Tuesday, June 12, 2012

The effects of "score creep". Trends in residency selection criteria

Every other year the National Resident Matching Program (NRMP) publishes a document called Charting Outcomes in the Match. This is accessible through http://www.nrmp.org/data/index.html. The document analyzes many datapoints of interest to medical students, medical schools, and residency programs. For example, many senior medical students look at the average step 1 and step 2 scores, number of research experiences, and number of programs needed to rank to feel comfortable matching. These indicators are all reported by individual specialty. 

A discussion on SDN sparked an interesting debate and analysis about the results of score creep on MD/PhDs. 

As I have written previously, clinical indicators of performance such as step 1 and step 2 scores are those most important for obtaining a residency position. Score creep is the effect that many MD/PhDs observe during their 7-9 year MD/PhD programs, where residencies seem to get more competitive each year through the long program.

To evaluate whether this "score creep" truly exists, I performed an analysis of markers of competition within Charting Outcomes in the Match over the time period since the beginning of Charting Outcomes analysis of 2005 residency match data to the most recent publication in 2011. I found dramatic evidence for this effect, as shown below.

After discussion with one of several program faculty who posts frequently on SDN, we decided to write a manuscript and publish this data to demonstrate two things. First, we wanted to show that residencies are overall becoming more competitive over time. This is likely due to expansion of medical schools and class sizes, especially osteopathic, with a relatively unchanged number of residency positions. I also personally believe that almost everyone believes step 1 is the single most important factor in residency selection. Thus, Step 1 specific preparation seems to increase every year--with regards to increased enrollment in question banks and other formal review courses, amount of time allotted by the medical schools to allow students to take off to study for the exam, and cirricula revisions to focus more on Step 1 material. I think this creates an artificial distraction from the true goals of medical education for the single purpose of creating a benchmark of competition that most would argue has little reflection of a medical student's future potential as a physician.

Second, our editorial position is that the "score creep" is a problem particularly for MD/PhDs. That is, MD/PhDs take the step 1 exam after second year yet compete with medical students for residency after a four year delay (the PhD). Thus, the MD/PhD student's score may not be as impressive when they graduate. Further, advising at the time of taking the step 1 may not be current by the time of graduation. For example, our MD/PhD program director frequently told us that step 1 score was unimportant as long as we passed. As I have written about previously, this is completely untrue. But this probably was reasonably true until about 10 years ago.

I submitted the following manuscript to three journals and had little luck with it. The first journal returned it without review. The second diplomatically declined to publish it as it was not felt to be relevant to residency programs. The third journal took six months to send back a review that was so off-topic I think they may have sent me the review to someone else's manuscript. Still, I think this data is important and relevant to the pre-medical community. It is self-published below.

There are a few benefits to self-publication. First, I can put all the figures in color. Second, I made a supplemental section with additional figures to show all of the data from Charting Outcomes for matched US seniors. See the very bottom for the supplement.

Saturday, January 2, 2010

Decoding MD/PhD match lists

Every year the National Residency Matching Program (NRMP) publishes a "Charting Outcomes in the Match" summary on their website about matching trends. Here is the 2009 version:

Comparing MD/PhD match outcomes from 2007 to 2009 gives the following information.

Charting outcomes 2007:
Total # of MD/PhD students: 563
Total # of unmatched MD/PhD students: 32

Charting outcomes 2009:
Total # of MD/PhD students: 624
Total # of unmatched MD/PhD students: 51

In just two years the number of unmatched MD/PhD students increased more than 50%. How would anyone know this is the case? How would anyone know that MD/PhD students fail to match at all? Certainly, there has been a culture within the MD/PhD world that MD/PhD students have no difficulty matching with matching. This is completely incorrect in my experience as a student, but nobody is talking about it. I want to tell you about how programs hide their non-matchers in various ways. So here's a quick guide to:

MD/PhDs don't match?! Decoding MD/PhD match lists.

"From my own experience (and others at my MSTP program), "Post-doc" is code for "did not match" in most cases." -- calvinNhobbes

This has been true from what I've seen as well. Post-doc seems to mean all kinds of things, including the one "post-doc" on the match list who went straight into industry. In my sixth year, four graduating MD/PhDs failed to match, but nobody outside the senior student circle and the program adminstration would ever know.

