MD-PHD

The MUD and the PHUD of the MD/PhD and physician-scientist pursuit

When we think of physicians in the contemporary health care system we often think of the numerous specialties and subspecialties. Within these specialties are physicians who spend 100% of their time on clinical tasks, as well as those who spend a portion of their time on clinical tasks and another portion on another task including teaching, administration, or research. Those spending time in research (typically 70-80%) and clinical tasks (typically 20-30%) are known as physician-scientists. They conduct research in a variety of fields which can include, but is not limited to, basic science, translational research, clinical trials, medical device engineering, the philosophy and history of medicine, law, English, economics and health systems research. There are many reasons people decide to become a physician-scientist, but often it includes some form of passion towards patient care as well as improving the practice of medicine through experimentation and inquiry. This pursuit is challenging but extremely rewarding to those who have taken it. (resource)

To become a physician-scientist there are several pathways with the one available at the pre-doctoral level being the MD-PhD program. It should be noted that there are also MD combined with a master’s programs, though these are newer and not as well established at this time. All exist with a common idea to provide medical and researcher education to prepare for the physician-scientist journey.

Focusing on the MD-PhD pathway, how exactly do you manage doing two doctorates? Program structure can vary though in general 3-4 years are spent completing the MD and 3-5 years completing the PhD. Traditionally the program is structured to start with 2 years in the MD program, then 3-5 in the PhD program, followed by the remaining 2 years of the MD program. For program specific details you can visit each program’s website (resource) or this 2016 peer-reviewed assessment of differences in program structure across Canada (ref figure 1).

Why Do a Combined MD/PhD

There can be a lot of uncertainty about if, and when, to pursue doctoral studies during your medical journey. In short, there is no right or wrong answer. Doing a PhD, on top of an MD, is not a quick and easy decision. What matters is that your timeline works for you and excites you, even when days get tough.

By pursuing both degrees in a combined MD/PhD program, you are taking an integrative approach. By pursuing a year or two of pre-clerkship medicine first, you have some time to explore your clinical interests and start to understand the relationship between medicine and research, which in turn can influence your PhD research question. You then have 4-5 consecutive years in graduate school. This is protected time to fully explore and appreciate research rigour and a range of research approaches. You then return to medical school with a new lens. Moving forward, you have two hats, and you can take one hat off and put the other hat on, interchangeably.

Here are a few reasons why pursuing the combined MD/PhD program is beneficial. Many personal factors determine a person’s decision, but some ‘universal’ ones are:

• Formal training in both research and medicine that can open and be competitive for many career opportunities
• An integrative approach, from the beginning, that allows both worlds influence the other
• A tight-knit community of students on the same journey, both in your institutional program but also across Canada (e.g. Clinician Investigator Trainee Association of Canada), which provides social relationships and mentorship opportunities from clinician scientists, senior students, and peers
• Specialized training seminars, workshops, and networking events on clinician-scientist-related skill sets
• A funding policy – although this differs from school to school, most MD/PhD students receive funding during both their research and medical training, given such a long career path
• Although you may not know your clinical speciality yet when deciding your PhD research question, you can still develop a research toolkit which you can then apply to future research aims, no matter the clinical field

However, it is important to be transparent about the potential challenges that arise while pursuing this dual degree program, among others:

• The program length can be 6-9 years, which can feel daunting, especially when it may require residency and/or post-doctoral training afterwards
• There is potential for lost income early in your career as a clinician scientist
• Funding for jobs in both research and medicine can be limited at times (although in high demand at other times)
• It can be difficult to take 4+ years away from clinical training to pursue the PhD degree, and there can be challenges for students transitioning between these degrees, both academically and socially

There are multiple other ways to pursue training that leads to becoming a clinician scientist. Here are a few other options to think about:

