MD-PhD: A Liability?

[CowPlant]

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Hi all. I'm an MD-PhD student with a question about Step 1 in research-heavy applicants.

I've been told that MD-PhD students who, like me, score mediocre on Step 1 (I'm 219) have a lower chance of matching into any specialty compared with straight MD applicants: our scores are automatically screened out by university residencies, yet our PhD is too ivory tower for community programs. The result is that we fail to match.

Is this true in psych? FWIW I started med school with psychiatry as my goal, and I don't value program prestige (e.g. I'd be very happy at a "low-end" university residency in a fun city if the faculty encourage research/publishing/etc).

I searched before posting this question and only found one thread from five years ago specifically on PhDs. Someone replied that Step mainly mattered at the top programs, which is good to know, but the discussion dissolved into people arguing the training quality at Columbia vs. Stanford (lol). I'm posting this to see how the Step/PhD problem has aged. Thanks for any opinions!

 

[FlowRate]

This is a thinly-veiled WAMC post.

Nevertheless, 219 won't keep you out of the majority of university psych programs. Just score well on Step 2. If you're in the middle of applying and don't plan on having your Step 2, then aim for low and medium tier university programs.

 

[CowPlant]

Great, thanks for the reply. I see now this should have been posted in WAMC and apologize.

 

[st2205]

If a program filters out an MD-PhD by lazily using a computer sorting cut-off, that's not a very good foreshadowing for how that program can actually build a good training program.

Regarding being at a disadvantage, this is not true. You'll have an advantage. I would qualify this statement, however. If for whatever reason you're wanting to apply to some small community program in Anytown, USA, but nothing on your application shows a tie to that area, then I'd contact them directly to indicate your reasons for interest. Coming from a small program, we have limited interview slots and try to fill it with people we think are serious about coming -- all you'll need to do is communicate that somehow if it isn't apparent.

 

[clausewitz2]

I applied as a MD/PhD with a meh step 1 from a no name med school, had a >90% invite:application ratio. You'll be fine.

 

[dl2dp2]

IMHO things have gotten "worse" (or better depending on your perspective). In the last few years psychiatry programs especially high end ones in wealthy locations that are capable of producing private cash pay psychiatrists are becoming vastly more competitive, as it's now at the receiving end of top life style applicants, as well as uber competitive administrative types. It's becoming a plausible career choice competitor to rad onc/deem for MDPhDs who have no interest in research but still are gunner enough for a shiny CV for that perfect lifestyle job. Depending on where you are doing your MDPhD, your chance at a top program especially in a research track is diminishing with a 210s step 1.

That said, you should obviously still apply to all the top programs that you are interested in, but don't be surprised if they don't even interview you. It used to be if you are MDPhD at all you are automatically in at least for interview everywhere. This appears to have stopped. You will for sure still get into a good university program if you apply broadly, but I would advise you to in fact apply broadly and keep the expectations well tempered. Also, if you are genuinely interested in pushing toward a research career, midwestern universities with very good reputation such as Wash U and Pittsburgh are probably a better fit than comparable but somewhat lower tier programs on the coasts, which can be more competitive and poorer mentorship but for no real good reason other than location.

 

[Bartelby]

I think any advice is premature. You have a step 1 score that is not great, but that isn't a red flag. You also (will) have a MD/PhD, which is great. If you have good publications, good clinical grades, good narrative comments and letters, a good step 2 score, and an otherwise good application I see no reason you can't be in the running for top programs! And for sure, I see no reason you would go unmatched. There is so much more to an application than a single test score.

 

[HarryMTieboutMD]

I don't know of any psych programs that screen beyond p/f (though this could have changed in the past 4 years since scores keep going up- seems like 230s-240s is the norm). That said though more and more MDPhDs are going into psych research heavy programs still salivate over them especially if they demonstrate a passion for an academic career.

