MD/PhD experience choosing non-traditional specialty over IM

[Shifty B]

A question came up in another thread about choosing a non-traditional specialty for an MD/PhD (http://forums.studentdoctor.net/showpost.php?p=9300221&postcount=89), but that thread was getting a little bit off topic and it wasn't a great place to address it. I decided to create another thread so it could be addressed separately. For the purposes of this thread, I will say the specialties that MD/PhDs are encouraged to pursue are IM, Peds, and Path. In other posts, I have expressed dissatisfaction with the notion of pursuing IM in particular (I am a radiology resident). The post basically asked me to expound upon why.

So, this is a complex issue that I will try to address from my personal perspective. I think there are two big factors here. One is that my interests started to deviate from the 80/20 "ideal" model, as I couldn't imagine myself doing that much basic science research anymore. The second is that I think internal medicine as a field is getting less desirable for all medical students.

I did my PhD in biomedical engineering, particularly in radiology oriented research, so the stage was set for me to do radiology. I had a very successfuly PhD in terms of producing papers, grants, etc., but I found the day to day operations to be very frustrating in general. In my mind, I was toiling away to obtain minor findings that only a few people in the world might be interested in. The findings were so incremental that I was unable to appreciate their role in the big picture of medicine in general. And my research is practically applied compared with a lot of basic science. So, I began to think that if I had a career that involved 20-40% translational/clinically oriented research, that would be nice. The biggest incentive to choose IM/peds/path is that they all have the possiblity of letting you do > 80% research time. Since I no longer needed that, pretty much every specialty was open to me.

Oh, and research is getting worse. Most people are struggling to get enough funding. > 50% of time is spent on grant-writing and revision, resubmission and politics. Few PIs really have control over their time, and their involvement in their own lab's research is dwindling. It's a constant battle to maintain your existing funding, let alone get new funding, get promoted, etc. Yikes.

With that in mind I decided I'd better choose a specialty that I really enjoyed. Of course, for each individual this will be different, but to me, this specialty was radiology. My favorite part of medicine is diagnosis, and in radiology set of films is a new diagnostic challenge, many of which are currently undiagnosed. Pretty much every patient with an interesting medical problem gets some sort of radiology, so you get to hear about basically every complex or atypical patient. I also dislike rounding and developing patient relationships is not particularly important to me. Plus, I think radiology has a rate of technology development that makes it wide open to research from a guy like me.

I did consider medicine though, particularly heme/onc (with emphasis on the onc). I enjoyed my time on medicine, but it was a couple of months and I couldn't imagine continuing it as a career. For one, I think IM is full of work that is unrelated to medicine. It's 40% scut and 40% social work, with only 20% interesting material. Nursing home placements, home oxygen requests, calling medicaid for drug preauthorization, ugh. Plus, by the time most patients make it to their IM doctor their primary issue has been diagnosed, they just need further management for a few days, micromanaging lab values and whatnot.

Over the last 20 or so years, medicine has gotten increasingly complex and dependent on subspecialties. As the IM doctor, you used to be the doctor to turn to in the hospital. Now you're like an administrator for other specialties and subspecialties. Any truly interesting problem is farmed out to ID, Onc, Neurology, Ophtho, ENT or one or more other specialties while the IM doc is the manager. At the same time, the complexity of medicine is the harbinger of doom for the 80/20 doc. The people spending 1 month of general wards a year, 1 month of consults, and specialty clinic the rest of the year will be mediocre clinicians on wards, and will be really good only at whatever their super-specialized area is. These days, cardiologists transfer patients to medicine teams because they don't feel comfortable managing people's medical problems. Seriously, these people are 100% clinical, completed a IM residency, and still keep up only with their subspecialty area.

So, if you want to do medicine the only refuge is the popular medicine subspecialties (GI, cardiology, maybe ID?). Here, your facing a 3 yr residency and 3 yr fellowship (or 6-7 yr "fast track"). Then I guess it's possible you could end up in a postdoc role for a little bit or go straight into a lower level faculty position, depending on what's available.

Or, you can consider the other specialties that your MD only colleagues are flocking to as well (radiology, neuro, derm, anesthesia, emergency, ophtho). Most are no more than 6 years including a fellowship. Might as well do the specialty if that's your thing. I mean, you were headed for a medicine subspecialty (or even supersubspecialty) anyway. You will have time to carve out for research if that's what you want and are willing to compromise on salary (which seems reasonable to me). The only thing you are probably giving up is the ability to do the 80% research, which will limit your ability to get your own R01 and whatnot. But if you don't believe in the R01/have your own lab/paperwork mountain path, maybe you can contribute more while avoiding the hassle. These specialty fields are ripe for academically minded people willing to spend time and effort on research and teaching, even if it's not 80%.

I can honestly say the only time I considered money is thinking about the post-fellowship period, when to pursue a basic science postdoc would be a huge drop in pay. You're talking about the difference in say, rads or hem/onc clinical attending (probably $150-250k or more) vs postdoc (50-70k, maybe?). I think in these cases though most people try to work out something where they are really "MD fellows" or something so they make more money. I'm not sure.