• You can complete a full PhD before entering medical school. This gives you time to mature and grow This also gives you a different perspective heading into medical school. This method may also not rush you – you decide when you feel ready to complete your PhD and when to apply to medicine. However, once you enter the world of medicine, undergraduate medical school and residency could be anywhere from 6-10 years. You can still be involved in research during these years, but it will be constrained and it can be a challenge to maintain your publication record and productivity during this time as you pursue an eventual career in medicine and research. Your PhD work may not seem as relevant or current after years of medical training, especially when you eventually want to apply for grant funding or faculty positions.
• You can complete a PhD during residency, in a program such as a Clinician Investigator Program (CIP), or similar. This gives you time to really explore different research projects and clinical interests during medical school, and tailor your PhD research question to your clinical speciality, perhaps stemming from clinical problems you face daily with your patients. In this structure however, you may not have the same valuable, protected time as you would in graduate school. It may also not be as integrated as doing research prior to residency (such as in a combined MD/PhD program).
• There is also the option of not doing a PhD at all, and pursuing research opportunities through medical training. You can be a clinician scientist without a PhD.

Misconceptions about Admissions Requirements for MD/PhD Programs

When applying to medical school and to the MD/PhD program specifically, many of us were worried that we did not fulfill the unwritten requirements of such a competitive and challenging program. These fears and assumptions of seemingly impossible standards were supported by hearsay of fellow applicants and by the accomplishments of the outstanding individuals that had succeeded in being accepted into MD PhD programs. We are confident that many of the individuals reading this guide will have heard similar information and are harbouring similar fears and anxieties as we did when we were applying. With this section, we aim to dispel some of these common misconceptions and hope to encourage individuals to apply to MD PhD programs.

Misconception #1: You need a first author Nature/NEJM paper to stand a chance.

While having published research to include on your application will certainly work in your favour with respect to increasing chances of being offered an interview or acceptance into MD/PhD programs, published research is not a requirement. Having published work related to a summer research project or to master’s work demonstrates a commitment to and a genuine interest in research, which is something that all MD PhD programs are seeking in applicants. However, having done the research even in the absence of a publication can also demonstrate these qualities. It is important not to be discouraged from applying simply due to a lack of publications; many of us were accepted into Canadian MD PhD programs without any. Also remember that if you are working on a research project that is close to being published, i.e. you are involved in completing final experiments before the paper is written, or you are contributing to a paper that is under review or revisions, you can speak about this if you are granted an interview to further show your interest in and dedication to research.

Misconception #2: You need a master’s degree in order to stand a chance.

Again, while having had extensive experience in a research setting through the pursuit of graduate studies is an asset on an MD PhD application, it is not by any means a requirement. This notion is supported by the findings of a study published in 2017 reflecting information about the degrees of 132 Canadian MD/PhD program alumni, where it was reported that only thirty-one respondents (23.5%) of alumni had entered MD/PhD programs holding master’s degrees (Skinnider et al., 2017). Most individuals reported having only completed bachelor’s degrees prior to applying to MD/PhD programs. It is highly recommended that individuals demonstrate through their application (i.e. personal statements, past research experience, etc.) that they are committed to the clinician-scientist path. If you do this and as long as your application is competitive in other respects, we encourage you to apply to your MD/PhD program of choice.

Misconception #3: You need to have a supervisor and/or lab and/or project lined up at the time that you are applying.

While some of the MD/PhD programs in Canada, like McGill and the University of British Columbia, expect students to attend their MD/PhD interviews having already thought about and even having contacted potential supervisors, this is not universal across all MD/PhD programs in Canada. The MD/PhD program at the University of Toronto, for example, does not require students to come to interviews prepared with a supervisor, lab, or project. Ultimately, this will vary by school; this guide does not aim to provide an exhaustive list of MD/PhD programs that require such preparations prior to interviews, as this information is available online. It is encouraged that students reach out to the MD/PhD program at their school(s) of choice to inquire about whether this is a requirement if it is not apparent on the MD/PhD program websites.

Misconception #4: Pursuing an MD/PhD program is financially infeasible.

While it does take MD/PhD graduates longer to begin earning a staff-level salary as compared to their MD counterparts, MD/PhD students at all Canadian medical schools receive a stipend beginning in their first year of studies to offset living expenses associated with being in a lengthy program. Whether or not pursuing the MD/PhD program and earning only this baseline stipend for 8 years is financially infeasible is highly dependent on each student’s personal situation as related to balancing the stipend with expenses. Before applying to MD/PhD programs, it is encouraged that students reflect on their personal circumstances and expenses and investigate the funding arrangements at their institution of interest.

