MD/PhD not matching residency? Options?

[Shifty B]

(2) In specialties like surgical subs and rads, sure, you can match into a community program, but be realistic, what are the chances that at the end of that training, you'll turn down your 350k and go back and do basic science? The answer is 0%. Sure you can sell your research interest, but you should make a decision at that point. If you want to continue doing basic science research, surgical subs, rads, rad onc, etc. are terrible residency choices for most people. You need to ask yourself: is basic science research important enough for me? (The vast majority of people, I know, by the way, say no to that question.) Do I like radiology enough? Pick one. If you are a superstar you match into a top rads program and research is still open to you, but you aren't...stop trying to do everything and make everyone miserable.

You're misrepresenting this, making it seem like somehow it is a choice between a non-competitive specialty (IM, Path, Peds) at a big name academic institution vs a more competitive specialty (ENT, Rad, Derm, Anesthesia, etc) at a community residency. It's not, and to make it seem so is false.

Year in and year out, MD/PhDs match in competitive specialties at top academic institutions. Just look at the lists. ENT, Ophthalmology, Derm, and Radiology are all packed to the brim with top 25 places. There is not a community program in sight. You're right, a PhD doesn't automatically get you a position in your #1 choice. The PD may not call you and beg you to come to JH or whatever. And yea, your stats need to be competitive with the MD only applicants. But most can and will match at top academic institutions.

The real problem only occurs with the applicants who are in the bottom 25% of their MD only colleagues. If subpar step 1 score, mediocre grades, and average letters are going to keep you from getting interviews at second tier academic programs (say #25-50), you can end up in some real trouble. Community programs (where MD only applicants with your credentials would normally match) may ignore you because of your PhD credential. Then, you're not getting interviews from academic programs OR community programs. Then you are at real risk of not matching. But honestly, the bottom 25% of the MD class is at risk of not matching competitive specialties as well.

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[nomogram3]

There are a couple of things that I think are worth re-emphasizing, especially for entering 1st year MD/PhDs.

(1) By design, MD/PhD is made for research intense specialties like IM/Path/Neuro/Psych/Peds, and for the research intense subspecialties within each of these fields (my dad's colonoscopist is an MD/PhD...)...

Great post. I'll give my 2 cents. I'm an MD/PhD finishing MS4 and matching into a short-track IM/Hem/Onc pathway. Right now, if you have decent board scores (and decent when I took it in 2004 was not decent today, my Step II was 20 pts better than my Step I in a large part because of USMLE World, which didn't exist when I took Step I), good grades (a few honors, but definitely not all), and good letters, you are competitive to short-track at the best places for IM in the country. This is whether you come from a top-10 med school or not (my medical school is not well known). If you look at the chairmen of internal medicine departments around the country, they are NOT full time clinicians. They are researchers, most MDs who did research because MD/PhD was not as available as it is today. There will always be a place for clinician scientists in IM, and the NIH has made funding available to make this happen. Right now its tough to get grants. I'm glad I'm training and not an assistant professor. But grant cycles have always been like this, and when I started R01s were funding at around 20% compared to 7% now in my PI's study section. The message is if you want to do IM and science, MD/PhD is a great pathway, if you want to do a less research-focused field make yourself just as competitive as the MD's in your class, because your PhD will not be a magic wild card when its application time.

 

[Shifty B]

Right now, if you have decent board scores (and decent when I took it in 2004 was not decent today, my Step II was 20 pts better than my Step I in a large part because of USMLE World, which didn't exist when I took Step I)...

Ugh. I agree with you that this score creep is definitely a pain. Average for my step 1 administration was something like 215 or 220. My step 1 score was definitely above average for the time when I took it and it ended up being the weakest part of my application. I also think this is due to USMLEworld.

As for IM, it was once the king of the hospital and the specialty of choice. As medicine has gotten more complex over the last 30+ years, the role of IM has decreased, and with changes in reimbursement, gotten less desirable. Only IM subspecialties or supersubpecialties remain commonly sought after. Our most competitive MD only classmates have bolted for other fields, and its not surprising that MD/PhDs will do so as well.

These fields have plenty of research of their own, and there is a place for MD/PhDs in them as well. It may be more competitive to match, but if you are an MD/PhD I encourage you to pursue whatever clinical specialty interests you, even if it is a competitive one that is viewed as "non-research". You can find your niche and make valuable contributions in any medical field.

I have very strong negative feelings about pressure for for MD/PhDs to go into IM-based fields, but I'll try to restrain it here. Perhaps it is better suited to another thread sometime. In short, I will just say you should not feel constrained by the design of a system (the MD/PhD educational process) which was put in place 30 years ago.

 

[Gotti]

Thanks for all the insights and its time for me to stop whining and just wait until match day. My last question is if you want to scramble into another field like anesthesiology or pathology, will I need a letter from someone? All I have are surgery letters and didn't do any rotations in anything else. I notice a lot of people who don't match surgery end up in anesthesiology.

 

[gbwillner]

Thanks for all the insights and its time for me to stop whining and just wait until match day. My last question is if you want to scramble into another field like anesthesiology or pathology, will I need a letter from someone? All I have are surgery letters and didn't do any rotations in anything else. I notice a lot of people who don't match surgery end up in anesthesiology.

When getting letters it is nice to have a "general" one from your sub-I that could help in all specialties. Otherwise there is nothing you can do since you will be notified that you did not match and need to scramble 3 days before the rest of the world matches. You don't have time to go looking for references- you need start calling places and try to find a spot.

Pathology is another field good for people interested in surgery as anatomic pathology is closely integrated with surgery (same patients, problems, etc.).

But I wouldn't worry.... if you are applying for general surgery... it's not like that's a competitive field.

 

[Gotti]

When getting letters it is nice to have a "general" one from your sub-I that could help in all specialties. Otherwise there is nothing you can do since you will be notified that you did not match and need to scramble 3 days before the rest of the world matches. You don't have time to go looking for references- you need start calling places and try to find a spot.

Pathology is another field good for people interested in surgery as anatomic pathology is closely integrated with surgery (same patients, problems, etc.).

But I wouldn't worry.... if you are applying for general surgery... it's not like that's a competitive field.

