Career Choice

Are MD–PhD Programs Meeting Their Goals?An Analysis of Career Choices Made byGraduates of 24 MD–PhD ProgramsLawrence F. Brass, MD, PhD, Myles H. Akabas, MD, PhD, Linda D. Burnley,David M. Engman, MD, PhD, Clayton A. Wiley, MD, PhD, and Olaf S. Andersen, MD

Abstract

PurposeMD–PhD training programs provide anintegrated approach for trainingphysician–scientists. The goal of thisstudy was to characterize the career pathtaken by MD–PhD program alumniduring the past 40 years and identifytrends that affect their success.

MethodIn 2007–early 2008, 24 programsenrolling 43% of current trainees andrepresenting half of the NationalInstitutes of Health-funded MD–PhDtraining programs submitted anonymousdata on 5,969 current and formertrainees.

ResultsThe average program enrolled 90 trainees,required 8.0 years to complete, and had anattrition rate of 10%. Nearly all (95%) ofthose who graduated entered residencies.Most (81%) were employed in academia,research institutes, or industry; 16% werein private practice. Of those in academia,82% were doing research and at least61% had identifiable research funding.Whereas two-thirds devoted more than50% effort to research, only 39% devotedmore than 75% effort. Many withlaboratory-based PhDs reported doingclinical, as well as basic and translational,research. Emerging trends includedecreasing numbers of graduates whoforego residencies or hold primary

appointments in nonclinical departments,increasing time to graduation, andexpanding residency choices that includedisciplines historically associated withclinical practice rather than research.

ConclusionsMost MD–PhD program graduates followcareer paths generally consistent with theirtraining as physician–scientists. However,the range of their professional options isbroad. Further thought should be given todesigning their training to anticipate theircareer choices and maximize theirlikelihood of success as investigators.

Acad Med. 2010; 85:692–701.

The concept of the MD–PhD programas an integrated approach to trainingphysician–scientists dates back to thelate 1950s. Although a long traditionexists of physicians becominginvestigators as well as clinicians, MD–PhD programs were established with therealization that the standard four-yearmedical school curriculum is neitherintended nor sufficient to trainphysician–investigators who are asproficient in the lab as they are in theclinic. As the term is now commonlyapplied, a physician–scientist or, morebroadly, a physician–investigator, is aphysician who is committed to the questfor new knowledge and new approachesto disease diagnosis, treatment, andprevention, and who devotes far more ofhis or her time to these activities than toroutine clinical care. It was expected fromthe start that most graduates of MD–PhDprograms would be employed by

academic medical centers, universities,and research institutes such as theNational Institutes of Health (NIH). Itwas also expected that links would existbetween program graduates’ medicaltraining, clinical activities, and researchinterests and that each of these wouldinform the others in ways that could notbe experienced by scientists who were nottrained as physicians.1

MD–PhD programs are not the onlyavailable approach for training futurephysician–scientists, but they have, in manyrespects, become the most visible.2–4 In anMD–PhD curriculum, students completethe requirements for both the MD andthe PhD, usually by starting with the firsttwo years of medical education and thenfocusing on graduate school beforereturning to complete the medical degree.Although initially available at only a fewuniversities, MD–PhD programs are nowoffered at most U.S. and a few Canadianmedical schools. These programs varyconsiderably in size and resources. Since1964, NIH support has been availablethrough institutional Medical ScientistTraining Program (MSTP) grants fromthe National Institute of General Medical

Sciences (NIGMS)4 and competitivelyawarded individual fellowships that areoffered by some of the NIH institutes. Inaddition to assisting with program costs,NIH funding has helped standardizetraining approaches and provides aregular source of external review asprograms compete to obtain andcontinue their MSTP status.

Because MD–PhD programs commonlyprovide full tuition and stipend supportto their trainees, they collectivelyrepresent a large investment ofinstitutional, federal, and societalresources. Therefore, it is reasonable toask whether they are meeting their goals.This was last done in the 1990s.4 –6 Recentdebates at national conferences and in theliterature about the best ways and timesto train physicians to be investigators7 ledus to believe it is time to evaluate MD–PhD programs again. To our knowledge,the present study, which analyzes the dataprovided to us by 24 MD–PhD programsin 2007 and early 2008, represents themost exhaustive look to date at the careerpaths of MD–PhD program alumni. Theparticipating programs collectively enrollapproximately 40% of the estimated

Please see the end of this article for informationabout the authors.

Correspondence should be addressed to Dr. Brass,University of Pennsylvania, Room 915 BRB-II, 421Curie Blvd., Philadelphia, PA 19104; telephone: (215)573-4669; e-mail: brass@mail.med.upenn.edu.

