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

[mercaptovizadeh]

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...

It's not that there aren't any diseases to be had in these other specialties. Or at least scientific mechanisms that remain to be explored. (I have not noticed any issues with psychiatry or neurology, btw, they are very common choices nowadays, especially neurology). I think the concern is more that if you do IM, path, neuro, peds, etc. your potential academic salary as a researcher is not so very far off from the salary in private practice, with a few notable exceptions (cards, GI, etc.) If you're trying to figure out the cure for TB or type 2 diabetes, you don't have all that financial incentive to jump ship from your academic ID or endocrine position to some crazy well paid PP job. There are not a ton of lucrative procedures in these specialties, thus making it less likely that you will feel financial pressure within academia itself to do clinical work over research.

In contrast, radiology, anesthesia, EM, rad-onc, derm, etc. - while perfectly amenable to research, have that constant temptation of doing more ER shifts, reading more scans, doing private practice rad-onc, concierge cash-only derm, etc. to make a LOT more money than the academic researchers. Not only that, but because they can make a lot more money from clinical work than from research, the academics face a lot more pressure from their department seniors to do clinical work rather than fight for two R01s so they can match what their clinic-only peers are making seeing patients.

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[r1oid]

I think some of the bias that Med, Peds, Path, neuro, rad onc ... is the way MSTPers should go comes in part on the end of getting hired by a department once you are done with fellowship. At that point if you aren't coming in with a K the number of say rad departments that will give a 80/20 candidate a shot is probably less then the number of med, ped, path departments. Its not to say they don't exist but just by numbers its less departments. Factor in possible location restrictions from life decisions and your options my be a lot less then when the same decisions needed to be made about med school, residency, and fellowship. This is not to say you should do a field that you don't want to do, but you should be aware of the realities of each point in our career path. If you are going to go into a "non-traditional" residency but in your heart really still want to do X kind of research you need a game plan on how and when you are going to get the research time in to get that K or position yourself in a location that may give you that shot if you don't have the K yet. Maybe that means planning to do fellowship at the same place or short tracking. We have a very clear roadmap for the MD/PhD training part but it can get very murky once you hit residency. At that point its up to us to find good and honest mentors to guide us over the humps of post med school research, grant writing, and getting that first department job.

 

[Neuronix]

Its not to say they don't exist but just by numbers its less departments.

This is misleading because of the size of the specialty. I'd like to know what percentage of programs are hiring for research-based positions in each of those specialties, and how many residents are competing for those positions. I doubt we'll ever see such comparative data. That said, for rad onc you can see the results, which are very favorable, for the research pathway residents here:

http://www.sciencedirect.com/science/article/pii/S0360301612005718

 

[gbwillner]

This is misleading because of the size of the specialty. I'd like to know what percentage of programs are hiring for research-based positions in each of those specialties, and how many residents are competing for those positions. I doubt we'll ever see such comparative data. That said, for rad onc you can see the results, which are very favorable, for the research pathway residents here:

http://www.sciencedirect.com/science/article/pii/S0360301612005718

That's also highly misleading because in all of diagnostic rads and rad onc they only found a whopping 35 people in the entire country, spanning several years in those specialties in that pathway.

So, the data could be interpreted as: go into IM/Peds/psych/neuro/path and have a clear shot at being a physician scientist, or go into a surgical subspecialty where your odds are 1/1000. Yes, there are specific pathways in rad onc and rads, but your odds there are 35/ (n in both those fields over several years), which is pretty insignificant, particulalry since if you go into rads or rad onc you are not likely to be in the Holman pathway anyway and will likely end up in PP.

 

[Neuronix]

That's also highly misleading because in all of diagnostic rads and rad onc they only found a whopping 35 people in the entire country, spanning several years in those specialties in that pathway.

Holman is almost entirely rad onc. Rad oncs don't commonly do fellowship, while radiologists almost always do fellowship these days. Thus in radiology, the serious research is often saved for fellowship.

As for me, I was offered the Holman pathway by my program and I declined it. But essentially anyone with an MD/PhD can enter this pathway if their residency program supports it, and many of the academic programs do support it.

So, the data could be interpreted as: go into IM/Peds/psych/neuro/path and have a clear shot at being a physician scientist, or go into a surgical subspecialty where your odds are 1/1000.