Actually, I'm not applying to general surgery, for which I wouldn't be as concerned. I'm applying competitive surgical subspecialty. I do have general surgery letters and one really good letter from IM attending. Would those be okay for pathology? If I don't match on the Monday, would it be feasible to ask my original letter writers to change a few words in their letters to reflect pathology or anesthesiology and have it ready for scramble by the next day? Overall, I still wouldn't have any letters from a pathologist or anesthesiologist and never even did those rotations. How would that look?

 

[dl2dp2]

The real problem only occurs with the applicants who are in the bottom 25% of their MD only colleagues. If subpar step 1 score, mediocre grades, and average letters are going to keep you from getting interviews at second tier academic programs (say #25-50), you can end up in some real trouble. Community programs (where MD only applicants with your credentials would normally match) may ignore you because of your PhD credential. Then, you're not getting interviews from academic programs OR community programs. Then you are at real risk of not matching. But honestly, the bottom 25% of the MD class is at risk of not matching competitive specialties as well.

We are talking past each other. This is exactly my point as well. However what I'm saying is that in IM/path, even if you ARE bottom 25% you are still going to match really well if you are mdphd--AND have a really chance of doing solid research, even basic science.

And sure year in year out mdphds match well in competitive specialties. But first how many of those stick around in academia? According to Skip Brass's data not many. Secondly I said some mdphds are superstars. Maybe u are one. But some people have real diificulties adjusting back to med school and I think they should be given some slack if there is real potential to contribution to a field. Thirdly I genuinely believe that if you want to do basic science (i.e. the stuff your basic science faculty does for a living), you should think twice about going into a competitive field. It's not a judgement. I am quitting basic science myself. I also tend to believe if that if you want to do anything worthy of an R01, you should probably not do a competitive specialty. But not every researcher needs to get his own R01. Again it's not a judgement. Finally I still believe that MD/PhD should not by design be used to get into a field like orthopedic surgery or ENT, because doing a PhD adds nothing to doing research in these fields. However, I do recognize that people's interests change and I'm not saying that there's anything wrong with it if you END UP there. But i'm just cautioning people going INTO MSTPs that by DESIGN the MDPhD track is MDPhD -> research residency -> faculty, or MDPhD -> postdoc -> industry. Not MDPhD -> competitive specialty -> private practice. This is just a matter of being efficient--the third pathway is inefficient and a waste of time. Although I'm beginning to see that there may be a point in doing the third pathway, especially in competitive subspecialties friendly to MDPhDs (i.e. rad onc, derm, optho and anesthesia)...I think I talked about this in one of more devious uses of MDPhD in one of the earlier threads forgot when...

The most competitive pathway is obviously MDPhD (at a top place) -> competitive residency (at a top place) -> R01 + busy surgical schedule (at a top place)...If THAT's what you want, then again I think my advice is perfectly legit: please work as hard as you can, and don't stop working ever--or perhaps you are blessed with a photographic memory and a suprahuman charm, in which case I have nothing but awe for you.

 

[gonogo]

No matter how you see it it's gonna be tough as an MD/PhD. Internship will be brutal because as an intern you'll have the feeling you've wasted 5 years of your life doing a PhD. You'll be much older than the rest of your class, and no one will appreciate or care about your research credentials. Moreover, you'll most likely not have the same stamina as your peers to work hard as an intern. And psychologically, you'll feel you're wasting your brain doing nonsense work and spending crazy amount of hours doing nothing productive. Hopefully things change after residency, but while you're at it it'll be tough.

 

[Shifty B]

And sure year in year out mdphds match well in competitive specialties. But first how many of those stick around in academia? According to Skip Brass's data not many.

Not true. Those ratios in that presentation (which can be found online at http://www.med.upenn.edu/mstp/program.shtml in slide #18 of the preparing for the future) are misleading.

In this case, the percentages are of all the MD/PhDs in academics (or PP), what % are in a given field. So, of all the MD/PhDs in academics, 0.3% are in family practice, 0.5% are in EM, and so on. Same for PP. Then, a ratio was created to basically compare how the composition of MD/PhDs in private practice was different from those in academics. That is, in PP family medicine makes up 6x as many of the graduates (by percentage, but not by raw number).

These ratios are difficult to interpret at best, and misleading at worst. This is particularly the case because 80% of all MD/PhDs end up in academics (which makes the numbers in that column look smaller).

Look at the raw data. (which is contained in the presentation noted above. you can find it by double-clicking on the graph on slide 18 in that planning for the future presentation on the UPenn website and getting the whole data set). More than 50% of the MD/PhDs in every field except family medicine end up in academics. For a field like radiology, it's almost 60%. Compared to maybe 5-10% for MD only and these are extraordinary numbers.

Wouldn't it make more sense to compare what fraction of MD/PhDs end up in academics vs their MD only colleagues? It's clear from this table most MD/PhDs end up in academics (even in ROAD specialties).

 

[QofQuimica]

In the interest of enlightening the rest of us, could you please label the columns? I don't understand what the right side of the table is showing. Percent out of all physicians?

Also, I hate to be demanding and all, but is there any way you could shrink the table a little so we could see the whole thing at once?

 

[Shifty B]

Ok, I managed to get all the information in the one post above. Hopefully it makes sense now. The gist of it is I think it's marginally correct to interpret the percentages or the odds ratio in the first graph and that it is better to look at the raw data, which shows that the majority of MD/PhDs in nearly every specialty, even competitive ones, end up in academics.

 

[QofQuimica]

Ok, I managed to get all the information in the one post above. Hopefully it makes sense now. The gist of it is I think it's marginally correct to interpret the percentages or the odds ratio in the first graph and that it is better to look at the raw data, which shows that the majority of MD/PhDs in nearly every specialty, even competitive ones, end up in academics.

This is awesome. Thanks so much for making the charts so reader-friendly, and also for finding us the raw data.