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5,000 MD–PhD students currently intraining and together represent nearlyhalf of the 42 programs that werereceiving NIGMS MSTP grants at thetime the data were collected. The datathat were provided allow us to addressissues raised in recent editorials callingfor an evaluation of MD–PhD trainingprograms,7,8 as well as concerns thatphysician–investigators are a vanishingspecies.1

Method

We sent a request for data to the directorsand administrators of 25 MD–PhDprograms, which we selected from amongparticipants at the 2007 nationalconference of MD–PhD programs. Wetried to achieve as much diversity aspossible in program size and location.This was not a prospective study; rather,we asked the program leaders to provideas much data as possible from theinception of their program through theend of academic year (AY) 2007 (the 12months ending in June 2007). Currentstudents were defined as those enrolled atthe time that the survey was completed,which was during AY2008. Twenty-fourprograms agreed to participate*; oneprogram was unable to comply withinthe designated time frame. Twenty of theparticipating programs were among the42 programs receiving NIGMS MSTPgrants. Our decision to overrepresentNIGMS-funded programs arose in partbecause they tend to be the largerprograms and in part because they are

required to track their graduates andreport on their activities every five years.In other words, they were more likelythan other programs to have thenecessary data on hand.

Each program submitted basicinformation, including the number oftrainees in AY2008, the number ofstudents entering the program inAY1998 –2007, the number of studentsresigning without one or both degreesfrom AY1998 to AY2007, the percentageof trainees in AY2008 who were women,the average number of years to completeboth degrees for graduates in AY1998 –2007, and the discipline in which the PhDwas awarded.

Program directors and administratorsalso provided information about alumni,including all graduates from programinception when possible. Program leadersobtained this information from acombination of alumni questionnaires,alumni Web sites, and searches of publicdatabases such as the NIH ComputerRetrieval of Information on ScientificProjects database. The identities ofindividual trainees and alumni were notavailable to us, and therefore we were notable to obtain additional primary dataourselves.

Statistical analysis

We calculated values in Figure 1 for r2,the square of the Pearson correlationcoefficient, using functions built intoMicrosoft Excel 2008 (MicrosoftCorporation, Redmond, Washington).

Results

Twenty-four MD–PhD programsprovided information about 5,969individuals, including 2,023 currenttrainees, 1,143 recent graduates who werestill in residencies or postdoctoralfellowships, and 2,803 older alumni whohad completed all phases of postgraduatetraining. This represents 43% of the 4720trainees enrolled in 2008 (www.aamc.org/data/facts/enrollmentgraduate/start.htm)and may represent a similar proportionof alumni, although the total number ofgraduates is currently unknown. Becausesome of the programs were unable tosupply answers to all of the surveyquestions, in the following presentationof the results we have indicated thenumber of programs and/or alumni thatanswered each question.

Program characteristics and trainees

The 24 programs that participated in thesurvey ranged in size in AY2008 from 31to 184 trainees; the average was 90trainees. Thirty-seven percent of traineesin AY2008 were women, but thisproportion varied considerably (range20%–60%). The unweighted averagetime to complete both degrees forgraduates in AY1998 –2007 was 8.0 � 0.4years (mean � 1 SD; 7.8 years whenweighted by program size, range 7.2–8.5years). On average, 10% of the 2,562students who enrolled from AY1998 toAY2007 withdrew without completingboth degrees (range 3%–34%, 1 SD �7%). We found no relationship betweenprogram size and either the time todegree or the attrition rate from the sameprogram (Figures 1A and 1B). Althoughwe were not provided information aboutstudents’ reasons for withdrawing, ourpersonal experience as program directorsand administrators suggests that most ofthose who withdraw from MD–PhDprograms complete medical school. Fewercomplete graduate school alone or drop outcompletely. Despite a recent report thatwomen are less likely than men to completeMD–PhD programs,9 we found norelationship between the attrition rate fromindividual programs and the percentage oftrainees enrolled in the programs who werewomen (Figure 1C).

Information on PhD disciplines wasprovided for 1,957 trainees enrolled inAY2008, including 306 first- and second-year students who had not yet declared adiscipline (a common practice in many ofthe programs). Of the 1,651 students whohad declared a discipline, 1,422 (86%)were enrolled in PhD programs withinthe broad arc of biomedical disciplines.Another 151 (9%) were in engineering.The others were working in diversedisciplines including health policy,epidemiology, public health,anthropology, sociology, chemistry,mathematics, philosophy, marinebiology, population health, psychology,and the history and sociology of science.

Positions of program alumni

Twenty-two programs providedinformation about then-current or lastknown positions of 2,413 alumni whohad completed all phases of postgraduatetraining. Our results show that 80% ofgraduates were employed full-time inacademic centers (1,625, or 67%),

* The 24 programs that participated are located atthe Albert Einstein College of Medicine of YeshivaUniversity; Baylor College of Medicine; Case WesternReserve University School of Medicine; EmoryUniversity School of Medicine; Harvard MedicalSchool; Johns Hopkins University School of Medicine;Medical College of Wisconsin; NorthwesternUniversity Feinberg School of Medicine; University ofCalifornia, San Diego, School of Medicine; Universityof California, San Francisco, School of Medicine;University of Colorado Denver School of Medicine;University of Iowa Roy J. and Lucille A. CarverCollege of Medicine; University of Maryland Schoolof Medicine; University of Medicine and Dentistry ofNew Jersey–Robert Wood Johnson Medical School;University of Michigan Medical School; Universityof Pennsylvania School of Medicine; University ofPittsburgh School of Medicine; University ofRochester School of Medicine and Dentistry;University of Texas Medical School at Houston;University of Texas Southwestern Medical Center atDallas Southwestern Medical School; University ofWisconsin School of Medicine and Public Health;Vanderbilt University School of Medicine;Washington University in St. Louis School ofMedicine; and Weill Cornell Medical College ofCornell University.

