By a variety of measures, combined MD–PhD training programs—designed to train investigators who could better bridge the gap between basic science and clinical research—have been greatly successful. The Medical Scientist Training Program (MSTP), the largest and most formalized support for biomedical MD–PhD training, was initially conceived by the National Institute of General Medical Sciences (NIGMS) in 1964 to fund three programs; it currently lists 41 institutions as participants 〈www.nigms.nih.gov/funding/mstp.html〉. A number of reports, including a recent study by the NIGMS, demonstrate that graduates of combined MD–PhD programs (MSTP and non-MSTP graduates) have found academic success: They are well published, occupy academic and research positions, and are well funded.1–6 These graduates not only help bridge the gap between the basic sciences and clinical activities, but they are also important sources of leadership in biomedicine, become role models for future students, and help to fill the pool of young physician–scientists, an endangered and important population in modern medicine.7–11
Despite the careful characterization of what MD–PhDs eventually do, the literature offers little in terms of the views, attitudes, and goals of these students before they graduate.12 A good understanding of the MD–PhD student's perspective should provide a variety of valuable results; for instance, it may help students better understand their community, programs and policymakers to better tailor the educational process, and residency directors and department chairs to more effectively recruit prospective residents and future colleagues. A more detailed understanding of the goals and attitudes of those currently in training will allow for the implementation of changes and improvements (based on that understanding) in a population that is neither fully committed nor differentiated—an effective way of proactively adjusting to the health care environment of the future. Although the views of PhD students have been well described in a recent study sponsored by the Pew Charitable Trust,13 and to a certain extent all MD students on a yearly basis by the Association of American Medical Colleges,14 a good description of MD–PhD students’ views has yet to be reported.
In this study, we report the views and opinions of MD–PhD students enrolled in the Combined Degree Program at the University of Pennsylvania School of Medicine. The major areas of investigation were students’ satisfaction with various aspects of their education, the future career goals and interests of students as well as the importance of factors that influence decisions about these goals and interests and students’ views on the current state and the future of physician–scientists.
During the spring of 2002, we invited all 167 MD–PhD students enrolled at that time in the University of Pennsylvania School of Medicine Combined Degree Program to participate in an online questionnaire that consisted of 81 multiple-choice questions on the following topics: students’ demographics, satisfaction with the MD–PhD educational experience, future goals and career aspirations, and attitudes and views concerning the physician–scientist model. The MD–PhD students matriculated at the University of Pennsylvania School of Medicine Combined Degree Program between 1994 and 2002.
After we received approval from the Institutional Review Board of the University of Pennsylvania, we sent all eligible students recruitment letters via e-mail that contained a hyperlink to the Web-based questionnaire. A raffle prize valued at US $75 was offered as incentive. The participating students gained access to the online questionnaire by inputting their e-mail addresses into an online form as described in the Informed Consent notification. We used e-mail addresses only to document participation in the study. Individual answers were stored on a secure server and were not linked in any way to an e-mail address. Students were able to discontinue participation at anytime before completing the final section of the questionnaire. After recruitment with three group e-mails (a generic form sent in mass e-mailing) and one individualized e-mail (sent one at a time to a student's individual e-mail address), we determined significance of comparisons among respondents using the chi-square test function of Microsoft Excel X (Microsoft Corporation, Bellevue, WA). We report p values. Data on recent graduates reflect residency Match results obtained from the Combined Degree office at the University of Pennsylvania School of Medicine.
Results and Discussion
Of the 167 students invited to participate, 96 (57.5%) completed the questionnaire. Respondents represented every stage of training: prethesis (26.1%), thesis (49.0%), postthesis (22.9%), and nontraditional path (2.1%). (Students traditionally complete the first two years of medical school, followed by their PhD thesis work and finally the last two years of medical school.) Forty percent of our respondents were women, 11.5% were minorities underrepresented in medicine, 39.6% had partners or spouses, and 5.2% had children. Students’ mean age was 26.6 years (SD = 2.4) with an absolute range of 22–34 years. Nearly half of the students surveyed (46.0%) participated in a year or more of full-time research prior to starting the University of Pennsylvania Combined Degree Program. Thesis research interests were predominately in the fields of cellular and molecular biology (25%), neuroscience (24%), and immunology (18%).