Anyway, I realize this is really an extended post, but feel free to ask any questions if you have them.

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[QofQuimica]

Tough to argue with that. I even agree with you about liking heme/onc the best. Particularly the onc.

I don't think very many MD/PhDs would want to be general IM docs. It's probably at least tacitly understood that you would be going into a subspecialty of some type. I for one will definitely be doing a fellowship.

 

[dl2dp2]

This sounds very nice. I have a couple of questions for you. The starting salary of an academic, fellowship trained radiologist is 250-300k. This is for someone doing 100% clinical work. Suppose after fellowship you want to do 50% research, how much of a reduction of your pay would you anticipate?

Is it fair then to assume that you would be unwilling to do this and thus spells the end of any significant research involvement?

My second question is, supposing your research is highly clinically relevant, and thus is under the purview of a "clinical research." Do academic radiologists who do significant clinical research get paid as well as a 100% clinical radiologist? I'm not very familiar with how academic departments in rads are incentivized for research...it's unclear to me that they are willing to significantly subsidize research if you aren't bringing in multiple grants. But as you said yourself, if you can't do >80% research how can you bring in multiple grants? And if there aren't co-PIs who are more senior how can you only do 50% research and not have to deal with the research paperwork?

I know for sure that in cardiology, for instance, an academic interventionalist gets paid SIGNIFICANTLY more than an academic heart failure clinical researcher.

Unless, there're untold millions in the unspeakable "Dean's tax" or "Chair's account", (I'm not even kidding, these things really exist, fellas)...ready to be used to subsidize young research minded radiologists?

The other problem is that if you do 50% research, even clinical research, you'll always be stuck at a "postdoc" level, where you have no control over the questions, methods and subjects. While in principle if you have a good mentor this shouldn't be an issue, I personally dislike the idea that when I'm 50 I have a boss to report to who's not a department head. However, in that regard I think if you decide to do purely clinical, that would be nice as well, as you do most of the revenue pulling without requiring grants. But in that case might as well go private. Then there's also the "tenure" issue. Doing 50% research won't get you a tenure...but tenure is really meaningless for pure clinicians anyway. Then there's "hard money" vs. "soft money". On and on...

The bottom-line is, I feel that the content of my work is significantly less important than the degree of autonomy I have. I'd be more willing to run my OWN practice or my OWN research group than doing 50% research and 50% clinical work. What I'm saying is that by the time I'm old I'd rather *manage* than *practice*. But I think autonomy is really not a huge issue for a lot of people. Also, is endless grant filing really "autonomous"? Radiologists usually don't set up their own shops anyway.

There's also the subject matter issue. Clinical research tends to be better funded and more relevant, which is satisfying, but they rarely yield any "mechanism." This could potentially be kind of meaningful for some people. There are questions that many millions of people do care about that are "basic science". Why did Albert Einstein get so famous? I have pretty much given up in getting to that level at all personally myself but there is something intellectually attractive about that...and I think a very selected few, those MDPhD candidates with significant success in basic science--and there are those amongst us who are really budding Linus Paulings and Eric Kandels--this drive is a powerful one. I've seen them, and I am just not as good, and though dwelling on this would be sophomoric, it nevertheless evokes a sense of melancholy of lost youth. But I agree completely with you that in everyday mundane scientific investigation, the minutiae can drive you crazy.

This is really complicated...I can tell you--you asked for my "plan", and I've thought about this a lot and can't really sort everything through in my head. My plan is to just walk one step at a time and see where things are when the time comes. There are significant hurtles in every stage of this game, with lots of competitions along the way, even in a relatively non-competitive specialty. Thankfully, every step of the way if there's a *significant* failure I'm very ready to settle into a nice comfortable life, which MD/PhD training affords you. Perhaps my unwillingness to tolerate a very ascetic life is a sign of my lack of "commitment" and thus dooms me to failure? I don't know. I just don't know.

Oh the other thing to consider is that nobody after residency/fellowship gets paid 60-70k as a postdoc in any specialty. There are things called T32s and K08s, and clinical research positions in other specialties as an attending is still usually significantly higher than that of a fellow.

 

[Shifty B]

Tough to argue with that. I even agree with you about liking heme/onc the best. Particularly the onc.

I don't think very many MD/PhDs would want to be general IM docs. It's probably at least tacitly understood that you would be going into a subspecialty of some type. I for one will definitely be doing a fellowship.

Of course this is true that you'll be doing a fellowship. My problem is with the IM scut that you are dealing with during the 6 years of training. Then, at a lot of places the subspecialty attendings will come back and do a combination of general wards, specialty consult, and clinic. I guess if you become specialized enough you can see only those 5 ridiculous cases a year and avoid general wards.

I think when choosing a specialty you need to decide how much basic research you want for your career. Probably anything >50% or so, then you have to go with IM/Path/Peds. Below that, your options are wide open.

 

[Shifty B]

This sounds very nice. I have a couple of questions for you. The starting salary of an academic, fellowship trained radiologist is 250-300k. This is for someone doing 100% clinical work. Suppose after fellowship you want to do 50% research, how much of a reduction of your pay would you anticipate?

