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Article Contents

Science in the academy and industry: differing goals and structures, physician-scientist careers in industry, other cultural aspects of life in industry, opportunities for physician-scientists to interact with industry while in academia, conclusions.

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Physician-Scientist Careers in the Biotechnology and Pharmaceutical Industries

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Don Ganem, Physician-Scientist Careers in the Biotechnology and Pharmaceutical Industries, The Journal of Infectious Diseases , Volume 218, Issue suppl_1, 15 September 2018, Pages S20–S24, https://doi.org/10.1093/infdis/jiy308

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Many careers are open to physician-scientists in the biotechnology and pharmaceutical sectors. However, research is structured very differently in these environments compared to academic medicine. This article highlights these differences and the reasons for them, then outlines the different career paths available to physician-scientists in the variegated worlds of biotechnology and pharmaceutical companies.

The contributions and roles of physician-scientists in research in academic clinical departments are well recognized. Discussions of the physician-scientist career path in the medical literature have typically focused on their criticality to the missions of academic medical centers and on ways to sustain their numbers in national training cohorts [ 1–3 ]. This academia-centric focus is not limited to US perspectives, but also dominates international analyses of the subject [ 4 , 5 ]. Surprisingly, the roles of these individuals in the biotechnology and pharmaceutical industries have been much less widely examined. Here I discuss how physician-scientists are integrated into the complex ecosystem of the biopharma industry, and consider how this relationship is likely to evolve in the future.

Before examining these issues, it is well to step back and consider the differing missions of academic and industrial research in biomedicine. The primary mission of academic biomedical research is the generation of new knowledge; by contrast, the mission of industrial research is the generation of a product, for example, a drug or vaccine. Certainly the quest for the latter is a knowledge-intensive one that is critically dependent upon recent discoveries in academic science, but the mission is nonetheless a very different and distinctive one. Academic research begins with a question—sometimes a very focused one, but often a very broad or profound one. Industrial research begins (usually, at least) with something very different: a target product profile (TPP). The TPP defines the properties of the medicine or product that the research effort is designed to make. It includes the disease state the drug is intended to treat, the selection of the molecular target of the drug (this is the part that is most heavily dependent upon academic research), whether the envisioned drug is a small molecule or a biologic, and the route (and frequency) by which it will be administered. Clearly, formulation of an achievable TPP requires a great deal of knowledge (much of which is clinical and therefore especially within the wheelhouse of the physician-scientist; see below), but the important point here is that the primary goal of the effort is to use existing knowledge to define the TPP and then design a research plan (usually screens and counterscreens) that will allow the TPP to be embodied in the product. Although new knowledge is sometimes generated during such a program, it is never the sole objective, and the quest for such knowledge is often a distraction that can delay or can even derail the program. Certainly, there are times when a project team will conclude, as a result of experiments conducted in pursuit of a given TPP, that the objective is not possible at the present state of knowledge—but this usually triggers abandonment of the objective rather than launching of a quest for the missing knowledge, a pursuit that may take years and is generally not compatible with the timelines under which industrial research operates.

To achieve these very different objectives, universities and companies structure their research efforts very differently. Academic biomedical research largely operates on a cottage industry model whose basic unit (cottage) is the individual research group, led by a principal investigator (PI) and composed of graduate students and postdoctoral fellows. This group is largely autonomous and self-sufficient; certainly such groups can engage in collaborations with other groups, especially when they need to employ techniques with which the group lacks expertise. However, such collaborations are usually transient, as the criteria upon which success is judged in academic science focus on the degree of independence and the perception of originality shown by the group’s PI. This model encourages and rewards imagination, ingenuity, and originality—all key aspects of knowledge generation. But it is not designed to convert those new ideas into products. The emphasis on attribution of credit to one individual or group virtually guarantees that most such collaborations will not last long, and is the major cultural force opposing teamwork and shared effort in academic science.