In addition to this baseline MD/PhD funding, students are encouraged to apply for competitive funding. There are several scholarships and grants funded by the universities, the provincial and federal governments, and other foundations/organizations, which students are encouraged to apply to. Furthermore, depending on the value of the award, students who are successful in receiving competitive funding may receive top-up funding from their graduate department or from their MD/PhD program. Furthermore, many MD/PhD students, like their MD counterparts take a line of credit when starting medical school to help with the costs of being in a lengthy program. While this option is not for everyone, it is an option if one feels that it is required.

Misconception #5: You need to decide on a clinical specialty before pursuing the program.

It is not required to have decided on a clinical speciality before pursuing MD/PhD training. Many students enter MD/PhD programs without even having decided on the type of PhD that they want to pursue, and many end up pursuing a type or field of research that is completely new to them. There is the argument that having a clinical specialty in mind and being able to align the PhD field of study with this clinical speciality is helpful in terms of future career prospects, as it allows the individual to make connections within that sphere and as it will reflect favourably on the applicant during the residency matching process. However, because of the dedication and hard work that is demanded of MD/PhD students, pursuing an MD/PhD program in and of itself reflects favourably on the individual and will be beneficial in the residency matching process. To summarize, while it may be helpful to have an idea of a clinical speciality before pursuing the MD/PhD program, it is not a requirement or expectation.

Misconception #6: Applying to the MD/PhD program increases your chances of getting a medical school interview as compared to applying to the MD program alone.

We, the writers of this chapter, have experienced mention from both past and present applicants that, for one reason or another, they came to believe that applying to the MD/PhD program at their school(s) or choice might increase their chances of getting a medical school interview. It is unclear where the idea that MD/PhD programs are a backdoor to medical school was derived, and we do not aim to address the possible sources. Based on what is published on MD/PhD program websites, there is no information to suggest that applying to the MD/PhD program at each respective school would increase an applicant’s chances of getting an MD interview. Furthermore, an applicant who is successful in gaining acceptance into an MD/PhD program would have gone through two separate interviews and would have had to demonstrate excellence in all of the areas assessed for general MD applicants, and additionally, would have had to show commitment and excellence within the research sphere.

If you are an individual that has a strong research background and has shown exceptional research productivity, then it is likely that MD/PhD programs would look upon your application favourably, but excellence in research does not waive the requirements for all of the other aspects assessed for MD programs (i.e. GPA, MCAT, extracurriculars, etc.). We would highly discourage anyone without a genuine interest in pursuing a clinician-scientist path from pursuing the MD/PhD program because of the belief that is a backdoor to medicine. Applying to MD/PhD programs with such motivations not only makes it more difficult for other applicants who are genuinely interested in the program to gain acceptance, but it would also be doing one’s self a disservice because the prog ram is challenging to begin with, and pursuing it without a genuine desire to do so would make it even more challenging.

MD/PhD Application Process

The overall MD/PhD application process is very similar to the MD application process: an initial application plus an interview prior to an offer of admission. The initial application is submitted to both programs. You can think of it as an additional application that accompanies your MD application to the admissions committee. Most, if not all, schools have two separate admissions committees: one MD/PhD committee and one MD committee. To be accepted to the MD/PhD program, both MD and MD/PhD applications must be successful.

It is important to note that every school has different requirements for their application. Commonly, some of these requirements include a CV highlighting research experiences, essay(s) answering why you want to pursue MD/PhD training which includes your field of interest, plus 2-3 strong recommendation letters from referees who have observed your research skills.

With any application, it is essential to plan ahead. By referring to and noting the important dates and deadlines from websites and guides of your program(s) of interest, you can plan and gather the necessary documentation for a successful application. It can be a daunting task since there may be many documents you need to prepare but try to spread out the work and treat it like a marathon, not a sprint. Also, if you are unsuccessful on your first try, reflect on your application, and try to find areas of weakness that you can improve on. Do not give up – many applicants apply multiple times before they get accepted!