Besides the all meaning "post-doc", be suspicious of any preliminary (internship) year only matches. Preliminary only matches can be due to a few legitimate reasons such as deciding on a specialty too late or a student changing their mind about specialty during the application process. These situations are very rare. Typically, any MD/PhD in a preliminary year only did not get a spot in a categorical residency.

Similarly, be highly suspicious of medicine or surgery matches to no-name community places. It might be a preliminary match, and some programs don't want to admit their student didn't match to a categorical program. So the student is listed as a medicine or surgery match to make it look like a categorical spot. When a categorical match was not achieved, an honest program will simply list their prelim match with a clear preliminary denotation.

For example:
Let's say I apply in radiology, which requires a standalone internship year. Let's say I apply separately for transitional years. Now what might happen to me:

I may ONLY get the transitional internship but not radiology. How will a program list me on the match list? Transitional Year if at all. Maybe with a "planning to apply in radiology" caveat.

I may ONLY get radiology position and not an internship. In this case I would likely scramble into a nightmarish surgical prelim. The prelim may not even be listed.

I may get NEITHER. In this case, I may elect to scramble into a nightmarish surgical prelim and reapply. This will likely be listed on the match list as surgery or surgery (prelim). Or perhaps I take a year off and decide to reevaluate life. This might be listed as post-doc. Or I might be left off the match list for that year entirely.

Here is another example:
Let's say I apply in radiation oncology, which requires an additional, typically separate, internship year.

Now radiation oncology is extremely competitive. Many will say to apply to medicine programs as a backup specialty since it is much less competitive. If I fail to match radiation oncology, my match will be listed as medicine, and you will never know I applied to radiation oncology at all. The difference in competition is so great, one could easily match a strong academic medicine program and not match into radiation oncology at all.

So maybe I am confident or can not come up with a backup plan, so I apply only to radiation oncology categorical programs and preliminary medicine internships. Then I only match to a preliminary medicine program. Some programs would list me on the match list as: internal medicine. Others would list me as Medicine (prelim) with nothing else specified. Analysis of match lists by one SDN expert has indicated that the number of internal medicine matches to community programs with easy preliminary year programs is increasing. It is assumed that these scenarios are driving this increase.

Unfortunately you would never know if a student had to take a less competitive specialty choice, go far down their rank list, not get interviews where they wanted to be at all, or just outright scramble. All of these issues are all far more common than I was led to believe when I began the MD/PhD program. It has been quite a surprise for me. The standard excuses I've heard from those who only peripherally know the person who didn't match have been:

1) "That student WANTED that residency at lower-tier academic program". Reality: usually far down rank list. Also possible: strong location preference if the location is not a big city.

2) "That student couldn't decide on a specialty." Reality: Didn't match categorical. Other possibilities: couldn't decide because they realized too late there's no way they'd get the competitive specialty they wanted, or couldn't decide because their curriculum gave them no time for fourth year electives.

3) "That student had personality issues." As much as I hear this one you'd think we're all demented freaks. Reality: Under 220 step I score and not AOA.

4) "That student didn't apply to enough programs/were overly cocky in programs applied to." The last student I heard this about applied to 30 programs and got interviewed at 3. See the *reality* for excuse #3.

The MD/PhD Trap

Caveat: The MD/PhD trap section is merely a guideline/thought process and should not be taken as gospel.

Academic programs in competitive specialties often have Step I cutoff scores for interview. Even if not a strict cutoff, step I scores, clinical grades, and LORs are examined closely. These factors are almost always far more important to programs than the research you have done. Thus even with a merely average medical school performance, you may not get the specialty you want.

It goes without saying that many programs will automatically cut students who have serious academic issues ranging from failing a course to failing a year to a bad LOR. I am not talking about these students with serious "red flags". What I mean is that to match to strong academic programs, you need to be a strong medical student in addition to having a solid PhD.

So MD/PhDs need to be strong medical students to match to competitive academic residency programs that have the research opportunities we need to persue academic careers. Conversely, MD/PhDs are essentially excluded from categorical community programs. These are the programs that usually match MD-only students with lower step scores and grades than the average for a specialty. These are your standard "backup" programs. But these programs know they don't have research to offer and assume an MD/PhD is going to go elsewhere. Even if an MD/PhD student tries to spin otherwise by downplaying their research experience, they will likely not be interviewed or match there. I've heard some stories of antagonistic interviewers along these lines--"What are you doing here? We don't have research!"--"Where else did you apply? You'd never come here." I've seen several applicants get burned either by thinking community would be a backup, or by applying to mostly community programs in some specific geographic region for family/relationship reasons.

