As early as 1979, James Wyngaarden, former director of the National Institutes of Health, warned that clinician-investigators (physicians who do research) would become an endangered species.23 More than 20 years later, numerous leaders in medicine agree that the current decline in the number of new clinician-scientists must be reversed if we are to avoid a critical shortage.3,7–9,12,17,18,20 Orthopaedic surgeons have recognized a relative dearth of clinician-scientists in the field and have discussed the importance of promoting more research in orthopaedics.2,5–7,14,15,22
To increase the number of clinician-scientists, the National Institute of General Medical Sciences has increasingly supported funding of MD-PhD or Medical Scientist Training programs.11 Numerous postgraduate analyses show that trainees of combined MD-PhD programs have experienced academic success.1,4,10,11,16,19 However, one study indicated that a disproportionately small number of graduates from Medical Scientist Training programs from 1964–1994 went on to a career in orthopaedics in particular, and careers in surgical fields in general.6
Although it is unclear why MD-PhD students choose not to enter certain specialties, these data suggest that surgical fields may need to recruit more vigorously to attract and retain interested students. Orthopaedics has much to gain by such efforts because clinician-scientists are relatively rare in the field.2,6 However, it is unclear how much of an interest MD-PhD students currently have in pursuing surgical specialties in general, and orthopaedics in particular. With the assumption that a better understanding of current student desires and goals will lead to better recruitment efforts, we examined a survey of MD-PhD students at our institution to see how much interest students have in pursuing surgical careers. We also attempted to determine at what stage in their training students develop these interests, if surgically oriented students are interested in being clinician-scientists, and the importance of various factors in deciding primary clinical interests.
MATERIALS AND METHODS
The study was approved by the IRB of our institution and consisted of an online survey (Appendix) that was completed anonymously. The survey consisted of multiple-choice questions addressing the topics of (1) satisfaction with the MD-PhD education; (2) attitudes concerning the physician-scientist model; and (3) future goals and aspirations. After three group invitations and one individualized invitation (through e-mail), the response rate was 57.5% (96 responders of 167) of all students currently enrolled in the MD-PhD program at our institution. One responder who indicated a preference for no medical residency was not included in this analysis. Statistical significance between subsets of responders was determined using the chi square test, and p values are reported.
As a proxy measurement of nonresponder bias, the responder and nonresponder groups were compared on the demographic parameters of age (mean age, 27.0 and 26.6 years respectively; p = 0.280, two-tailed t test), gender (58 of 96 and 45 of 70 were males respectively; p = 0.612, chi square test), years since matriculation (4.3 and 4.8 years respectively; p = 0.125, two-tailed t test), and funding status (56 of 96 and 37 of 70, respectively, were fully funded with the remainder having partial funding; p = 0.483, chi square test).
Twenty-four percent of responding students (23 of 95 responders) had a primary clinical interest in the surgical fields of general surgery, neurosurgery, obstetrics and gynecology, ophthalmology, orthopaedic surgery, and otolaryngology (Table 1), and will be referred to as surgical students. Three students (of 95) were interested in orthopaedic surgery (Table 1) and have matched in orthopaedics in the 2003 match. Two PhD-level students indicated that orthopaedics was a secondary clinical interest. Students in the program typically begin medical school (2 years), begin and complete their PhD (3–5 years), and then finish the clinical requirements of their MD degree at the end of the program (2 years).
The 23 responding surgical students rated the importance (extremely important, moderately important, minimally important, or not important) of numerous factors leading them to their primary clinical interest. The five factors ranking highest in importance for surgical students were: (1) interest in the clinical subject matter; (2) interest in types of procedures; (3) personal or family issues; (4) gut feeling; and (5) clinical role models (Table 2). The five factors ranking lowest were prestige; ease of obtaining a residency position; matching patterns at the student’s school; opinions of other students; and a need for more clinicians in a field (Table 2).
A comparison of surgical students and nonsurgical students (72 students interested in fields that are not primarily surgical) revealed that the two groups are similar (Table 2). Surgical and nonsurgical students are comparably satisfied (very or somewhat satisfied) with their education (100% and 87.3%, respectively; p = 0.27) and are similarly represented by female (35% and 40%, respectively; p = 0.64) and minority (9% and 13%, respectively; p = 0.62) students.
Despite the observation that MD-PhD recipients in surgical fields frequently seem to leave research after they begin clinical practice,6 a surprisingly low percentage (13%) of surgical students reported that they were not going to become physician scientists. This value was similar to that of the nonsurgical students (10%; p > 0.5). Furthermore, 52.2% of the surgical respondents wanted research to be their future primary or secondary career activity (34.8% primary and 17.4% secondary); 80% of those who chose clinical work as the primary activity wanted research as their secondary career activity. These data suggest a strong interest among MD-PhD students, even those headed toward surgical fields, to become clinician-scientists.