Is it fair then to assume that you would be unwilling to do this and thus spells the end of any significant research involvement?

From what I can tell, most academic radiologists at big institutions are getting 1 academic day a week for teaching/research with a full salary. I think you should be able to negotiate another day with perhaps only moderate reduction in salary (which would bring you to roughly 40% research). Choosing hypothetically between, say 300k as full clinical vs 200-250k with more research time, I can accept the difference. More drastic drop, then it would depend on how bad I wanted it.

And if there aren't co-PIs who are more senior how can you only do 50% research and not have to deal with the research paperwork?

I think this is really the key if you want this to work. You need to get tied in with PhD researchers in a mutually beneficial relationship. By bringing your clinical input, recruiting subjects, collecting clinical data, helping with grant and paper submissions, you can bring a lot to the table as a clinician working with a PhD. Plus, you can deliver a lot of clinically relevant ideas. Just by bringing your clinical expertise, you can help increase the quality of submitted papers and grants. In return, your co-PIs are going to offload a lot of management in terms of hiring postdocs, mentoring grad students, teaching, etc. Just by being a secondary PI, though, you can probably offset a decent fraction of your salary. Then there are center grants (P50s, etc) that you can get on for seed projects. But you don't necessarily have to have your name at the top of an R01.

Haha, for most clinicians tenure is kindof irrelevant because it is probably harder for the institution to replace you than for you to replace the institution.

The bottom-line is, I feel that the content of my work is significantly less important than the degree of autonomy I have.

The only thing I can say about this is that it really helps to know what you value. Then when you're thinking about your career you can direct things in a way to get what you want. The scenario I describe above doesn't have 100% autonomy, but I don't particularly want that.

This is really complicated...I can tell you I've thought about this a lot and can't really sort everything through in my head. Thankfully I still have a number of years to go before these irreversible branching points really occur.

It is really complicated, and I don't think anyone expects that ahead of time. You're not thinking of this when you sign on for MSTP programs.

Oh the other thing to consider is that nobody after residency/fellowship gets paid 60-70k as a postdoc in any specialty. There are things called T32s and K08s, and clinical research positions in other specialty as an attending is still usually significantly higher than that of a fellow.

I kindof alluded to this b/c I am aware of it but don't know that much about the details.

 

[Gfunk6]

Oh the other thing to consider is that nobody after residency/fellowship gets paid 60-70k as a postdoc in any specialty. There are things called T32s and K08s, and clinical research positions in other specialties as an attending is still usually significantly higher than that of a fellow.

I'm interested in discussing this more. I've got < 18 months left in my Rad Onc residency and am considering applying for an institutional T32 post-doc. I'm trying to figure out what stipend I would be receiving (I would be a PGY-6) by then and came upon the following website:

http://grants2.nih.gov/grants/guide/notice-files/NOT-OD-10-047.html

Looks like the maximum the NIH will provide for salary is ~ $50K. I'm wondering if the institution can sweeten the pot. Though I am eager to launch a research career, there is only so many years of salary loss I can take. For instance, if I forgo a post-residency postdoc I can still get a 50-50 or 80-20 physician scientist position as an assistant professor for more than triple the NIH stipend.

Thoughts?

Added: Looking through my old emails, I have one from the director of a T32 in the southeast who quoted a $75K stipend for MDs. So I guess the question is how much the individual institution is willing to supplement your salary. This is probably something you have to ask programs directly.

 

[solitude]

thanks everybody for the honesty--this is great. As an MSTPII I have nothing of value to add, but I really appreciate the candid discussion so that I can start thinking about these things along the way. And be motivated for boards studying .

 

[alacast]

Seconded!

 

[Shifty B]

I'm interested in discussing this more. I've got < 18 months left in my Rad Onc residency and am considering applying for an institutional T32 post-doc. I'm trying to figure out what stipend I would be receiving (I would be a PGY-6) by then...

That's basically what I was saying above about there only being so much you can tolerate in terms of deferred salary. If your time is being supported by a T32 grant, what the institution may be willing to add will probably be negotiable (as you have pointed out). You may be able to obtain more by providing some clinical effort, such as covering the call pool on some weekends or occasionally covering a clinical service. In radiology, it is fairly easy to supplement your income by moonlighting, either at your own or a different institution.

Also, after some reading online it seems like the K08 awards are slightly more lucrative. From what I can tell, you can get 75% salary support at a level of $75k. I assume that the remaining 25% of your time could be spent in clinical duties and provide the remaining $25k to bump you up to at least $100k.
http://www.nigms.nih.gov/Training/CareerDev/MentoredClinicalCareerQA.htm

Perhaps you can use that as a basis for negotiating a slightly better salary when the time comes.

 

[Shifty B]

thanks everybody for the honesty--this is great. As an MSTPII I have nothing of value to add, but I really appreciate the candid discussion so that I can start thinking about these things along the way. And be motivated for boards studying .