Thus it is possible to be caught in the middle. If you have a merely average medical school performance, you will often be shut out of research heavy academic training programs for lack of competitive statistics such as step scores and AOA. Yet if you are an MD/PhD, the community programs don't want you. This is the trap which can lead to you not matching. If one wasn't so research-heavy there would be a chance to match community where your MD-only classmate with similar stats matched. But you can't match at those community programs. In these situations lower-tier academic is the best bet, but still risky.

Overall point

MD/PhD! Your ticket into top residencies anywhere!***

***Offer valid only in certain residency specialties. Offer not valid at community programs. Offer may only be used in conjunction with above average to excellent medical school performance. May not apply to residencies in competitive locations.

Anyone who tells you other than what I have told you here is lying to you. This may either be for recruiting purposes, or simply because that person is too junior to know the reality. They may have had an extremely strong application overall and assumed their PhD counted for more than it really did.

I am always amazed at how out of touch senior faculty are with this reality I am presenting to you. In general, your best source of information for applying to a specialty is the PD at a program that would seriously consider you or junior MD/PhD residents. The PDs at big name academic programs will set you up nicely for this trap. Since there isn't a lot of communication between programs, the PD at a top program will tell you to apply community and then come back there for fellowship. The PD at the community program will tell you that there's no way you should be at their program. Try it yourself.


When I look at my school's matchlist I can see examples of almost everything I talked about in this post. Four students failed to match recently and another student failed to match the following year. Though you wouldn't necessarily know it because one was left off the matchlist entirely and one scrambled into a prelim spot that was not listed as a prelim.

I don't know if what I've seen reflects an aberration or a rapidly progressing problem. I tend to think it's not an aberration given the posts here by this expert in MD/PhD residency outcomes:

Should I apply to community programs?

For the merely average MD/PhD student applying in a competitive specialty the question is: should I apply to community programs or risk not matching? Despite having an above average residency application and a very strong graduate school portfolio in the department, I was advised to apply to many community programs so I could match. This is advice received from several members of the department who do significant amounts of research. The reason being? "We only interview AOA or close to it." "You need a 99 step 1 score. Your 98 (240/98) will hurt you."

There are fine rationales for this. For example, residency is a clinical training time, not a research training time. One can then hopefully obtain an academic fellowship, though this is specialty dependent and the big name residency helps you do that. Still, advisors in highly academic programs don't realize the MD/PhD trap exists. MD/PhD faculty often don't review residency applications, and when they do they have often already been heavily filtered for clinical grades and step scores before they hit their desk.

Why should I care if you are cashing in your PhD for a shot at a lucrative clinical career?

This question bothers me on many levels. It assumes there is no research in competitive subspecialties. I did my PhD in a subspecialty department with a multi-R01 funded investigator. There are many examples of this across subspecialties where I trained. A member of my thesis committee was an anesthesiologist who performed 90% research. Conversely, many senior MD/PhD students do not plan on a research-based career for various reasons. In my experience they are just as likely to apply to traditional MD/PhD specialties such as internal medicine with the goal of subspecializing. In this case, the extra "suffering" of a fast-track residency seems appealing compared to an extra year of wards in a general medicine residency. But you won't meet these senior students when you interview at an MD/PhD program. I think the attitudes for the 6th year students were along a spectrum of "I don't know if I want to keep doing research" (most optimistic group, including myself) to "There's no way I want to keep doing research." Why would any of us come tell you bright eyed bushy tailed juniors about this? It just reflects badly on you. Everyone will assume there is something wrong with you personally, and the program will be unhappy with you.

In the end I think anyone who insists one should go only into particular specialties to do academics is extremely narrow minded. I know in the department where I did my PhD, there was an incredibly difficult process recruiting attendings. You could easily get an academic subspecialty faculty position as an attending. The problem is that nobody wanted to stay in academics, and instead went to private practice for drastically increased (3-fold) pay and vacation time.

The sad thing is that the MD/PhDs are most likely to continue in academics regardless. The vast majority of the MDs who claim to love academics based on their few months of research in fourth year will go right off into private practice. But, program directors in general don't care. As long as they get the residents who will produce the most clinically and get a little bit of clinical research out of them, everyone stays happy. It's bad for these fields in general to focus so much on step I scores and third year clinical grades, but nobody seems to care. 