"clear shot" vs 1/1000? I want to see data. The percentage in private practice is not that different between internal medicine and surgery (http://journals.lww.com/academicmed..._PhD_Programs_Meeting_Their_Goals__An.35.aspx Table 3).

I believe it's very hard to become a physician-scientist no matter what residency you choose. I do not believe it is this black and white at all. If you have actual data to back up your opinion, I'd love to see it. I have seen aspiring physician-scientists in most specialties continue as physician-scientists, and I have seen aspiring physician-scientists in most specialties (including IM/path/peds) not continue as scientists. IMO, anecdote is not sufficient for your claims.

but your odds there are 35/ (n in both those fields over several years),

I was posting for the research pathway in the specialty. Those are self-selected, highly motivated, research-oriented residents. But if you are such a person, my point is that the opportunities are there for you.

But I think your logic is ridiculous. If there is a paper for the fast track in internal medicine, would you say that your chances of doing research within internal medicine is whatever number they've had divided by all internal medicine residents in the country? Because I would suspect that the fast track in internal medicine is even smaller as a proportion of residents in internal medicine (which is the largest resdency) than the Holman pathway is as a proportion of residents in radiation oncology.

Of course the paper I cited does not include the sizable number of non-Holman pathway residents who go on to become physician-scientists. Those opportunities are there as well, though does often require 1-2 years of fellowship (just like anything else...). Radiation oncology is somewhat unique in that you can go from a 5 year residency straight to being a physician-scientist faculty member if you are successful in your Holman pathway. For me, that would argue that the barriers are actually lower within radiation oncology to becoming a physician-scientist faculty member.

particulalry since if you go into rads or rad onc you are not likely to be in the Holman pathway anyway and will likely end up in PP.

Complete nonsense. See again the paper I referenced above. Radiation oncology had a lower percentage in private practice than internal medicine (albiet they are roughly equivalent: 15% vs 16% with small n for rad onc).

Also note that rad onc is a very academic field in general. I would suspect the overall percentage of practitioners within academics in rad onc is higher than internal medicine. This line of logic that choosing residency in rads or rad onc means that you will likely go into private practice is not only silly based on my own experiences, but not supported by actual data.

 

[gbwillner]

Anecdotally, including everyone i've ever known in MSTP, I have come to the conclusion that if your intention is to become a physician-scientist, you will have a clear path, institutional support, and greater chance for success if you go into the traditional programs- IM, path, peds, neuro, etc. Now, it's true that most MSTP graduates will give up on science at some point anyway, but from my experience, choosing a surgical specialty or rads pretty much cements it.

The reasoning for why those who go into IM/peds/etc are more likely to succeed is very logical. Besides the disparity of salaries in academia vs. PP, let's consider the pink elephant in the room: as an 80/20 P-S you must pull in ~80% of your salary from grants to cover your salary. Now, in neurosurgery, PP salaries are often near $1M/year, and academics it's like $400K. Same for rad onc. 80% of that is $320K. How many R01s do you need to get to sustain an academic salary? You need 1 just to pay for your bloated salary. How many chairmen are going to pay you a fat salary to see a loss on their investment on an annual basis? Not many. In reality what will happen is that they will force you to work 50/50, then 60/40, then 70/30, unless you pull some major awards. Either that or take an academic job where you make IM money ($140K). So now you're not making 1/2 of PP money, you are making less than 1/6. Almost no one will take that.

I know of no studies that have looked at this directly. However, this does not mean that specialties are the same. I can get you some data, however.

The NIH provides information on R01s given per institution, but it also provides information on what department gets those grants. Would you not say the number of R01s is a measure of academic research success? Below is the grants given to 1 institution:

Department total $$ total # of grants
ANATOMY/CELL BIOLOGY $20,212,698 55
ANESTHESIOLOGY $1,114,640 4
BIOCHEMISTRY $8,727,977 14
GENETICS $60,142,576 70
INTERNAL MEDICINE/MEDICINE $25,781,546 66
MICROBIOLOGY/IMMUN/VIROLOGY $7,755,413 18
NEUROLOGY $2,280,735 9
NEUROSCIENCES $9,114,173 30
NEUROSURGERY $355,325 4
OBSTETRICS & GYNECOLOGY $413,167 1
OPHTHALMOLOGY $1,878,046 5
OTOLARYNGOLOGY $1,033,471 3
PATHOLOGY $8,397,476 25
PEDIATRICS $38,394,397 85
PHARMACOLOGY $1,822,268 6
PHYSICAL MEDICINE & REHAB $609,408 1
PHYSIOLOGY $8,913,100 23
PSYCHIATRY $5,288,173 12
RADIATION-DIAGNOSTIC/ONCOLOGY $334,627 1
SURGERY $917,068 4
UROLOGY $1,702,911 4
NONE $3,260,189 14
Total $208,449,384 454