Industrial laboratories are structured very differently: Groups of scientists are assembled from diverse domains to create a project team with all the capabilities needed to achieve the TPP. Such teams can be large, including biologists, biochemists, crystallographers, medicinal chemists, pharmacologists, and (later on) toxicologists. Team composition is fluid, with subteams delegated to solve certain issues while other parts of the team advance their parts of the project. Leadership of a team may change several times during the life of a product; biologists are typically in charge when bioassay development and screening are the main activities, but projects often transition to leaders who are expert in medicinal chemistry when lead optimization is the order of the day. (Once the TPP is preliminarily achieved and proof of efficacy and safety in animals is obtained, projects transition to being directed by clinical investigators, who design and conduct the key clinical trials required for proof of human efficacy and registration with the US Food and Drug Administration [FDA].) Unlike academic science, in which emphasis is on individual achievement, in corporate work the reward is for smooth and efficient teamwork and the early attainment of project goals.

Scientists contemplating a career in industry need to consider the above differences carefully as they make their decision. It is a fantasy of some postdoctoral fellows that a career in industry consists of asking open-ended scientific questions of the type they are accustomed to, without the pesky constraints of having to apply for grants. Nothing could be further from the truth. The decision to opt for a career in industry should be based on an underlying commitment to applying cutting-edge science to the development of effective therapeutics (or diagnostics or preventatives) for human disease. If this is not an interest of yours, don’t even think about applying to an industrial job. Certainly this quest will involve solving many sophisticated scientific challenges along the way, but the resolution of those conundra is, in industry, the means to an end, not an end in itself.

The expression industry scientists use to encapsulate this philosophy is “staying on the critical path.” That is, team scientists can address any and all problems directly related to advancing the project, but must avoid the siren song of interesting issues that may arise that are tangential to said mission. Obviously, judgments about what is and isn’t critical are not always easy, and companies do vary in the latitude they give team leaders to adjudicate such issues. (Small, financially stressed startups are typically much more stringent in their demands that teams stay on a narrowly construed path.) But in no case will a team leader allow such a quest to derail or redirect the entire project away from its therapeutic mission.

In most firms, the bulk of physician-scientists are employed as clinical investigators. While laboratory science training is not essential to being hired into a clinical investigator unit, it remains highly prized in corporate clinical development teams. The reasons are several. First, these individuals often advise preclinical science teams. At the early stages of a project, they supply the clinical expertise needed to help shape the TPP; in many firms, they also consult with the basic science teams as the program matures through hit finding and (especially) lead optimization and selection of candidate compounds for the clinical trials. As such, being at home with the vocabulary and culture of preclinical science is a considerable plus: It allows the physician-scientist to help shape the program at multiple points in its evolution, and avoids potential errors that may arise from miscommunication between laboratory scientists and clinicians. It also helps the clinical team think about what kinds of monitoring the trial will need to implement—often a key step in assuring that the new drug is being dosed correctly in the clinic.

It is important to recognize that if a physician-scientist wants to pursue a career in clinical development, he or she will need to complete not only a primary residency but also training in a subspecialty. Since clinical knowledge is at a premium in this role, it is important for the would-be clinical investigator to have deep roots in a subspecialty; there are few positions available in development organizations for those lacking subspecialty board eligibility. Interestingly, while prior direct experience with clinical investigation is usually a plus, in many companies this expertise can be acquired on the job by those hired into entry-level positions. Obviously, being hired into more senior roles in clinical development organizations does require direct experience with clinical trial organization. Typically, such jobs are awarded preferentially to those who have substantial experience running trials in the industry setting, as leadership positions in this sector of the industry often involve substantial interaction with commercial partners, government regulators, and payers—interactions that are seldom part of an academic career.

Following 7–10 years as clinical investigators, numerous other options usually open up for physician-scientists in clinical development. Because they have acquired extensive experience with the governmental regulatory hierarchy, they often can take leadership positions in divisions of regulatory affairs, the departments in large pharma companies that advise the teams on regulatory strategies. Another well-traveled path for physician-scientists in development organizations is to migrate to senior roles in business development, the branch of companies that deals with in-licensing of novel therapeutics from other firms, as well as mergers and acquisitions of companies. Going down this path usually means forsaking active participation in clinical trials, and learning the vocabulary of finance officers, venture capitalists, and other businesspeople. However, knowledge of science and medicine remains critical here, as every acquisition discussion begins with these questions: (1) How good is the science behind the asset being acquired? (2) Does it address an unmet medical need? (3) How does it stack up against competitor compounds? These are precisely the questions the physician-scientist is in a perfect position to adjudicate.