What else can you tell me about how to get a good residency?

The advice at my program was consistently that one shouldn't worry about residency choice before the PhD. We were told that MD/PhDs all match extremely well and this wasn't an issue. The important things we were told was the mentor and the project in graduate school, and not to try to tailor your research to your residency. We were also told not to worry about step 1 score. This was BAD ADVICE.

My opinion is that you should tailor your PhD to your future residency. This helps not only to sell yourself later to residency programs, it also helps you to make connections in your field. In the long run, you come into residency already fairly well versed in some area of research within that specialty for which to launch your own research based career.

I wrote this entry because I want applicants and junior students to know about these things. The MD/PhD isn't a ticket into whatever specialty or residency program you want. Ignore advice to "pace yourself", "keep balance", and that you will "get whatever you want since you're MD/PhD, just don't fail." Yes, you need to maintain some work-life balance, but this is a topic for another day.

Fortunately, I realized fairly early that something was amiss in the usual MD/PhD advising. This is because I was drawn to a PhD in a competitive subspecialty department, and I realized that the clinical faculty who controlled the residency didn't care about my research. So this is not sour grapes on my part. Junior students will find out quickly that negative feedback comes back to you in bad ways. But I don't mind irking the senior community to help junior students.

In the end, for those looking for a rule of thumb on how best to get a strong residency: look at what your MD classmates are doing to match into your specialty of choice, especially at the big name academic programs. This includes everything from grades to LORs to step scores to electives and away rotations. Set yourself up to match to the top academic programs even if you didn't have that PhD.

Finally, one last story from SDN to drive home my point. 

Saturday, March 7, 2009

How long is an MD/PhD program anyway?

The meeting about the return

This past week I had an important meeting. It’s a meeting I’ve been looking forward to for years now--with both anticipation and anxiety. It’s the turning point; the light at the end of the tunnel for the mudphud. It’s the meeting for all the MD/PhDs returning to the clinics in the next few months. The room swelled with over 25 people, all in the same excited and anxious mood. The excitement comes from finally being done with graduate school.

Not everyone will come out with the same opinion of graduate school. My once very optimistic and outgoing MSTP friend calls graduate school “soul crushing”, for example. Our once weekly or more frequent meetings have slowed to about once every couple months as he struggles almost without sleep to get enough data for a single abstract after his project was scooped by someone in his own lab. While not every story is as extreme as his, almost nobody wants to stay in the lab for yet more time once they’ve been in for a few years. If anyone ever tells you that a MD/PhD wanted to stay in graduate school longer, point your finger in their face and call them a liar for me. Tell them Neuronix told you to do it.

Finally! Once you were never sure when you would be allowed to defend, when that last experiment would work, or whether that paper central to your thesis would ever get accepted. But that’s over now. There’s a direct timeline to graduation. Of course, things are never so simple for me. Before the meeting the program director tapped me on the shoulder and asked me to speak with him in private after the meeting. Would I really be finishing this year? How could I not know so close to the deadline? What do I mean my committee wouldn't come to a consensus about it? Didn't I already have many papers, presentations, a grant, etc? My committee still doesn't seem to want to let me finish?!? But that’s a story for a later time.

Still, there’s that nagging anxiety about returning to medical school. I remember every time we, as newbie 1st and 2nd years, used to ask a MD/PhD graduate if it was hard going to grad school, the response was almost invariably, “No. The hard part is coming back to medical school.” I mean, do you remember with minute detail what you learned 3,4,5 or more years ago? I spent 4 mornings during my entire PhD shadowing a physician—and that was a Radiologist in the reading room! Of course, I’m not the only one. During the meeting we heard advice from the Medicine clerkship and MD/PhD directors. The advice was surprisingly useful until the director joked—“If you don’t remember what Wegner’s or Goodpasture’s is, come see me after the meeting.” We all giggled nervously and whispered to one another. I think this was the intended effect. But, finally one of the students exclaimed “Wegman’s is a supermarket!” We burst into laughter.

As we sat there I thought about who was in attendance. We sat in clusters, those who had just become 6th years like me, 7th years, 8th years, and even a bunch of people I didn’t recognize. You see, if I return to the clinics this October, I will graduate in 7 years total. But looking around I realized that I am one of a lucky few. There are exactly 5 out of 16 students in my year who have a strong change of graduating in 7 years. Well… That’s a little bit unfair. One classmate took a year leave of absence. I’m strongly considering doing the same. One classmate dropped the PhD entirely in my year and another seems to be heading in the same direction. Still, there were far more students in that room who will graduate in 9 or more years than there was who will graduate in 7 years total. Or less?! I had never personally seen a 6 year student. 

