Considering Combined MD and PhD: Thoughts From an MD/PhD Student
“So what year of medical school are you in?”
“My course is five years long, so I graduate in a few months! Looking forward to starting as a doctor. How about you?”
“I’m integrating a PhD into my medical degree. I’m half way through, only another five years left”
*Awkward silence*
Over the last couple of years, the above exchange has happened with my medical school colleagues’ numerous times. As a UK-based medical student interested in research, it seemed the right thing to do to undertake a PhD at some point in my medical training. For many academically inclined clinicians in the UK, a PhD is often done years after medical school graduation. At the beginning of 2017, I made a big decision and enrolled into an MB/PhD program; the UK equivalent of the MD/PhD. US MD/PhD programs enroll between 5,000-6,000 new recruits each year. The US started such programs in the 1950’s whereas the UK followed suit several decades later in the late 1980’s. Be it US or UK, the principle holds: intercalate a PhD within your medical degree and graduate as both a doctor in medicine and a doctor in science, after 8-10 years of study. Lots of people around me, some clinically trained and some not, find this idea totally loopy. There are several misconceptions that I notice put medical students off from intercalating a PhD. Using my experiences of undertaking an MB/PhD in the UK, I want to dispel some of these misconceptions, five of which are listed below. I’d like to argue the case that integrating a PhD into a medical degree might not be such a crazy idea after all.
Misconception 1: “The research component of your MB/PhD must align with your future clinical specialty”
My MB/PhD project is based around the biology of kidney lymphatics. I’ve lost count of the number of times I have been asked where and when I want to do my nephrology training. The answer is: I don’t know whether I want to do nephrology at all yet (albeit, the way things are going, I probably will)! At later stages of clinical training, it totally makes sense to tailor a PhD to a specialty that you’ve already committed to. However, for those just starting out in medical school or having not had much clinical exposure, I think it is impossible to know exactly what the future holds, and to restrict PhD options to something you think will align with your future career choices may not work out exactly the way you think it might.
So, are there consequences of doing a PhD in a specific research topic, and then committing to training in a different specialty? My opinion: absolutely not! PhD projects tend to go into incredible depth into one particular question, in one particular topic, in one particular aspect of one particular specialty. The likelihood is that your PhD research will be so niche that it won’t necessarily give you the clinical aptitude and knowledge required for that specialty anyway. For instance, despite undertaking a nephrology-related PhD, I would anticipate that cohort from medical school, who are currently undertaking their first years of residency, would far surpass me in their knowledge of renal medicine. The transferrable skills and lessons taught from doing a MD/PhD are applicable to any specialty, or indeed any career. Anecdotally, several of my mentors, who are themselves MD/PhD graduates have two things in common. The first: many did their PhD project in something completely different to their current clinical interests. The second: they are all leading extremely promising and successful careers.
Misconception 2: “As an aspiring clinician scientist, your project must be patient-based”
It is surprisingly common to be asked when and how my PhD research is going to translate into some kind of a magical fix for kidney disease. Of course, there are many MD/PhD students who directly work with patients or material derived from patients. There is such a vast range of PhD projects available, particularly in the area of fundamental laboratory science, which is where my heart lies. Increasingly, institutes focused on laboratory science are developing pathways for clinically-trained researchers. An excellent example in the UK is the Francis Crick Institute which, since its inception in 2015, is establishing itself as a dominant force for biomedical research in Europe and has a range of opportunities for newly trained and upcoming clinicians.
Won’t doing a PhD in laboratory science, as part of an MD/PhD, be too far removed from the clinical world? The main reason why my answer to this is a resounding ‘no’ is the way that doing a MD/PhD in laboratory science trains you to think. Despite only being three years into my PhD, my mindset and the way I approach research has completely changed. Be it due to the high proportion of laboratory experiments that fail and the requirement to meticulously troubleshoot each step, or the stringency of the reviewing and editorial process for papers and grants, doing an MD/PhD has given me a (mostly) healthy level of academic cynicism that has become invaluable in my ability to critically appraise clinical literature. I’ve noticed that I can distinguish between good and bad science much better than I could several years ago; back when I would have probably blindly believed just about anything and everything that appeared on PubMed.
My own personal example of this ability to critically appraise comes in the field of regenerative medicine. Advances in tissue engineering and regenerative medicine have opened up a range of possibilities; by tapping into the regenerative capacity of cells and their environment a new era of treatment for previously incurable diseases are predicted. As a young medic, I was entranced by the idea of producing functional organ tissue in laboratory and implanting these into patients. However, the developmental biology component of my MD/PhD has given me a completely different perspective. There is a large interface between developmental biology and tissue engineering: developmental biology heralds the discovery of genetic, chemical and mechanical signals guiding cell fate, which are harnessed by tissue engineering to repair or replace diseased or damaged organs. Doing developmental biology has made me realize the importance of proper characterization, rigorous pre-clinical testing and appropriate licensing and regulation before putting cells or constructs into patients. If not done properly, the consequences of such therapies can be disastrous.
