented applicant want to train at a nonacademic community program? In terms of prestige, most people won't really care that you have a PhD, assuming they even understand what it means. So unless you want to get the PhD for its own sake, as an end itself and not just as a means to an end, I'd argue that you shouldn't get one.

FWIW, I obviously wasn't an MSTP student, but I went to one of the MSTP med schools.

 

[Ombret]

What we are seeing in this thread are several different responses of MD/PhD graduates to being put through a bottleneck. There are too many MSTP graduates for all to become NIH funded basic scientists (much less highly successful chiefs, department chairs or HHMI investigators), plus life itself puts us through a bottleneck as we get older and face different personal issues. It's a pyramid scheme. That sounds like a criticism, but I'm not sure how else you would select the finest performers from a group of promising candidates. It just creates a lot of collateral damage.

This type of bottleneck is present in any high-performance line of work. I mean, think about the Olympics. Most of those athletes have been through a heck of a selection process. All of them were the best swimmer, archer, runner in their home towns, they poured years of effort into training, huge sacrifices on the part of their families and their own selves, major expenses, and still by definition most will be weeded out of the field before making it to the Olympics, much less winning a medal. (I know there are other measures of achievement in sports, but I'm just saying.) Meanwhile they are perfecting a skill for which, unless they are Michael Phelps, they will not be highly paid. How do athletes feel about being put through a bottleneck? Probably the same as we do... a lot would not do it again. But you have to suit up if you want to have any chance of hitting a home run at all.

 

[regularbobj]

What we are seeing in this thread are several different responses of MD/PhD graduates to being put through a bottleneck. There are too many MSTP graduates for all to become NIH funded basic scientists (much less highly successful chiefs, department chairs or HHMI investigators), plus life itself puts us through a bottleneck as we get older and face different personal issues. It's a pyramid scheme. That sounds like a criticism, but I'm not sure how else you would select the finest performers from a group of promising candidates. It just creates a lot of collateral damage.

This type of bottleneck is present in any high-performance line of work. I mean, think about the Olympics. Most of those athletes have been through a heck of a selection process. All of them were the best swimmer, archer, runner in their home towns, they poured years of effort into training, huge sacrifices on the part of their families and their own selves, major expenses, and still by definition most will be weeded out of the field before making it to the Olympics, much less winning a medal. (I know there are other measures of achievement in sports, but I'm just saying.) Meanwhile they are perfecting a skill for which, unless they are Michael Phelps, they will not be highly paid. How do athletes feel about being put through a bottleneck? Probably the same as we do... a lot would not do it again. But you have to suit up if you want to have any chance of hitting a home run at all.

This was really quite an interesting way to think about it. Thank you for putting this into words.

 

[uniqenam]

This was really quite an interesting way to think about it. Thank you for putting this into words.

I totally agree, I really appreciate that analogy. I think at the end of the day, I'd rather give it my all and "go for broke" with a high chance of failure than live my life wondering what I could have done. Besides, I think at the end of the day "just being a physician" is quite a good back-up plan if the whole research thing doesn't work out, right?

 

[Shifty B]

There are too many MSTP graduates for all to become NIH funded basic scientists (much less highly successful chiefs, department chairs or HHMI investigators), plus life itself puts us through a bottleneck as we get older and face different personal issues. It's a pyramid scheme. That sounds like a criticism, but I'm not sure how else you would select the finest performers from a group of promising candidates. It just creates a lot of collateral damage.

This type of bottleneck is present in any high-performance line of work. I mean, think about the Olympics...

The sentiment here is true, but it's mostly a broader problems with basic science/research in general. I would argue that there aren't too many MD/PhD graduates, but that there are too many PhD graduates in general, with combined degree graduates only making up a small fraction.

To make it much worse, the pyramid effect is much less prominent on the MD side. There is a very tight bottleneck at the admission to medical school, but after that the relative competition is much less (with a few notable exceptions).

The path from medical student -> resident -> fellow -> clinical faculty is significantly less fraught with bottlenecks than the graduate student -> postdoc -> junior faculty -> senior faculty pyramid.

 

[Neuronix]

It's a pyramid scheme. That sounds like a criticism, but I'm not sure how else you would select the finest performers from a group of promising candidates. It just creates a lot of collateral damage.

When I signed up for MD/PhD, I was under the impression that society valued and needed physician-scientists. I was not expecting it to be a pyramid scheme. I mean sure, we can only have so many department chairs, very highly funded faculty (HHMI, multiple R01s), I get that.

However, there was a time back in the 90s when grants were funded in the 40s-50s percentile. When the bar for grant funding is at that level, anyone can have a research career if they work reasonably hard towards it. Departments would be willing to support scientists because there is a good chance at their faculty being reasonably successful. As a result, back in the 90s there was explosive growth in biomedical research. Many of our program directors and other program faculty grew up in this time, and if you talk to them they still see becoming a new investigator as it was during that time. At least, they will acknowledge the difficulties today, but always say that things will go back to the good times. When is that exactly? Because it's been at least a dozen years since things were good for scientists, and it just seems to be getting worse.

So if you want to describe becoming a funded basic science investigator as a physician-scientist as a pyramid scheme, I have no problem with that. But I didn't do an MD/PhD because I thought my career goal was part of a pyramid scheme. If you talk to programs out there now, nobody is going to tell you it's a pyramid scheme. But on here, in private, on an anonymous internet forum, I will agree with you. It is a pyramid scheme. It's one that requires extreme hard work, extreme high talent, sacrifice of most of your personal life, and even then you only have a chance of success in keeping your career as a scientist.