Surprisingly, in most firms (especially in smaller biotechnology firms), physician-scientists are underweighted in the ranks of preclinical scientists, which are heavily dominated by PhDs in the relevant disciplines (eg, biochemistry, cell and molecular biology, structural biology, immunology, neuroscience, pharmacology, synthetic and medicinal chemistry). Mostly, this is a reflection of the greater numbers of PhDs in these fields but is also partly a reflection of the lesser costs associated with hiring them, relative to MD-PhDs. However, the value of admixing physician-scientists into this early setting has been recognized by several firms, and a few have made it a point to hire biologically and clinically literate physician-scientists into leadership roles in the preclinical research arm of the business. In general, the physician-scientists who have become leaders in preclinical research in pharma companies have tended to enter industry after long and successful careers in academic biomedicine, during which time they not only established deep scientific literacy but also maintained their clinical credentials and interests. The latter are important to companies because, after all, the medicines they make have to fit into the realities of current medical practice. Therefore, a deep awareness of the landscape of current therapy options and their costs/toxicities/ limitations is mandatory, as is a more general fluency with other aspects of contemporary medical practice—for example, the pressures on length of hospital stay, the trends in home intravenous therapy, the roles of antibiotic stewardship, and other regulatory phenomena. Those who abandoned practice soon after their residency do not bring this kind of skill set to the table and are unlikely to be competitive for such top positions.

The above remarks have focused on the goals of industrial science, how they differ from those of university research, and how those differences engender a different research structure and culture in industry. But there is another difference that also shapes the culture inside a firm. In academia, there is no mission other than the generation of knowledge. In pharmaceutical companies, however, the research mission exists side by side with 2 other missions: manufacturing of the drug, and commercialization of the resulting product. These 2 activities are far removed from research and their cultures are not even remotely influenced by academia or by the firm’s own research organization. The manufacturing side is influenced more by traditions that derive from other high-tech manufacturing sectors, including chemical manufacturers, aerospace and computer hardware firms, etc. These traditions involve optimization of synthetic routes, quality assurance, supply chain management, and the cost of goods; these are important issues but have little impact on the environment of the research and development (R&D) operation. The commercial side is even more divergent from the research enterprise, but paradoxically can have a greater impact on its culture. Although its job is to sell the firm’s drugs to physicians and hospitals, which requires some physician input, most commercial leaders have no medical lineage; the culture of commercial units tends to be dominated by ideas emanating from the worlds of finance, sales, and marketing—worlds with which the average physician-scientist is largely unfamiliar (and toward which many are either indifferent or hostile). Wall Street and its imperatives loom particularly large in this critical portion of the industry. Current Anglo-American capitalism is in thrall to the notion that creation of shareholder value is the primary mission of public companies—and shareholder value is inspected on a quarterly basis. This creates a strong push on the commercial side toward rewarding short-term thinking. Since it is the commercial side that generates the profits from which the research budget is derived, in many firms those same short-term pressures can reach down into the research organization and subtly but unmistakably influence research directions and practices. Leaders of the most successful firms have found ways to blunt or mitigate these influences, but the pressure is unremitting and, like the steady drip of water on stone, threatens to erode the will of all but the most resolute of R&D directors. At one extreme, there are firms in which commercial forces almost entirely drive R&D prioritization; such firms tend to have disempowered research operations that grow accustomed to taking dictation from their commercial; over time, such firms have trouble attracting or retaining top-notch scientists. Firms that have been able to separate R&D from commercial units have generally fared better in terms of maintaining the caliber of their research staffs, but often at the cost of inefficient transfer of assets from one part of the operation to the other. How to reconcile these competing forces is one of the least recognized—but most important—unsolved problems in pharmaceutical management.