MD/PhD Personal Statement

As previously mentioned, when applying to an MD/PhD program, some schools require additional MD/PhD essays accompanying the MD application. These materials generally focus on your research experiences, your motivation for pursuing a clinician-scientist pathway, and what you wish to pursue in your PhD. This may be required to be written in one short essay or required to be written in multiple separate essays. If written in one essay, it may be called a “personal statement” or “letter of intent”. It is important to read and carefully follow the instructions for the particular school you are applying to. Schools across Canada also have different application deadlines, so be sure to carefully make note of each deadline!

The MD/PhD essay is the best opportunity you have in order to make the case of why you will be most fulfilled working both as a physician and a scientist. This is a fine balancing act between your desire for patient interactions and your passion for research. If this is out of balance in your application, it may seem that you should apply to an MD only route or a PhD only route. This a common challenge that will re-occur throughout interviews as well.

Prior to writing your essay(s), it is best to give yourself enough time to reflect on your experiences and brainstorm your ideas. It is important to look up the skills and competencies that the school values (generally listed on their website) and try to reflect on your experiences that can highlight these skills. Another early and important task is to find a few trusted people that can commit to assisting you with editing later on. Constructive criticism is essential to enjoy science and wanting to combine the fields of science and medicine as a career. Brief anecdotes are always enjoyable to read and offer an inside look into who you are and is one of the best ways to make your essay unique. When writing an anecdote, it is important not only to write what you did, but to show reflection on what you have gained from these experiences and how it has shaped you moving forward. You want to make sure you highlight your understanding of the MD/PhD career path as well as your passion for it. It is important to be clear, direct, and concise with the points you make and remember to focus on answering the question.

When discussing your research background, it may not be necessary to include much detail, depending on the word limit of the essay. Also, when discussing your PhD research interests, most schools do not ask for a project proposal, so providing brief insight into your field of interest and briefly describing your research goals in that field is the best approach. It is normal to not know exactly what research you want to pursue at the time of applying and having an open mind is helpful in finding the right fit. It is sometimes the case that the research you propose in your application is not what you end up pursuing. This is okay; however, it is important to express what you are genuinely interested in so that the admissions committee can get to know you better.

Overall, these essays are an important part of the application since the admissions committee will be able to get a better idea of who you are and what your interests are. It is also a great opportunity to demonstrate your passion and understanding of the MD/PhD career path. Many applicants may want to focus on trying to stand out in their essays, however, if you are showcasing who you genuinely are, then you will stand out!

MD/PhD Interviews

If you have received an MD/PhD interview – well done, that is an accomplishment in itself! You are one step closer to your goal! You will notice that the MD/PhD interview session is in addition to the MD interview session. These interviews may be scheduled on the same day or on separate days. The format of the MD/PhD interview may be a series of multiple short interviews, or a panel in which you would need to present a short presentation (prepared in advance) plus a question period.

As you prepare for the interview, it is useful to think about why the program even interviews applicants. This is so that they can evaluate your communication skills, professionalism, and maturity; to hear your motivation to pursue medicine and science in your own spoken words; to hear your experiences and how it has confirmed your desire to become a clinician-scientist; to learn if you have realistic expectations of the career and the work-life balance; and to decide if you are going to be a suitable future colleague and peer that is enjoyable to work with.

The tips for your MD interview will also apply to your MD/PhD interview, but there are a number of ways in which the MD/PhD interview process is different. For instance, be prepared to speak about your research at different levels, for example, prepare an “elevator speech” (90-second duration) to describe your research to a non-expert audience. It would help if you also were comfortable to discuss your research with an expert in the field. Additionally, as previously mentioned, you should perform thorough research on the career to understand the profession and the expectations from it. Also, it is ideal to have some knowledge of the specific MD/PhD program you are applying to (how the program is structured, what resources are available, etc.) and how you envision yourself succeeding in it.

In terms of the PhD research you want to pursue, it would be helpful to identify a few Principal Investigators you would like to work with. More thought into the research field and questions you want to pursue can positively demonstrate your passion and critical thinking.