MD-PhD students represent a significant pool of future clinician-scientists and their recruitment into orthopaedics has the potential to benefit research in the field. This study was done with the goal of understanding the surgical interests of MD-PhD students so that they may be better encouraged to pursue surgical specialties such as orthopaedics.
The level of interest in surgical fields by MD-PhD students (24%) shown in this study is contrary to the common notion and previous data that MD-PhD students have little interest in pursuing postgraduate surgical training (12.4% of all MD-PhD recipients in practice examined in one study6). Furthermore, the data suggest that surgical MD-PhD students are interested in pursuing research during their careers as much as their nonsurgical counterparts. By most parameters, surgical MD-PhD students were not as disparate from their nonsurgical counterparts as might have been speculated (Table 3). The main difference was that a greater proportion of surgical students (43% versus 17% of nonsurgical; p < 0.01) had completed their PhD and had returned to clinical rotations (Table 2); students tend to develop surgical interests later during medical school than they do nonsurgical interests. This is not an unexpected finding because students typically do not receive much surgical exposure in the early years of medical school or during graduate school.
The shortage of MD-PhD physician-scientists in surgical fields, therefore, may reflect one of two realities: (1) our current cross section reflects a population of students different from physicians who now are practicing and that in the next 10–15 years, the number of MD-PhD physician-scientists in surgical fields will increase dramatically; (2) the more likely scenario is that the strong level of interest developed during clinical undergraduate medical training is lost in translation to postgraduate practice. To increase the number of MD-PhD graduates who become physician-scientists in practice in surgical fields, initial student interest must be nurtured and supported.
How can orthopaedics attract more MD-PhD students? Residency programs could make efforts to be more understanding of and flexible toward family issues because MD-PhD students tend to be older and more likely to have started their families. The rank list of factors in deciding clinical direction (Table 2) stresses the importance of exposure to clinical role models and to information regarding orthopaedics as a field and career choice; orthopaedists need to share their excitement about the field with students. This enthusiasm needs to be shared with senior students, but perhaps more importantly, with junior students who have not yet developed strong interests in surgical fields. The lower ranking of field or type of research interest on the list (Table 3) suggests that students are willing to tackle various problems and do not feel restricted to their PhD topics. In other words, they may consider research in the musculoskeletal system (a system not often the topic of PhD dissertations) independent of their specific thesis topic during doctoral training. The presence of earning potential, residency program length, and hours worked lower on the list (Table 3) indicates that perhaps lifestyle issues are not critical internal barriers for these students.
A particular subpopulation that needs to be targeted (as is true with nonMD-PhD students) is women. Although the overall percentage of women among surgical students (35%) was similar (p > 0.5) to that of nonsurgical students (40%; Table 2), none of these women indicated an interest in orthopaedics. Recruitment of women into orthopaedics, with and without research interests, is an important issue.3,13,21
The conclusions offered by this study should be considered within the context of its limitations. The response rate, although adequate, was not high enough to confidently exclude significant nonresponder bias. To better address this issue, a comparison of demographic data between responders and nonresponders was done; the results indicated no significant differences between the two populations on the parameters examined (see Materials and Methods). Also, the survey did not randomly sample from all MD-PhD students, and it is a one-institution study. Our institution’s training program is one of the largest in the nation (largest program in a recent survey of MD-PhD program directors was 182; unpublished data. Presented at the Directors Meeting of the 2002 National MD-PhD Student Conference, Aspen, CO), and the graduates of our program have shown similar patterns of clinical interest and professional activities as graduates from other programs.1,4,10,16,19 However, we cannot accurately generalize the results to all MD-PhD students because detailed data on students currently in training are unpublished. To overcome some of these limitations, we are doing a survey of 15 MD-PhD programs nationwide, and in that study, a formal nonresponder bias analysis will be done.
Nevertheless, these data suggest that there is significant surgical interest among MD-PhD students (especially late in their training), that the research interest of these students is strong, and that they have not committed their clinical interests based on their PhD research topics. We think that the number of physician-scientists in orthopaedics and other surgical fields can be increased successfully through better understanding of MD-PhD student attitudes and desires and implementation of supportive policies and programs based on that understanding.
We thank Maggie Krall of the University of Pennsylvania Combined Degree Program for assistance with the survey, and Frederick Kaplan, Alice Ha, Fran Watt, and Tessa Sundaram for critical input.
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