I apologize for the formatting, but you can see a clear trend (ignoring the basic science departments)... at this institution, IM pulls in 66 R01s, peds gets 85 R01s, path gets 25 R01s. If you COMBINE ALL the surgical subspecialties, OB/GYN, AND Rads AND Rad Onc, you get... a whopping 17 R01s. And this institution has one of the best surgery departments in the country. And path is smaller in terms of faculty and residents than most of those surgical departments.

 

[gbwillner]

Here is another institution, if you think I was biased in my selection of one place.

Yours- University of Pennsylvania

IM: 251 R01s
Peds: 5 R01s (CHOP is a different entity)
Path: 99 R01s
Neuro: 26 R01s
Psych: 110

Surgery: 15
ENT: 5
Uro: 0
Ortho: 11
Rads AND Rad Onc: 52.

So penn has a lot of rads and rad onc research... but comparatively it is very little.
Rads faculty: 99 clinical faculty at HUP only (not bothering to count other hospitals) + 40 PhD only research staff.
Rad Onc faculty: 46 (some are PhD only)
total: 185+ faculty- for 52 R01s- probably most going to PhD only (or what else are they doing there?)

Compare to Psych:
111 faculty, 110 R01s

I won't touch medicine since I've already spent too much time looking at this. Point is, there is data. And from what you've said, Penn is one of the top Rads/ Rads research places, so it probably doesn;t get much better.

 

[Neuronix]

Either that or take an academic job where you make IM money ($140K). So now you're not making 1/2 of PP money, you are making less than 1/6. Almost no one will take that.

So then the MSTP graduate has to decide: do you pick a specialty with limited clinical revenue or do you pick a specialty that pays better and have the choice whether to potentially make less money and pursue research or switch into clinical only and make much more? Because to me, having the choices seems better.

There are some awfully miserable attendings out there in low paying clinical specialties who couldn't make it work in research, spent many years making little, then switched into clinical and continue to make little. At big name rad onc programs, I have heard "your consolation prize for failing at research is a 500k/year job in clinical radiation oncology". I like having that option as a fallback!

Now, program directors may want to push you into low clinical revenue specialties because they believe you will be less tempted by higher income and thus more likely to stay in research. I don't believe that to be true based on the data I posted earlier. But, if it is true, I find that incredibly selfish on the part of the programs. The goal of the mentor should be to do what is right for the mentee, not what is right for the mentor.

But, regardless, the MSTP student has to decide based on their own goals and interpretation of the issues what residencies are for them. For me, I was always interested in high tech electronic work and the interface with patients, and so surgery, rads, rad onc were my interests from early on in medical school.

Below is the grants given to 1 institution:

Department total $$ total # of grants
ANATOMY/CELL BIOLOGY $20,212,698 55
ANESTHESIOLOGY $1,114,640 4
BIOCHEMISTRY $8,727,977 14
GENETICS $60,142,576 70
INTERNAL MEDICINE/MEDICINE $25,781,546 66
MICROBIOLOGY/IMMUN/VIROLOGY $7,755,413 18
NEUROLOGY $2,280,735 9
NEUROSCIENCES $9,114,173 30
NEUROSURGERY $355,325 4
OBSTETRICS & GYNECOLOGY $413,167 1
OPHTHALMOLOGY $1,878,046 5
OTOLARYNGOLOGY $1,033,471 3
PATHOLOGY $8,397,476 25
PEDIATRICS $38,394,397 85
PHARMACOLOGY $1,822,268 6
PHYSICAL MEDICINE & REHAB $609,408 1
PHYSIOLOGY $8,913,100 23
PSYCHIATRY $5,288,173 12
RADIATION-DIAGNOSTIC/ONCOLOGY $334,627 1
SURGERY $917,068 4
UROLOGY $1,702,911 4
NONE $3,260,189 14
Total $208,449,384 454

This is essentially anecdote as well. Not all residency programs are strong at a given institution. Their institution may be strong in medicine, peds, and path, but weak in rad onc. The faculty members in clinical departments may get grants listed in those clinical departments in some departments, but listed under other departments in other departments (i.e. it's not unusual for a rad onc to have grants under cell and molecular biology for cancer biology work). Additionally, some departments are spread out. If you listed all the R01s for Harvard Rad Onc, you'd have a hard time because the Harvard residency program is spread out among a number of area hospitals.