 

[dl2dp2]

It's one that requires extreme hard work, extreme high talent, sacrifice of most of your personal life, and even then you only have a chance of success in keeping your career as a scientist.

I think a better way to do this is a system where most of the projects are carried out in a horizontal rather than vertical fashion. Currently, basic research is done in a model where one principle investigator takes most of the credit for a small army of junior people who have terrible lives. A better system would be once the PI gets funding, it gets thrown into a pool, and then people who are interested in doing a project would work on that project in loosely organized teams that organically form and dissolve. Salaries are guaranteed and not directly connected with publication or grant success.

However, this still creates problems in terms of how to evaluate who's more or less productive and who gets promoted.

 

[miz]

How insecure are MD/PhD job prospects after residency and postdoc? Are there ways to minimize risk (for example, would spending more time in postdoc help)? What are the disadvantages of this approach? What are your options if, say, after five-six years in a tenure track position you are denied tenure?
How about location stability?

 

[Neuronix]

How insecure are MD/PhD job prospects after residency and postdoc?

If you have research funding to cover your salary, your research position is pretty secure. If you don't, it isn't.

Are there ways to minimize risk (for example, would spending more time in postdoc help)? What are the disadvantages of this approach?

http://forums.studentdoctor.net/showpost.php?p=13285245&postcount=4

What are your options if, say, after five-six years in a tenure track position you are denied tenure? How about location stability?

You hope you might find a job elsewhere that will let you keep doing research. It's unlikely you'll ever be offered tenure again. Don't be too sad about that, tenure really doesn't exist in clinical departments anyway. If you run out of research funding, you will go clinical or be forced out.

Location stability depends on how much money you bring in. Big grants means nobody will touch you. High patient volume and revenue means nobody will touch you, though administrations can make it so unpleasant for you that you'll want to leave. The reality is, research funding is terrible these days. This means you will often change locations many times during your career, and this will involve taking the one job offered to you when that change happens, wherever that might be.

 

[Neuronix]

Here's a good post on this topic from today: http://forums.studentdoctor.net/showpost.php?p=13356317&postcount=4

 

[Foxhunter]

Just wanted to pop in and say as someone doing the animal version of an MD/PhD program this thread has been an interesting read. For me, I don't have to think of money as much because the pay differences between a PhD and a veterinarian are negligible. On top of that paying off student debt on a veterinarians salary is very difficult, so to me delaying entering the work force by 3-4 years is definitely worth entering the work force with little to no debt, even if I "just" do private practice. Because there are so few combined DVM/PhD programs, in vet medicine I think the PhD will actually make me more competitive for residencies (especially as residencies aren't required of veterinarians). Lastly, the PhD may actually put me in a higher pay range as it allows me to more easily get a job at a vet school or there's always the "sell out" option of going into pharmaceuticals. It was just interesting seeing the differences.

 

[Vader]

Yes, one's career pathway certainly has many twists and turns, often leading to unexpected routes. I agree with all of the above thoughts and sentiments.

I graduated from one of the top MSTP programs in the nation, total of 8 years, with several high-quality publications. I went to one of the best residency programs in my field. Nearly all of my MSTP classmates are in the same boat as I am, with perhaps 1-2 going into a research-predominant career; the rest are in heavily clinical fields and not planning to do research as far as I know.

We went through and are still going through what is probably the worst period of scientific enterprise in this country since the NIH invented and started investing in MSTP programs. The 1990's under President Clinton were a boom time for research and NIH funding levels (he doubled the level of funding over several years). This was followed by flat (and effectively decreased due to inflation) funding levels for many years under Bush. While the American Recovery and Reinvestment Act (i.e. the Stimulus bill) provided some short-term boosts, it was a short-sighted effort and did not address the underlying problem of boom-bust cycles and the extended bust period which we have experienced. Obama has not yet made it a priority and has not articulated, in my opinion, a clear direction for the NIH and other research funding enterprises in this country. And unfortunately we are headed for a period of drastic budget cuts which will limit investment in research.

In the mean time, medicine is also taking an enormous hit in terms of the defunding of Medicare. As margins become slimmer and rules become more stringent to control costs, private practice physicians will be pressured to move toward employment in large medical groups. Academic departments will become even more dependent on NIH grants to stay afloat.

Therefore, we are experiencing a squeeze on medicine and science from both ends of the spectrum. There will simply be no where to go for American physicians, except to large groups where they will hold limited sway in shaping policy, remuneration, and benefits. Research for most physician-scientists will become even less of a career option due to the additional bottleneck wrought by the ever worsening funding situation. The worst part is that there is really no end in sight.

I agree that the American research enterprise is a pyramid scheme, and agree that this is not advertised to prospective MD/PhD applicants. Unfortunately, the current system is a complete travesty and perversion of what an efficient and effective research system should be. The current system is an individual (or more often now a team) competition between investigators that is rewarded by publication in what are deemed "prestigious" journals, career advancement, obtaining coveted academic positions, and winning the equivalent of the Olympian gold medal--the Nobel prize. Contrary to this, I would like to believe that research should NOT really be about the individual, but rather a collective of people working together toward a common goal, i.e. to generate new knowledge and apply it for the betterment of society (be it medical or non-medical purposes).

What makes me very sad is that in another system that funds and values science, the majority of trained physician-scientists might actually pursue research careers and thrive. Unfortunately in the pyramid system we have, we waste the potential of an enormous number of talented people who are trained and ready to make a contribution. In the Olympics, the purpose is to identify the very best athletes. In science, we should be in the business of supporting all those trained and able/willing to make a contribution (i.e. something along the lines of sluox's idea).