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research institutes such as the NIH (105,or 4%), or in industry (189, or 8%), eachof which is an outcome consistent withthe goals of MD–PhD training. Of theremainder, 386 (16%) were in privatepractice.

Because of concerns about possibleascertainment bias arising from thegreater ease in tracking individualsemployed in universities and researchinstitutes, we also analyzed the datafocusing solely on the 16 programs ableto provide information on at least 98%(n � 1,927) of their alumni. Thenumbers we obtained are essentiallyidentical to those derived from the largerdata set: 68% employed in academia, 4%in research institutes, 8% in industry, and16% in private practice.

Information about primaryappointments was provided to us for1,621 alumni of 22 programs working inacademia (Table 1). Collectively, internalmedicine, pediatrics, pathology, andneurology accounted for 975 (60%) ofthe alumni in academia, but most alumni(1,428, or 88%) held primaryappointments in clinical departments.Many also had secondary appointmentsin basic science departments.

Research activities of program alumni

At least 921 (82%) of 1,118 alumni (of 17programs) in academia indicated thatthey were doing research; 141 (13%)reported that they were not, and no datawere available for 56 (5%). However,considerable variation existed in theamount of time that 814 alumni of 16programs were willing or able to devote

to research: Nearly two-thirds (521, or64%) reported committing at least half oftheir time to research activities, but only39% (317) devoted at least three-quartersof their time; 19% (155) reportedspending one-quarter or less (Figure 2A).

Interestingly, even though the vastmajority of trainees completed their PhDstudies in basic biomedical orengineering disciplines, 736 alumni of 14programs gave a variety of answers to aquestion about the kinds of research thatthey do. The choices provided were basic,translational, clinical, and health services.More than one answer was allowed, andmore than one was commonly given.Although relatively few programgraduates were engaged in health servicesresearch at the time of the survey, nearlyequal numbers reported doing basic,translational, and clinical research(Figure 2B).

Information about research funding wasavailable for 1,120 alumni of 17 programswho were in academia. Of these, at least685 (61%) had funding; 154 (14%) saidthat they did not. Of the 281 (25%) forwhom no data were available, nearly half(131, or 12%) reported research activitiesand may have had research support thatwas not reported, which means that thecorrect proportion of those in academiawho have research funding may be asmuch as 73% (61% plus 12%). Note thatmany of the individuals working atinstitutes or in industry would also beexpected to be doing research, but theywere not included in this analysis, so theoverall percentage of alumni doingresearch may be even higher thansuggested by our analysis of those inacademia.

Trends over time

As noted above, our data show that mostMD–PhD graduates enter academia and

Figure 1 Relationships among MD–PhD program size, time to degree, attrition rates, and the percentage of trainees who are women. (A) Therelationship between program size in academic year (AY) 2008 and time to degree for students entering in AY1998–2007 using data from 23 MD–PhD programs (r2 � 0.018). (B) The relationship between program size in AY2008 and attrition rate over the period from AY1998 to AY2007 usingdata from 24 programs (r2 � 0.034). (C) The proportion of trainees in AY2008 who are women and the attrition rate over the period from 1998 to2007 using data from 24 programs (r2 � 0.043).

Table 1Primary Department of MD–PhDProgram Alumni in Academia*

Department

MD–PhD programalumniNo. (%)

Internal medicine 427 (26.3)...............................................................................................Pediatrics 203 (12.5)...............................................................................................Pathology 192 (11.8)...............................................................................................Neurology 153 (9.4)...............................................................................................Surgery 116 (7.2)...............................................................................................Psychiatry 85 (5.2)...............................................................................................Ophthalmology 61 (3.8)...............................................................................................Anesthesiology 50 (3.1)...............................................................................................Radiology 43 (2.7)...............................................................................................Dermatology 43 (2.7)...............................................................................................Radiation oncology 24 (1.5)...............................................................................................Obstetrics–gynecology 19 (1.2)...............................................................................................Emergency medicine 7 (0.4)...............................................................................................Physical medicine andrehabilitation

5 (0.3)

...............................................................................................Nonclinical 175 (10.8)...............................................................................................Unknown 18 (1.1)...............................................................................................

Total 1,621 (100.0)

* Summary of data provided by 22 MD–PhD programson 1,621 alumni, each of whom had completedpostgraduate training and was employed full-time inacademia at the time that the survey data werecollected in 2007–2008. “Surgery” includes all ofthe related disciplines. “Nonclinical” includes, but isnot limited to, basic science departments.

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have their primary appointment in aclinical department. The choices thatsenior students make for their next stepafter graduation strongly affect wherethey are likely to end up and may affectthe likelihood that they will choose andsucceed in a research-oriented career.Table 2 summarizes the choices made by939 recent graduates of 21 programs. Ofthese, 892 (95%) chose to continue theirclinical training. Only 47 (5%) elected todo a postdoctoral fellowship withoutpostgraduate clinical training. Amongthose opting for a residency, internalmedicine was the most popular choice(270, or 29%), and, collectively, internalmedicine plus pediatrics, pathology, andneurology accounted for 518 (55%)recent graduates. The next most popularchoice was surgery (107, or 11%), acategory that combines all of the surgery-related disciplines.