I dwell on these matters because many of the ancillary aspects of life in industry result from traditions and practices that emanate from the business world, not from science. For example, university researchers are accustomed to tenure, or at least to multiyear commitments or contacts, but these are unknown in industry, where even the most senior researchers (and executives) are subject to annual renewal based on performance. Although between World War II and the 1970s, employment in the pharmaceutical industry tended to be very stable, with solid researchers being able to spend most of their careers at a single company, those days no longer exist; trainees now taking jobs in this sector should expect to work at multiple firms over the course of their careers. In addition to the normal churn caused by individual turnover, firms not infrequently restructure their research priorities, exiting whole areas and entering new ones. When that happens, layoffs of several entire research teams can be the result. The good news is that other firms looking to hire staff generally do not regard such layoffs negatively—they understand that these result from corporate decisions rather than individual shortcomings. In fact, because industry experience is highly prized, those released in such layoffs can often rapidly find new employment if they were in good standing at their prior firm and if the overall healthcare sector is not in recession. When comparing job security in industry with that in academics, it is also well to remember that despite the formal assurances of tenure in university life, loss of grant support usually results in major difficulties maintaining a viable presence on a university faculty, and that opportunities to rescue an academic research career following loss of a university position are few.

I am often asked about work-life balance in industry. It is hard to generalize, since small and large companies face different pressures. Startups in biotech often have limited staffing, with the result that the existing staff must stretch its efforts to get all the requisite tasks done. When crises erupt, such as the need to meet a deadline for a regulatory or patent filing, it is sometimes a matter of “all hands on deck,” whether it is within traditional working hours or not. Larger firms, for the most part, are staffed to avoid these difficulties and there, more predictable work hours tend to be the norm. Considering how many demands are made on one’s time in academic medicine, in terms of teaching, clinical care, administration, and research (not to mention pro bono work like manuscript reviewing), on the whole I think it defensible to say that work-life balance is probably more regularly achieved in industry—although exceptions to this dictum surely exist.

In the past, it has been difficult for academic physician-scientists to interact with their counterparts in industry, save for participating in an industry-sponsored clinical trial at their medical center. However, this landscape is slowly changing, although not always for laudable reasons. In the first decade of this millennium, the view became ascendant on Wall Street and in US business schools that in-house research at Big Pharma companies has little value. This was based on the fact that the sizable escalation of R&D budgets by Big Pharma in the 1990s did not yield a proportional increase in registration of novel drugs with the FDA. Of course, this interpretation is scientifically illiterate; it takes 20–30 years for an initial investment in research to lead to development of a novel drug based on that research [ 6 ]. Moreover, since every success in drug development raises the bar for registration of the next drug in that field, drug development becomes progressively more difficult with time—a paradox that puts the lie to simple-minded thinking about drug pipelines based on other research-intensive fields like computer science or electrical engineering.

Nonetheless, under pressure from Wall Street, many Big Pharma companies have slashed their internal research budgets and drastically reduced their internal research staff. In the belief that true innovation comes only from academia or small biotechnology companies, some of this money has been diverted to those venues. This has contributed to a recent boom in the biotech sector, but has also led some firms to invest in academic–industry partnerships. These take many forms, but usually involve grants to individual PIs or groups of PIs. These awards are welcome in academia in times of tight federal grant support, but they rarely result in true partnerships between university scientists and their industry counterparts, in no small measure because of the huge differences in research goals, structures, and culture mentioned at the beginning of this article. On top of those issues, firms can rarely afford to allow mission-critical work in their fields to go on in settings outside of their control, since they would lose intellectual property rights that will be essential to commercialization. As a result, the academic work they fund tends to be rather basic and not immediately related to drug development. This is fine, but academic scientists should not expect that by entering into such agreements they are going to be able to experience what industrial science feels like without having to leave the university. However, such industry-academic contact may provide a venue for academic scientists to get to know some of their peers behind the industrial veil, as firms often make certain technical capabilities (eg, high-throughput screening, metabolomics, or pharmacokinetics) available to their academic partners on a limited basis, as appropriate to their projects.

Training as a physician-scientist opens the door to a plethora of different opportunities in industry, many of which offer unique opportunities for professional advancement and career satisfaction. But it is imperative that those electing this option understand that they are entering a world with very different predicates and goals from the one in which they trained. Careful consideration of those differences in advance can usually lead physician-scientists to an informed decision that will fit well with their own talents and aspirations.

Supplement sponsorship.  This work is part of a supplement sponsored by the Ragon Institute of MGH, MIT, and the Harvard University Center for AIDS Research P30 AI060354.

Potential conflicts of interest.  D. G. is an employee and shareholder of Novartis. The author has submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.

Milewicz DM , Lorenz RG , Dermody TS , Brass LF ; National Association of MD-PhD Programs Executive Committee . Rescuing the physician-scientist workforce: the time for action is now . J Clin Invest 2015 ; 125 : 3742 – 7 .