Now that we see the absolute numbers, it's clear that we shouldn't put much stock in the FM odds ratio. So few MD/PhDs go into that field that there is no way we can justifiably draw the conclusion that family practice = private practice. You're talking about a difference of three whole people out of 13 total over the past couple of *decades.*

Another thing is that slide 18's conclusion assumes that the specialty and practice choices of MD/PhD graduates are constant over time, which is highly unlikely to be the case. A person who chose dermatology in 1979 was probably not in the same mindset as a person who chose dermatology in 1999. I'm guessing that an MD/PhD who goes into a nontraditional specialty today would be more likely to stay in academia, simply because it's more acceptable now for MD/PhDs to not want to be pathologists and internists when they grow up. In 1979, derm could have been looked at as a good way to escape from academia, which is not necessarily the outlook of a 1999 grad.

 

[calvinNhobbes]

Finally I still believe that MD/PhD should not by design be used to get into a field like orthopedic surgery or ENT, because doing a PhD adds nothing to doing research in these fields.

I would 100% absolutely disagree. In fact, several papers have been written by prominent orthopaedic surgeons lamenting the lack of MD/PhDs in the field and how this is hurting scientific discovery and the progression of the field with comparison to other specialties.

A field like orthopaedic surgery is ripe for the harvest for an MD/PhD because there is so little translational research being done with a huge disconnect between the clinicians and basic scientists compared to other fields. However, in order to reap the scientific rewards, I have to accept losing millions of dollars of potential lifetime earnings as an opportunity cost. While MD/PhDs going into any field will have to sacrifice income to some extent, the cost is much higher in the surgical subspecialties.

 

[Shifty B]

A field like orthopaedic surgery is ripe for the harvest for an MD/PhD because there is so little translational research being done with a huge disconnect between the clinicians and basic scientists compared to other fields.

I'm with you in general. I think these specialties are ripe for interest from MD/PhDs and that research in these "research unfriendly" specialties can drive medicine in upcoming decades.

Because all surgery was lumped in that previous graph, I sorted it out from the raw data this time for subspecialties.

I think it's really rocking that 80.7% of MD/PhDs in general surgery are in academic departments. Another field that impressed me above was anesthesia (77%). Plus, family gets a bad rap because it's only been 13 people over all this time. I wish I knew what percentage of all MDs ended up in academics for these fields. It would likely make it look all the more impressive that so many people go into academics in these fields like derm and ophtho.

Those stupid ratios in that first graph make it look like there are huge differences in these fields (like 6-fold). In reality, it is a fairly tight spread between 55%-90%.

 

[Gotti]

Man, I wish you guys had provided those numbers for surgery subspecialties when I was interviewing a few months ago. Quoting these numbers may have helped.

 

[calvinNhobbes]

Man, I wish you guys had provided those numbers for surgery subspecialties when I was interviewing a few months ago. Quoting these numbers may have helped.

Unfortunately, probably not. Quoting numbers to some grizzled old surgeon set in his ways wouldn't have done a darn thing to change his mind, it probably would just piss him off.

 

[Gotti]

Yeah, I agree, but if he said something like MD/PhDs in surgery don't have time to do research, depending on how this guy is, I might have said something like "Actually, a majority of MD/PhDs in this field somehow find time to do research." I guess I would have to see how grizzled this guy was.

Once again, calvinNhobbes knows my pain. I thought they told us this was going to be easy with people trying to recruit us and encourage us after this long road. All my friends applying IM/Neuro/Psych are having a grand old time, while we're here getting head-shrunk to see if we'll fit in.

 

[dl2dp2]

Yeah, I agree, but if he said something like MD/PhDs in surgery don't have time to do research, depending on how this guy is, I might have said something like "Actually, a majority of MD/PhDs in this field somehow find time to do research." I guess I would have to see how grizzled this guy was.

The data you quoted doesn't support the above statement. There IS a 6 fold difference in the percentage of people who go into academia, in different specialties, first of all. Secondly, we don't know what's the percentage of people who go into academia who stay in research--you can be "clinical assistant professor" and still call yourself academia, and I don't think this counts. By the way, the answer to that question is also in that presentation and someone did an under the envelop calculation, and the results are not good.

The argument that MDPhDs should do research in surgery is an old one, but I'm not sure I buy it. The main issue isn't that there's no useful research to be done in surgery, but that there's NOTHING that can be done can't be done without a PhD. This ineffective use of time is just much more dramatic in surgical fields than in "cognitive" fields.

But again, at the end of the day this becomes an ideologic/personal opinion kind of argument. If I'm Republican, you are Democrat, and there's nothing we can do or say... I'm just saying, if you want to go into subspecialty surgery and radiology, BE CAREFUL. If you want to do IM/Path, you can relatively chill out.

 

[Shifty B]

You're right to say that being in academics does not equate to being a basic science researcher. However, it does usually involve either research or teaching. You're also right to suggest that it is not the same to be in IM and do 100% research vs in surgery and do 20% research.

You could say that there is actually an 8-fold difference if you want: 62% of FP go into PP while 8% of pathology go into PP. Not that interested in that difference. More meaningful is to me is that on average 20% of MD/PhDs go into PP, and for these so-called "non-cognitive fields" it tops out at around 40%. But, you have the raw numbers and you can look at them however you want.

Of course I wouldn't recommend surgery, ortho, or EM to anyone who wants to do full time bench research. I think people who are applying to these specialties know that they will have less of a time role. That doesn't make it any less meaningful.

 

[gonogo]

Of course I wouldn't recommend surgery, ortho, or EM to anyone who wants to do full time bench research. I think people who are applying to these specialties know that they will have less of a time role. That doesn't make it any less meaningful.

But if you want to do 100% basic research, why go in the first place through residency?

 

[QofQuimica]

But if you want to do 100% basic research, why go in the first place through residency?

By that logic, why get an MD at all?

(I'm not meaning to rag on you; just following this line of thought to its logical conclusion.)

 

[Shifty B]

Haha! Why do an MD at all? or a residency?

I'm not laughing because the questions are funny. I'm laughing because this thread has pretty much come full circle now. It started by someone asking how their career path might change if they don't match, took a huge detour through specialty choice, and it's all come back to this: the questions most MD/PhD applicants/students/grads have hopefully asked themselves multiple times.

They are good questions but maybe for a separate thread entitled, "Why do an MD at all? or a residency?" I can't walk into a trap like that in this thread. It'll never end.