Irrespective of their choice of residency,the vast majority of the alumni includedin Table 2 completed their PhD trainingin a biomedical laboratory discipline. Itis interesting to compare the residencychoices of the whole group with thechoices made by the small number (21)of recent graduates in the survey who didtheir PhD training in anthropology,demography, English, epidemiology,health policy, history of science, or publichealth. In this group, internal medicinewas overwhelmingly the most popularchoice, with 62% (13) choosing itcompared with 29% (Table 2) in the totalpool of recent graduates.

For an analysis of changes over time, wedivided the data on program alumni intoarbitrary cohorts of approximately 10years based on graduation year. Severaltrends were evident. The percentage ofgraduates choosing to forgo a residencyin favor of a postdoctoral fellowship,which has never been a common choice,has declined to 4% to 5% (Figure 3A).

There has also been a decline in thenumber of graduates choosingresidencies in internal medicine,neurology, pathology, and pediatrics—disciplines that have historically provideda protected environment for thedevelopment of physician–scientistcareers—and an increase in thoseselecting dermatology, ophthalmology,radiation oncology, and surgery (Figure3B). Others have noted similar trends inresidency choice by all medical schoolgraduates.9 –11

Is choice of residency field predictive ofwhether MD–PhD program graduateswill stay on track to becomeinvestigators or enter private practice?In Table 3, we present the outcomesdata for 1,862 alumni of 22 programswho had completed all phases ofpostgraduate training, askingretrospectively whether those whochose clinical training in a particularfield eventually ended up in privatepractice. There was considerablevariability: 8% of pathology graduatesended up in private practice comparedwith 62% of those who completedfamily medicine residencies. Overall,14% (165 of 1,220) of graduates whochose residencies in internal medicine,neurology, pediatrics, or pathologyended up in private practice, comparedwith 36% (120 of 338) of graduateswho chose dermatology,ophthalmology, or surgery (three of thefour areas noted above as showing anincrease in popularity).

Table 2Residency Choice of Recent MD–PhDAlumni Still in Training*

Department

MD–PhD alumniin training

No. (%)

Internal medicine 270 (28.8)...............................................................................................Surgery 107 (11.4)...............................................................................................Pediatrics 98 (10.4)...............................................................................................Pathology 79 (8.4)...............................................................................................Neurology 71 (7.6)...............................................................................................Radiology 61 (6.5)...............................................................................................Psychiatry 54 (5.8)...............................................................................................Dermatology 51 (5.4)...............................................................................................Radiation oncology 32 (3.4)...............................................................................................Ophthalmology 33 (3.5)...............................................................................................Anesthesiology 19 (2.0)...............................................................................................Obstetrics–gynecology 10 (1.1)...............................................................................................Emergency medicine 7 (0.7)...............................................................................................Postdoctoral trainingwithout residency

47 (5.0)

...............................................................................................Total 939 (100.0)

* Summary of data provided by 21 MD–PhD programson 939 recent graduates who were still inpostgraduate training at the time that the surveydata were collected in 2007–2008.

Figure 2 MD–PhD program graduates’ responses to questions about their recent research activities. (A) How much time do you devote to research?Responses from 814 alumni of 16 programs who are now in academia. (B) Which kinds of research do you do? Data from 736 alumni of 14programs; more than one answer was allowed.

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Figure 3 Emerging trends in choices made by MD–PhD program alumni and in the length of time required to graduate from MD–PhD programs. (A)Trends in the choice to do a postdoctoral research fellowship and forego doing a residency. Analysis drawn from data on 3,172 alumni from 23programs divided into cohorts: 1965–1978 (n � 144), 1979–1988 (n � 551), 1989–1998 (n � 1,160), and 1999–2007 (1,317). (B) Trends inchoosing a residency in internal medicine, neurology, pathology, or pediatrics compared with choosing a residency in dermatology, ophthalmology,radiation oncology, or surgery. Analysis drawn from data on 3,172 alumni from 23 programs divided into cohorts as shown in (A). (C) Trends inhaving a primary appointment in a basic science department. Analysis drawn from data provided by 22 programs divided into cohorts: 1965–1978(n � 97), 1979–1988 (n � 383), 1989–1998 (n � 820), and 1999–2007 (n � 306). (D) Trends in choosing a career in academia, a research institute,industry, or private practice. Analysis drawn from data provided by 22 programs divided into cohorts: 1965–1978 (n � 163), 1979–1988 (n � 601),1989–1998 (n � 1,198), and 1999–2007 (n � 306). (E) Average time to graduation. Trainees who graduated between 1998 and 2007 from theprograms included in the present study required an average of 7.8 years (weighted) to complete both degrees. The data from studies completed in1980, 1985, and 1995 are from the National Institute of General Medical Sciences.4

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An additional trend that emerged shows asteady decline in the proportion ofgraduates working in academia whoseprimary appointment is in a basic sciencedepartment (Figure 3C). Overall,however, the proportion of graduateschoosing careers in academia, researchinstitutes, or industry has changed littleover almost 50 years (Figure 3D).