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• v.29(8); 2018 Apr 15

Is an MD/PhD program right for me? Advice on becoming a physician–scientist

We are living in a golden age of biomedical research in which it is increasingly feasible to translate fundamental discoveries into new diagnostic and therapeutic approaches to human illnesses. Inherited diseases are being cured with gene therapy. Cancer cells are being eliminated with less toxic small molecule inhibitors and reengineered T-cells. Direct connections are being made between the central nervous system and prosthetic devices. These efforts are being led by scientists and engineers, some of whom are also physicians. This article is intended to help anyone considering a career as a physician–scientist, but unsure about how best to begin. It is also intended for faculty, staff, and parents who are on the front lines of advising talented students about the options that they have for their future. With this in mind, I have tried to answer common questions about MD/PhD programs, but I have also included information about other paths to becoming a physician who does research.

INTRODUCTION

Because this is a perspectives piece, I will begin it with a confession: I have been a physician–scientist for more than 30 years and I like what I do. I am also a graduate of one of the earliest MD/PhD programs and have been director of the University of Pennsylvania’s MD/PhD program for 20 years. Being a physician who is also a scientist already makes me atypical. According to the American Medical Association, only 14,000 U.S. physicians (out of nearly 1 million) consider research to be their major job, and a search of National Institutes of Health (NIH) databases in 2012 turned up only 8200 physicians who were principal investigators on NIH research grants ( Ginsburg et al. , 2014 ). To put that number in context, there were 28,000 total investigators with NIH grants in 2012. In other words, most NIH principal investigators are PhD scientists, not physician–scientists (MD or MD/PhD).

My primary day (and sometimes night and weekend) job as a card-carrying physician–scientist is overseeing an NIH-funded research team. My clinical responsibilities include taking care of patients with the kinds of bleeding and blood clotting disorders that we study in the lab. Some of these patients have medical problems that are common in the United States. Some of them are true “zebras,” the kinds of patients who get referred to a well-respected academic medical center because physicians are unsure how best to proceed or lack the resources to manage the patient’s problem. I also teach medical students and graduate students, and I direct a very large MD/PhD program. In my spare time, I talk to lots of undergraduates and recent college graduates who are thinking about becoming physician–scientists and wondering whether they should be applying to MD/PhD programs. I meet them at Penn, but also on visits to other colleges and universities. This article is a distillation of some answers to questions that I am commonly asked. If you are an undergraduate trying to decide whether to go to medical school, graduate school, or both, this article may help you. Whatever you decide, I wish you success.

WHAT IS THE PURPOSE OF MD/PhD TRAINING?

MD/PhD programs were established in the 1950s to combine training in medicine and research. They were specifically designed for men and women who wanted to become research physicians, also known as physician–investigators or physician–scientists. Most of the graduates of MD/PhD programs in the 60-plus years since then have become faculty members at medical schools and universities, investigators at research institutes such as the NIH, or leaders in in the pharmaceutical and biotech industries ( Brass et al. , 2010 ). Regardless of where they eventually end up, MD/PhD trainees are being prepared for careers in which they will spend most of their time doing research or translating that research into new therapeutic and diagnostic approaches. It is a busy, challenging, and hugely rewarding career. A study of what has happened to MD/PhD program graduates from 24 schools appeared in Academic Medicine in 2010 and is worth reading not only for the data set, but also for the discussion of what the data mean ( Brass et al. , 2010 ). An even larger outcomes study that includes data on over 10,000 MD/PhD program graduates is scheduled for publication as a AAMC report in April 2018 ( Akabas et al. , 2018 ).

HOW CAN ONE PERSON DO TWO JOBS?

When I was an undergraduate and trying to decide what to do with my life, my mentors told me that I could become a doctor or a scientist, but that trying to combine two busy professions was futile. Many years later, I know that many current undergraduates are being told the same thing. However well-meant, that advice misses the point. The goal of MD/PhD program training is not to prepare you for two unrelated full time jobs. Instead, you should think of physician–scientists as chimeras—blends of a physician and a scientist with the two parts fitting closely together. A more relevant question is: if you are going to become a physician–scientist, do you have to go through an MD/PhD program? I will try to answer that one a bit later in this article. First, I’ll provide some definitions.