I would advise anyone seriously considering a career in clinical or translational research to pursue the MD-> residency -> fellowship + loan repayment program route. It is a more efficient pathway that will lead you to your goal sooner, when you still have more good years ahead of you. Beyond that, is a life of immense sacrifice, as others have stated. As others have mentioned, you have to decide whether you will be willing to make those sacrifices.

VADER- long time no see...

Interesting to see how our careers are shaping up, huh? What you stated above was the entire reason behind my "how to fix MSTP" post last year. reality changes for us as we get older, and the real world intervenes with our youthful idealizations of what we want to do with our lives. The physician-scientist track is still available- but the amount of work necessary to achieve it is ever-growing. And we are not living longer. And funding is decreasing. Basically, you have to be borderline insane to continue it at this point. I guess I am still that insane, but have been tempted to the "dark side" many, many times. Specifically when all my friends have basically given up at this point.

I hope to finish my Post doc in the next year or so (I gave myself a max of 1.5 years) and take an academic job that will be somewhere between 50-50 and 80-20.

You can get there with less effort but, either A: you will not get the time/space required to be successful, or B: you will not get the start-up necessary to be successful. Personally, I am seeking a $1M startup. That's 1.5-2 years post-doc, a few decent papers, and a few grants. If I wanted 50-50/70-30 with less cash (like $200K), I could have probably gotten that without the post-doc. At a not-top institution, where my chances of success would have been far less.

It's really surprising to see someone like you to say this.

When I signed up for MD/PhD, I was under the impression that society valued and needed physician-scientists. I was not expecting it to be a pyramid scheme. I mean sure, we can only have so many department chairs, very highly funded faculty (HHMI, multiple R01s), I get that.

However, there was a time back in the 90s when grants were funded in the 40s-50s percentile. When the bar for grant funding is at that level, anyone can have a research career if they work reasonably hard towards it. Departments would be willing to support scientists because there is a good chance at their faculty being reasonably successful. As a result, back in the 90s there was explosive growth in biomedical research. Many of our program directors and other program faculty grew up in this time, and if you talk to them they still see becoming a new investigator as it was during that time. At least, they will acknowledge the difficulties today, but always say that things will go back to the good times. When is that exactly? Because it's been at least a dozen years since things were good for scientists, and it just seems to be getting worse.

So if you want to describe becoming a funded basic science investigator as a physician-scientist as a pyramid scheme, I have no problem with that. But I didn't do an MD/PhD because I thought my career goal was part of a pyramid scheme. If you talk to programs out there now, nobody is going to tell you it's a pyramid scheme. But on here, in private, on an anonymous internet forum, I will agree with you. It is a pyramid scheme. It's one that requires extreme hard work, extreme high talent, sacrifice of most of your personal life, and even then you only have a chance of success in keeping your career as a scientist.

I think a better way to do this is a system where most of the projects are carried out in a horizontal rather than vertical fashion. Currently, basic research is done in a model where one principle investigator takes most of the credit for a small army of junior people who have terrible lives. A better system would be once the PI gets funding, it gets thrown into a pool, and then people who are interested in doing a project would work on that project in loosely organized teams that organically form and dissolve. Salaries are guaranteed and not directly connected with publication or grant success.

However, this still creates problems in terms of how to evaluate who's more or less productive and who gets promoted.

 

[debateg]

As an graduating MD/PhD leaving one of the top institutions, I also have very mixed feelings about my training. On one hand, my mentor and lab training was phenomenal. On the other hand, I am approaching middle age, not making any money, and while my other friends with real jobs are planning the rest of their life, I feel like I am in perpetual adolescence in terms of my time and money. On top of that, academic research training can be vicious, with students being bullied, lied to, manipulated, discarded, and overall mistreated with essentially no protection.

The job prospects don't seem to be that great either, with large labs I know laying long-established technicians off and postdocs finishing with no jobs to take. The very best clinical fellows with the personal connections get promoted to the top, while those in the middle are sent off to have their careers languish elsewhere, usually in places where clinical medicine is dominant. Leaving academia or research is viewed as akin to betrayal, so career guidance for those thinking about it is very difficult to come by.

As others have pointed out, academic medicine should not be like this. Instead of being an environment supporting people of all different skills and career aspirations, it ends up being run like a business with the people at the top doing well while everyone at the bottom finds themselves increasingly squeezed in terms of their time and money. There does not seem to be an academic middle class. Do I want to be the guy at the top? I don't know.

If I had to do it again, I would probably do the MD -> residency -> fellowship -> research pathway. I still have to do that anyhow, and getting a PhD just let me languish in a low paying and abused (not by my PI, thank goodness) PhD student position. At least when you do a postdoc as a fellow, you are getting paid a decent salary.

 

[miz]

It's hard for me to internalize your experiences at this stage in my career. It is very difficult to relate your experiences to my own and even harder to use them to make concrete decisions about my own MD/PhD at this early stage. Without using your experiences to change my pathway, the most valuable things I can gather from your advice are to adjust my expectations and pick good mentors.

Are you guys married, do you have working spouses? Do you guys have kids? Does making money matter to you? Stability? Respect from peers? Hobbies? What kind of things motivate you? How did those things change from your 20's to your 30's and beyond?

 

[Neuronix]

Without going into details, I would say that I have very different goals and interests in my 30s than I did when I was in my 20s. I remain unmarried and have no desire to have children.

 

[Vader]

It's hard for me to internalize your experiences at this stage in my career. It is very difficult to relate your experiences to my own and even harder to use them to make concrete decisions about my own MD/PhD at this early stage. Without using your experiences to change my pathway, the most valuable things I can gather from your advice are to adjust my expectations and pick good mentors.

Are you guys married, do you have working spouses? Do you guys have kids? Does making money matter to you? Stability? Respect from peers? Hobbies? What kind of things motivate you? How did those things change from your 20's to your 30's and beyond?