Misconception 3: “You will lose clinical acumen if you do a PhD so early in medical training”:
Given the significant time commitment required to undertake a PhD, it is often not feasible to uphold hospital-based clinical learning opportunities as frequently as non-academically inclined medical school colleagues do. This is particularly the case for universities and institutions that do not formally have an MD/PhD program, but instead allow students to take 3-4 years out of medical school to pursue a PhD project. However, In the UK, established MB/PhD programs enable candidates to attend clinical or surgical teaching alongside their PhD, be it hospital rounds, group teaching at the bedside or lecture-based tutorials and seminars.
Ultimately, it is down to you as an individual to maintain clinical competency outside a PhD project. Of course, there will be times when clinical confidence waxes and wanes, but this is the case whether the PhD project is taken in medical school or time out of training is taken later after medical school graduation. Ultimately, I think the MD/PhD is a foreshadowing of the requirement placed on physician-scientists to develop the clinical acumen of their non-academic colleagues, whilst also furthering their careers as independent scientists.
Misconception 4: “I won’t be able to find funding to do a PhD during medical school”
Financial concerns are one of the most common reasons I have heard from individuals who have been dissuaded from doing a PhD during medical school. Fortunately, a number of MD/PhD programs in the US are fully funded, including covering tuition fees and provision of a stipend during doctoral studies. Some institutions in the US, including the National Institute of Health and the Department of Veterans Affairs, provide a range of funding opportunities not only to MD/PhD students, but for clinician-scientists at various stages of their training. Given the ever-increasing demand for clinician-scientists, a number of charitable organizations in the UK have also developed dedicated funding streams for students who want to undertake an MB/PhD. These include schemes by the British Heart Foundation and, more recently, Cancer Research UK. In cases where no dedicated funding streams are available, MB/PhD programs can help students to source funding by applying for funding streams originally designed for non-clinical PhD students (this is what I ended up doing!). Or, if you’re lucky, your laboratory or supervisor of interest might have a pot of funding available for you to use for an MD/PhD stipend.
How long MD/PhD funding lasts can vary from program to program. I cannot speak for the US, but in the UK, our MB/PhD’s tend to be fully funded for up to three years of study. Some students in the UK find extra support from current funders or other sources to extend their PhD by a year. The Rosetrees Trust provides such a source of support via its ‘PhD Plus’ scheme, which is worth considering if you’re planning an MB/PhD in the UK. Whatever you opt to do, I feel that it is important to be proactive and to plan early. Identifying putative sources of funding, being forthcoming and asking potential supervisors about funding and stipends and discussing options with MD/PhD program advisers can all increase your chances of securing funding. Honestly though, this is probably good practice for the future, as it is no secret that securing grant funding or successfully applying to fellowships is no menial task.
Misconception 5: “Your clinical colleagues of the same age will reach a higher career stage than you”
Indeed, as an MD/PhD student, your non-academic colleagues will graduate earlier than you by several years. A typical worry is that doing a PhD will cause you to fall behind in the career ladder, and that the same clinical colleagues with whom you shared anatomy labs and lectures will eventually end up as your seniors. From what I’ve heard and seen this may not be entirely true. Firstly, having a PhD by the time you leave medical school could have a large impact on your likelihood of matching in a job or specialty of your choice. In a survey of Canadian MD/PhD graduates who had completed their degrees before September 2015, 97.8% of the 136 respondents matched with their first choice of specialty, and 89.7% matched with their first choice of location. These statistics are pretty promising, particularly during an era when medical schools are expanding and more and more students are being recruited, making certain specialties ever more competitive.
How about after graduation? Funnily enough, if you are an MD/PhD student, it has been argued that you can reach your long sought-after academic position at around the same time as colleagues who graduate from medical school several years earlier than you. This is because the early PhD will result in a shorter period of postgraduate research and training required to reach academic independence than your medical school colleagues. Not to mention, individuals who opt to do a PhD after completing medical school will have to climb the steep learning curve of academia, whilst potentially maintaining clinical duties; a learning curve that you will have already surmounted years beforehand.
Though I have attempted to dispel the misconceptions around doing an MD/PhD, undertaking a PhD so early in clinical training is definitely not for everyone. However, I, for one, couldn’t have thought of a better time to experience the intensity of laboratory science, coupled with the independence of planning out and conducting my own experiments, whilst reading papers down to the most detailed of minutiae. These skills and others, such as the ins and outs of writing papers and grants, delivering effective presentations and learning to work in a multidisciplinary team with members from a range of academic backgrounds have allowed me to approach the clinical realm with a totally different mindset. In a recent Viewpoint in the Journal of Clinical Investigation, this dual perspective from both laboratory science and clinical practice was coined the ‘Gemini effect’ and places physician-scientists in an excellent position for careers in academia, industry, government and policy or beyond. So why wait until after medical school to experience that?
Daniyal Jafree, MB/PhD student, UCL Great Ormond Street Institute of Child Health, University College London, London
Dr Swapnil Hiremath, Associate Professor, University of Ottawa, Ottawa, Canada