As for pathology particularly, the job market is notoriously awful in pathology. Just go to the Pathology forum on SDN sometime if you want to see a bloodbath. Further, there are a lot of research interested residents who go into pathology for the research. Thus, could it be a saturated field where it's difficult to get the desired physician-scientist positions? Thus, I'd still like to see data showing that all those research interested residents can get the R01s and faculty positions they are seeking.

 

[Neuronix]

Here is another institution, if you think I was biased in my selection of one place.

Yours- University of Pennsylvania

IM: 251 R01s
Peds: 5 R01s (CHOP is a different entity)
Path: 99 R01s
Neuro: 26 R01s
Psych: 110

Surgery: 15
ENT: 5
Uro: 0
Ortho: 11
Rads AND Rad Onc: 52.

So penn has a lot of rads and rad onc research... but comparatively it is very little.
Rads faculty: 99 clinical faculty at HUP only (not bothering to count other hospitals) + 40 PhD only research staff.
Rad Onc faculty: 46 (some are PhD only)
total: 185+ faculty- for 52 R01s- probably most going to PhD only (or what else are they doing there?)

Compare to Psych:
111 faculty, 110 R01s

I won't touch medicine since I've already spent too much time looking at this. Point is, there is data. And from what you've said, Penn is one of the top Rads/ Rads research places, so it probably doesn;t get much better.

Assumptions based on NIH grant funding numbers are misleading. First, because the departments and faculty appointments are more fluid than you might suspect. Second, because as you point out for pediatrics, Penn is a completely separate institution from the Children's Hospital of Philadelphia, which means the grants aren't listed there. Meanwhile, some departments may be highly research/academic at Penn, while some departments may have a component of research/academic and a component of clinical only. In any case, I will give specific examples of why I can't agree with your analysis.


I haven't been at Penn in years since I finished my MSTP training... But, IM is a HUGE department at Penn. It's the largest department in the institution, and also includes many PhD only faculty. There are some IM faculty who were hired to be entirely clinical, and there are some IM faculty who were hired to be mostly (or entirely) research. So when you throw out 256 R01s, I'd be interested to know how many IM faculty there are, particularly that are mostly clinical. Because the total number is probably many more than 256.

But this is no different in rads/rad onc. There are some radiology and rad onc faculty who were hired to be entirely clinical, and there are some radiology and rad onc faculty who were hired to be mostly (or entirely) research. Many of the clinical faculty in radiology are out in satellites, but still listed as Penn faculty. There is no way that there are 99 clinical radiology faculty members solely at HUP. So the clinical component of the department inflates the number of Penn faculty in radiology and radiation oncology, but those faculty are primarily revenue generators.

Psych doesn't have the revenue generation emphasis that the cancer center and radiology subsites have, so there aren't a bunch of psychology/psychiatry offices out on the main line like there in radiology/radiation oncology. In fact, HUP got rid of its psychiatry unit several years ago, replacing it with an interventional cardiology unit. You'd have to be a very research oriented psychiatrist to be there at all. Of course, it's a separate issue that a chunk of psychology and neurology faculty publish radiology research such as fMRI and rely on radiology faculty to support their research technically.

Further, some of the research faculty who are listed as radiology faculty on the website have adjunct appointments in radiology and are primarily bioengineering or biophysics faculty. Their grants are typically awarded under bioengineering or biophysics.

 

[gbwillner]

As for pathology particularly, the job market is notoriously awful in pathology. Just go to the Pathology forum on SDN sometime if you want to see a bloodbath. Further, there are a lot of research interested residents who go into pathology for the research. Thus, could it be a saturated field where it's difficult to get the desired physician-scientist positions? Thus, I'd still like to see data showing that all those research interested residents can get the R01s and faculty positions they are seeking.