I think you hit the nail on the head... it is extremely difficult to imagine your own internal state 10 years down the road. How the millions of experiences during that time will affect you is a virtually impossible thing to predict. You may have noticed during interviews that this is a common question to at least fish out if you have put some thought into it. Despite all the efforts applicants and just-starting MD/PhD students can make to project themselves forward in time, it will still at best result in a rough approximation. However, in order to make an educated choice, one has to try their best. It would all be so much easier if we could find that darn crystal ball.

Particularly in recent times (i.e. last 10 years), I think a good fraction of people at the late MD/PhD program stage are married or are close to it. Any data on this? The percentages no doubt increase when you get to residency and then fellowship. My hunch is that more residents and fellows are having kids during training. In my residency program, most of my class came in married and about half had kids already. There have been several "residency babies" in the few years that I have been here. I don't know if my program is typical, i.e. it is relatively large with several elective months. Almost all of the clinical fellows at my program are married or in a serious relationship, and most have kids.

I think the major change overall that takes place when you get married and especially when you have kids is that you make a transition from being self-centered to family-centered. I'm not being derogatory when I say "self-centered", as many people have other responsibilities, i.e. care for sick family members, other family-related responsibilities, or other life circumstances. However, when you are single, you have much more time available to dedicate to yourself and your career. Optimizing your career can take precedence, you are relatively free to move anywhere you like to pursue your interests, and others do not depend on your for food, shelter, love and attention.

I think one of the major problems with the MD/PhD pathway and physician-scientist career is that it is extremely difficult to balance all these aspects of life on an individual basis, and there exists little support inside or outside of the program. Under the "ideal" model, most people are not able to or don't find adequate satisfaction in the way they do it. It is very easy to run into problems when too many demands are placed on your time, particularly if there is not adequate career and peripheral (i.e. child care, housing) support through training and beyond. Those who are successful usually find creative ways to "make things work", but this requires stretching and some sacrifices no matter how talented, smart or skilled the individual.

Motivations and priorities change with age... at some point biology kicks in, aging pain kicks in, you wonder why your friends have all moved on with their lives, wonder why your parents or pretty much anyone else still has no idea what you are doing or why you don't have a "real" job. You have invested more years into education post-high school than pre-high school and still have no idea if you'll have any job security!

More importantly and realistically, if you have a spouse and kids, there are other people you need to think about and support. And the reality is that things cost money. Swim lessons, dance class, art, music lessons, field trips, vacations all cost money. Paying a mortgage or rent, paying for a car. Health, dental, vision, auto, home, liability, earthquake (in Cali) insurance all cost money. Saving for kids college, weddings, parties, all cost money. Gifts for kids friends and families cost money. Donating to your religious organization or charities costs money. God forbid saving for your own retirement. When I was in my early 20's, I can say for sure I had no idea how much life costs!

In the end, there are very few people who wish to remain dedicated monks in a monastery working toward a higher ideal. We need those people, and it would be great if we as a society placed higher value in this and made it more comfortable for those monks, but that unfortunately is not the world we live in.

 

[aiwe]

I hope that it is not out of line for me to ask this here... but I am curious.

For those of you who say you would not have done the PhD, do you think there are opportunities as an MD-only med student to receive the research training necessary to become some sort of "physician-scientist"? Do you personally know of any MDs pursuing research fellowships who have led you to believe this is quite possible? I ask because it seems like an MD would lack the experience and scientific education that an MD/PhD would have, and I am curious how they would make up for that lack of knowledge without going to graduate school.

 

[solitude]

I think you hit the nail on the head... it is extremely difficult to imagine your own internal state 10 years down the road. How the millions of experiences during that time will affect you is a virtually impossible thing to predict. You may have noticed during interviews that this is a common question to at least fish out if you have put some thought into it. Despite all the efforts applicants and just-starting MD/PhD students can make to project themselves forward in time, it will still at best result in a rough approximation. However, in order to make an educated choice, one has to try their best. It would all be so much easier if we could find that darn crystal ball.

Particularly in recent times (i.e. last 10 years), I think a good fraction of people at the late MD/PhD program stage are married or are close to it. Any data on this? The percentages no doubt increase when you get to residency and then fellowship. My hunch is that more residents and fellows are having kids during training. In my residency program, most of my class came in married and about half had kids already. There have been several "residency babies" in the few years that I have been here. I don't know if my program is typical, i.e. it is relatively large with several elective months. Almost all of the clinical fellows at my program are married or in a serious relationship, and most have kids.

I think the major change overall that takes place when you get married and especially when you have kids is that you make a transition from being self-centered to family-centered. I'm not being derogatory when I say "self-centered", as many people have other responsibilities, i.e. care for sick family members, other family-related responsibilities, or other life circumstances. However, when you are single, you have much more time available to dedicate to yourself and your career. Optimizing your career can take precedence, you are relatively free to move anywhere you like to pursue your interests, and others do not depend on your for food, shelter, love and attention.

I think one of the major problems with the MD/PhD pathway and physician-scientist career is that it is extremely difficult to balance all these aspects of life on an individual basis, and there exists little support inside or outside of the program. Under the "ideal" model, most people are not able to or don't find adequate satisfaction in the way they do it. It is very easy to run into problems when too many demands are placed on your time, particularly if there is not adequate career and peripheral (i.e. child care, housing) support through training and beyond. Those who are successful usually find creative ways to "make things work", but this requires stretching and some sacrifices no matter how talented, smart or skilled the individual.