Wait, so how long does the MD/PhD program take?
I write about this because it surprises me. When I applied, I remember asking every program what their average time to graduation was. Conventional wisdom was that a program should take 7-8 years. We heard some strange rumors about some programs that kept students for 9 or more years. We heard in person and on the forums that these students were rare and had serious personal problems, and these few bad programs that kept more than one were passed in whispers. The directors at those programs of course claimed any problems were “fixed” and that long graduation times were due to personal problems on behalf of the student. One even told me that one of his 9 year graduates stayed in graduate school because he didn’t want to leave (LIAR!). But when I asked what the average time to graduation was, most directors dodged the question or feigned ignorance. One big exception was when I asked the assistant MD/PhD director at URochester. Once he told me the average was 8.5 years there, I, in my typical insanity, asked him why it was so long at his school. The answer was, “We get a real PhD at URochester.” Please, evaluate this statement for yourself. My response got me a rejection letter that beat me home from the interview. 

Yet now I’ve come to realize that there are many 9 and even 10 year graduates. I’ve spoken to several personally and asked them if it was for personal reasons. The unanimous response has been—“No, I’ve been working my ass off!” The average time to graduation is trending upwards. If you average over the lifetime of the program, I was told when I applied that the average time to graduation here was 7.53 years. The reality is, that over the past 5 years the average is just shy of 8 years. In this batch graduating this year, I am certain from seeing the crop with my own eyes that the average graduation time will be well over 8 years. Shhh. Don’t tell anyone I told you all this. But it’s not just us. I wish I could tell you who some of the more knowledgeable forum posters are. One who would know this sort of thing informs us that nationally the average is up to about 8 years. In this thread http://forums.studentdoctor.net/showthread.php?t=534722 for example we learn that another school does similar things—posting an overall average of 7.3 years over the lifetime of the program, but they are also now up to 7.7 years over the past 5 years. So what was the national average time to graduation 20 years ago?

The average was as low as 6.8 just that long ago (in 1985)! So we are trending sharply upwards and there is no end in sight. 

Why does this matter?
This hurts us MD/PhDs in numerous ways:

1) The average time until a MD/PhD gets their first R01 grant is 43 years Physician-Scientist Training—Reply Ley, Rosenberg JAMA 295 (2006):623-4. For those of you who don’t know about grants, the R01 grant is essentially the grant you need to establish yourself as an independent investigator. At my school for example, word of mouth is that once you have 2 of these grants, you can be eligible for tenure. You have 7-10 years to accomplish this feat, at a rate of funding of about 10% depending on the institute. Good luck, ye who wants to be a basic scientist. At your mid 40s do you still want to be fighting for tenure—a stable job? Imagine, obtaining tenure at the age of 50, just in time to retire at 65. At face this seems silly—training for a lifetime for a job you spend less than two decades performing. How far will this timeline stretch as R01s get harder to get, residencies get longer, and MD/PhD programs get longer? We can already tack on a year to the 43 number because the MD/PhD programs themselves have gotten at least a year longer. 

2) Women feel this more than ever. In my opinion, long training times account for why there are more male MD/PhD students http://www.aamc.org/members/great/mdphd/presentations/garrisonhandout.pdf

Nationally, MD and PhD programs have equalized by gender and yet MD/PhD programs still have not. Everyone notes that training is a difficult time to have children due to time requirements of residency, graduate school, medical school, fellowship, etc etc etc. I think it’s a sad reflection on society that women still shoulder more of this burden than men, but regardless of that, such a long a grueling training time is a difficult time for families. Women also seem more likely in my limited experience to drop out of MD/PhD programs (does anyone have data on this?).

3) Does this long training time contribute to an increasing number of MD/PhDs not persuing basic science? The Hopkins website has some great pie charts on career choice by decade of their graduates-- http://www.hopkinsmedicine.org/mdphd/images2/Career_Trajectory.png. Note the upward trend of the private practice graduates (1995-1999 and beyond still has a sizeable percentage “In Training).

I want to move through my program as quickly as possible, what can I do?

