The Need to Restructure MD???PhD Training

In this issue, Ahn and colleagues report the results of a survey of students from 13 MD–PhD joint-degree training programs across the country. The investigators asked the students to share their views of their MD–PhD education and future career plans. A total of 492 students, representing around one eighth of all U.S. MD–PhD students, participated in the study. As is true with almost all forms of survey research, the reported results are open to some question because of the wording of the questionnaire items and how they are interpreted. Nonetheless, the study findings warrant serious consideration because they raise an important question about whether MD–PhD joint-degree programs are really meeting expectations. By doing so, the survey results challenge the logic of the design of these programs, which has remained relatively unchanged for more than 40 years. At present, the great majority of medical schools in this country offer an MD–PhD joint-degree program to a select group of their students. At 40 schools, most, if not all, of the MD–PhD students are enrolled in medical scientist training programs, supported by the National Institute of General Medical Sciences. In general, students are accepted into the programs at the time of admission to medical school and receive a stipend, tuition allowance, and other funds to cover certain educational expenses. The students generally complete the first two years of the medical school curriculum in standard fashion, and then spend the next three or more years immersed in their doctoral studies. Once they have completed virtually all of the requirements for the PhD degree, they reenter the medical school to complete the last two years of the course of study leading to the MD degree. At the time of graduation, therefore, they receive both an MD and a PhD. The survey results reported by Ahn and colleagues reveal that many of the respondents (44%) did not intend to pursue research as their primary professional activity once they completed all of their training. While it is true that the majority expressed a desire to have a career in academic medicine, they were primarily interested in activities related to patient care, and they saw themselves as being involved in research in a limited way. These results certainly suggest that the current programs are not likely to be highly successful in producing a cadre of physician scientists committed to careers in fundamental research. Based on these results, the authors conclude that if the societal investment supporting MD–PhD joint-degree programs is to reap the expected rewards (presumably a high percentage of graduates pursuing research on a full-time basis), improvements are needed in the design of the training programs. I've thought for some time that the design of the programs is flawed, largely because of my understanding of the challenges faced by new faculty members who hope to become successful biomedical scientists. Given the incredibly competitive nature of the current biomedical research environment, individuals who wish to be successful as physician scientists need to be engaged in research on a full-time basis. And it is particularly important that they become heavily involved in research from the time they complete their research training. The reality of modern science is such that being away from the laboratory for a prolonged period creates a serious disadvantage for one who desires to be a successful research scientist. Indeed, this is why such a large number of PhD graduates are willing to spend extended times as postdoctoral fellows in an active laboratory, awaiting the opportunity to become independent investigators. Given this state of affairs, it seems clear to me that the design of MD–PhD joint-degree programs is illogical. Why? Because virtually all of the programs' graduates are going to spend an extended period of time away from the research laboratory before they have an opportunity to begin their research careers. After completing almost all of the requirements for the PhD degree, MD–PhD students will spend two years completing the clinical education requirements for the MD degree. They then will spend an additional three to five years acquiring clinical training in the specialty of their choice. And an increasing number now pursue subspecialty training in a fellowship program. When all is said and done, the MD–PhD graduates who might aspire to careers as full-time research scientists will have been away from significant involvement in a research laboratory for five to seven years or longer before embarking on their research careers. I doubt that anyone responsible for training PhD scientists for research careers in the biological sciences would argue that this is a rational approach for training physician scientists for those careers. Now, some will undoubtedly challenge my view by quoting data that suggest that the MD–PhD programs have been successful in producing physician scientists, based on the percentage of graduates who have successfully competed for grants from the National Institutes of Health (NIH). But I am not swayed by the data I hear quoted most often, which include a sizable number of MD–PhD graduates from a time before the competitiveness of the research enterprise rose so dramatically. I believe that one can judge the current effectiveness of MD–PhD programs only by analyzing the research productivity of more recent graduates. Unfortunately, there is very little information available about the career activities of those graduates. But an evaluation published in 1998 indicates that only 25% of those who received their MD–PhD degrees from 1986 to 1990 had even submitted grants to the NIH.1 While that percentage might grow a bit as the years pass, the overall data presented in the evaluation document suggest strongly that fewer than half of the graduates are likely to become independently funded investigators. So what needs to be done to increase the effectiveness of the federal investment in the production of physician scientists committed to careers as research scientists? It seems self-evident that the requirements for the PhD degree, if, in fact, they are necessary to produce a physician scientist, must be integrated more fully into the period when the MD graduates are involved in their advanced clinical studies. In fact, the Task Force II on Clinical Research convened by the Association of American Medical Colleges has recently acknowledged the importance of that principle. In its recent report, the task force called for a fundamental restructuring of the training for careers in clinical research by recommending that research training and experience should occur seamlessly from medical school through residency and fellowship training.2 This approach would not only create a more coherent training experience, it would also allow those so trained to embark on careers as independent investigators at the earliest possible time. If this approach makes sense for the training of clinical investigators, it certainly should make sense as well for those physicians who may wish to pursue full-time research careers as physician scientists. The bottom line is that the MD–PhD joint-degree programs need to be redesigned so that the bulk of the research training occurs not during medical school but, instead, when the trainees are pursuing advanced clinical training in one of the specialties or subspecialties of medicine. Having staked out that position, I must be candid and add that I think that a relatively small number of resident physicians would pursue such research training. The appeal of clinical medicine and the financial incentives to enter practice would likely obviate the outcome desired from integrating doctoral training into residency and fellowship programs. But this in and of itself is not a reason to retain the outdated structure of the existing MD–PhD programs. In the end, one would like to match individuals who are strongly committed to careers as research scientists to the most logical training experiences. Data from Canada show that physicians who acquired their PhD degrees after graduating from medical school pursued more research-focused careers than did those who acquired the PhD degree before graduation.3 Clearly, the federal and institutional investment in MD–PhD joint-degree programs could be more effectively used to create the next generation of physician scientists. Someone needs to be willing to take a leadership role in working toward a different approach that could serve the public's interests more effectively. Michael E. Whitcomb, MD

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