On a more general note, it is important when preparing for your interviews to start early and practice often! Practicing with as many people as possible can help you recognize different perspectives and provide you with more comprehensive feedback. Try to practice as many questions as you can but know that you will not be able to practice for every possible question, so becoming comfortable with spontaneity is imperative. Lastly, remember to be genuine with your responses and be confident – this is the final stage to showcase yourself as an ideal MD/PhD candidate!

What comes next?

We recognize that thinking about an eight-year program after undergrad sounds daunting itself, let alone thinking about what comes after that! However, a common thread of conversations with both our research and clinical mentors is that the MD/PhD program (and med school in general) -- is just the beginning of a deeply fulfilling and meaningful career! In this section we aim to offer some insight into what that looks like. First, we begin by outlining the most likely pathway for MD/PhD graduates, further clinical training in the form of residency and fellowship to become an independent clinician-scientist. Next, we outline ‘non-traditional’ career paths other than that of a clinician-scientist in an academic medical centre. Finally, we end our chapter by sharing some brief messages from clinician-scientists across the country.

Walking further down the clinician-scientist pathway:

The majority of MD/PhD trainees in Canada and the United States pursue further clinical training after graduation. In a Canadian survey of MD/PhD program alumnae published in 2017, 99% of respondents had either completed or were currently in a residency program while 82% completed at least one fellowship program [CMAJ Open Paper]. The primary objective of residency programs is to train competent, independent clinicians--however, many residency programs incorporate some time for research. The amount of research time allocated during fellowship (i.e. subspecialty training programs) is often higher than residency and some MD/PhD alumnae also pursue a post-doctoral fellowship. Science moves quickly and MD/PhD trainees must be aware that it takes special efforts to remain connected with their scientific pursuits during the busy years of focused clinical training! All-in-all, the median training time for MD/PhD alumnae in Canada was 13.5 years. Following their training, 83% of respondents were appointed as faculty at an academic medical centre . They balance their time by conducting research, caring for patients, teaching trainees (from medical students to advanced subspecialty fellows) and various other administrative duties.

While a detailed overview of American MD/PhD programs is outside the scope of this resource, American ‘Medical-Scientist Training Programs (MSTPs)’ have been well studied. Some challenges for MD/PhD graduates are universal, such as financial constraints and not enough protected research time during clinical training to remain productive scientifically. In both Canada and the US, there are active calls to support MD/PhDs as the links from the “bench to the bedside” and drivers of clinical breakthroughs.

“Physician-scientists are among the most highly trained investigators in the research enterprise. Their efforts will be crucial to improving health care. Our world needs a growing, corps of professionals who bring a human understanding of patients to medical research, and a researcher’s expertise to improving patients’ lives.”

A fork in the road - non-traditional career paths for a clinician-scientist:

While the majority of MD/PhD alumnae enter careers as academic clinician-scientists, we briefly wanted to outline other career possibilities. These other career paths are not unique to physician-scientists, but also to our peers in clinical medicine and pure scientific/biomedical research. These careers outside academia and academic medicine include:

• entrepreneurship
• management consulting and wealth management
• venture capital
• pharmaceuticals, biotechnology, digital technology
• healthcare and non-profit management
• humanitarian response
• education
• and more!

• The reasons why MD/PhDs choose to enter alternative career paths are varied and often personal. However, what we wish to stress is that training in an MD/PhD program offers you skills that allow you to: identify meaningful problems, make sense of the intricacies around these problems, test your assumptions, generate new insights, design solutions, and translate them into real-world impact. These skills are extremely highly valued, no matter what field you choose to enter. A unique draw to a career as a clinician-scientist is that you are bound to have outlets to explore your interests and curiosity as they evolve over time. Many clinician-scientists spin-out their research into start-ups, consult for various companies, lead organizations, and more over the course of their careers. To use the old cliché, the world is your oyster.

  When thinking of career paths, the authors have found the ‘careers blogs’ of Nature and Science to be invaluable resources of information, inspiration, and validation. Both journals also offer podcasts (Nature has one general podcast

**Extra Resources**

• More

We came together to write this book to break down the barriers some of us faced when applying to medical school. When you know better you do better- together!