Finally, we asked whether there has beena change in the time required to completeboth degrees over the years that MD–PhD programs have been in existence. Asnoted above, the unweighted averagetime for graduates in AY1998 –2007 wasnearly 8 years, which represents asubstantial increase from the 6.6 yearsnoted in 19804 (Figure 3E).

Discussion

MD–PhD programs have expandedgreatly in size and have become nearlyubiquitous since their beginnings about50 years ago at a handful of medicalschools. However, the number ofapplicants to these programs each yearremains a small fraction of those applyingto medical school, and the number ofMD–PhD graduates remains a small

fraction of total medical schoolgraduates. In 2007, there were only 1,721applicants to MD–PhD programs, whichrepresents about 4% of total medicalschool candidates. Of these 1,721individuals, 536 matriculated.12

As program numbers increased, someschools and groups of schools madeefforts to analyze the careers of theirgraduates.5,6,13,14 In 1998, NIGMS madeavailable some of the outcomes data thathad been reported by MSTP-fundedinstitutions as part of their training grantrenewals.4 The results of these studiesshowed, much as we have found, that themajority of MD–PhD graduates are inacademia. However, none of the previousstudies are recent, and none of themaddress recent trends. Although an all-encompassing prospective database aboutMD–PhD program graduates would beuseful, none currently exists.

In an effort to obtain a snapshot within areasonable length of time, we asked the24 participating programs to provideinformation that they had alreadycollected. As a result, not all programscould answer all questions about allalumni, a recognized limitation of the

data. Nonetheless, a number of theresults that we obtained are in goodagreement with those from the earlierstudies cited above. Given the size of thesample, our conclusions are likely to beapplicable to MD–PhD programs as awhole and especially to those programswith NIGMS MSTP funding, nearly half(20 of 42) of which were included in oursurvey. To what extent this heavy relianceon data from programs with MSTPgrants has affected the results will remainunclear until a fully inclusive MD–PhDprogram graduates database—such as theone under consideration by theAssociation of American MedicalColleges (AAMC)—is launched. Untilthen, important questions aboutcomparative outcomes between programsthat receive MSTP support and those thatdo not will have to wait.

Nevertheless, we can draw several clearconclusions from the data that areavailable. The first is that most MD–PhDprogram graduates (80%) are in careersgenerally consistent with the goal of MD–PhD training, which is to train physicianswho are committed to the quest for newknowledge and new approaches todisease diagnosis, prevention, andtreatment. This number is essentially thesame as the 81% of 2000 –2006 MD–PhDgraduates who reported in the AAMCgraduation survey that they plannedsubstantial career involvement inresearch.9 Approximately 67% are inacademia, a number that is alsoremarkably similar to what has beenreported previously.4,6,13,14

A second conclusion is that most (82%)of the program graduates at academicmedical centers are doing research andhave funding to support their efforts.Presumably at least as many of thegraduates at research institutes such asthe NIH are doing research as well. Thedata, however, also clearly show that therange of career choices among MD–PhDprogram graduates is very broad withrespect to both research interests andtime spent on research. This diversity isnot currently reflected in the curriculumdesign and admissions policies of MD–PhD programs, which typically focus onthe recruitment and training of benchscientists. The unstated assumption isthat if MD–PhD graduates start inlaboratory-based research, that is whatthey will continue to do—an assumptionthat is challenged by the number of

Table 3Residency Choice as a Predictor of Eventually Choosing Private Practice*

MD–PhD program alumni

DepartmentTotal

no.No. in private

practice% in private

practice

Family medicine 13 8 62.........................................................................................................................................................................................................Emergency medicine 13 6 46.........................................................................................................................................................................................................Dermatology 70 31 44.........................................................................................................................................................................................................Ophthalmology 101 44 44.........................................................................................................................................................................................................Radiology 69 28 41.........................................................................................................................................................................................................Obstetrics–gynecology 26 8 31.........................................................................................................................................................................................................Surgery 167 45 27.........................................................................................................................................................................................................Anesthesiology 57 13 23.........................................................................................................................................................................................................Physical medicine and rehabilitation 5 1 20.........................................................................................................................................................................................................Internal medicine 578 93 16.........................................................................................................................................................................................................Radiation oncology 27 4 15.........................................................................................................................................................................................................Neurology 173 23 13.........................................................................................................................................................................................................Pediatrics 243 32 13.........................................................................................................................................................................................................Psychiatry 94 11 12.........................................................................................................................................................................................................Pathology 226 17 8

* Summary of data provided by 22 MD–PhD programs on 1,862 alumni, each of whom had completedpostgraduate training at the time of this study in 2007–2008. Note that overall, 16% of the alumni who hadcompleted training were in private practice at the time that the survey data were collected. The columns indicatethe total number of alumni who completed a residency in each department and the number of those whosubsequently entered private practice. The percentage for each department is the number who entered privatepractice divided by the total number who completed a residency in that department.

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graduates who have decided to dotranslational and clinical research. Theskill set needed to conduct well-designedresearch in humans is simply notaddressed in most graduate schooltraining programs.