Well, you have the right idea. If there is anything you can do to help out in your future career it is to do well on step 1. It's amazing that on your residency app, summarizing 8 years, the thing that can limit you most is that step 1 score. Stupid, but true.

These issues are complex, and ultimately can end up influencing what kind of career you have. Most of us want research oriented careers and know that there is going to be some trade-off in salary. But you have to do what you can to make it reasonable.

I'll try to provide whatever information I can about these issues, because there probably aren't enough participants on this forum who have actually finished programs and are now in residency. If you have questions about other aspects I will be happy to try to address them as well.

 

[gbwillner]

Since I am on a "traditional" track I thought I would put in my 2c and respond to your initial post. I don't mean to disrespect or argue but to give another viewpoints to your arguments.

So, this is a complex issue that I will try to address from my personal perspective. I think there are two big factors here. One is that my interests started to deviate from the 80/20 "ideal" model, as I couldn't imagine myself doing that much basic science research anymore. The second is that I think internal medicine as a field is getting less desirable for all medical students.

I did my PhD in biomedical engineering, particularly in radiology oriented research, so the stage was set for me to do radiology. I had a very successfuly PhD in terms of producing papers, grants, etc., but I found the day to day operations to be very frustrating in general. In my mind, I was toiling away to obtain minor findings that only a few people in the world might be interested in. The findings were so incremental that I was unable to appreciate their role in the big picture of medicine in general. And my research is practically applied compared with a lot of basic science. So, I began to think that if I had a career that involved 20-40% translational/clinically oriented research, that would be nice. The biggest incentive to choose IM/peds/path is that they all have the possiblity of letting you do > 80% research time. Since I no longer needed that, pretty much every specialty was open to me.

1. On your comment of the desireability of IM: Nothing in medicine is static. A few years ago radiology and rad onc were not high-paying, desireable fields. Now they are. If current legislation holds up, IM may once again become desirable. Regardless, the loss of interest in IM, IMHO, is the fact that it does not reimburse as well as other specialties. How much would you wager that the highest-paying specialties are the most sought-after (i.e., competitive)? Just saying.
2. There are a lot of ways of interpreting your comment that you don't want to do the 80/20 model. There is nothing that says that's what you get in the traditional model. You can do 20/80. You can do 50/50. However, as time goes on and you get more and more into your work, in general, the more time you WILL WANT to spend in your own lab. Your research will hopefully prosper and you will become more relevant in your field.

Oh, and research is getting worse. Most people are struggling to get enough funding. > 50% of time is spent on grant-writing and revision, resubmission and politics. Few PIs really have control over their time, and their involvement in their own lab's research is dwindling. It's a constant battle to maintain your existing funding, let alone get new funding, get promoted, etc. Yikes.

This is really pretty far-fetched. Maybe your time is spent >50% writing rants for a 3 month span every 3 years or so. I've never seen anthing like this, ever. Hopefully this is just hyperbole on your part. There are also plenty of scientist out there in the "traditional" and "non-traditional" specialties that do lots of great research, primarily applied, without a cent of NIH money. Most comes from departmental funds. Also, the politics part you mention and the fight for promotion have nothing to do with research. You will see that in any academic department or private practice setting. You can't escape from it, so you better learn to play these dumb games. Admittedly, the games with be somewhat different depending on your setting.

With that in mind I decided I'd better choose a specialty that I really enjoyed. Of course, for each individual this will be different, but to me, this specialty was radiology. My favorite part of medicine is diagnosis, and in radiology set of films is a new diagnostic challenge, many of which are currently undiagnosed. Pretty much every patient with an interesting medical problem gets some sort of radiology, so you get to hear about basically every complex or atypical patient. I also dislike rounding and developing patient relationships is not particularly important to me. Plus, I think radiology has a rate of technology development that makes it wide open to research from a guy like me.

A lot of people will be attracted to the diagnostics side of things. If you wanted to have significant research component to your career, be it basic science or applied/translational, and are interested in diagnostics, you should look at pathology. Same focus, but the field in general is FAR more research friendly. Lots of reasons why, and for the most part I would be speculating. And the field is in the middle of a high-tech renaissance. You also see *all* of the interesting cases that come into the hospital, the routine stuff never comes across your desk. Now, if you are interested in all the things you said, wanted to be a physician-scientist, and didn't consider pathology, you either 1) aren't really interested in being a physician-scientist because this is currently the best way to get there, or 2) thinking about the $$. Now, if you just loved everything about rads and hated path, and didn't particularly care about research, that's fine. The only problem I have is making an argument that there are no options for such folks. Saying "I love diagnostics but there is no option for a research career" is a false dichotomy. Again, I'm not saying it is impossible to do rads AND research, but you are making things hard for yourself, and there may be paths of less resistance to satisfy your clinical interests and maintain interest in research.

I did consider medicine though, particularly heme/onc (with emphasis on the onc). I enjoyed my time on medicine, but it was a couple of months and I couldn't imagine continuing it as a career. For one, I think IM is full of work that is unrelated to medicine. It's 40% scut and 40% social work, with only 20% interesting material. Nursing home placements, home oxygen requests, calling medicaid for drug preauthorization, ugh. Plus, by the time most patients make it to their IM doctor their primary issue has been diagnosed, they just need further management for a few days, micromanaging lab values and whatnot.