WHAT IS THE DIFFERENCE BETWEEN AN MD/PhD PROGRAM, A COMBINED DEGREE PROGRAM, AND AN MSTP PROGRAM? A BIT OF HISTORY AND A WORD ABOUT FUNDING

None. Programs designed to train physician–scientists go by all of these names. For the most part, the terms are interchangeable, although at some schools “combined degree” programs can include MD/JD and MD/masters programs as well—also VMD/PhD programs, which train veterinary physician–scientists. A list of MD/PhD programs can be found at http://www.aamc.org/students/research/mdphd/applying_MD/PhD/61570/mdphd_programs.html . The NIH uses the term MSTP (short for “medical scientist training program”) to refer to programs at schools that have been competitively awarded special training funds to help support MD/PhD candidates. There are currently 46 MD/PhD programs that receive support from the National Institute of General Medical Studies. A list can be found at http://www.nigms.nih.gov/Training/InstPredoc/PredocOverview-MSTP.htm .

When they first started, there were only a handful of MD/PhD programs. I can clearly remember reading a small booklet about applying to medical school that had a single page at the back about MD/PhD programs. Over time, the number of programs has grown. Now there are ∼90 active MD/PhD programs that admit anywhere from a few students per year to 25 or more. The average size of an MD/PhD program in 2017 was ∼90 students in all stages of training. Compared with the many thousands who apply to medical school in each year, only 1900 (∼3%) apply to MD/PhD programs. About one-third of the applicants are accepted, which is similar to the acceptance rate for medical school. 1 When I began medical school, there were very few MD/PhD trainees—I was one of two in my entering class. That has changed considerably. There are currently ∼5500 men and women in training in MD/PhD programs.

Most MD/PhD programs provide tuition waivers for both medical school and graduate school plus a stipend to help cover living expenses. Such fellowships are exceedingly valuable for trainees and very expensive for medical schools and the NIH, so admissions committees work hard to pick the right students for their programs. Despite the high training costs, when I visit other MD/PhD programs to conduct reviews, it is not uncommon to hear deans refer to their MD/PhD program as “the jewel in the crown.” One can easily argue that the existence of MD/PhD programs is evidence of the high value that our society places on physician–scientists.

ARE MD/PhD PROGRAMS LIMITED TO THOSE INTERESTED IN LABORATORY RESEARCH?

The answer varies from school to school. Not all schools offer PhD programs in all disciplines. The majority of MD/PhD students receive their PhD in biomedical laboratory disciplines such as cell biology, biochemistry, genetics, immunology, pharmacology, neuroscience, and biomedical engineering. The names of departments and graduate programs vary from school to school. At some schools, MD/PhD trainees do their graduate work outside of the laboratory disciplines, in fields such as economics, epidemiology, health care economics, sociology, medical anthropology, or the history of science. This is not an exhaustive list, and you should check before you apply to see what is actually offered at any particular school.

Although there is no fully up-to-date and reliable list of which MD/PhD programs offer training in which graduate disciplines, a place to start is at the Website of the AAMC MD/PhD section (which is a good source for other types of information as well). 2

ARE THERE OTHER WAYS TO BECOME A PHYSICIAN–SCIENTIST?

Yes. Definitely. MD/PhD programs are a great choice for people who decide early that that they want to be physician–scientists and have built the necessary track record of academic success and research experience before they apply. Not everyone does this, however, either because he or she did not learn about the option early enough, he or she did not make a decision in time, or he or she does not have an academic and research experience record that supports an application. Not finding out early enough turns out to be a common problem. In my experience, college prehealth advisors know much less about MD/PhD training than MD training—not surprisingly, since only 3% of medical school applicants in the United States every year apply for MD/PhD training. As a result, some people choose (or are obliged) to do MD/PhD training in series, rather than parallel—finishing one degree and then starting the other. The disadvantages of this approach include taking longer to finish training and the likely need to cover the cost of medical school on your own.

I am frequently asked about the strategy of starting medical school and then applying to graduate school as a medical student. Some schools will consider you for transfer into their MD/PhD programs after you have completed a year or two of medical school or graduate school at the same university. Although it is very rare that an MD/PhD program will consider accepting a medical or graduate student from a different school, it does occasionally happen when faculty move from one institution to another and want to bring their students with them. The rules and requirements vary from school to school.