 

[phonyreal98]

Actually the OP isn't the only one with these questions...I just haven't asked in the past few years because I've been in grad school and I'm still 2 years or so away from applying (I'm also an MD/PhD, should be finishing up my PhD within the next year and headed back to med school but who knows?). I've been involved in psychiatry research since undergrad, my PhD is psychiatry-related, my advisor is well known and publishes often in psychiatry journals, I already have several good publications (and will have more as I finish my PhD)....but my Step 1 score is in the 210's as well. The takeaway that I'm getting from the conversation is that I still should be competitive for very good programs with strong research tracks outside of places like NYC/LA/SF, would I be correct? Research is still a big passion of mine and I would like to continue it throughout my career (time/grant funding permitting).

If a program filters out an MD-PhD by lazily using a computer sorting cut-off, that's not a very good foreshadowing for how that program can actually build a good training program.

I actually thought the same thing a few months ago- good to know that there are people out there with more experience than I do that think the same way.

That said though more and more MDPhDs are going into psych research heavy programs still salivate over them especially if they demonstrate a passion for an academic career.

I've been hearing this as well, but when I checked the Charting Outcomes in the Match from the past few years, it appears that the number of MD/PhD's applying to/matching in psychiatry has stayed relatively constant (between 30-35 MD/PhD's in each of the reports since 2011, or about 4.5-5% of US seniors matching in psychiatry each year are MD/PhDs). Is there something I'm missing or am I possibly miscalculating something?

 

[HarryMTieboutMD]

Actually the OP isn't the only one with these questions...I just haven't asked in the past few years because I've been in grad school and I'm still 2 years or so away from applying (I'm also an MD/PhD, should be finishing up my PhD within the next year and headed back to med school but who knows?). I've been involved in psychiatry research since undergrad, my PhD is psychiatry-related, my advisor is well known and publishes often in psychiatry journals, I already have several good publications (and will have more as I finish my PhD)....but my Step 1 score is in the 210's as well. The takeaway that I'm getting from the conversation is that I still should be competitive for very good programs with strong research tracks outside of places like NYC/LA/SF, would I be correct? Research is still a big passion of mine and I would like to continue it throughout my career (time/grant funding permitting).

Yes- a strong research career before residency (meaning PhD with good publications) outweighs a step 1 score for academic programs. Not everything is coastal... the midwest and the south have a lot of really strong programs with good research

 

[SmallBird]

Actually the OP isn't the only one with these questions...I just haven't asked in the past few years because I've been in grad school and I'm still 2 years or so away from applying (I'm also an MD/PhD, should be finishing up my PhD within the next year and headed back to med school but who knows?). I've been involved in psychiatry research since undergrad, my PhD is psychiatry-related, my advisor is well known and publishes often in psychiatry journals, I already have several good publications (and will have more as I finish my PhD)....but my Step 1 score is in the 210's as well. The takeaway that I'm getting from the conversation is that I still should be competitive for very good programs with strong research tracks outside of places like NYC/LA/SF, would I be correct? Research is still a big passion of mine and I would like to continue it throughout my career (time/grant funding permitting).

You would be incorrect. A psych related MDPhD with publications and an otherwise good application is absolutely competitive at Columbia, UCSF, pretty much anywhere, even with a 210 USMLE. If those programs think you could eventually pull in RO1s they really don't care about your step scores.

 

[phonyreal98]

Yes- a strong research career before residency (meaning PhD with good publications) outweighs a step 1 score for academic programs. Not everything is coastal... the midwest and the south have a lot of really strong programs with good research

I'm interested in ending up in the midwest or the south so that's good!

 

[CowPlant]

Thanks again so much for everyone who chimed in. It's a relief to hear I'm still on the table for most places.

If those programs think you could eventually pull in RO1s they really don't care about your step scores.

May I ask how one convinces programs that they'll get R01s? Hope this doesn't sound naive - I was once told by a research mentor that the best predictor for future funding is previous funding, and you can't even get "real" grants until residency or postdoc. NIH has MD-PhD grants but I'm advised these are highly political. Maybe authorships and the occasional travel award are the best realistic bet?

