Surgery as an MD/PhD....

[brotherbu]

I'm just curious as to whether some of you feel that an MD/PhD can do meaningful basic science research if they were to go into a surgical residency. Even the best advocates of the dual degree admit that its not very possible to be a GREAT doctor in addition to being a great scientist, but it seems to me that if you were a surgeon interesed in doing basic science research, you must need to be great at both. I can see a surgeon being in a scientific team with basic scientists and collaborating with scientists, but I don't know if you need to be an MD/PhD physician scientist to go this route. I also know many surgeons have labs, but is it truly practical to do cutting-edge basic science research in addition to being a great surgeon??? Thoughts would be appreciated!

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[PostalWookie]

Personally, I'd never go to an MD/PhD surgeon who did any serious research. Surgery requires constant practice, and for most conditions, the outcome really depends on the experience of the surgeon, so I think it's pretty much impossible to do both things well.

I think our program director was pretty disappointed when he found out 3 MD/PhDs matched into surgery this year.

 

[relentless11]

I have yet to meet an MD/PhD surgeon at UC Davis in the many years i've been at the medical center. Doesn't mean that there isn't any here, or at any other school/hospital though. I always wondered about this, so glad to see someone posted a thread about it. I agree PostalWookie though, research takes up time, and so does being a surgeon.

However I do know that our surgeons do run some kind of research projects, to what extent, I do not know.

 

[Neuronix]

Please don't take this personally PW. I post this because I'd like to stimulate discussion on this issue, because I think it deserves more discussion. Your post reflects to me the mainstream MD/PhD thinking, and as such serves as a good jumping post.

Personally, I'd never go to an MD/PhD surgeon who did any serious research. Surgery requires constant practice, and for most conditions, the outcome really depends on the experience of the surgeon, so I think it's pretty much impossible to do both things well.

I've heard the same said for any kind of doctor, including medicine. How is an internal medicine doc supposed to keep up on his skills and the latest advances if he only does it a month or such a year? I'd never want to be the patient of that doctor!

I hear the surgery research MD/PhD wannabes advocating for something like a day or two a week of surgery and the rest research. This fits into the MD/PhD dream propogated by most PDs of 80%-90% research, 10%-20% clinical. But, somehow according to your post it's okay when some fields of medicine do it, but not others. Maybe it's just that oncology or rheumatology aren't as complicated as surgery? In reality, what program directors are talking about you doing is super-specializing yourself in any field so you can only do it 10-20% of your time. I don't see why you can't do that in surgery, and some people do. The question is why only a proportion of people in a given specialty actually end up doing research. That's a more complicated question, and you can't just write it off as "Well surgeons just can't do research because they have to keep up their skills".

I'm heading into Radiology, and even here at one of the most academic places there is, I'm consistantly told no future employer is ever going to give me 90% protected research time, and even the 80/20 split would be very unlikely (impossible in some minds). It would depend on me taking a gigantic pay cut over my academic clinical colleagues and becoming successful in basic science very quickly. Why is this? Supposedly they wouldn't trust me to read neuro MR/CT if I didn't do it at least 50% of the time. I call BS. Radiology just supports the hospital with all the money it generates so Radiology attendings have to do plenty of clinical work. Where I'm at, at least 50% clinical is what I've seen unless you are big name and take on administrative duties as well. I bring all this up because I don't think this whole issue is as simple as "Well some specialties are good for research and others aren't."

The vast majority of IM, peds, pathology, neurology, and psychiatry docs can't bring in nearly the clinical revenue radiology and surgery docs would bring in (just as limitations of their subspecialties), so it doesn't hurt the departmental bottom line (as badly) for one of their docs to do research. Not to mention that you're not going to take a big salary cut personally, because most of the "research" specialties don't pay will to begin with.

I'm beginning to think that these sorts of financial decisions drive most of what's really going on around here. Think about it for yourself. When you're 40 and have a couple kids, are you going to turn down $250k/year to go make $100k/year? But what if your only option is to make $100k/year, are you more likely to pick research then? I always hear "I could go make more money if I really wanted to". Yeah, a huge switch from academics to private practice. Many of these specialties in the exact same place your salary is going to change drastically based on what you do with your time. Are you willing to work 80 hours a week instead of 50 to keep going with research? If you're a Radiologist how can you not just leave the department if your grants don't get funded, and have your salary and vacation time tripled (this happened recently here)? When you're program director and they're looking on you to support the hospital which is barely in the black, are you going to hire MDs to do research in a time of very uncertain grant funding? What if your department is a big money loser anyway? Does it still matter then?

I think our program director was pretty disappointed when he found out 3 MD/PhDs matched into surgery this year.

Why? Was he disappointed at some people I talked to going into more traditional MD/PhD fields who had no desire to continue doing research? I think it would be pretty narrow minded to write off anyone who doesn't go into certain specialties as not going to continue research. Most MD/PhDs will NOT go on to do mostly basic science research. Instead, they will continue to do a broad spectrum of clinical, translational, and basic research with clinical practice. Are they disappointed at all of them? Surgeons never go on to do clinical, translational, or basic research? I can give you examples of all 3. I'm not even sure that the assumptions about who does research by specialty chosen for residency are true anymore. I'd like to see data breaking down the fates of MD/PhD graduates by specialty, and NOT JUST whether they're in an academic department which tells you pretty much nothing about what they do in life.