The average period of time students expected to take to complete both degrees was 7.8 years (SD = 0.9). The majority of students felt that the length of time required to complete the MD and the PhD was “just right” (81.3% and 68.8%, respectively), and only a small minority (14.6%) felt that time pressures had adversely affected their educational experience. Although anecdotal evidence suggests that there are serious concerns about the time required to complete both degrees, most of the students seemed to feel that a long training program was justified. However, 36.5% of the students surveyed had seriously considered leaving the MD–PhD program at some point during their training (with the total number increasing with seniority in the program, data not shown). This response indicates that a substantial percentage of students, who may otherwise appear to be doing perfectly well, questioned their enrollment in the MD–PhD program, which further emphasizes the importance of peer and administrative support throughout the educational process.15
All of the students surveyed reported some degree of financial support, with 58.3% stating they received full funding (i.e., funding of all standard academic costs associated with the MD–PhD program, including a monthly stipend for living expenses). Despite this excellent level of support, 57.9% of the respondents had some educational debt, and 27.2% owed US $50,000 or more. Higher debt burden (US $50,000 or greater) was not significantly associated with a decrease in overall satisfaction with the MD–PhD program (p = .08), but was significantly associated with an increase in consideration of leaving the MD–PhD program (60% for debt US $50,000 or greater versus 33% for debt less than US $50,000; p = .04). These data suggest that reducing the debt burden of students—although certainly not a sure way to make “happier” students—may decrease some of the doubts of being enrolled in a program with such delayed financial gratifications. It may then be speculated that attrition rates (data not shown) would decrease along with a reduction in the average educational debt of students.9
As Table 1 shows, the majority of MD–PhD students at the University of Pennsylvania School of Medicine (90.5%) reported an overall satisfaction (very satisfied or somewhat satisfied as apposed to neutral, somewhat unsatisfied, or very unsatisfied) with the Combined Degree Program. Students indicated the strongest satisfaction with the following educational components: clinical medical school education (84.4% satisfied), PhD education (76.1% satisfied), preclerkship medical school education (74.7% satisfied), activities specifically designed for MD–PhD students (71.9% satisfied), faculty advising (68.4% satisfied) and the coordination between the MD and the PhD programs (58.9% satisfied). In contrast, students were strikingly less satisfied with the amount of information provided concerning more ancillary but arguably as important aspects of professional education: how to obtain extramural funding both as a student (28.9% satisfied) and as a professional (10.1% satisfied). Other areas that could be improved are the amount of information provided to students about choosing and applying to a residency (45.3% satisfied), the amount of information provided about various career options for an MD–PhD (50.5% satisfied) and finally peer advising (55.1% satisfied).
As a personal assessment of the training they had received, we asked students to rate their satisfaction with their ability to recognize clinical problems that can be approached scientifically. Sixty-one percent of the students reported being satisfied (19.8% neutral and 10.4% unsatisfied, no. = 96). A related question that would have further characterized this satisfaction (but not asked in this survey) is the following: How satisfied are you with your ability to plan and execute scientific studies to help solve a clinical problem? Nonetheless, these data suggest that the Combined Degree Program is succeeding, from a student's perspective, in training individuals with skills in translational research.
The career decisions of students in MD–PhD programs have important long-term influences on the future of academic medicine. Graduates of combined degree programs have continued and will continue to contribute to the active pool of physician–scientists and the full gamut of academic physicians. In addition, they have the potential to significantly affect the quality, quantity, and direction of research in fields that are currently underrepresented with MD–PhDs and other physician–scientists.16 For these and other reasons, we sought to characterize the career goals of MD–PhD students.
The primary clinical interests of 92 of the 96 respondents are shown in Table 2. Internal medicine (21.7%), neurology (10.9%), pediatrics (9.8%), and pathology (8.7%) were the four most frequently selected clinical subspecialties. It is worth noting that 73.9% of the students reported being extremely interested in the clinical subspecialty they chose (19.5% moderately interested, 5.4% somewhat interested, and 1.1% not interested). For comparison, the residency choices of University of Pennsylvania MD–PhD graduates from 1998 to 2002 (n = 65) are also shown in Table 2. Among these graduates, internal medicine (23.1%), pediatrics (16.9%), dermatology (10.8%), and ophthalmology (9.2%) were the four most frequently selected primary clinical interests. The differences between the primary clinical interests of these two populations as a whole are statistically significant (p = .04). Based on an examination of NIGMS reports submitted by 27 different institutions from 1991 to 1995,17 the distribution of MSTP graduates by subspecialty (internal medicine 31.7%, pathology 15%, pediatrics 14.4%, and neurology 7.7%) appears to show a pattern more similar to the interests of current MD–PhD students than to those of recent University of Pennsylvania graduates.