Other programs worth checking out include the NIH MD/PhD program that provides support for the PhD phase at the NIH campus or in Oxford/Cambridge, with the MD training taking place at one of the participating MSTP-designated programs. Note that not all of the MSTP programs have chosen to participate, so if you have your heart set on a specific medical school, you should be sure to ask. 3

Another option is to complete medical school and residency training before doing an extended period of supervised research. A number of Nobel Prize–winning physician–scientists did just that. However, with the increase in the number of MD/PhD training programs nationwide, most people who make the decision to become physician–­scientists while still in college should think hard about doing both degrees together in an integrated MD/PhD program that combines graduate school and medical school into a joint program that currently takes 8 years on average to complete ( Akabas et al. , 2018 ).

DO I REALLY NEED A PhD TO DO RESEARCH? CAN I SAVE TIME BY SKIPPING IT?

The answer to the first of these questions is “Clearly not.” However, while medical school will put you firmly on the path to becoming an accomplished clinician, it does not provide training in how to do research. At some point you will benefit from that additional piece of your education if you intend to become a physician–scientist.

As noted above, in years past it was not uncommon to learn how to do research by doing an extended postdoctoral fellowship after (or instead of) a clinical residency. I am often asked whether it is possible to save time on the path to becoming a physician–scientist by skipping graduate school and just going to medical school. The available data suggest that the answer to this one is “No.” Physician–scientists get their first jobs in academia and their first independent NIH grants at approximately the same age regardless of whether they completed an MD/PhD program or went solely to medical school and then did a more extended postdoc ( Ginsburg et al. , 2014 ). As a result, I normally tell undergraduates that if they are ready to make the commitment before starting medical school, MD/PhD programs offer many advantages, including integrated training, mentored research training, and medical school tuition waivers. On the other hand, if you are sure you want to be a doctor, but less sure about being a scientist, then my advice is to go to medical school and figure out the rest of what you need when you know more about the opportunities that being a physician provides.

HOW DOES MD/PhD TRAINING WORK AND HOW LONG DOES IT TAKE?

The answer varies from school to school, but historically students begin with 2 years of medical school, switch to graduate school in the third year of the program, and then return to finish medical school after completing (and defending) a thesis research project. When I was an MD/PhD student in the 1970s, there was little, if any, communication between the medical and graduate phases of the program. That has changed considerably. Now most programs emphasize integration of the MD and PhD parts of the training, with graduate school courses during years 1 and 2 and clinical experiences during graduate school. Some programs allow completion of 3–12 months of clinical training before the start of full-time graduate training. Be sure to ask how things are organized at schools that you are considering. In programs leading to a PhD in laboratory science, MD/PhD trainees usually spend the summer between the first and second years of medical school working in the laboratory of the faculty member they are considering as a potential thesis advisor. Some programs also ask students to do one of these “lab rotations” in the summer before starting medical school classes as well. Depending on the number of clinical months completed before starting the thesis research, students returning to medical school will need 1–2 years to finish their training and meet the requirements for medical licensure. The stated goal is to complete an MD/PhD program in 7 or 8 years. However, numbers from across the country show that some students finish in 6 years, while others take 10 years (or more). The average currently is 8 years ( Akabas et al. , 2018 ). Note that medical education in the United States continues to evolve. One trend is away from the classic two years of preclinical education followed by 2 years of clinical education. The earlier start in clinical training made possible by shortening preclinical time enables some MD/PhD programs to offer full-time clinical experiences before the start of graduate school. However, some schools are choosing not to do this. The only way to find out what is being done is to ask, if it is not evident from the program’s Website.

HOW LONG DOES IT TAKE TO COMPLETE TRAINING AFTER GRADUATING FROM AN MD/PhD PROGRAM?