Again, lots of hyperbole, hopefully. Patient contact is PART of medicine, just not your favorite part. Patient management is PART of medicine, just not your favorite part.

So, if you want to do medicine the only refuge is the popular medicine subspecialties (GI, cardiology, maybe ID?). Here, your facing a 3 yr residency and 3 yr fellowship (or 6-7 yr "fast track"). Then I guess it's possible you could end up in a postdoc role for a little bit or go straight into a lower level faculty position, depending on what's available.

Most of the IM fellowships have significant research built-in, so that at the end of your fellowship you have already completed your post-doc and are ready for a junior faculty position, with possibly your own lab. In the same 6 years you do Rads + fellowship you could do IM+Heme Onc, which would include a 2 year post-doc in a fast-track program. The latter would put you in line for a junior faculty position, and you may already have a K award at that point.

Or, you can consider the other specialties that your MD only colleagues are flocking to as well (radiology, neuro, derm, anesthesia, emergency, ophtho). Most are no more than 6 years including a fellowship. Might as well do the specialty if that's your thing. I mean, you were headed for a medicine subspecialty (or even supersubspecialty) anyway. You will have time to carve out for research if that's what you want and are willing to compromise on salary (which seems reasonable to me). The only thing you are probably giving up is the ability to do the 80% research, which will limit your ability to get your own R01 and whatnot. But if you don't believe in the R01/have your own lab/paperwork mountain path, maybe you can contribute more while avoiding the hassle. These specialty fields are ripe for academically minded people willing to spend time and effort on research and teaching, even if it's not 80%.

From what I have seen, people who go into these fields with an MD/PhD 1)are burnt out on science and don't really want to do it anymore or 2) think they can "carve" out a niche for themselves with research, only to be disappointed (generally) with the lack of real research opportunities they are allowed by their departments. Regarless, if research is no longer a main interest (other than the occasional case report), you've already wasted about 4 years of your life. By all means, focus on the clinical work you want to do. I think there comes a time when every MD/PhD (at the end of training) has to ask themselves how much commitment they have to research. If you still want to do basic science, or hard-core translational work, you should really think critically about going into these fields, because it is an uphill battle. If you just want to dabble and the clinical work is the most important to you, then go ahead.

I can honestly say the only time I considered money is thinking about the post-fellowship period, when to pursue a basic science postdoc would be a huge drop in pay. You're talking about the difference in say, rads or hem/onc clinical attending (probably $150-250k or more) vs postdoc (50-70k, maybe?). I think in these cases though most people try to work out something where they are really "MD fellows" or something so they make more money. I'm not sure.

I'm not saying you shouldn't consider lifestyle when choosing a specialty- you should, and the criteria are different for everyone. My experience is that internship year is worse in IM than many fields (but not surgical ones), but once you are done with residency lifestyle seems to even out across all specialties. And a more realistic comparison that you mention above would be between fellow salary/post-doc (most academic centers will pay you PGY salary for a post-doc BTW) to an instructor salary, which may be comparable.

Sory for the long-winded response!

 

[Spacedman]

I'm interested in discussing this more. I've got < 18 months left in my Rad Onc residency and am considering applying for an institutional T32 post-doc. I'm trying to figure out what stipend I would be receiving (I would be a PGY-6) by then and came upon the following website:

http://grants2.nih.gov/grants/guide/notice-files/NOT-OD-10-047.html

Looks like the maximum the NIH will provide for salary is ~ $50K. I'm wondering if the institution can sweeten the pot. Though I am eager to launch a research career, there is only so many years of salary loss I can take. For instance, if I forgo a post-residency postdoc I can still get a 50-50 or 80-20 physician scientist position as an assistant professor for more than triple the NIH stipend.

Thoughts?

Added: Looking through my old emails, I have one from the director of a T32 in the southeast who quoted a $75K stipend for MDs. So I guess the question is how much the individual institution is willing to supplement your salary. This is probably something you have to ask programs directly.

Thought I'd throw in my 2c, as this issue came up at almost every residency interview i had (i'm MSTP -> anesthesiology "research" track). admittedly, anesthesiology is much less competitive than rad/onc for MSTPs, so the situation for you may differ substantially.

anesthesiology is more like a surgical subspecialty when it comes to research- not much going on, except for several academic centers. the research oriented programs mostly offered a "super-fellow"/instructorship for 1-2 yrs post residency, on a T32 or similar with a salary supplement from the department (usu coming to 90-110K). during that time one would be writing a K08 etc. if you secured research funding, a number of programs were willing to subsidize the salary of 80/20 faculty to the full salary earned by 100% clinical faculty (200-300K). few programs were willing to put a postgraduate salary in writing, of course (one PD told me "really, i can promise you whatever i want, but three years from now no one would ever hold me to it!")

i did meet several faculty who'd gone through this system (if you can call it that), and they'd negotiated full attending salaries and protected research time. a few jumped right to this level fresh out of residency (lucky + smart as hell). the hardest transition (not surprising) was in those 3-5 years after residency. i met a few who were attendings, doing clinical work 2-3 days a week, scraping by on institutional/chairman slush funds, compensated for their clinical time + institutional salary support (~150K). still trying for a K08, running a small lab. it looked like an especially stresssful lifestyle.

overally, this deal seems generous to me (especially since they pad residents' salary 10-20K for doing the research track), and a large part of it stems from the shortage of academic anesthesiologists. i have a close friend doing rad/onc at a mid-tier academic center who's described similar incentives at his program (subsidized salary for research attendings). i have no idea how widespread a practice this is, since i imagine rad/onc as a field has no shortage of aspiring physician scientists.