There are a number of potential explanations for these findings, two of which we proffer here. One, recent graduates of the program are an anomalous group, a statistical “blip” that does not reflect the national norm or any emerging trends. Two, although the students in our study showed more “traditional” clinical interests, interests of recent graduates portend a significant trend influenced by a state and environment of medicine quite different from those of previous years—that is, current students will progress to more closely reflect interests of the recent rather than distant graduates. A continuation of such a trend may result in a greater influx of MD–PhDs into “underrepresented” fields such as dermatology, radiation oncology, and surgical specialties. We believe that such an injection, even if not entirely desired, is sorely needed. Conjecture aside, however, nationwide and longitudinal studies will help explain these potential changes.
To gain insight into the process of selecting a clinical subspecialty, we asked the MD–PhD students to rate the importance of various factors in determining their primary clinical interest. As shown in Table 2, the majority of surveyed students (no. = 95) rated the following factors as “extremely important” in the decision making process (from choices of extremely important, moderately important, minimally important, or not important): interest in clinical subject matter (72.6%), gut feeling (56.8%), field or type of research interest (56.8%), and personal/family issues (54.7%). Factors that were rated less influential in determining a given student's clinical interest included a perceived need for more physician–scientists in a given field (9.5% extremely important and 34.7% not important), ease of obtaining a residency position (6.3% extremely important and 27.4% not important), prestige (3.2% extremely important and 27.4% not important), opinions of other students (3.2% extremely important and 31.6% not important), perceived need for more clinicians in a given field (2.1% extremely important and 47.4% not important), and matching patterns of students at the student's school (1.1% extremely important and 43.2% not important).
Not surprisingly, clinical and research interests as well as personal and family issues featured prominently in importance. The lower ranking of “earning potential,” “prestige,” and “ease of obtaining a position” suggest that MD–PhD students are not overly driven by superficial factors. They also do not seem especially motivated by societal or professional needs. Interestingly, students did not report the actions (i.e., matching patterns) or opinions of other students as being all that important in formulating their choices. We find this especially surprising in light of the anecdotal evidence that the MD–PhD program is an environment rich in peer discussion about clinical interests and residency choices. It is possible that peer influences become amalgamized into the black box of “gut feeling” and exert their importance in an indirect fashion. It should also be noted that these factors do not reflect true causal influences that were measured quantitatively, but rather they are self-reported perceptions of influence as measured subjectively.
Here we provide further insight into the career aspirations of MD–PhD students at the University of Pennsylvania. Consistent with a recent NIGMS study3 and studies of previous graduates of Duke University, Washington University in St Louis, Harvard University, Johns Hopkins University, and the University of Pennsylvania,1,2,4–6 most of our respondents were interested in obtaining a position in an academic medical center (79.2%) with their primary professional activity being research (62.5%). Among the 36 students who did not report research as their primary professional activity, 58.3% reported research would be their secondary professional activity. In other words, 84.4% of the surveyed students were planning a career associated with research. While the level of research and academic interest expressed by the students in our study may have been somewhat lower than percentages reported by previous studies of MD–PhD graduates, our findings nonetheless signify a strong academic and research commitment on the part of those still in training.
When asked to describe the type of research they were most likely to engage in, the majority of students reported a primary interest in either disease-oriented research (53.1%) or basic science (25%). A notable percentage of students indicated a primary or secondary interest in “patient-oriented” research (25.1%), possibly reflecting the kind of research emphasis (research directed and guided by clinical contact and observations) espoused by Goldstein and Brown18—or this finding could merely reflect confusion over the definition of the term “patient-oriented.”
As Figure 1 shows, a comparison between the primary professional goals of male and female MD–PhD students revealed some interesting trends. Although female students (no. = 38) were not more likely to consider leaving the program (p = .21) or were not less satisfied with their training experience than were male students (p = .46), they appeared to have been more interested in pursuing a patient-oriented career than were male students (no. = 58) (36.8% versus 19% for patient care; 50.0% versus 70.7% for research; p = .04). These data suggest that in addressing a general lack of female MD–PhDs and physician–scientists in practice and training,19,20 we may need to nurture a potentially different set of professional goals for females than for their majority male counterparts.