Good luck Gotti and CalvinNHobbes! I only fed the runaround about competitive specialties to let you know that I believe in the choice you have made to pursue them. It may be a harder path, but I respect that you have chosen it and I think your skills (and those of more MD/PhDs) are needed. That's what I meant by the above posts.

 

[Gfunk6]

The main issue isn't that there's no useful research to be done in the field of medicine, but that there's NOTHING that can be done can't be done without a PhD.

Fixed it for you.

 

[calvinNhobbes]

The main issue isn't that there's no useful research to be done in surgery, but that there's NOTHING that can be done can't be done without a PhD. This ineffective use of time is just much more dramatic in surgical fields than in "cognitive" fields.

Of course you don't NEED a PhD to do research no matter what clinical specialty you go into, medical or surgical. But to do competitive basic science research you need to put in the time somewhere. Whether that time is doing a formal PhD, or broken up into several research years throughout med school, residency and fellowships.

Reading the crap that passes for baic science research that gets published in clinical journals makes my PhD skin crawl.

The MDs I know who also have a successful basic science research career spent 3+ years of dedicated research to get there (ie. basically doing a PhD). There are no short cuts.

 

[dl2dp2]

But if you want to do 100% basic research, why go in the first place through residency?

These are very interesting questions. We live in very strange times.

People who want to do competitive specialties use the PhD to gain an advantage over their MD-only clinical colleagues.

People who want to do 100% research use the MD license to leverage more funding, more time, more security, more pay. I'm under the impression a lot of really excellent people who originally want to do only a PhD say in basic cancer biology took one look at the NIH funding rate and decide to give MDPhD a go, because good luck getting a 100% research job with only a PhD--or for that matter, MDPhD with no residency.

Nobody is using their training to do what it's supposedly designed to do.

 

[Neuronix]

People who want to do competitive specialties use the PhD to gain an advantage over their MD-only clinical colleagues.

I find this silly on a few levels.

The reason particular residencies are competitive is because they are research-oriented residencies. That's what gives an academic program its prestige. If MD/PhDs are looking to match big name academic programs, it's because they're doing what they're supposed to. As for "competitive specialties", what, are we all supposed to go into things that aren't competitive? I did my PhD in MRI Physics for a reason. Are people really picking residencies based on what's competitive?

Second, really? How many MD/PhDs do you know that even in private would say a primary reason for spending four extra years getting a PhD is simply to get a more competitive residency? I mean some might say it's a secondary bonus of an MD/PhD program, but the best way to get a competitive residency is AOA and 260+ step 1.

Also, as I post extensively in other threads, how helpful is the PhD really? I'd feel more comfortable about matching if I was an MD-only student. You all say, huh?!?! But then I could apply to the ton of community programs out there. As it is I'm virtually locked into a small number of extremely competitive programs that have research in my area that still value clinical grades and sky high step 1 scores the most. I hope my PhD DOES give me an advantage so I can actually have a physician-scientist career, rather than match and go to post-doc.

 

[calvinNhobbes]

I would have to agree with Neuronix. If you look at the data from competitive specialties, there are very few where the PhD gives an advantage (ie. there is a significantly greater percentage of people with PhD who match compared to those that don't). In most cases, the MD/PhDs match at the same rate as their MD only colleagues.

The only competitive specialties where it seems to give an advantage is Derm and maybe RadOnc. It seems to actually decrease your chances in plastics. Everything is no real difference for the competitive specialties.

I personally chose my area of specialty based off my research interests before I had any real clue about the competitiveness.

 

[calvinNhobbes]

Good luck Gotti and CalvinNHobbes! I only fed the runaround about competitive specialties to let you know that I believe in the choice you have made to pursue them. It may be a harder path, but I respect that you have chosen it and I think your skills (and those of more MD/PhDs) are needed. That's what I meant by the above posts.

Thanks Shifty B!

 

[Gotti]

Good luck Gotti and CalvinNHobbes! I only fed the runaround about competitive specialties to let you know that I believe in the choice you have made to pursue them. It may be a harder path, but I respect that you have chosen it and I think your skills (and those of more MD/PhDs) are needed. That's what I meant by the above posts.

Thanks as well, Shifty B and thanks everyone for answering my self-doubt and self-questioning that came from my tough interviews, which may indicate that I don't fit in as a surgeon as they are always sure of themselves.

I agree that maybe as a surgeon, I won't be able to do full-time the hardcore basic research we were originally recruited for. However, I still think I would have contributed a new way of thought to my chosen field and added something for my colleagues. Hopefully, I would eventually contribute a basic knowledge, however small, that would never have come if I wasn't there.

But however this turns out, as CalvinNHobbes said, it won't be the end of the world and I'll have to pick up the pieces and just move on to a more traditional MD/PhD field and just take pride in more fully utilizing my also hard-earned research skills.

 

[QofQuimica]

Thanks as well, Shifty B and thanks everyone for answering my self-doubt and self-questioning that came from my tough interviews, which may indicate that I don't fit in as a surgeon as they are always sure of themselves.

Actually, you may be a *better* surgeon because of it. Every human being on the planet has doubts, even surgeons. Of course you don't want to fall to pieces in front of patients and colleagues because you lack confidence. But it's pretty scary when people refuse to admit that they ever have doubts, not even to themselves.

 

[calvinNhobbes]

Agreed, Q of Q. There is a fine line between doubt and humilty, or confidence and arrogance in many careers; but especially medicine. Doctors that never learn the difference at the ones that get into trouble, ethically and legally.

 

[RxnMan]

I find this silly on a few levels...Second, really? How many MD/PhDs do you know that even in private would say a primary reason for spending four extra years getting a PhD is simply to get a more competitive residency?

I find it silly too, but a number of MD/PhDs have bragged to me that they're glad they have their PhD to fall back on, which will make them so much more competitive residency program X or specialty Y.

I also know a sub-set who started as MD-only, took Step 1, got what would be considered a non-competitive score for their desired specialty, and then went MD/PhD. That is a real mistake in my mind.

...I mean some might say it's a secondary bonus of an MD/PhD program, but the best way to get a competitive residency is AOA and 260+ step 1...

Exactly. PDs are always going to look at any applicant through the lens of grades and Step 1. They are recruiting residents first and foremost.