 

[Shifty B]

I appreciate the reply, gbwillner. It summarizes a lot of reasons why another individual might choose to do internal medicine or path. That's why I titled the thread "MD/PhD experience..." to suggest that it was a single experience rather than "Why all MD/PhDs should flee IM!"

I appreciate your comment that you certainly aren't required to do 80/20 in other specialties. My point was really to say if you know you don't need that much research in your career you're freed up to consider non-traditional paths. Regarding money and competitiveness, I did not consider money in choosing a specialty. I would choose radiology again if all fields of medicine had equal compensation.

I enjoy patient contact, but I did not feel like my career would be missing something if I had less of it. Path is an interesting choice, and I did not direct really any of my prior post toward it. Many of the things I like about radiology are present in path, so I can see why people might like it. I think it is a good choice for MD/PhDs, particularly those who want to focus on basic science.

The things that I describe as undesirable about IM, the patient issues, the social issues, placement, patient-noncompliance, the increasing supersubspecialization of medicine, are real but may be less concerning for some than for others. It will be up to each individual to decide whether they consider that hyperbole.

Politics is real and is in every job/department. Constant begging for funding through submission and resubmission of grants is not. I do not think it is wrong to say that many PIs end up allocating as much time on grantsmanship as other tasks. It is much more than 3 mos out of 3 years. Once you successfully get one grant, it is time to renew the old one. Once you renew your personal grant, it is time to submit the department's P50 grant. A large fraction of PI time is spent in this process. If you can use this as your time to think creatively and come up with your new ideas and experiments, then I think it can work. It's too much for me personally.

I wouldn't say that I am burnt out with science, but I would say that my 4 years of PhD research exposed me to what science is really like. I didn't necessarily like what I saw. There are aspects that I really liked, like making an important breakthrough. But overall, the developments were too small and too inconsequential to really engross me in it as a career. I can't say those 4 years were a waste though. I learned a lot about many topics, a lot about my own interests, and about what kind of career I did want. Plus, I had a great lifestyle for 4 peak years during my 20s, which was nice. I'm still not sure how much of a role research will have in my ultimate career, but I think it will be there at least in part.

And for me (and for gfunk6), that salary comparison is real. At the end of our training, we will have to choose whether to take a job as full-time clinical staff or do another fellowship year of research at a PGY-6/7 salary (much less).

 

[malchik]

Good discussion.
I would offer two points.
There seems to be some consensus that IM/Peds/Path, and for GBWillner Path above all else, are required or at least optimal for a heavy research-oriented career. I disagree somewhat with this formulation. First I would add neuro, psych, even derm to the list of specialties with very realistic possibilities for an 80/20 career, because I know several people (some of whom aren't that brilliant tbh) succeeding at this. That being the case, I would say it's more a question of the kind of department you're in, the kind of chairman you have. Because there are plenty of path departments with chairmen who are not very supportive of research and if you find yourself in this kind of department, despite your choice of apparently science-friendly field, you will fail.

Dam, forgot my second point.

 

[Shifty B]

Because there are plenty of path departments with chairmen who are not very supportive of research and if you find yourself in this kind of department, despite your choice of apparently science-friendly field, you will fail.

True.

 

[bigmike7104]

These may be stupid questions, but do you have to (or should you) do your phd in the same area your doing your residency in. For instance say you do radiology, could you get a phd in neuroscience and maybe use imaging to do studies on the brain or a phd in molecular biology (though I feel that the latter would actually be a good fit considering all the advancements coming in molecular imaging for radiology, but I really have no idea on the subject), or something even further apart such as infectious disease and not even use imaging in your research.

 

[Neuronix]

These may be stupid questions, but do you have to (or should you) do your phd in the same area your doing your residency in.

It will help, but will it help a lot? Eh. It's mostly about clinical performance.

For instance say you do radiology, could you get a phd in neuroscience and maybe use imaging to do studies on the brain

That is about as close as most people will get. My buddy who didn't match Rads last year did a strong neuroscience PhD, but it wasn't neuroimaging.

or a phd in molecular biology (though I feel that the latter would actually be a good fit considering all the advancements coming in molecular imaging for radiology, but I really have no idea on the subject)

This is how your average MD/PhD spins their cell/mol PhD for Radiology. Shrug. Since it's mostly about grades and Step 1 scores, it doesn't matter all that much anyway. Case in point, the research resident I worked with in my radiology lab did an Immunology PhD.