Motivations and priorities change with age... at some point biology kicks in, aging pain kicks in, you wonder why your friends have all moved on with their lives, wonder why your parents or pretty much anyone else still has no idea what you are doing or why you don't have a "real" job. You have invested more years into education post-high school than pre-high school and still have no idea if you'll have any job security!

More importantly and realistically, if you have a spouse and kids, there are other people you need to think about and support. And the reality is that things cost money. Swim lessons, dance class, art, music lessons, field trips, vacations all cost money. Paying a mortgage or rent, paying for a car. Health, dental, vision, auto, home, liability, earthquake (in Cali) insurance all cost money. Saving for kids college, weddings, parties, all cost money. Gifts for kids friends and families cost money. Donating to your religious organization or charities costs money. God forbid saving for your own retirement. When I was in my early 20's, I can say for sure I had no idea how much life costs!

In the end, there are very few people who wish to remain dedicated monks in a monastery working toward a higher ideal. We need those people, and it would be great if we as a society placed higher value in this and made it more comfortable for those monks, but that unfortunately is not the world we live in.

Wholeheartedly agree. Applicants--read and consider carefully!

 

[K31]

I've said this in other threads--no, if I had to go back I wouldn't do the PhD again. Not because of any inherent problem with the MD/PhD track--I still think it is the best pathway to become a physician-scientist. I just don't think it is possible to know with any degree of certainty when entering that you want to spend your career running a lab.

I thought I wanted the typical MD/PhD career when starting, but I've realized over the past 8 years that I want my career to be more clinically oriented. I enjoy research, but what being a successful PI entails just isn't what I see myself doing for a career. So I don't regret doing the MD/PhD--as Neuronix said, it was the right decision for me at the time--but I wouldn't do it again.

 

[mercaptovizadeh]

I would do it again. If you had asked me this during the PhD I would have said "no" or "maybe." Right now I am seeing that while there is much fulfillment in clinical medicine, there are downsides there too (like having zero free time, no time to really think through things and ponder them, time/economic pressures, lingering doubts regarding one's own competence and whether the best treatment has been meted out to the patients, being a highly fungible cog in the healthcare machinery, etc.). Having the versatility to do clinical work or research or both is great. So is the lack of being saddled with insane debt (that's not a popular point or one you should make with administrators or even colleagues, but it is a patent falsehood that economic considerations are unimportant in choosing MD vs. MD/PhD, in this economy and with the advent of Obamacare with its promised slashes to our clinical reimbursements - if you like research and science, I would think VERY hard about doing a dual degree, even if you don't necessarily end up running a lab). I think having both degrees also lends you more mobility - you can probably shift between states, countries, industry vs. academia somewhat more easily than MD-only colleagues.

 

[miz]

Thank you. I feel very lucky to get to hear about your experiences.

 

[Fencer]

I would do it again too. I love what I do as a practicing clinician scientist doing for the past 16 years until recently 50/50. It has been hard but extremely enjoyable, Over the last 2 years, I have change to 20% research / 30% admin / 50% clinical. I was able to live within my means (not driving expensive, putting into retirement, limiting vacation and going out, etc.). I was married and had 2 kids during my PhD years. I under 50, tenured, full prof, empty nester, paying too much for college of the kids.

Science remains a team effort. As a reviewer (grants or papers), I aimed to be constructive and generous with giving out ideas, which help me build a reputation in my field. I can undoubtedly say that I have made a mark in my field in science and training. Although I been offered up to 3 times my salary to give out research, why should I do it when I love what I do...

The environment is difficult... The squeeze on both ends is real. I choose to emphasize the positives, which makes me happier. Your attitude and approach to your life is something that you can choose. Choose wisely.

 

[debateg]

I hope that it is not out of line for me to ask this here... but I am curious.

For those of you who say you would not have done the PhD, do you think there are opportunities as an MD-only med student to receive the research training necessary to become some sort of "physician-scientist"? Do you personally know of any MDs pursuing research fellowships who have led you to believe this is quite possible? I ask because it seems like an MD would lack the experience and scientific education that an MD/PhD would have, and I am curious how they would make up for that lack of knowledge without going to graduate school.

There are lots of opportunities to get into research as an MD only. You could take a year off to do a master's degree and work in a lab. Many fellowships have protected research time where you're expected to do a scholarly work, and many choose to work in a lab. They then often extend their time in lab as a post-doc if they want to transition into research. Before the MD/PhD, this is how physician scientists were made, and many, many of the current physician scientists (including my PI) went that route and still do. As an MD/PhD, you still need to do that whole fellowship/post-doc thing, so doing it the MD-only way is about 4-5 years faster.

It's really your productivity as a post-doc (as well as your political connections) that allows you to stay in science. No one cares about your productivity as a graduate student. As an MD/PhD having been out of lab for 3-5 years doing a residency, having lost touch with modern methods and the state of the field, you're not that far ahead of a total science newbie who has never picked up a pipette. Also, I think it's expected that MD/PhD's go that route, so the level of support you get isn't as great as you'd think. As an MD-only, you're definitely going to get more enthusiasm as people try to recruit you, which can do quite a bit to jump-start your career. Some of the PSTP programs do provide that support, but having interviewed at quite a few of them, most do not.

 

[Neuronix]

There are lots of opportunities to get into research as an MD only. You could take a year off to do a master's degree and work in a lab. Many fellowships have protected research time where you're expected to do a scholarly work, and many choose to work in a lab. They then often extend their time in lab as a post-doc if they want to transition into research. Before the MD/PhD, this is how physician scientists were made, and many, many of the current physician scientists (including my PI) went that route and still do. As an MD/PhD, you still need to do that whole fellowship/post-doc thing, so doing it the MD-only way is about 4-5 years faster.