Sluox raises an interesting point, though. I've never thought about the converse - would-be pure researchers going MD/PhD just for the increased funding rate. Given that the increase is in part due to those MD/PhDs going through residency, that's another painful 3-5 years and a lot of high-stress exams for a better %age that may not be around when you get to the end of the pipeline. Also a big mistake.

 

[dl2dp2]

You've misunderstood me. What I meant to say is a student who originally had a "heart of gold" and was planning on a oh so noble career of translational research going into MSTP, during the program had enough of the torture of basic science, had a change of heart and now decides to instead become a well compensated radiation oncologist. But even though he knows he has no interest whatsoever in research, he nevertheless tells all the residency programs that he loves research and has every plan to continue--in fact he went into "Holman Pathway", except he used all his research electives to surf the beautiful Santa Barbara waves.

He used his PhD to get into a competitive residency program. And trust me, this is not uncommon.


The other scenario, btw, is the cut throat science guy who got a couple of Cell papers during PhD, and would be perfectly fine going straight to a postdoc. But instead, he decides that he'd rather do a fast track IM/heme-onc residency, suffers through all the clinical training, then at the end of it spend 2hrs a week seeing 5 patients with a weird tumor that only has 5 cases in the world per year, and spends 95% of his 70 hr work week doing clinical medicine. He gets paid 50% more than his PhD->postdoc colleagues in the same department, tenure was a breeze, stays at his prestigious institution as an assistant professor, while his labmates during his PhD years scrambles across the country for postdoc jobs, fighting against 1000 candidates for an assistant professor job in Kansas that pays 80k had involves teaching 8 classes, and hopefully avoiding the fate of Amy Bishop 8 years later when the tenure clock starts to chime.

He's using his residency training to get, eventually, to a 100% research job. And trust me, this is not uncommon either.

I'm not passing judgement. I'm just making observations.

 

[calvinNhobbes]

You've misunderstood me. What I meant to say is a student who originally had a "heart of gold" and was planning on a oh so noble career of translational research going into MSTP, during the program had enough of the torture of basic science, had a change of heart and now decides to instead become a well compensated radiation oncologist. But even though he knows he has no interest whatsoever in research, he nevertheless tells all the residency programs that he loves research and has every plan to continue--in fact he went into "Holman Pathway", except he used all his research electives to surf the beautiful Santa Barbara waves.

He used his PhD to get into a competitive residency program. And trust me, this is not uncommon.

Like I said, a PhD really only helps for a couple specialties, if that. It is debatable if it even helps in Rad Onc (21% vs 19% of matched vs non-matched Rad Onc applicants with a PhD). Someone gutting it out to finish the PhD because they THINK it will give them an edge for competitive specialties is fooling themselves. The experience I have had with my own program over the past decade is people are more likely to quit during their PhD than gut it out. The one person I know who gutted it, told residencies they didn't want to do research any more, and they applied to a competitive field and still matched.

The other scenario, btw, is the cut throat science guy who got a couple of Cell papers during PhD, and would be perfectly fine going straight to a postdoc. But instead, he decides that he'd rather do a fast track IM/heme-onc residency, suffers through all the clinical training, then at the end of it spend 2hrs a week seeing 5 patients with a weird tumor that only has 5 cases in the world per year, and spends 95% of his 70 hr work week doing clinical medicine. He gets paid 50% more than his PhD->postdoc colleagues in the same department, tenure was a breeze, stays at his prestigious institution as an assistant professor, while his labmates during his PhD years scrambles across the country for postdoc jobs, fighting against 1000 candidates for an assistant professor job in Kansas that pays 80k had involves teaching 8 classes, and hopefully avoiding the fate of Amy Bishop 8 years later when the tenure clock starts to chime.

He's using his residency training to get, eventually, to a 100% research job. And trust me, this is not uncommon either.

I agree this scenario is much more common, but honestly, who cares? In fact some would say this is what the NIH expects MD/PhDs to do. The extra 4+ years of clinical experience should give you an edge over straight PhDs.

 

[Shifty B]

You've misunderstood me. What I meant to say is a student who originally had a "heart of gold" and was planning on a oh so noble career of translational research going into MSTP, during the program had enough of the torture of basic science, had a change of heart and now decides to instead become a well compensated radiation oncologist. But even though he knows he has no interest whatsoever in research, he nevertheless tells all the residency programs that he loves research and has every plan to continue--in fact he went into "Holman Pathway", except he used all his research electives to surf the beautiful Santa Barbara waves.

He used his PhD to get into a competitive residency program. And trust me, this is not uncommon.

The other scenario, btw, is the cut throat science guy who got a couple of Cell papers during PhD, and would be perfectly fine going straight to a postdoc. But instead, he decides that he'd rather do a fast track IM/heme-onc residency, suffers through all the clinical training, then at the end of it spend 2hrs a week seeing 5 patients with a weird tumor that only has 5 cases in the world per year, and spends 95% of his 70 hr work week doing clinical medicine. He gets paid 50% more than his PhD->postdoc colleagues in the same department, tenure was a breeze, stays at his prestigious institution as an assistant professor, while his labmates during his PhD years scrambles across the country for postdoc jobs, fighting against 1000 candidates for an assistant professor job in Kansas that pays 80k had involves teaching 8 classes, and hopefully avoiding the fate of Amy Bishop 8 years later when the tenure clock starts to chime.

He's using his residency training to get, eventually, to a 100% research job. And trust me, this is not uncommon either.

I'm not passing judgement. I'm just making observations.

In your lasts couple of posts, you've posted some pretty judgmental comments questioning the motives of MD/PhD grads who pursue several different career paths. These posts express disapproval of a variety of paths taken by for MD/PhD grads (competitive specialties, too much clinic, too much science). Of course, some of your previous comments are probably just for the sake of argument about what is ideal.

In light of your previous posts, I believe turnabout is fair play . So, I have 2 specific questions for Sloux:

1) what are your motivations for getting an MD/PhD? or perhaps, what were they when you started?
2) what career path do you envision for yourself now? that is, how do you intend to use your MD/PhD in your career?

I was just wondering where on the spectrum of these possible career paths that you fall. And please take this post only in the kindest possible way. I'm only curious because you've expressed strong feelings about these areas.

