Program of Study

A View of the Pathway: There and Back Again
 
It has been said that one of the top reasons for going through M.D./Ph.D. training is to postpone entry into the real world until the third decade of life. These programs truly represent scholastic longevity, as many who graduate from these programs remain in academics throughout their entire career. We sometimes like to joke that at our 10-year high school reunions, we’ll likely be the few still in school.

M.D./Ph.D. programs are among the longest and most rigorous training programs in the world. Program length varies considerably between schools. During the past twenty years, there has been a trend of increasing time to graduation for M.D./Ph.D. students. This has paralleled the increase in time for graduate students to earn the Ph.D. According to available NIH statistics, the current average time to graduation from start to finish in MSTPs is 7-8 years. This includes the four years of medical school and three or more years of Ph.D. work toward the thesis requirement. Recently, the NIH has pressured certain programs that had notoriously long training times to reduce the number of years students spend in the program. In particular, the Ph.D. phase needed to be condensed, as students were spending as much time as regular graduate students in laboratories, and hence taking as many as 8, 9, or 10 years to graduate.

The typical program of study includes the first two years of the basic medical sciences curriculum, followed by three or more years of graduate school and thesis research, and then the final two years of clinical clerkships. The transitions between the medical and graduate curricula are usually fairly abrupt, and there are not many avenues for easing the process. Programs vary in the level of integration between the medical and graduate years (see below). There are many exceptions to the traditional pathway, and programs are becoming increasingly flexible in terms of scheduling. However, most currently follow this general 2-3-2 pattern.
 
 
Years 1-2: Basic Medical Sciences
 
During the first two years, you are essentially a medical student, although schools sometimes often encourage you to pursue graduate courses, journal clubs, laboratory rotations, program retreats, and other graduate school requirements. Some allow you to place out of certain medical or graduate courses, depending on the degree of overlap. Laboratory rotations during the first two years are encouraged in many programs, and even required by some. This allows for earlier selection of a thesis laboratory, which can reduce the time to graduation.

Whatever flexibility is offered at a particular program, you will be exposed to a wide range of medical material during the first two years. You may have come into the application process with specific research interests, but realize that these may change during your first years as you are exposed to diverse fields under the medical curriculum. Some M.D./Ph.D students find themselves somewhat frustrated at the approach to learning during years 1-2. Medical classes require the absorption of huge volumes of information. Memorization tends to be emphasized, with the effect of scientific thinking being at the losing end. Innately curious M.D./Ph.D. students often find their questions regarding basic biological mechanisms deflected or relegated to “see me after class.” However, recent attempts have been made to increase the focus on problem solving and evidence-basedmedicine, which make use of the scientific method to a certain degree.

Some schools offer a seminar-style learning experience called “Molecular Grand Rounds” which typically involves the presentation of a clinical case and the relevant biological mechanisms. These seminars allow M.D./Ph.D. students to interact with each other and faculty, and highlightthe interface between science and medicine through review of biomedical literature. Many schools have initiated similar programs, often at the behest of students in the program. In some cases, it is the students themselves that have initiated these seminars.

Typically, at the end of the second medical year, students take Step 1 of the U.S. Medical Licensing Exam (USMLE), also known as “The Boards.” Some schools allow students to do some clinical clerkships before starting the graduate years and thesis work. This can provide an early introduction to clinical medicine and provide a context for integration with the basic sciences of the thesis years.
 
 
Years 3-5 (or more): Graduate School and Thesis Research
 
Over the next few years, M.D./Ph.D. students typically complete the graduate school requirements (coursework, rotations, exams, journal clubs, etc.), select a thesis laboratory, take the qualifying exam, and conduct thesis research. The number of years spent in this phase is highly variable, and is largely responsible for the overall program length.

Rotations are designed to allow you to “test the waters” without committing to one lab from the outset. Many students say that selection of your thesis lab is one of the most important choices you will make in your academic career. Research laboratories vary in terms of size, environment, level of funding, and other factors that you may want to take into account when deciding in which lab to pursue your thesis project. The best measure of how successful you will be in a particular laboratory is how well you get along with your advisor.

The goal of Ph.D. training is to produce a highly competent and independent investigator who is capable of seeking out answers to basic questions and eventually running a laboratory. Thus, some advisors (and programs) feel that the Ph.D. training must be of equivalent rigor to that obtained by regular graduate students. People say this often to alleviate potential concerns that M.D./Ph.D.’s are somehow receiving a “watered-down” Ph.D. Sometimes, however, it can be a warning sign that students typically take a long time to complete their thesis work in that particular laboratory. You must conduct your own investigations when selecting a thesis lab. It is important to ask for the opinions of people who have experience with the P.I., including current lab members or collaborators. Often, students who have rotated in a lab before can give valuable advice.

Recently, many programs have been urging M.D./Ph.D. students take the qualifying exam after their first year in graduate school so that they can begin thesis work earlier. The qualifying exam usually involves the defense of a thesis proposal and another proposal that is not related to the student’s area of research. Of course, this varies between institutions. Thesis work consists of completion of the project and a successful defense before a committee consisting of your advisor and other faculty in related areas of research. Typically, thesis research warrants publication, and programs expect that you will have published before graduating.
 
 
 
Years 6-7: Clinical Clerkships
 
The final two years of M.D./Ph.D. training consist of the core clinical clerkships, subinternships, advanced courses, and clinical electives. This period allows you to decide what specialty of medicine (if any) you wish to pursue. Requirements vary between programs, but typically consist of specific 6-8 week clerkships in various areas, including medicine, surgery, anesthesiology, obstetrics and gynecology, pediatrics, neurology and psychiatry, family practice/ambulatory care, and other subspecialties. On typical clerkships, you admit patients, conduct interviews and physical exams, attend rounds, give presentations, and take classes. During subinternships, you are given more responsibility for patient care. Electives may give you free time to pursue research or other interests. The requirements tend to be fairly rigid during the clinical years and thus there is often little flexibility in scheduling.
 
 
Transition Points: A Game of Ping-Pong
 
The transition between the first two medical years and the subsequent graduate training is fairly abrupt. It can be fairly disconcerting that many of your friends in medical school will go onto their clinical rotations, while you must spend several years in a laboratory before you reach that point. You marvel at the fact that they will one day be your residents or attendings.
After the thesis work, you are a budding researcher, trained to operate in the realm of science. Suddenly, you are thrust back into the hierarchical world of clinical medicine, where stress runs rampant, adrenaline is pumping, and you are at the low end of the proverbial totem pole. It has been years since you studied the basic medical science material and passed the boards. Many of your friends have graduated medical school and have gone onto residencies. You may find that some former classmates are your residents, which can be either a dream or your worst nightmare. Let’s just say it’s better to have friends than enemies. With expectations high an d your clinical skills low, you may feel like a fish out of water at first.

Needless to say, this ping-pong process can be fairly disconcerting. However, some efforts have been made to ease the transition points. As mentioned above, students can pursue some clinical clerkships before starting graduate training. Additionally, some programs allow students to pursue longitudinal clinical experiences throughout the graduate years to maintain contact with medicine while conducting thesis research. This often consists of a weekly outpatient clinic in a medical area of interest. Moreover, some programs offer a period of re-orientation to the clinics upon completion of the thesis. Nevertheless, students still find the transitions fairly difficult at first, and each requires a period of adjustment.