Although there are no standard criteriato identify a physician–scientist, giventhe complexity of modern researchmany of us advise our students andprospective students that they will needto spend 75% to 80% of their time onresearch-related activities, leaving theremaining time for clinical care,teaching, and other activities that willhopefully integrate well with theirresearch interests. However, our studydata show that if the designationphysician–scientist is limited to thosewho spend at least 75% of their time onresearch-related activities, then manyMD–PhD graduates fit this definition,but many do not (Figure 2A).

A third conclusion is that recentconcerns that the dropout rate fromMD–PhD programs is very high andthat many of those who stay in theprogram until the end enter privatepractice are not justified by the data.We found that most MD–PhD studentscomplete the program, and mostalumni are not in private practice. Theaverage attrition rate of students whoentered programs in AY1998 –2007 was10%, very similar to the 12% reportedby Fang and Meyer15 for MSTP-fundedtrainees who matriculated between1980 and 1988, but considerably lowerthan the 29% that was reported in 2008by Andriole and colleagues.9 Theattrition rate varied from 3% to 34%among the schools in this study, avariation that deserves closer scrutinyto establish cause. Our study does notdirectly address gender differencesregarding attrition—whether womenare less likely than men to persist in aphysician–scientist career.9,16,17 Genderwas not included in the informationsupplied on each trainee. At theprogram level, however, we did not finda correlation between the percentage oftrainees who are women and theattrition rate from the program.

Overall, we found that 16% of the MD–PhD alumni who completedpostgraduate training eventually enteredprivate practice, a number that is largerthan one might hope but is perhaps

unsurprising given the challenges ofpredicting what a 21-year-old applicantwill actually do when he or she is 30 to 40years old. A retrospective analysis doessuggest that some choices of a clinicalfield for residency are more likely thanothers to lead to a career in privatepractice (Table 3), but given the mannerof data collection, we cannot determinewhether graduates chose to enter privatepractice as a consequence of theirresidency choice or whether the choice ofa residency was a consequence of adecision not to pursue a career inresearch. We note that graduates of threeof the fields that have shown recent gainsin popularity (dermatology,ophthalmology, and surgery) had higher-than-average rates of going into privatepractice. But it is equally important tonote that at least some of the alumni whochose those fields eschewed privatepractice and reported performing fundedresearch.

A final conclusion from the data is thatMD–PhD program graduates pursue abroad range of types of research, perhapsreflecting their training in both scienceand medicine as well as their originalgoals when choosing to apply to MD–PhD programs. Our survey shows thatinstead of becoming basic scientists withonly a distant memory of their medicaltraining, many MD–PhD programgraduates are conducting translationaland patient-oriented research as well asbasic research. In keeping with this trend,discussions at the annual meetings ofprogram directors and administratorssuggest that many MD–PhD programsare paying increased attention to the needfor their students to be trained (or at leastexposed) to the skills needed fortranslational and clinical research. Oursurvey did not address the question ofwhether MD–PhD trainees receive theformal training in the design andimplementation of human studies thatis increasingly being viewed as essentialfor clinical investigators. Although thetraining they receive in the scientificmethod will be helpful, if MD–PhDgraduates are to be successful in thisrealm as well as in the laboratory,additional thought should be given towhat they will need to know and whenthey should learn it. Timing isespecially important given the need toresist making a lengthy trainingprogram even longer.

Alternative paths to research careers

If MD–PhD programs are to be viewed asan experiment in training physician–investigators, then what is theappropriate comparison group? Mostmedical students are not planningresearch careers, so using all medicalstudents as a control group is notespecially helpful. In considering asmaller group, the subset of physicianswho apply for NIH grants, Dickler andcolleagues18 reported that MDs whobecome investigators are less successfulthan MD–PhDs and PhDs in obtaining afirst NIH research project grant (R01)and, if funded once, are less likely toreceive a subsequent R01. They are alsomore likely to do clinical rather thanbasic research. There has also been adecrease in MDs serving on NIH studysections.19

All of this makes perfect sense ifsuccessful MD–PhD program candidatesare viewed as individuals who have gonethrough a rigorous vetting process thatemphasizes early research experience andcommitment as well as academicexcellence. It does not mean thatattending an MD–PhD program is theonly way to become a physician–scientist.From our experience as programdirectors, we have found that MD–PhDprograms are particularly well suited toindividuals who decide early enough intheir college careers that they have acommitment to discovery in medicineand are fortunate enough to receiveguidance that includes information aboutphysician–scientist training programs.There will always be a need for alternativepathways to capture the “late bloomers”because there are not currently (andlikely never will be) enough MD–PhDprogram graduates to maintain the ranksof active physician–scientists. However,in general, avoiding an MD–PhDprogram is not a strategy that shortensthe time to an independent career, eventaking into account the rising time tograduation that we noted for suchprograms. The average age at first R01was the same (43 years) for both MDsand MD–PhDs in 2007.20 This suggeststhat if one intends to be aphysician–scientist at the time of entry tomedical school, skipping graduate schoolwill not save time—presumably becausean independent research career requiresan extended period of mentored researchtraining, whether it is completed duringmedical school or after residency.