 

[dl2dp2]

In your lasts couple of posts, you've posted some pretty judgmental comments questioning the motives of MD/PhD grads who pursue several different career paths. These posts express disapproval of a variety of paths taken by for MD/PhD grads (competitive specialties, too much clinic, too much science). Of course, some of your previous comments are probably just for the sake of argument about what is ideal.

In light of your previous posts, I believe turnabout is fair play . So, I have 2 specific questions for Sloux:

1) what are your motivations for getting an MD/PhD? or perhaps, what were they when you started?
2) what career path do you envision for yourself now? that is, how do you intend to use your MD/PhD in your career?

I was just wondering where on the spectrum of these possible career paths that you fall. And please take this post only in the kindest possible way. I'm only curious because you've expressed strong feelings about these areas.

I'm not sure where in these posts I've expressed "strong feelings". I explicitly stated that I pass no judgements onto any of these pathways, and consider them to be all legitimate career choices. People are "devious" not because they chose a particular pathway that's not its explicit designed goal, but that they misrepresented themselves along the way to gain an advantage. Now, all is fair in love and war--and it's a war out there trying to get a rads spot--or an R01, for that matter, so I really do not think I have any authority to position myself on any kind of moral high ground. Maybe some of my comment sound sarcastic to you, but trust me, they are more directed at the system. I've said once that the only thing more dysfunctional than the healthcare system in America is the biomedical research enterprise, and unfortunately nobody has enough wherewithal to "reform" it. Perhaps we can hope that it'll "evolve" in the right direction.

Meanwhile, as far as the "ideal" endpoint of an MDPhD training, it can be controversial, but there is a consensus in the MSTP training directors community. If you ask Skip Brass or Nancy Andrews you'll get a standard answer: academic career in a "traditional" specialty, >75% research in a translational subject, 15% or less in medical practice. There's a lot of leeway to what is acceptable. Pure basic career is deemed okay. Private practice is not. Industry is more or less acceptable. Consulting is not. I think everyone knows this answer already. Obviously this doesn't make everyone happy, and anti-establishment sentiments run high... but this is the party line and the bottom line, and even though I don't endorse it necessarily myself, and I certainly don't think it's fair to judge everyone based on their tendency to conform to an arbitrary goal, I don't think it's a terribly bad "ideal" banner to pose to NIGMS and the Congress. MD/PhDs are by designed to fill a translational gap.

I don't really think my own individual case is relevant. People shouldn't model themselves after me. They should do what they think is right for them. I think while it's important to help Gotti over his personal trials and tribulations, sometimes it's important to not loose sight in the big picture. I mean, there is something very systematically absurd about fantastic MD/PhD candidates stressing over landing ANY residency spot in some specialty, while taxpayers essentially invested half a million dollars in their careers.

 

[Neuronix]

I don't really think my own individual case is relevant.

Sure it is. It's easy to criticize others but not talk about yourself. He who cast the first stone sort of thing.

 

[Shifty B]

I'm not sure where in these posts I've expressed "strong feelings"..

Regardless of saying at the end that there is no judgment, I think your posts come out pretty strongly for or against certain choices.

I don't really think my own individual case is relevant. People shouldn't model themselves after me. They should do what they think is right for them. I think while it's important to help Gotti over his personal trials and tribulations, sometimes it's important to not loose sight in the big picture.

I couldn't disagree more, because this is the problem with having a standard answer for NIGMS or whatever. It doesn't consider the individual. I personally think you give people far too much credit for being devious, and I don't think most individuals are guilty of deceiving anyone, except perhaps themselves. Most 20-22 yr olds entering these programs cannot possibly know what exactly they are getting into in terms of what clinical medicine or research is really like.

The behavior of most people choosing MD/PhD careers, to me, reflects continual growth of their personal goals and acknowledgment that they change over time. I feel like most MD/PhDs start out with exactly what you describe as the ideal but their goals are shaped by their experiences and every changing ideals. What you call deception is actually just an open reconsideration of what someone wants to do with their life. Individuals truly taking advantage of the MD/PhD system are like rocking horse manure.

Consider some of the possibilities:
1) doing the MD/PhD to pay for medical school. This is the most realistic way of taking advantage of the system, but also the most foolish. Applying medical students might be naive enough to try this, not realizing that it's not worth it. Most of these people probably drop out, or finish and later realize that they could have just taken loans more easily.

2) doing an MD/PhD to land a more competitive specialty. I don't think most people are thinking that far ahead. Only a small fraction of medical students are definitively interested in one specialty and end up sticking with it. Plus, this is even more foolish because the time would be better spent on studying for step 1 and getting to know the right people. I think it's much more likely that these people decided that they really liked a competitive specialty during their research or 3rd year of medical school. Plus, there's plenty not to like about IM, path, and peds. Very few people could guess what a real career in IM might be like when starting medical school.

People choose competitive specialties because they see interesting medical problems, have nice lifestyles, they find them exciting, and to a certain extent money. I think most people choose them because they personally find them interesting. There is a reason they are competitive.

3) doing an MD/PhD just to go into a lucrative private practice. From the tables above, it is clear that only 1/5 go into private practice anyway. I doubt these people are really grabbing for money, I suspect they just went through 4 years of research and realized that they didn't like it very much. There is a lot of stuff not to like. Plus, the 4 years of PP salary they gave up by doing the PhD sort-of proves that they weren't in it for the $25k stipend, if you know what I mean. Maybe they considered staying in academic medicine but didn't enjoy the constant politics, jockeying for power, etc.

4) staying in a residency as a backdoor into a tenured faculty position. this is an interesting one, because it is easier to get a clinical appointment than basic science appointment. However, you have to do at least a 3 yr residency and probably a 3 yr fellowship. If you don't like clinical medicine, this is going to be torture. Plus, the extra 6 years you could have been building up a resume of publications and academic work might offset the advantage. I suspect that people finishing their MD/PhDs who envision themselves as 95% researchers stay in medicine because they like clinical medicine, particularly patient interaction. People interested in basic science may do a residency just to protect the option to do clinical work in the future, because it's basically impossible to do a residency later.