One of the biggest name basic science researchers here, an MD/PhD who is very well regarded by the program, recently told me in private that if he was to do it all over again he'd still do 100% basic science research, but he'd go into a field that wasn't oversaturated with researchers like his IM subspecialty. He suggested maybe Urology or Dermatology, because he could have a bigger impact there. Maybe those three students were listening to him...

 

[surgwannabe]

Let me just chime in here. I am an MSTP who is interested in GS. I worked with several MD, PhD and MD/PhD before I came back to school. Personally, I think brotherbu hits the nail right on the head that it is NOT possible to be great at both. This applies to all the fields in medicine. There is a reason why you cannot be a Howard Hughes when you are in an administrative position. Most MD/PhD's with labs who attend heavily spend little time in the labs. They most likely function as the "brain" in the lab, thinking about grants and experiments. It is NOT impossible, however, it takes determination to accomplish that.

Having said that, I think a GREAT physician can still make a significant contribution to the field. As a surgeon, you are the bridge between a basic science lab and the OR. If you are motivated, I think both being a surgeon and doing research can be done well.

 

[Hard24Get]

Neuronix, you rock. I agree that we need to talk about "traditional" vs "non-traditional" paths more as MD-PhD students, because our program is not going to have a panel on it anytme soon.

If a surgeon specializes in say, the Whipple procedure or something, and does it once week, he/she is probably going to have more practice at it than a regular general/GI surgeon who does it once a month or even less often. Thus, specializing really is key. I would argue, however, that often the innovative thinking we are taught in the lab makes up for any deficit in practice, because MD-PhDs seem to understand the science behind the diseases better than most docs, and can think of new ways to address a problem more readily.

Even fields like EM, where breadth rather than depth is emphasized, there is ample access to clinical samples as well as some common diseases that could be fabulous for a MD-PhD, but no one talks about these options.
Also, I know plenty of PIs who still are only in the lab 2-4x per week, yet are very successful (the key is a good lab meeting), so I think that saying you can't be a good researcher without that 80% is also misleading, as well.

I think you hit the nail on the head with the $ issue. The poorer fields are much harder to get protected time from but I think PDs are becoming more and more committed to research in other fields.

EVERY field needs quality research in order to advance, and with our training we are some of the best equipped to do it. So I think we all need to think a little harder about what works for us, not just what works for our PDs. We can't just be lemmings, here. Why should the future look just like the past?

Please don't take this personally PW. I post this because I'd like to stimulate discussion on this issue, because I think it deserves more discussion. Your post reflects to me the mainstream MD/PhD thinking, and as such serves as a good jumping post.



I've heard the same said for any kind of doctor, including medicine. How is an internal medicine doc supposed to keep up on his skills and the latest advances if he only does it a month or such a year? I'd never want to be the patient of that doctor!

I hear the surgery research MD/PhD wannabes advocating for something like a day or two a week of surgery and the rest research. This fits into the MD/PhD dream propogated by most PDs of 80%-90% research, 10%-20% clinical. But, somehow according to your post it's okay when some fields of medicine do it, but not others. Maybe it's just that oncology or rheumatology aren't as complicated as surgery? In reality, what program directors are talking about you doing is super-specializing yourself in any field so you can only do it 10-20% of your time. I don't see why you can't do that in surgery, and some people do. The question is why only a proportion of people in a given specialty actually end up doing research. That's a more complicated question, and you can't just write it off as "Well surgeons just can't do research because they have to keep up their skills".

I'm heading into Radiology, and even here at one of the most academic places there is, I'm consistantly told no future employer is ever going to give me 90% protected research time, and even the 80/20 split would be very unlikely (impossible in some minds). It would depend on me taking a gigantic pay cut over my academic clinical colleagues and becoming successful in basic science very quickly. Why is this? Supposedly they wouldn't trust me to read neuro MR/CT if I didn't do it at least 50% of the time. I call BS. Radiology just supports the hospital with all the money it generates so Radiology attendings have to do plenty of clinical work. Where I'm at, at least 50% clinical is what I've seen unless you are big name and take on administrative duties as well. I bring all this up because I don't think this whole issue is as simple as "Well some specialties are good for research and others aren't."

The vast majority of IM, peds, pathology, neurology, and psychiatry docs can't bring in nearly the clinical revenue radiology and surgery docs would bring in (just as limitations of their subspecialties), so it doesn't hurt the departmental bottom line (as badly) for one of their docs to do research. Not to mention that you're not going to take a big salary cut personally, because most of the "research" specialties don't pay will to begin with.