It's really your productivity as a post-doc (as well as your political connections) that allows you to stay in science. No one cares about your productivity as a graduate student. As an MD/PhD having been out of lab for 3-5 years doing a residency, having lost touch with modern methods and the state of the field, you're not that far ahead of a total science newbie who has never picked up a pipette. Also, I think it's expected that MD/PhD's go that route, so the level of support you get isn't as great as you'd think. As an MD-only, you're definitely going to get more enthusiasm as people try to recruit you, which can do quite a bit to jump-start your career. Some of the PSTP programs do provide that support, but having interviewed at quite a few of them, most do not.

Well stated. A lot of pre-meds assume that you have to have that PhD after your name to be taken seriously in research. You don't. There are also opportunities to get that PhD later if you really want one. There are many MDs out there setting up research careers right now. This is not something theoretical that we are talking about.

Another thing: the whole system is "what have you done for me lately". Even if you are very productive as a graduate student, nobody is particularly going to care when you are applying for faculty or tenure. It doesn't even get you the best residency positions to do a very strong PhD.

I'm not arguing that the PhD is worthless, but I am arguing that MD/PhD and MD with some research to extended fellowship/post-doc are equivalent means to get to an end. Don't overvalue the PhD, and don't overvalue what MD/PhD does for you in the future.

 

[Guyton Killah]

I would do it again too. I love what I do as a practicing clinician scientist doing for the past 16 years until recently 50/50. It has been hard but extremely enjoyable, Over the last 2 years, I have change to 20% research / 30% admin / 50% clinical. I was able to live within my means (not driving expensive, putting into retirement, limiting vacation and going out, etc.). I was married and had 2 kids during my PhD years. I under 50, tenured, full prof, empty nester, paying too much for college of the kids.

Science remains a team effort. As a reviewer (grants or papers), I aimed to be constructive and generous with giving out ideas, which help me build a reputation in my field. I can undoubtedly say that I have made a mark in my field in science and training. Although I been offered up to 3 times my salary to give out research, why should I do it when I love what I do...

The environment is difficult... The squeeze on both ends is real. I choose to emphasize the positives, which makes me happier. Your attitude and approach to your life is something that you can choose. Choose wisely.

Inspiring. It's always good to hear something positive about MD/PhD.

 

[Fencer]

Nevertheless:

MD/PhDs are only 3% of the graduate physicians and get over 50% (and this number has progressively been increasing) of R-01s, earning first R-01 at roughly the same age than PhDs or MDs.

MDs in Academic Medicine are 16% of the graduate physicians earn the other 50% (and this number is decreasig) of R-01s. This means that non-PhD MDs still have to earn their stripes during a period of time when other responsabilities are ticking very much. There is no question that late-bloomer PSTP MDs are very good and sometimes better than MD/PhDs in that area of research, but keep in mind that their body of research work is much fresher, thus, they ought to be...

As the financial pressures on the medicine side of things increase, Chairs will be choosing wisely who they can support... They will only support well those with a track record. MD/PhDs and PSTP graduates.

 

[Textbookversion]

Nevertheless:

MD/PhDs are only 3% of the graduate physicians and get over 50% (and this number has progressively been increasing) of R-01s, earning first R-01 at roughly the same age than PhDs or MDs.

MDs in Academic Medicine are 16% of the graduate physicians earn the other 50% (and this number is decreasig) of R-01s. This means that non-PhD MDs still have to earn their stripes during a period of time when other responsabilities are ticking very much. There is no question that late-bloomer PSTP MDs are very good and sometimes better than MD/PhDs in that area of research, but keep in mind that their body of research work is much fresher, thus, they ought to be...

As the financial pressures on the medicine side of things increase, Chairs will be choosing wisely who they can support... They will only support well those with a track record. MD/PhDs and PSTP graduates.

Come on all that education and you don't see the basic fallacy in that argument? Causation/correlation issue there buddy. Obviously those who pursue and complete a PhD are going to seek grants and a career in basic science research at a dramatically higher rate than pure MD's.

 

[dl2dp2]

Come on all that education and you don't see the basic fallacy in that argument? Causation/correlation issue there buddy. Obviously those who pursue and complete a PhD are going to seek grants and a career in basic science research at a dramatically higher rate than pure MD's.

You are saying that it's not the PhD that makes it easier for the MDPhD graduates to get the award. This may be true. However, lately I've noticed a disturbing trend where all the awards and things are given out to people with MDPhDs. It's very possible given how competitive things are that in the future MD onlys will be blacklisted in terms of research, especially basic science research, getting Ks etc., without some kind of extensive post-residency track record, which imo makes the whole MD->residency->LRP/postdoc trackway also very much sucky.

Everything sucks! The best way to be alive is to have rich parents!

 

[Fencer]

As a faculty member who has grown a division and had to justify the hiring of faculty, I can tell you that this is the way of the recent past and the future. Faculty members are hired for very specific job descriptions based upon projected or existing clinical revenue. Every 3+ slots, the Chair might consider gambling in a Clinician Scientist by investing 3 years of 25-30% protected time for the new hire with the idea that as soon as a K arrives, the protected time expands to 75%. Who would that Chair choose? ... Track record (i.e.: MD/PhD w 1 yr postdoc or MD w 3-4 yrs of postdoc). You might berate the self-fulfilling prophesy of the Chair's choice but it is the reality. You must have the qualifications to get these positions now.

Regarding the argument, in the late '70s, the figure of MD/PhD getting R01s out of all physicians was below 20%. This is a trend and it is getting more difficult for late bloomers.