I mean, there is something very systematically absurd about fantastic MD/PhD candidates stressing over landing ANY residency spot in some specialty, while taxpayers essentially invested half a million dollars in their careers.

I don't think that you can possibly worry about the ramifications of this. The government has decided to invest money in this program for its own potential benefit by promoting research and academic careers and doesn't care about you as an individual. The government benefits from having highly educated physicians around regardless of what career you pursue. You will pay more than that half-million back in taxes throughout your career anyway. In fact, the taxes on that extra $100k you might make as a clinician over a 30 year career (33% marginal tax rate x $100k x 30 years = $1 million, just on the extra 100k) is more than enough to pay them back the half mil. It's a win-win situation for the government, so don't worry about them.

People end up choosing different career paths because although that 80/20 goal is nice, it doesn't account for different individuals and how their interests are going to change over time. I've said before, if you're interests and career goals don't change at least a little in 8 years in an MD/PhD you were either gifted with excellent foresight or aren't very introspective.

 

[solitude]

Shifty B you have mentioned numerous times that you personally, are not attracted to the traditional IM/Peds/Path career. Perhaps this isn't the right thread, but I would be interested to hear your in-depth opinion on that. In other words, I'm presuming that you have chosen a competitive specialty for "interesting medical problems, have nice lifestyles, they find them exciting, and to a certain extent money", but you've also noted a few times that IM would be horrendous for you without going into details. Can I ask why? And I am NOT judging, just curious. This forum is great because it is the only place where I get to hear from older students who have already been through the rigamarole.

 

[ellifino]

The other scenario, btw, is the cut throat science guy who got a couple of Cell papers during PhD, and would be perfectly fine going straight to a postdoc. But instead, he decides that he'd rather do a fast track IM/heme-onc residency, suffers through all the clinical training, then at the end of it spend 2hrs a week seeing 5 patients with a weird tumor that only has 5 cases in the world per year, and spends 95% of his 70 hr work week doing clinical medicine. He gets paid 50% more than his PhD->postdoc colleagues in the same department, tenure was a breeze, stays at his prestigious institution as an assistant professor, while his labmates during his PhD years scrambles across the country for postdoc jobs, fighting against 1000 candidates for an assistant professor job in Kansas that pays 80k had involves teaching 8 classes, and hopefully avoiding the fate of Amy Bishop 8 years later when the tenure clock starts to chime.

He's using his residency training to get, eventually, to a 100% research job. And trust me, this is not uncommon either.

I'm not passing judgement. I'm just making observations.

For the record, assistant professor jobs for biology PhDs in Kansas start at around $48,000. But the 8 classes thing is right & so is the competitiveness of the job. :/

 

[Shifty B]

Shifty B you have mentioned numerous times that you personally, are not attracted to the traditional IM/Peds/Path career. Perhaps this isn't the right thread, but I would be interested to hear your in-depth opinion on that. In other words, I'm presuming that you have chosen a competitive specialty for "interesting medical problems, have nice lifestyles, they find them exciting, and to a certain extent money", but you've also noted a few times that IM would be horrendous for you without going into details. Can I ask why? And I am NOT judging, just curious. This forum is great because it is the only place where I get to hear from older students who have already been through the rigamarole.

To avoid further clutter to this thread, I posted a reply in a new thread:

http://forums.studentdoctor.net/showthread.php?t=705264

I am hard to offend, so feel free to ask whatever you might about my judgment, logic, etc. Like you, I think this is a good forum to address these things because you can get some interesting perspectives.

 

[gbwillner]

People choose competitive specialties because they see interesting medical problems, have nice lifestyles, they find them exciting, and to a certain extent money. I think most people choose them because they personally find them interesting. There is a reason they are competitive.

4) staying in a residency as a backdoor into a tenured faculty position. this is an interesting one, because it is easier to get a clinical appointment than basic science appointment. However, you have to do at least a 3 yr residency and probably a 3 yr fellowship. If you don't like clinical medicine, this is going to be torture. Plus, the extra 6 years you could have been building up a resume of publications and academic work might offset the advantage. I suspect that people finishing their MD/PhDs who envision themselves as 95% researchers stay in medicine because they like clinical medicine, particularly patient interaction. People interested in basic science may do a residency just to protect the option to do clinical work in the future, because it's basically impossible to do a residency later.

Do you honestly believe that that people choose the competitive subspecialties because they are interesting and not because they pay more? Really????? Someone here should show a correlation between pay/lifestyle and competitive specialties. I would be shocked if it's not a perfect 1:1 ratio. Skin is SOOO interesting- a thousand types of red rashes with essentially one treatment for all of them. Oh, wait, I remember, Dermatologist work 4 days a week and make $400K. BTW, to those that don't know, a speciatly's competitiveness does not in any way dictate reimbursement- this is a direct consequence of billing and how you can be paid for your services, so this is not a "chicken and the egg" story.

As for the second paragraph, I think that as an MD/PhD, it is actually easier to get a research position that a clinical one. Esp. If you are in the "traditional" track. It's just harder to keep your job 3 years out if you don't get your own grant support.

 

[Neuronix]

Do you honestly believe that that people choose the competitive subspecialties because they are interesting and not because they pay more? Really?????

I thought about responding to you in the other thread, but you've made IMO a ridiculous question here. I find these sorts of generalizations insulting.

My PhD is in MR physics. I'm an excellent computer programmer. I chose to do a Radiology PhD purely out of interest and personal abilities in computers/circuits with no knowledge of (or interest in) pay/lifestyle/whatever. Since then, I've become quite an expert in my own little field and very much enjoy the technical aspects of the research that I do. If I keep doing research, I'd like to keep doing it in my area. So yes, Radiology is extremely interesting to me. I have considered Pathology, but you don't have the same sorts of physics involved there. Instead I'm strongly considering other high physics specialties--Rad Onc and Nuc Med in particular. Do I care that Rad Onc is competitive? No. I care that there's cool physics involved in the treatment of patients.

Path in general is more of a cell/mol biologist's game. Which is fine for the 90% (?) of MD/PhDs who do PhDs in cell/mol biology. That's not me.

 

[calvinNhobbes]

Same for me.

My PhD is in orthopaedic tissue engineering and regenerative medicine. I selected my MSTP program because it had one of the biggest ortho tissue engineering research groups in the world.