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Research careers require researchtraining, which is not usually part of themedical school curriculum. Onealternative path is offered by the HowardHughes Medical Institute-sponsored NIHCloister Program, which participantstypically complete after their third year ofmedical school. Fang and Meyer15 foundthat participants in the Cloister Programwere more likely to hold research-oriented faculty positions at medicalschools than were unsuccessful applicantsto the program, but they were less likelyto hold such positions than were thegraduates of MSTP-funded programs.Other alternative pathways includeobtaining mentored research training oreven attending graduate school aftercompleting postgraduate clinical training.Our anecdotal impression is that fewerare choosing these last two alternatives, atleast as a means to move toward anindependent laboratory-based researchcareer. Currently, most of those whosegoal is to focus exclusively on patient-oriented rather than basic research obtainthe required clinical research trainingpostresidency, usually in programs thatlead to a master’s degree rather than aPhD.

Trends over time

We observed several notable trends in thedata on program alumni. The proportionof graduates that choose to foregoresidency training has always beenrelatively small. It seems to be decliningfurther, as is the proportion of alumniworking in academia with their primaryappointment in a nonclinical department(Figure 3C). The decline in primary basicscience appointments occurred during aperiod that saw a large growth in both thefaculty size21 and the research portfoliosof clinical departments. One mightspeculate that clinical department chairsview MD–PhD investigators as a safer betthan investigators with a PhD but noMD—individuals with an MD–PhD canpotentially generate clinical revenues;those with a PhD cannot. The increase inprimary appointments in clinicaldepartments may also speak to thecommitment of MD–PhD graduates topursue disease-related research that findsa more comfortable home in clinicaldepartments. This would be consistentwith the high percentage of alumni whoreport involvement in translational andclinical research (Figure 2B). A shift ofphysician–scientists to clinicaldepartments was also noted in 2000 by

Zemlo and colleagues.19 Nonetheless, arecent survey of clinical departmentchairs still reported a large number ofvacant positions for physician–investigators able to do clinicalresearch.22

The distribution among clinical fieldschosen by MD–PhD program graduateshas also gradually changed over the past50 years. Like Andriole and colleagues,9

we found that the proportion choosinginternal medicine, neurology, pathology,and pediatrics has declined, whereasthose choosing fields such asdermatology, ophthalmology, radiationoncology, and surgery has increased(Figure 3B). In other words, more of therecent graduates of MD–PhD programsare choosing clinical training indisciplines outside those that havehistorically been the most willing toprovide the large amounts of protectedtime required to do meaningful research.To the extent that residency choice is apredictor of which department MD–PhDprogram graduates eventually join, areview performed 20 years from now islikely to find that a far broader range ofclinical departments have become the“home” for MD–PhD program alumni. Ifso, then the critical question is, what willthey be doing in those departments?

Although the reasons underlying thisshift can be debated, the change mayresult in either a continued positiveoutcome (i.e., a wonderful opportunityto extend inquiry into new fields) or avery undesirable outcome (i.e., moreinvestigators leaking out of the pipeline).It is too soon to tell, but, as we alreadynoted, the data from this retrospectivestudy clearly show that graduates of someresidency fields have been far more likelythan others to eventually become privatepractitioners (Table 3). Private practicefits nobody’s definition of a desirableoutcome for MD–PhD program alumni.In 2007, Ahn and colleagues23 reportedon the attitudes and career intentions ofcurrent trainees; Andriole andcolleagues’9 similar survey followed.These studies differ from ours in theirfocus on career intentions rather thanactual career choices, but it is worrisomethat, if true, their survey data raisequestions about some trainees’commitment to research careers.9,23,24 IfMD–PhD programs continue to expand,admission of candidates who lack astrong commitment is clearly an area that

requires continuing attention byindividual program leaders, and effortsshould be directed toward both theselection and the nurturing of trainees.

Finally, the time required to complete anMD–PhD program is increasing, a trendthat bodes ill for reversing the ever-increasing age at first facultyappointment and first R01.2 The averagetime to graduation has risen from 6.6years4 to 7.8 years (weighted by programsize) since the early years of MD–PhDtraining programs, which is an 18%increase (Figure 3E). This trend may inpart reflect the increasing demands ofmedical education. If so, some thoughtshould be given to the educationrequirements of physician–scientistsversus those who will become full-timeclinicians. Some of the upward trend mayalso reflect increasing trainingrequirements for PhD students25 and adiminished willingness to cross-countcredits for work done toward eachdegree. Data to substantiate thesepossibilities were not obtained for thisstudy but need to be collected in the nearfuture. Because graduates of MD–PhDprogram typically complete six or moreyears of postgraduate training, they havea long additional training period beforetheir first faculty appointment. If anunacceptable total duration of training isto be avoided, more attention must bepaid to the requirements at each phase oftraining that contribute to the whole. Toooften, each step on this path toindependence is overseen by a differentorganization or certification group, andthese groups rarely communicate witheach other. For this reason and others, itis easy to argue for much better verticalintegration in the training of physician–scientists. A call to make this and otherchanges is part of a recent report fromthe Association of Professors ofMedicine.26

Limitations of this study

This study is the largest of its kind todate. It is not, however, withoutlimitations arising from the method usedto collect the data, and we would like topoint some of those out. The studyincludes data from only 24 programs,albeit ones that included 40% of the MD–PhD trainees in the United States at thetime of the survey. The programs varywidely in size and location, but 20 of theparticipating programs had NIGMSMSTP grants at the time of data

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collection, and, as already noted, resultsfrom the MSTP-supported programs mayprove to be different in meaningful waysfrom the large number of programs thathave not yet benefited from NIH support.These differences may prove to be quiteimportant when assessing theperformance of individual programs, butthey may not change the aggregateanalysis by much. MSTP-supportedprograms tend to be larger on averagethan those without MSTP support. Thefour smallest programs in this studyenrolled only 31 to 34 trainees and had 36to 71 alumni at the time of the study. Incontrast, even the four smallest of the NIH-supported programs had more trainees(52–66) and more alumni (60–133).