Not sure what this has to do with the subject at hand. There are a handful of crazy trolls on that forum who think if they cry and scream about the sky falling, they can dissuade med students from going into the field, as they think this will increase their competition and reduce their bottom line. As someone in the field I can tell you it's not as bad as they say. Like rads, things could be better, and everyone is now forced to do fellowships (who want to go into PP), but in academics there are a ton of opportunities.

Back to the point- my samples, though small, illustrate that even in the best-case scenarios (Rads at Penn) there are relatively few successful scientists as a percentage of academic faculty members. At worst (looking at surgery and surgical subspecialties at the 2 institutions I mentioned) it is much more difficult to maintain a lab and funding in those fields. You can't tip-toe around the funding your salary issue. My rare MSTP fiends in surgical fields who actually wanted to continue research were dismayed when they were forced (shock!!) by their chairmen for more OR time to pay their lofty (by academic standards) salary. Both friends I had in the Holman pathway left academics after their "post docs" ( I say that because they had to be in the dept of rad onc) when they were facing looking for underpaid salaries as asst. prof or instructor vs. double that with clinical only or 400K+ in private practice. You can dismiss this only as anecdote, but it stands to reason that if someone can continue research in path making $180K, which is the same as the academic salary of a clinical track asst prof or ~$180-250 starting in PP they may do it; whereas if someone in rad onc is offered $140-180 to do research, or they can take $400K at the same institution for clinical only or double that for PP they are much less inclined to do so.

 

[Neuronix]

You can't tip-toe around the funding your salary issue.

My rare MSTP fiends in surgical fields who actually wanted to continue research were dismayed when they were forced (shock!!) by their chairmen for more OR time to pay their lofty (by academic standards) salary. Both friends I had in the Holman pathway left academics after their "post docs" ( I say that because they had to be in the dept of rad onc) when they were facing looking for underpaid salaries as asst. prof or instructor vs. double that with clinical only or 400K+ in private practice. You can dismiss this only as anecdote, but it stands to reason that if someone can continue research in path making $180K, which is the same as the academic salary of a clinical track asst prof or ~$180-250 starting in PP they may do it; whereas if someone in rad onc is offered $140-180 to do research, or they can take $400K at the same institution for clinical only or double that for PP they are much less inclined to do so.

I didn't try to tip-toe around it. It comes down to a philosophical difference about whether MSTPs should go into fields where they are locked into less pay so they'll be more likely to stick with research. Alternatively, should they choose fields where they have the backup of more clinical revenue if their research doesn't work out. The same arguments can be made even within internal medicine when considering fellowships like cardiology or GI vs. rheumatology or hematology.

So I'll repeat what I typed earlier because I think it's relevant to repeat.

The MSTP graduate has to decide: do you pick a specialty with limited clinical revenue or do you pick a specialty that pays better and have the choice whether to potentially make less money and pursue research or switch into clinical only and make much more? Because to me, having the choices seems better.

There are some awfully miserable attendings out there in low paying clinical specialties who couldn't make it work in research, spent many years making little, then switched into clinical and continue to make little. At big name rad onc programs, I have heard "your consolation prize for failing at research is a 500k/year job in clinical radiation oncology". I like having that option as a fallback!

 

[dl2dp2]

The MSTP graduate has to decide: do you pick a specialty with limited clinical revenue or do you pick a specialty that pays better and have the choice whether to potentially make less money and pursue research or switch into clinical only and make much more? Because to me, having the choices seems better.

One could make decent money in any field of clinical medicine. Maybe not rad onc money, but doctors get paid well in the country. I don't think going into a specialty solely for the money is generally a good idea.

I think the idea for the MST programs to dissuade residency applicants to apply to certain specialties makes sense, but I doubt that these dissuasions have any teeth to it. MDPhDs who got sick of research will do whatever they want to get out of research.

The squeeze is basically in the mid 30s period when you start to have little kids and a mortgage, and money seems to flow out so quickly. It is a structural issue, but one I'm not sure how to solve...considering that PhDs in the same position get paid EVEN LESS. With clinical supplements, a MDPhD fellow can realistically pull a basic biology assistant professor salary, but it's substantially lower than their clinical peers, which creates resentment. It sucks when your peers live in expensive neighborhoods and send their kids to private kintergardens and have ski trips in Colorado, when you have to barely scrape by in expensive markets.