Some of my undergrad research was in the same area, purely due to interest. I wasn't even sure I would like surgery until I got to actually do it, and now I could not imagine doing a non-surgical specialty. Seems only natural to pick the surgical field that relates best to my research, regardless of the how competitive it is.

In fact, I'm not even sure how competitive ortho was 10+ years ago when I actually started down my planned career path; it used to be one of the easiest!

 

[gstrub]

Like I said, a PhD really only helps for a couple specialties, if that.

I'm sorry, but from what I've seen at my own institution and others, as well as speaking to our program directors here, you are completely incorrect. Are you in a MD/PhD program or were you? Because I'm not sure where you ae getting your information.

Of course unless you are considering specialties "other" than plastics, NSG, ENT, Derm, or radiology, 10 IM programs, top 10 path programs, rad onc...what's left? That's the list of matches from our MD/PhD program in the last few years..all at excellent institutions (Vandy, UCSF, Duke, Pitt, Hopkins). And again, as I said earlier, these students were not some superstar 270 step I all H's types. They were mature, balanced, well published, dedicated physician scientists...exactly what academic programs in any department hope to attract.

All things being equal, the PhD has been a tremendous help for our graduates.

 

[gbwillner]

I thought about responding to you in the other thread, but you've made IMO a ridiculous question here. I find these sorts of generalizations insulting.

Dude, We all know what your interests and background is. If you saw what I was responding to, it wasn't that Shifty B chose rads over other fields because he found it more interesting. That is fine. It was that he said:

"People choose competitive specialties because they see interesting medical problems, have nice lifestyles, they find them exciting, and to a certain extent money. I think most people choose them because they personally find them interesting. There is a reason they are competitive."

Believing this would necessitate that you ignore the fact that the competitive fields pay more and/or have better lifestyle. End of story. He suggests they are more competitive because they are more interesting in the last sentence. Personal taste dictates what is interesting. My point is not that subspecialties are NOT interesting. Derm can be interesting, I'm sure. But that's not why it is competitive.

 

[Shifty B]

Believing this would necessitate that you ignore the fact that the competitive fields pay more and/or have better lifestyle. End of story. He suggests they are more competitive because they are more interesting in the last sentence. Personal taste dictates what is interesting. My point is not that subspecialties are NOT interesting. Derm can be interesting, I'm sure. But that's not why it is competitive.

I certainly don't ignore that money and lifestyle play a role in specialty decisions. I believe lifestyle/hours are more important than money to most people. That is, the difference between being on call or not and working weekends or having more vacation is more significant to most people than the difference between 400k/yr and 200k/yr. Unfortunately, it may be difficult to extract the two.

Derm is competitive because for all three reasons. A certain subset are going to find it interesting, it has a nice lifestyle, and there is good money. However, the biggest reason derm is so competitive is the sheer paucity of spots (300/yr vs IM with almost 5000/yr).

There are factors other than money which made IM less desirable for me, which I detailed in the other thread. Factors such as the supersubspecialization of medical care and pervasiveness of social/financial issues in IM patients apply to all MD graduates, who are flocking to specialties. It's not all just money.

 

[gbwillner]

Derm is competitive because for all three reasons. A certain subset are going to find it interesting, it has a nice lifestyle, and there is good money. However, the biggest reason derm is so competitive is the sheer paucity of spots (300/yr vs IM with almost 5000/yr).

Herein lies the "chicken and egg" argument of competitiveness. Of course competitiveness, as you state, is because of the lack of spots. This is a result of those in charge or dermatology training to purposefully prohibit an increase in dermatology positions, to artificailly inflate demand for their services and keep their salaries higher. I'm not saying it's wrong, but that's how it is. This, in turn, gives them better lifestyle/money. This, then, increases the student's desire to enter the field.

 

[Gotti]

Honestly, hate to be so judgmental, but even a just MD person choosing dermatology to go into private practice really has lost the original sense of the med school personal statement that said they wanted to help people in need. I know there are exceptions to this like someone passionate about skin cancer because of personal experience or a dermpath guy fascinated by the histology, but many of these guys go into affluent neighborhoods to treat teenagers with acne. To each their own, but it is a waste of talent as that person was probably top of his class. Much more, the MD/PhD who has a lot of skills to contribute. Its not really shame on that MD/PhD because somewhere in his training he lost the desire for academics and shouldn't be forced to do it, its just a shame for society to have put so much investment in him.

 

[calvinNhobbes]

I'm sorry, but from what I've seen at my own institution and others, as well as speaking to our program directors here, you are completely incorrect. Are you in a MD/PhD program or were you? Because I'm not sure where you are getting your information.

First, I get my information from the NRMP. Second, you can call me Dr. Dr. Third, my personal experience, as well as several other graduates of my program would disagree. Therefore, I am no more incorrect than you if we are simply basing this on anecdotal evidence.

Of course unless you are considering specialties "other" than plastics, NSG, ENT, Derm, or radiology, 10 IM programs, top 10 path programs, rad onc...what's left? That's the list of matches from our MD/PhD program in the last few years..all at excellent institutions (Vandy, UCSF, Duke, Pitt, Hopkins). And again, as I said earlier, these students were not some superstar 270 step I all H's types. They were mature, balanced, well published, dedicated physician scientists...exactly what academic programs in any department hope to attract.

And the NRMP data says they would have most likely matched at those specialties without the PhD. There is no NRMP data to address match location one way or the other, so unlike you, I won't speculate.

All things being equal, the PhD has been a tremendous help for our graduates.

The NRMP data shows it doesn't matter. Anecdotal evidence is just that.

EDIT: One thing I also need to add, the apparent success most MSTP programs claim is really due to bias. How can that be, you ask? That is because they are usually associated with Top 40 med schools. So, you ask? Well, the three categories that are most significantly different between matched and unmatched applicants in ALL specialties are Step 1, AOA status, and graduate of a top 40 med school. Conclusions, MSTP grads get great residencies because they go to great med schools, and are usually exceptional students to even get into an MSTP program (which relates to AOA and Step 1). According to NRMP data, the PhD has a debatable benefit, and may actually decrease ones chances in certain fields.