 

[bigmike7104]

So would the person that did the immunology phd be able to get a position doing immunology research will doing some clinic time in radiology?

 

[Neuronix]

So would the person that did the immunology phd be able to get a position doing immunology research will doing some clinic time in radiology?

No. He was doing radiology research. I'm pretty sure he's heading to a mostly clinical position. I've never seen or heard of what you're asking.

 

[bigmike7104]

I know it's probably not common, but could you get a position to practice in one field and do research in another field, like the radiology-molecular biology example i gave above. I'm just curious.

 

[Neuronix]

I know it's probably not common, but could you get a position to practice in one field and do research in another field, like the radiology-molecular biology example i gave above. I'm just curious.

Very unlikely.

 

[calvinNhobbes]

The closer your research and clinical interests are to each other, the more likely you are to be succesful at both. Trying to be up to date on the literature in one area is difficult, but trying to do so in two unrelated fields would be extremely time consuming to a point something would have to give.

 

[mercaptovizadeh]

The closer your research and clinical interests are to each other, the more likely you are to be succesful at both. Trying to be up to date on the literature in one area is difficult, but trying to do so in two unrelated fields would be extremely time consuming to a point something would have to give.

I think this depends on the field. If you want to just be a general IM or pediatrician or radiologist who practices up-to-date medicine I doubt most of your "free time" (i.e. free time in the office when not seeing patients) is consumed with reading articles in the clinical field. Many fields do not move *that* fast. You could decide that clinically you'll just deal with the bread-and-butter cases so you can maintain patient contact and make money, and then devote most "paper" time to the research topic of interest.

Yes, it's impossible to be a "groundbreaker" clinician and researcher unless clinical and research work are in a very narrow field.

 

[calvinNhobbes]

Yes, it's impossible to be a "groundbreaker" clinician and researcher unless clinical and research work are in a very narrow field.

Which is exactly what I stated in my previous post. Something has to give, which in your example is your clinical knowledge and career.

 

[gbwillner]

Good discussion.
I would offer two points.
There seems to be some consensus that IM/Peds/Path, and for GBWillner Path above all else, are required or at least optimal for a heavy research-oriented career. I disagree somewhat with this formulation. First I would add neuro, psych, even derm to the list of specialties with very realistic possibilities for an 80/20 career, because I know several people (some of whom aren't that brilliant tbh) succeeding at this. That being the case, I would say it's more a question of the kind of department you're in, the kind of chairman you have. Because there are plenty of path departments with chairmen who are not very supportive of research and if you find yourself in this kind of department, despite your choice of apparently science-friendly field, you will fail.

Dam, forgot my second point.

I totally agree. I only mentioned the IM/Peds/path because they are the most popular, but there are certainly other fields that are as receptive the being a physician scientist.
And I agree about the chairman, but those issues will easily be sorted out during the interview/application cycle. The good departments will recruit you, not the other way around.

 

[gbwillner]

I know it's probably not common, but could you get a position to practice in one field and do research in another field, like the radiology-molecular biology example i gave above. I'm just curious.

Yes- this happens all the time. As you go on with your training/life, your research focus may change- but your clinical specialty probably won't. IMHO, this is common, and as these guys progress in lab, they are more likely to withdraw their clinical activities that are no longer relevant to their primary interests.

 

[Shifty B]

I know it's probably not common, but could you get a position to practice in one field and do research in another field, like the radiology-molecular biology example i gave above. I'm just curious.

People are able to tie their research to their clinical specialty in a wide variety of ways. There are areas of molecular biology that might relate well to radiology, like how cell signaling changes when cells are exposed to radiation. Or how one can take advantage of cell receptors to design targeted contrast agents. However, it seems exceptionally unlikely to have two totally unrelated things going on in your career. Not that you couldn't, but it doesn't make much sense.

Imagine you spend 10-15 years training, practicing, and learning techniques to become a professional golfer. You're now a professional golfer, but on the side you've always been interested in engineering type stuff and equipment design. You decide you want to get into the equipment business during the off season. Does it make more sense for you to spend your time designing and testing golf clubs or tennis rackets?

 

[calvinNhobbes]

Does it make more sense for you to spend your time designing and testing golf clubs or tennis rackets?

Nice analogy and exactly what I was trying to communicate.