It is also worth emphasizing that thedata on MD–PhD alumni wereprovided to us by the programs and notdirectly by the alumni. Some programsdid not include all alumni, and becausethis was not a prospective survey, notevery question was asked by everyprogram when they last surveyed theiralumni. However, it is somewhatreassuring that essentially identicalresults were obtained when our analysisof outcomes was limited to just thoseprograms that submitted data on morethan 98% of their alumni.

Conclusions

In summary, this study shows that manyMD–PhD program graduates are stayingon the physician–investigator careertrack. It provides an interim response to arecent call7 for evidence that MD–PhDprograms accomplish their mission:Clearly, they can and do. However,looking beyond the very positiveconclusions driven by the aggregateanalysis, the data collected in this surveyalso show that the range of eventualprofessional “phenotypes” of programgraduates is very broad. It is thereforeentirely legitimate to ask whether all ofthese phenotypes are consistent with thecurrently espoused goals of MD–PhDtraining. Recognition of this point willhopefully prompt further debate.Whatever the outcome of those much-needed debates, continued attention willneed to be paid to the selection of themost appropriate candidates, thementoring and training of matriculants,and the care of program graduates as theytraverse the challenging divide betweengraduation and independence.

Dr. Brass is professor, Department of Medicine andDepartment of Pharmacology, University ofPennsylvania School of Medicine, Philadelphia,Pennsylvania, where he directs the MD–PhDprogram. He was 2007 chair, MD–PhD Section,Association of American Medical Colleges Group onGraduate Research, Education, and Training (AAMCGREAT Group).

Dr. Akabas is professor, Department of Physiologyand Biophysics, Albert Einstein College of Medicine,Yeshiva University, Bronx, New York, where hedirects the MD–PhD program. He is co-chair, Dataand Analysis Committee, MD–PhD Section, AAMCGREAT Group.

Ms. Burnley is director, Administration andFinance, Harvard–Massachusetts Institute ofTechnology Combined MD–PhD Program, HarvardMedical School, Boston, Massachusetts. She is co-chair, Data and Analysis Committee, MD–PhDSection, AAMC GREAT Group.

Dr. Engman is professor, Department ofPathology, Northwestern University, Feinberg Schoolof Medicine, Chicago, Illinois, where he directs theMD–PhD program. He was 2008 chair, MD–PhDSection, AAMC GREAT Group.

Dr. Wiley is professor, Department of Pathology,University of Pittsburgh School of Medicine,Pittsburgh, Pennsylvania, where he directs the MD–PhD program. He was 2009 chair, MD–PhD Section,AAMC GREAT Group.

Dr. Andersen is professor, Department ofPhysiology and Biophysics, Weill Cornell MedicalCollege, Cornell University, New York, New York,where he directs the MD–PhD program. He was2005 chair, MD–PhD Section, AAMC GREAT Group.

Acknowledgments: The authors thank the MD–PhD program directors and administrators whoprovided data for this survey.

Funding/Support: None.

Other disclosures: None.

Ethical approval: Not applicable.

Disclaimer: This study was performed with thesupport of the leadership of the NationalAssociation of MD–PhD Programs and theAssociation of American Medical Colleges Groupon Graduate Research, Education, and Training(GREAT Group) Section on MD–PhD Programs.However, the views expressed are those of theauthors alone and do not necessarily reflect thoseof either organization.

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Schools. Available at: https://services.aamc.org/publications/index.cfm?fuseaction�Product.displayForm&prd_id�211&cfid�1&cftoken�8A91BEF8-B9BB-BF89-888382FD9D06C5DD.Accessed December 13, 2009.

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Correction

In the article by Shomaker1 in the February issue of Academic Medicine, there was a mistake regarding the number of schoolsthat have received full accreditation from the Caribbean Accreditation Authority for Education in Medicine and Other HealthProfessions (CAAM-HP). There was also a mistake regarding the accreditation status of Ross University and St. George’sUniversity medical schools as accorded by CAAM-HP.

To date, there is only one medical school that has received full accreditation from the CAAM-HP. The CAAM-HP accorded thestatus of Accredited to the medical programs of Ross University’s and St. George’s University’s medical schools, not FullAccreditation. These schools were accredited for four years with conditions.

Full accreditation is granted without conditions for five to seven years, depending on the length of the program.

Reference

1 Shomaker TS. For-Profit undergraduate medical education: Back to the future? Acad Med. 2010; 85:363–369.

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