So, what can you do individually to try to graduate in 7 years? A quick glance at the 5 MD/PhDs in my cohort who can graduate in 7 years reveals a simple truth. Here’s a list of the graduate programs the 7 year students are in by graduating student/# of students in that department in my year:

Economics – 1/1 Student

Pharmacology – 1/1 Student

Genomics (GCB) – 1/1 Student

Immunology – 1/? Students (I think we have 3?)

Biochemistry and Molecular Biophysics (BMB) – 1/2 (That’s the imaging guy in Biophysics by the way. The biochemist was the once cheerful fellow I was referring to earlier).

The most popular graduate programs at my school are Cell and Molecular Biology, Neuroscience, and Immunology. Hmmmmmm… So why are these atypical PhDs getting done sooner? Simple. BMB requires one course and lets you take the rest as electives. That’s a full year of classes at most, and you can cut that if you take a bunch of classes during med school. The same goes for Pharmacology. Economics PhDs seem to be mostly simulations and analysis of existing data, and there’s no publishing requirements. Genomics is a mixed bag, as can be imaging, but in general we always hear it’s easier to publish when you do those. I mean, I know one guy who got 3 publications and a PhD in 14 months from a Genomics lab with no prior experience. Let’s contrast this with one other graduate program for example, which at my school requires a full year of teaching undergrads (one course a semester), and more or less requires 2 years full time of classes. The graduate chair tells MD/PhD students openly you should expect it to be a 8-9 year program. The two dropouts in my year were both in that department.

So young student—choose your graduate department wisely. Nobody at the school is ever going to tell you teaching is a waste of time. How can they? They are faculty and their job is not particularly stable as it is. A big part of being faculty is politics! Well, I’ll stick my neck out for you and tell you—it’s a big waste of time. If you ask faculty at schools that don’t require teaching how they feel about teaching they will also tell you this. Besides, if you’re not required to teach, you’ll always have opportunities to teach for money. I’ve never seen a single MD/PhD take that money. But, from a departmental standpoint money from the NIH is getting tighter and someone needs to teach those courses… Hence the true motivation; let’s force the students to do it!

Now we should all recognize that two big parts of getting your PhD quickly, or even at all, is hard work and luck. But we’re talking about averages, so we’ll assume that students today aren’t lazier or have more problems than their earlier counterparts, and let’s talk some more about how to stack the deck in your favor. First, pick a PI who has had MD/PhD students before and moved them through in a reasonable amount of time. Ask them straight out—how do you feel about MD/PhD students? Many will be upfront—whether that means they don’t think MD/PhDs are real PhDs or they recognize the pressure we’re under. Then, grab a project that will likely yield data, and keep a few side projects going just in case. With money as tight as it is, it simply isn’t practical to flounder around for a few years trying to find a project that works like some hardcore old-time PhDs seem to feel is necessary. In many cases you need to produce data for your lab and yourself so it can stay afloat. Finally, be sure to stack your thesis committee with those who aren’t going to badger you and as many MD/PhDs as possible. Some projects, heck, most in molecular biology, are just freaking hard to do. They take a long time and are risky. You aren’t going to cure cancer in your PhD.

The cries are coming: "don’t listen to Neuronix!"

Now the more hardcore among us will flame me into oblivion. What you’re describing isn’t a real PhD! This sort of lax attitude won’t get you the training you need to succeed! You will be undesirable to your future employers! To all this criticism, I have a simple reply: I’m not buying it. During your PhD, what you really want are skills so you can move on, thinking like a scientist (For a similar point of view, see: How to succeed in science: a concise guide for young biomedical scientists. Part I: taking the plunge, Yewdell, Nature Rev Mol Cell Bio, 9 (2008):413-6. 

Residency programs will want to see you published once—preferably in their area of specialization. Most are more concerned with Step I scores and clinical grades anyway. For Radiology, the 4th most popular MD/PhD specialty choice: Key criteria for selection of radiology residents: results of a national survey., Otero et al, Acad Radiol, 13 (2006):1155-64. Research intensive fellowships are practically begging for applicants, given the salary increase given by going into mostly clinical practices. Then when it’s time to be hired as an assistant professor, do you really think they’re going to scrutinize your PhD record? Did med school scrutinize your high school record? Will residency care about your undergrad record? Never forget that whole system is a “what have you done for me lately” system. Similarly, you likely won’t be working on the same thing in fellowship that you were for your PhD. You probably won’t even be in the same field. So what does all that extra toil do for you in the long run? 