 

[Vader]

You are saying that it's not the PhD that makes it easier for the MDPhD graduates to get the award. This may be true. However, lately I've noticed a disturbing trend where all the awards and things are given out to people with MDPhDs. It's very possible given how competitive things are that in the future MD onlys will be blacklisted in terms of research, especially basic science research, getting Ks etc., without some kind of extensive post-residency track record, which imo makes the whole MD->residency->LRP/postdoc trackway also very much sucky.

Everything sucks! The best way to be alive is to have rich parents!

Or win the lottery!

The odd thing is that we keep hearing about the "shortage" of physician-scientists. Yet job qualifications/requirements are getting more stringent. Funding is increasingly going to folks with more qualifications. The pyramid system is designed to to produce the "cream of the cream", which means weeding out a whole lot of good scientists.

Is science increasingly becoming restricted to those who are A) independent wealthy or B) unmarried monks willing to be poor? What about having a healthy "middle class" of scientists?

 

[dl2dp2]

Is science increasingly becoming restricted to those who are A) independent wealthy or B) unmarried monks willing to be poor? What about having a healthy "middle class" of scientists?

Hahahahahaah

There is a shortage in the sense that every department has a spot for anyone who has his own grant. We'll hire you if you can pay for youself...whut? Here's Skip Brass (highlights mine)

"The number of individuals emerging from medical schools each year who become physician-scientists (M.D.-Ph.D. or M.D.) has barely been enough to maintain a steady level. Meanwhile, the age of the average physician-scientist continues to rise [2]. The number of people emerging from M.D.-Ph.D. programs per year (500 to 600) is small and shows little sign of increasing. If you divide this number by the number of clinical specialties, it becomes obvious why the competition for young physician-investigators with promise can be so fierce...

So, if the jobs are there, what do you have to do to make sure that you exit the bridge years with an offer or two in your pocket? Think like a department chair. Hiring new tenure-track faculty members is expensive, and, at best, it will be several years before you can cover your costs by bringing in research grants. The people who hire you will want to be as certain as possible that you will succeed. The search committee members will ask themselves: How well did you do as a graduate student? Did you continue to do well when you reentered the lab as a postdoc/fellow? Have you acquired the skills needed to flourish as an independent investigator? Did you select (and complete) interesting projects? Have you published quality manuscripts? Do you write well and can you give a coherent seminar? Did you compete successfully for peer-reviewed training awards, such as the National Institutes of Health F-awards and K-awards? Will you arrive at your first faculty position with some grant funding in hand, or will you be starting from scratch?"

I'm assuming if you answered no to the above questions, you are not "with promise". Sure, if you have a K everyone wants you. But the K is precisely where the bottleneck is. And, let's not even get started on the K to R transition.

By the way, I'm starting to realize that this 95k thing is not very prevalent even in psychiatry...it's sort of a quirk for a few institutions, one of which I'm lucky enough to be in right now. More prevalent is a PGY5,6,7 level salary, which is...frankly...not acceptable. And this is given that in specialties other than psychiatry or dermatology you really can't do private practice to dramatically supplement your salary.

Maybe we can try to figure out ways to make this 100k thing happen for physician scientists in research fellowships? Given that private practice pays 200k after residency and a research fellowship pays 65k, is it a wonder that the pipeline is "leaky"? Maybe a better system is say, everyone in a research fellowship needs to work 20% clinical, which translates to say, 40k, then plus 40% of 65k = 85k? The problem is full time clinical instructors get paid really crappy...I suppose there's private practice supplement, but that's not viable for IM or neurology. It's REALLY painful to live in SF (say) on 100k for a family.


Reference:
http://sciencecareers.sciencemag.org/career_magazine/previous_issues/articles/2009_05_15/caredit.a0900061

http://sciencecareers.sciencemag.org/career_magazine/previous_issues/articles/2008_12_05/caredit.a0800174

 

[TRPA1works]

Hello everyone,

Firstly, thank you for all of your advice/opinions. You wouldn't believe how difficult it is to find quality and true advice from people concerning the MD/PhD program. I myself am currently debating whether or not to matriculate to an MD-only or MSTP program this upcoming fall and, like most who are fortunate enough to have a choice, I am hitting some serious road-blocks.

Now to my question. I was curious if someone could explain a little more regarding the typical path that one takes in going the MD-->Residency-->Research Fellowship route. I have heard very little about it (as a matter of fact, the majority of what I have heard has come from this forum) and it is a path that may just be somewhat of a better fit for me than the MD/PhD path that I am currently thinking about.

From what I have heard about this track, it is geared mostly towards students that come from MD/PhD programs (I wasn't even aware they took MD applicants). Or are you referring to separate programs (i.e. doing residency at one institution and the research fellowship at another)?

Additionally, on a more personal note, I am interested in research and an academic career is highly likely for me. But will I really need the PhD to accomplish this task? I already have a lot of experience in research (5+ years) so will I really benefit from the PhD if I can just substitute it for a 3-4 year fellowship after residency (which will probably be more focused on what I want to study than my PhD anyway)? I seem to be hearing mostly negative things about the PhD program in the MSTP on these forums and I am somewhat worried.

Any advice is greatly appreciated!!!

 

[debateg]

Hello everyone,
Now to my question. I was curious if someone could explain a little more regarding the typical path that one takes in going the MD-->Residency-->Research Fellowship route. I have heard very little about it (as a matter of fact, the majority of what I have heard has come from this forum) and it is a path that may just be somewhat of a better fit for me than the MD/PhD path that I am currently thinking about.

It's a bit confusing. What you're thinking of is only available medicine, pediatrics, and occasionally radiation oncology, radiology, and dermatology (thanks Neuronix for pointing this out). I'll talk about medicine since that's what I know most about.