 

[dl2dp2]

May I ask how one convinces programs that they'll get R01s? Hope this doesn't sound naive - I was once told by a research mentor that the best predictor for future funding is previous funding, and you can't even get "real" grants until residency or postdoc. NIH has MD-PhD grants but I'm advised these are highly political. Maybe authorships and the occasional travel award are the best realistic bet?

You are still on the table, which is why you should apply to all programs you are interested in. There's no real way to tell who will eventually get an R01 and who won't. There's also no clear way to try to do that at the residency level. This is IMHO a huge bug in the system, not a feature. Gaining an R01 isn't an outcome at the end of the day, it's an arbitrary decision. And since it is just as arbitrary as picking residents, if not more so, they (NIH, etc.) should do that early. Instead, no one on an institutional level wants to make that decision and instead leaves it to a faceless group of reviewers.

This judgement essentially rests on cronyism: the recommendation letters, articles published, and word of mouth. There is some predictive validity, as in general people who go to top schools and have most prestigious advisors end up succeeding. Nevertheless, in the end large training centers don't really care about any specific applicant. You can work your ass off in trying to guess their mind, but the real game they are playing is statistical. If each year they get a handful of research oriented MD/PhDs, they will end up with one who will get an R01. People who start out with a strong research bend but drop out midway are much more common than those who persist and eventually stay. This may be a starting point to learn the real world business of science: to advance in science, the game of the day is salesmanship. With the package you have in your hand, you need to articulate an argument why people would give their limited resource to you as opposed to anyone else. As in anything else in sales, sometimes in you win, sometimes you lose, and a lot of times it's not fair.

Right now, the tendency for large training centers is actually to start building their long neglected clinical programs. Given the lackluster increase in NIH funding, the kind of unreal profit margin from indirects from R01s (in the 40%) is no longer covering overhead, and even major centers are bleeding money from doing research. On the other hand, resources, collaborators, and other favorable factors have now concentrated much more to specific geographical centers that it is often difficult to execute some types of research outside of that network of large training centers. There's a LOT of inequity in this system and just like inequity in other areas are of life they are extremely recalcitrant to attempts of reform for a variety of reasons, not all of which are necesarily nefarious at the start. For example, recently NIH wanted to limit the total # of grants senior researchers can receive to support junior people (who are often outside of major training centers). This was scraped very quickly because they realized that the senior people's center grants are often in name only and support lots of junior people who have less independence...

 

[tr]

There's no real way to tell who will eventually get an R01 and who won't. There's also no clear way to try to do that at the residency level. This is IMHO a huge bug in the system, not a feature. Gaining an R01 isn't an outcome at the end of the day, it's an arbitrary decision..

THIS IS SO TRUE. I think it should be stickied on the MD/PhD forum.

Given that, and not to hijack too badly, sluox were you as annoyed as I was by the bent of that NIGMS request for public comment on physician-scientist training?
The whole thing was predicated on the faulty assumption that there was some intrinsic quality ("persistence") that would predict success in obtaining an R01, and asking how they could best identify that quality in 22 y/o applicants. Like, huh? There was zero acknowledgement, either that the reasons for the MD/PhD exodus to clinical practice are large market forces that can't be countered by individual personality traits, or of the enormous role of various chance factors in the selection of the tiny minority that actually ends up getting the R01. Gah.

 

[OldPsychDoc]

Thanks again so much for everyone who chimed in. It's a relief to hear I'm still on the table for most places.



May I ask how one convinces programs that they'll get R01s? Hope this doesn't sound naive - I was once told by a research mentor that the best predictor for future funding is previous funding, and you can't even get "real" grants until residency or postdoc. NIH has MD-PhD grants but I'm advised these are highly political. Maybe authorships and the occasional travel award are the best realistic bet?

Get a research mentor in residency, preferably in a situation in which you can essentially function as a post-doc under an established PI. Publish stuff. Do a research fellowship after residency. Apply for a K award. Publish some more. Nobody gets an R01 right out of the gate.