This all leads me to advise you to get a PhD, get done, and get on with life. That is what every recent MD/PhD graduate has told me.

We have a problem, here's how I would fix it.
So how do we fix the system? This is where I’m going to get even more controversial. I think we should redefine what the PhD is. In my opinion, the rule of three publications to PhD is outdated and sets the student up to too much abuse and politics. It is simply getting harder to publish, especially in any reputable journal. Many projects don’t lend themselves to publishing quickly. Further, publication acceptions and rejections are often up to fickle and overly critical reviewers and political decisions. Everyone knows this is true and everyone says it is a normal part of research life. And still I have seen MD/PhD students held up because their third paper was not yet submitted for publication (http://drslounge.studentdoctor.net/showthread.php?t=280743)! And still this rule of three publications still remains in many cases. Why?! It benefits the lab PI and the department, but not you.

I propose we go to a four year fixed system. One year of classes and three years of full time research. You can complete it faster if you do manage to get your three papers quickly, but if you make satisfactory progress you’re done in four years by default. Does this hurt the integrity of the PhD? In my opinion no based on two factors:

First, many schools in Europe typically give PhDs in a shorter and often fixed amount of time. Yet, the percentage of publications worldwide are increasing from Europe while the percentage from America is decreasing: Biomedical publication—global profile and trend, Public Health, 117 (2003):274-80. If their training is so poor, how could this be so?

Second, there are many residency programs which now offer you a PhD. They typically claim to offer the PhD in 3-4 years. As a few examples:

Why does our PhD have to be longer? I’m not going to claim it would be easy to make this change. I just think it’s the right thing to do. Fortunately, I’m a student, and I can make these wild suggestions without actually having to implement them. Unfortunately, many graduate programs already view us as MD/MS students or that we don’t get a “real” PhD (whatever the **** that means), so making this happen is unlikely.

So, just how long is an MD/PhD program, anyhow? Count on it being 8 years, possibly 9. Eight years is the new average. If you get done in 7, the old norm, consider yourself lucky.

Saturday, June 14, 2008

A quick note on "balance"


When one works 80 hours a week, there is no time for anything else significant. There are 168 hours in a week. About 56 of those hours should be spent sleeping, leaving 112 hours. With 80 hours of work, one is down to 32 hours. That leaves 4.5 hours per day to do everything else you want to do in a day. If you figure a half hour for personal grooming, an hour for meals (prep/obtaining/eating), and 45 minutes for commuting, that leaves you 2 hours a day to wind down. It leaves you 2 hours for any hobbies you might have or businesses you need to conduct in those usually very oddly timed hours you’re left with. That’s just 14 hours a week for every other activity you might have in your life. In medicine we don’t expect this of you just for a year. This is most of your life. It’s a life almost completely dominated by work. And it’s a high stress life. It’s a life full of constant competitive examinations. It’s also a life where one bad exam, one battle chosen with the wrong person, can lead to all of your hard work going up in smoke.

MD/PhD students are usually told they should find “balance”--the balance between professional obligation and personal fulfillment. There is no balance at 80 hours of work per week. There’s no time for anything outside of work. In my mind, the entire concept of balance in this career has become laughable. For MD/PhDs, there’s just a MD curriculum that expects you to be top of your class while doing PhD work. There’s a PhD experience that expects you to be as thorough as any other PhD student while completing your PhD work much faster. Then there’s an abbreviated fourth year and it’s time go off again to residency, where you can expect more of the same. You can be expected to continue with research and clinical work, being an expert in both, working hard in both simultaneously, well into your 40s. There’s no balance in this equation I just presented. From the time you start college to the time you get your first R01 grant, you are expected to be the best of the best. Everything from that 3.8x average undergrad GPA and 95th or higher percentile MCAT, to the high Step I and medical school grades to get the top “research” residency, onwards to the 10th percentile funding rates of the R01 grants. I find it funny that at every point everyone else is complaining. MD students complain about how hard it is for them, PhD students complain about how hard it is for them, residents complain about how hard it is for them. We do all of it. We have longer training, but with each piece condensed into a shorter amount of time, and with multiple pieces on top of each other. There is no balance there. 

Well, unless you think balance is what I’ve found—an expensive and hard to get bottle of beer in a city with crappy liquor laws and hopefully a dinner from a cart along side the street.