 

[KD1655]

I have a related yet somewhat off topic question. For starters, I am not a MD/PhD student; I am currently a PhD student in Materials Science and Engineering conducting research examing the change in dielectric properties of neural tissue as a function of traumatic brain injury severity. I am interested in going to medical school after the completing my PhD (and possibly a post-doc in TBI-related research). I have been pondering the idea of applying for MD/PhD programs for Fall 2011 but have pretty much decided against it because I will likely finish my PhD in 2012. I have been working like a dog doing research and taking classes; I graudated with my BS in Spring 2009 and will finish my coursework requirements for the PhD at the end of this semester. I have also collected enough data to write two first author manuscripts that I will be submitting for review within the next week or two. I should mention that I took several graduate courses and conducted a few months of research as a senior undergradaute. Given my progress towards the PhD in a field that I am very interested in (and one that I probably couldn't pursue as a MD/PhD student) does it make sense for me to do the PhD then MD approach? I know that the major downside to this approach is the tuition for medical school but is there any type of financial aid that I could apply for? As far as residency, I am interested in pursuing a "non-traditional" residency somehow related to trauma given my research interests in traumatic brain injury (specifically as a result of non-impact blast waves) and my 7+ years of experience as a volunteer/paid emergency medical technician and firefighter. I am still very involved in the EMS/fire/technical rescue community. Given my research interests and my experiences, would I have a problem doing a residency in say emergency medicine or general surgery with a trauma fellowship? I don't necessarily want to be "locked in" to a IM residency path because I decided to complete a PhD because I find my research terribly interesting prior to medical school. Thanks.

 

[calvinNhobbes]

KD1655,
Awesome research stuff, and it is good to see you have really thought about this.

First thing I must ask, is the school you're doing your PhD associated with an MD/PhD program? Although it is uncommon, I personally know two people in my MD/PhD program that applied while in graduate school (both engineering PhDs). They have been allowed to finish their PhD and then start med school with full funding.

That being said, I have also known people apply during the PhD, stop the PhD, go through the first two years of MD, and then start back on their PhD. This is also very uncommon though.

If neither of those is possible for you. I would personally finish the PhD and then decide if you want to spend another 4 years in school or not. I would not quit a PhD you seem to really enjoy just to try and get into an MD/PhD program. Another possibility is PT training. Shorter and less expensive training, but still gives you that access to the patient population you seem most interested in. Of course, you would not have the eventual financial rewards you would with an MD.

As far as specialty choice, I know several EM physicians that work on TBI research. I think that is an excellent combo. Gen surg trauma would be a tougher road (like all surgical fields and research) because of difficult schedules and time constraints. However, if it turns out you really love surgery and can't imagine yourself doing a non-surgical field, then go for it. But you won't really know that until third year of med school.
EDIT: Also consider neurology, where perhaps you could extend your research to not just TBI, but stroke, movement disorders, etc.

Hopefully this helped!

 

[RxnMan]

From the things you talked about - TBI, neurosci, materials science - other fields to consider are neurology, PM&R, and maybe neurosurgery. All deal with TBI patients at different points in their care, all have neuro aspects to their practice, there is fair-to-great support for physician-scientists in these fields, and PM&R in particular can make use of your materials sci and engineering knowledge (e.g. prosthetics and gait analysis).

 

[calvinNhobbes]

Oh ya, PM&R, how did I mention PT and totally forget PM&R! That would definitely be a good non-surgical specialty that would seem to fit your research interests.

 

[KD1655]

Thank you very much for all the great information. To answer some of the questions posed, my program is not affiliated with a MD/PhD program. The biomedical engineering program is because it is a joint program with the medical school. I did my undergraduate work in biomedical engineering at the same school and decided that I wanted to pursue more of the theoretical and "traditional" engineering principles offered by materials science. I could transfer to the biomedical engineering PhD program but that would require me essentially starting the required coursework for the candidacy exam over again. I took a TON of graduate classes as an undergraduate and essentially had my first year of my PhD done (both in terms of coursework and research) completed before even earning my BS. Therefore, my advisors think that I can do a "quick" PhD (~3 years post BS) and then head off to medical school.

 

[Shifty B]

I'm on the side of those who advocate not stopping your PhD at this point. If you are reasonably within sight of the end of a PhD (a year or 2), then the cost of stopping and attempting to transfer or move to a different place are too high. There is no conceivable way that you would be able to obtain a PhD in this amount of time at another institution, so carry on. Even if you factor in the cost benefits of switching to a funded MD/PhD program, the extra years that it would cost you would offset any gains. The only time it makes sense to stop a PhD is after 1-2 years when you can get a MS and bail without too much lost.

As for entering medical school after your PhD, I think that will be a tough decision for you. There have been multiple threads on this board in the past regarding experiences of PhD-to-MD students which may help you.

In my opinion, the only compelling reason to do an MD after a PhD is if you feel like your career is going to be incomplete if it doesn't involve direct patient care. You need to have the feeling that you are going to be unsatisfied if you are not directly seeing patients with traumatic brain injury in your clinic, or whatever. To go to medical school is 7 more years of training (not even including a fellowship of another 1-3 years). The majority of those years will have nothing to do with your direct research interest.

If you're thinking, "Well, it's really only 4 years and I wouldn't necessarily want to do a residency," then you have your answer: do not go to medical school. It's not enough to just want to get more clinical perspective for your research career. If you want more clinical perspective, it would be better for you to take a job as a researcher at a X medical center, find the clinician who sees TBI patients, and start a collaboration with him. Then you can go to his clinic and see patients with him whenever you want.

If you did decide to go to medical school, you are not locked into IM and the advice you have received above about PMR and neurology is sound.

I'm not really trying to discourage you from going to medical school, but you need to really understand your motivation and be willing to forgo the next decade for it.