MD/PhDs apply for residency like everyone else. Some residency programs have what they call a physician scientist training program (PSTP) or physician scientist track. It's not really as well structured as the MSTP by any means; what PSTP means for each school varies dramatically. In some residency programs, it's an entirely different residency program that you would rank separately in the match, but in many, you just indicate a preference for it and they have special interview days. Typically, those programs support you to pursue the American Board of Internal Medicine (ABIM) Research Pathway way of getting your internal medicine license. This is often called short-tracking, e.g. cutting your internal medicine training from three to two years. Many programs also guarantee you admission to the fellowship of your choice at that institution, outside of the match. You usually do your fellowship clinical years, do the research time that most fellows do, and then do an extra year of research on top of that, all of which is usually funded by a T32 training grant and you get paid a fellow's salary. You usually have some clinical duties during this time as well (clinic one half day a week and service one month out of the year). Most fellows use that extra year of funded time to prepare a K award, which can transition them into faculty. After that extra year, the fellows are eligible to sit for the internal medicine boards and usually their sub-specialty boards as well.

It's confusing because it's called short tracking even though it's not any shorter. In fact, it's probably longer since you do your extra year of fellowship and then typically stay on as a post-doc in lab trying to build up your resume before you apply for junior faculty. It's also confusing because you can short track outside of the PSTP. Also, you can choose to do that third year of residency at some PSTPs, so you don't even need to short track at all (although many really want you to do it). In essence, PSTP guarantees you fellowship admission. Short tracking changes how your time is allocated. They are two different things that people usually do both, but some do one or the other.

Anyone can decide to cut their training from three to two years to pursue research. Most residencies allow you to do this (they support the ABIM pathway), although if you do it outside of the PSTP, you have to apply for fellowship late during your intern year and go through the fellowship match like everyone else. You also only get funded during your fellowship and once that's done, you don't get that extra year and have to seek out funding yourself. Another issue is that if you short track but get sick of research and drop out during your fellow research years, you no longer qualify for the ABIM track and have to go do another year of residency as a fellow. That happens quite a bit, actually. So only do it if you're pretty much 100% committed to research or there may be quite a bit of pain.

A word to the wise: not all PSTP fellowships allow you to do your research after your clinical years. Some want you to do it before, which completely defeats the point. You get your funded fellowship research, stop that, do the clinical stuff, and then go back to researching what you were doing 2-3 years earlier. It completely destroys your momentum of getting a grant. Also, the "guarantee" of fellowship seems to be somewhat wishy-washy at some programs; they reserve the right to refuse it for a variety of reasons. Some fellowships don't have training grants so they will allow you to short track but will not fund you. Some fellowships outright refuse short-trackers, but the residency directors may not mention that up front. Many programs want to know what your fellowship is going to be when you apply for residency, which is insane since you probably just finished your third year clerkships at that time. The entire process is usually a "gentleman's agreement," and there are lots of opportunities for the programs to weasel out of it. Of course, you don't sign any contract, so you can bail as well...

 

[Neuronix]

It's a bit confusing. What you're thinking of is only available medicine, pediatrics, and occasionally dermatology.

A physician scientist track is also available through radiation oncology and radiology as well. See: http://www.theabr.org/ic-holman

Debateg gave a nice summary of some of the pathways which allow for shortening of the clinical training in order to pursue research earlier by shortening the clinical training. Whether you are competitive without a PhD is up to the individual program. I think all of these programs are open to someone with extensive research background but without a PhD. A very strong medical school performance is typically necessary also.

Your statement "I am interested in research and an academic career is highly likely for me" is not helpful in guiding you. An academic career can be anything from 100% clinical to 100% research based. The vast majority of academic physicians do not perform bench research. The pathways mentioned above are intended for a majority bench research based career. A bench research career does not require a PhD, though it is the intended pathway for PhD graduates. Any other career choices (clinical research, mostly clinical work, etc) do not require a PhD, though may require some degree of fellowship training.

The short answer to your question is that anyone can do extended research fellowship after residency if they so choose in order to pursue research, publications, and obtain funding to transition into a research-based career. These fellowships are generally not competitive, unless they are integrated with a competitive clinical fellowship (such as cardiology, GI). Few want to train for 10+ years in medical school and residency (+/- clinical fellowship) with $200k+ of debt over their heads to go into fellowship for several years, be paid poorly, continue to be just a trainee and treated as such, all to get a job that pays less than if you just went and performed clinical work alone. The ones who do it tend to be either extremely focused on research (usually without families), or they hate or are terrible at clinical work.

 

[jv24601]

I know I'm late to the party, but this is a fascinating thread. I'm a graduating MSTP at a competitive program and most of my classmates and I have extensively discussed these issues. One particular aspect that we've noticed is that there seems to be pressure for MSTPs to go into more "traditional" fields of training for residency (at least at our school). We've been flat out told that if we don't go into Medicine, Pediatrics, or Pathology we're wasting our training. This is likely in response to the fact that over the last several years there has been a noticeable increase in our MSTP graduates going into "non-traditional" fields such as Psych, EM, Anaesth, Derm, and Ortho. My personal opinion is that this expansion of MSTP graduates into a variety of fields is healthy because it spreads out research-trained physicians instead of concentrating them in a few fields. Additionally, some of the "lifestyle" specialties have more research-friendly schedules. Whether the research funding available in these fields is another question...

 

[Fencer]

One secret of been able to do 50/50 is to be proficient in a "procedure". However, you can't be the only guy doing that procedure in the practice. You must have a clinical partner that helps grow the practice. The reason for been helpful is that procedures generate greater revenue than seein patients allowing to pay for your extra research time even when you have somewhat of a draught of research funding (like now!).