I don't think most tax payers will have sympathies for these issues though (i.e. the "difficulties" of raising kids on 90k), considering how poor the overall economy is. So, I'm not sure how far it'll go in terms of advocacy ("pay physician scientists more!"...but WHY? LOL can you imagine a MD/PhD lobbying presence inside the beltway?) It's a supply vs. demand issue. Loads of PhDs can do "research". The supply for dermatologists is artificially clamped.

 

[gbwillner]

One could make decent money in any field of clinical medicine. Maybe not rad onc money, but doctors get paid well in the country. I don't think going into a specialty solely for the money is generally a good idea.

I think the idea for the MST programs to dissuade residency applicants to apply to certain specialties makes sense, but I doubt that these dissuasions have any teeth to it. MDPhDs who got sick of research will do whatever they want to get out of research.

The squeeze is basically in the mid 30s period when you start to have little kids and a mortgage, and money seems to flow out so quickly. It is a structural issue, but one I'm not sure how to solve...considering that PhDs in the same position get paid EVEN LESS. With clinical supplements, a MDPhD fellow can realistically pull a basic biology assistant professor salary, but it's substantially lower than their clinical peers, which creates resentment. It sucks when your peers live in expensive neighborhoods and send their kids to private kintergardens and have ski trips in Colorado, when you have to barely scrape by in expensive markets.

I don't think most tax payers will have sympathies for these issues though (i.e. the "difficulties" of raising kids on 90k), considering how poor the overall economy is. So, I'm not sure how far it'll go in terms of advocacy ("pay physician scientists more!"...but WHY? LOL can you imagine a MD/PhD lobbying presence inside the beltway?) It's a supply vs. demand issue. Loads of PhDs can do "research". The supply for dermatologists is artificially clamped.

I agree with the above. I will say however, that I think a major restructuring of Rad Onc salaries is pretty much a certainty. They are and have been a small boutique specialty, and have been under the radar by medicare reimbursement slashes so far. It will happen, just like it did to rads like 5 years ago. It doesn't matter how good their lobbying is, they won't be able to justify their $25K/new patient sticker price forever.

 

[Neuronix]

It will happen, just like it did to rads like 5 years ago. It doesn't matter how good their lobbying is, they won't be able to justify their $25K/new patient sticker price forever.

You hear this all the time for every higher reimbursing specialty. It may happen. It may not. I think it's silly to predict the future as something "will happen". There are a lot of people out there saying that the end of the world "will happen" very soon also. There have been some small reimbursement cuts to radiation oncology recently, but whether that and possible future cuts will affect future incomes is yet to be seen.

Radiology on average still pays about what it did 5 years ago.

Now let me clarify so nobody takes me out of context: I'd never tell someone who loves a lower reimbursing specialty to go into a higher reimbursing specialty specifically for the money. I also would never tell someone who loves a higher reimbursing specialty to go into any other specialty because of a perceived better ability to do research in that other specialty. I think you need to pick a specialty primarily based on your clinical interests. In my opinion, everything else is secondary.

I agree with much of what sluox posted as well. MD/PhDs will never starve either in clinical medicine or research. I just said that I like the option of choosing research or a high paying clinical position, rather than choosing research or a lower paying clinical position. It's all in the choice. It seems very silly to me to limit your future choices for the possibility that you might choose an option that will seem better to you in the future.

However, what MD/PhD programs can do is set up their graduates to have mediocre clinical residency applications in various ways that have been discussed recently in this forum and repeatedly by yours truly. If someone focuses entirely on research and gets the national average on step 1, they will likely have no chance at things like radiology and radiation oncology. If someone is very limited in their clinical rotation and elective choices due to scheduling, it may prohibit them from putting together a competitive application for competitive specialties. Then what? Then the applicant may not match. What a disaster. They may also not get a spot at the top academic programs, limiting their ability to perform the serious research they wanted. So a common thing happens when a CD8 comes for advice and doesn't have a competitive application for something like rad onc because they listened to advice to not worry about step 1... The advice is: "Well why take a chance on rad onc when you can apply to medicine instead. I'm sure you can get a great spot there." That is where the "teeth" are. It's subtle, it's sneaky, and it may not even be intentional. But, it happens frequently.