As shown in Table 3, the questionnaire also gauged students’ views and attitudes about the physician–scientist model. This model describes a physician–scientist as any individual who holds at least an MD degree and performs research as his or her primary professional activity, a common definition in the literature.7 Although the vast majority of the 96 responding students (83.4%) believed that physician–scientists should focus on bridging the gaps between basic science and clinical medicine (consistent with the original goals of the NIGMS in funding MD–PhD programs), only half (50.0%) agreed with the basic definition; an accepted “student” definition or perception of a physician–scientist remains to be determined. Concerning the two main activities of a physician–scientist, students were asked to consider the importance of time; 82.3% agreed (agree or strongly agree among other choices of neutral, disagree of strongly disagree) that being a “successful” researcher requires more than 50% of one's professional time whereas about half (47.9%) of the students indicated that being a “successful” clinician requires more than 50% of one's professional time. Analyzed simply, these responses may reflect students’ perceptions that research inherently requires more time for “success” than do clinical activities or that they would have been more willing to sacrifice some clinical responsibilities than they would research time. However, the data also reflect feelings of conflict and ambivalence: 45.8% of respondents agreed that both research and clinical success require more than 50% of their time. These data suggest that students did not hold fast to any particular model of a physician–scientist. Perhaps students believed that a physician–scientist, despite the current paradigm, could do research as a limited activity.
In terms of their own futures, 60% of the respondents reported intentions to become a physician–scientist in agreement with the proportion of MD–PhD students who indicated research as their primary professional activity. However, when asked if an MD–PhD graduate should become a physician–scientist, only 33.3% of the participants agreed, while 31.3% disagreed. These data reveal a tendency for students to be open-minded about career options in general for MD–PhD graduates despite their own academic or research-oriented leanings.
Students showed optimism for their future with 78% of respondents reporting the opinion that job opportunities for physician–scientist were excellent. Students also revealed their limited knowledge as more than a third of respondents (35.4%) failed to realize that MD–PhDs are only a minor fraction of all physician–scientists. Interestingly, the MD–PhD students in our study as a whole seemed to be ambivalent as to whether the number of physician–scientist being trained needed to be increased (47.9% agree versus 41.7% neutral), perhaps reflecting students’ lack of knowledge about the current shortage of physician–scientists. Not surprisingly, most MD–PhD students believed that combined degree programs are the best way to train physician–scientist (67.7% agree).
Although, our study has revealed some interesting insights into the education of MD–PhD students, it does have a number of limitations. The response rate, although acceptable for this type of observational study, certainly leaves room for some response bias. Our demographic profile, however, suggests that we were able to pool a wide and diverse section of the student population. In addition, a direct comparison of four demographic parameters (age, sex, year of matriculation—as a proxy for stage in program—and funding status) revealed no statistical differences between the respondents and nonrespondents. The mean age of respondents and nonrespondents respectively were 27.0 and 26.6 years (two tailed t test; p = .280). In addition, 58 of 96 respondents were male whereas 45 of 70 nonrespondents were male (chi-square test; p = .612). The mean year of matriculation for respondents was 1997.7 versus 1997.2 for nonrespondents (two-tailed t test; p = .125). Finally, 56 of 96 respondents received full funding (40 received partial funding), whereas 37 of 70 nonrespondents received full funding (33 received partial funding) (chi-square test; p = .483).
It is also possible that the students we surveyed at the University of Pennsylvania School of Medicine did not reflect MD–PhD students in general (despite being in one of the largest programs supported by the NIGMS). There are likely to be some significant program-to-program differences based on the number of qualities that make programs unique and indeed desirable to different students. It will be important in the future to assess programs on both an individual and collective basis to determine what characteristics are program specific and which ones are truly generalizable. We are currently initiating such a nationwide, multiprogram survey of MD–PhD students’ attitudes, goals and education (SAGE).
Our study has demonstrated that the preponderance of students from the University of Pennsylvania Combined Degree Program that we surveyed were satisfied with their education. Not surprisingly there are opportunities for continued student-oriented improvements. Students in this program have interests in line with goals that have historically been those of MD–PhD programs in general: to educate academic physicians who will be furthering research as it relates to human health. As a point of departure, however, the emphasis of academic efforts may be transitioning more toward activities related to patient care (especially for women) and toward fields currently not well represented by MD–PhDs and physician–scientists. Although combined degree students seem optimistic about a career as a physician–scientist, there appears to be some ambiguity as to what such a career really entails. On one hand, some of these opinions may be fleeting and will “mature” with progression. On the other, they may more closely reflect contemporary changes that will only become the dominant paradigm in years to come. In any case, reflecting on students’ opinions and improving their education based on those reflections is sure to lead to better future physicians, scientists, and medical leaders.
This work was supported by the Combined Degree and Physician Scholars Program at the University of Pennsylvania School of Medicine. Portions of this paper were presented at the National MD–PhD Conference, Aspen, Colorado, July 12–14, 2002.
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