I'm beginning to think that these sorts of financial decisions drive most of what's really going on around here. Think about it for yourself. When you're 40 and have a couple kids, are you going to turn down $250k/year to go make $100k/year? But what if your only option is to make $100k/year, are you more likely to pick research then? I always hear "I could go make more money if I really wanted to". Yeah, a huge switch from academics to private practice. Many of these specialties in the exact same place your salary is going to change drastically based on what you do with your time. Are you willing to work 80 hours a week instead of 50 to keep going with research? If you're a Radiologist how can you not just leave the department if your grants don't get funded, and have your salary and vacation time tripled (this happened recently here)? When you're program director and they're looking on you to support the hospital which is barely in the black, are you going to hire MDs to do research in a time of very uncertain grant funding? What if your department is a big money loser anyway? Does it still matter then?



Why? Was he disappointed at some people I talked to going into more traditional MD/PhD fields who had no desire to continue doing research? I think it would be pretty narrow minded to write off anyone who doesn't go into certain specialties as not going to continue research. Most MD/PhDs will NOT go on to do mostly basic science research. Instead, they will continue to do a broad spectrum of clinical, translational, and basic research with clinical practice. Are they disappointed at all of them? Surgeons never go on to do clinical, translational, or basic research? I can give you examples of all 3. I'm not even sure that the assumptions about who does research by specialty chosen for residency are true anymore. I'd like to see data breaking down the fates of MD/PhD graduates by specialty, and NOT JUST whether they're in an academic department which tells you pretty much nothing about what they do in life.

One of the biggest name basic science researchers here, an MD/PhD who is very well regarded by the program, recently told me in private that if he was to do it all over again he'd still do 100% basic science research, but he'd go into a field that wasn't oversaturated with researchers like his IM subspecialty. He suggested maybe Urology or Dermatology, because he could have a bigger impact there. Maybe those three students were listening to him...

 

[RxnMan]

Personally, I'd never go to an MD/PhD surgeon who did any serious research. Surgery requires constant practice, and for most conditions, the outcome really depends on the experience of the surgeon, so I think it's pretty much impossible to do both things well.

I think our program director was pretty disappointed when he found out 3 MD/PhDs matched into surgery this year.

I believe the difference is not the speciality per se ("you need constant practice"). It's whether the speciality is amenable to breaking up your time into one or two days of research a week. Depending on the service and their severity, a surgery patient may require weeks of constant care. A pulmonologist or anesthesiologist can work a shift and then change gears the next day and do research.

But then again, I work with an ortho surgeon (traditionally a very time-consuming field,) who's been published in 3 or 4 journals over the last year. It can all be done.

 

[lundysd]

I'm doing a summer rotation in a lab right now, and the PI is a vascular surgeon scientist. He happens to be chair of his department, and he has published in PNAS, Nature, Circ, etc. It's certainly not easy, and you must tailor your career and lifestyle accordingly, but it's not a bad plan for those who truly wish to do it.

 

[dl2dp2]

Neuronix you made some very good points. I just want to add a couple of things.

Neurosurgery, as a special case of surgery, is VERY amenable to a research oriented career. The case load for an individual surgeon is often low enough that one only has to work a couple of days a week in the clinics. However, the sort of research you do won't be hard core basic research.

Secondly, in large academic centers, as I've observed, many, if not most of the center director level "clinicians" have at least one R01 sponsored projects. For instance, most of the attendings at Columbia's neuromuscular disorder clinic have R01s. It could just be that Columbia has such an amazing neurology dept, but I suspect the situation is fairly analogous in other places.

As a researcher you can either align yourself in a basic science dept @ a university, in which case you get evaluated by the faculty committee of the department, or, if you are a licenced physician, align yourself in a clinical dept. Even though many of the positions in the clinical depts are NOT tenured, MANY others are. Tenure has less to do with the actual bearucratics than the amount of funding that you can bring in. Remember most of the clinical studies are ALSO funded by R01s.

So the encourgaing thing is that, yes, Neuronix is right, getting and sustaining a grant (R01/etc) sponsored lab is hard, but it might not be as hard as you think, if you are a well trained MDPhD. The second good thing is that at a good academic center, the salary for a clinical faculty is almost ALWAYS slightly higher than a normal basic science faculty. And, normal basic faculties are getting paid pretty well these days at high powered intitutions. So I think as far as money goes it's not as much of a problem. (I think a new MD assisstant prof at Columbia in a clinical dept get $150,000 these days.) Don't worry too much about money.

As I'm slightly deeper into this whole game I'm seeing ins and outs of this getting money thing I think actually we can do very well and the careers can be structured in very interesting ways if you do an MDPhD.

 

[Doctor&Geek]

From what I've observed, many successful surgical physician scientists, including the junior level surgeons, often have to resort to lieutenantcy to maintain progress. Of the examples that I know of, most cannot be bothered with daily experimental troubleshooting in detail.

 

[venevite]

I don't think it's realistic. Anything is possible - such as winning the lottery- but I think the chances of doing meaningful basic science research and surgery are slim. A lot of the reasons are obvious and have been enumerated above. In addition, you are competing against very smart, hardworking scientists who do 100% research, so the chances of being successful are slim. Note, however, everyone, has their own yard stick for success. For me, if I am not doing research at the highest level, why bother?