Corny as this may sound, the process is never really finished. Your education will continue throughout your career. A more pragmatic answer is that training will extend beyond medical school and graduate school as you complete your post graduate education. Here are some typical numbers: MD/PhD program, 8 years. Residency, 3–6 years. Postdoctoral fellowship, 3–6 years. For most people the term “postdoctoral fellowship” includes another year or two of clinical training, followed by a return to research for 2 or more years ( Figure 1 ). For example, I completed an MD/PhD program in 6 years, followed by a residency in internal medicine (3 years) and a fellowship in clinical hemato­logy and oncology that was combined with postdoctoral training back in a lab (3 years). After that I became an assistant professor and started my own lab. That timing was fairly typical when I did it. Now it would be considered fast. On the other hand, my job description when I finished included running a research team, looking after postdocs and graduate students, and taking care of sick people with complicated medical problems, so maybe all of that training time was necessary.

Paths to becoming a physician who is also a scientist. Integrated MD/PhD training programs that combine research and medical training are not the only path to becoming a physician–scientist. Alternatives begin with doing a research year in medical school (MD+ in the figure) or just doing the standard four-year medical school education. These save time at the start, but usually require a longer period of postgraduate clinical and research training to reach the point where a job as a physician–scientist in academia becomes feasible. As a result, physician–scientists often arrive at the “get a job” point at about the same age whether they began as medical students, MD+ students, or MD/PhD students, although usually with greater student debt if they have not been in an MD/PhD program. See the text for details.

WHAT HAPPENS TO THE GRADUATES OF MD/PhD PROGRAMS?

Short-term, nearly all do additional clinical training. Those who do not are usually headed toward careers at research institutes or outside clinical medicine entirely. Those who do apply for residencies often find that their MD/PhD training makes them particularly appealing to residency programs at top institutions. Long-term, most program graduates end up with careers in which they combine patient care and research. The research may be lab-based, translational, or clinical. Most (75–80%) end up at academic medical centers, at research institutions such as the NIH, or in the pharmaceutical/biotech industry ( Figure 2 ; Brass et al. , 2010 ; Akabas et al. , 2018 ). A much higher percentage of MD/PhD program graduates have ended up in academia than of medical school graduates in general ( Brass et al. , 2010 ). Those who build research careers and apply for NIH research grants find that having the PhD in addition to the MD improves their chances of obtaining funding ( Ginsburg et al. , 2014 ).

Where are they working? Data from 2202 MD/PhD program alumni who have completed all phases of postgraduate clinical and research training. Adapted from Brass et al. (2010) . Industry includes the biotech and pharmaceutical industries. Pvt Practice refers to full-time clinical practice outside of an academic medical center.

HOW DO I APPLY?

The process of application varies from school to school. Some schools have an MD/PhD-focused committee that will screen your application and coordinate the interview and admission process. Other schools consider MD/PhD applicants only after a decision has been made about MD admissions. Finally, some schools consider students for the MD/PhD program only after they have completed a year or more of medical school. Schools that subscribe to AMCAS will ask you to indicate your interest in an MD/PhD program and then to provide additional information as part of a secondary application.

WHEN DO I APPLY?

Most people apply after finishing their junior year in college, but a growing number of applicants finish college and work for a year or more before applying. Some people use the time after college to take courses needed for medical school admission or to gain more full-time laboratory research experience. Some people simply were not ready to make decisions about their future careers and postponed choosing beyond the finish of college. It is a mistake to assume that MD/PhD programs are interested only in applicants who have worked in a lab for a year or more after college. That is clearly not the case, and some of us who direct MD/PhD programs are concerned about the growing percentage of applicants who have waited to apply after they graduate in the mistaken impression that it will improve their resumes. My advice is that for a training path that lasts as long as this one does, it is best to get started as soon as possible.

WHAT DO ADMISSIONS COMMITTEES LOOK FOR?

The answer clearly varies from school to school, but some basic principles apply. In general, admissions committees will look for evidence of academic success, extended research experience, letters of recommendation from people who know you well, and your plans for the future.

• Evidence of academic success. This includes your GPA and MCAT scores, but is not limited to them. Admission committees use a holistic approach and will undoubtedly consider where you went to college and what types of courses you took. They will not necessarily be dismayed if you got off to a slow start, as long as you did well later. They will place the greatest emphasis on courses that are relevant to your chosen area of graduate school training. I have not encountered a program director who seriously believed that the MCAT tests your ability to be a physician–scientist. Nonetheless programs use MCAT scores in a variety of ways, including seeing how you compare with the national pool of applicants and predicting how you will do on the numerous standardized tests that all of us have to take in medical school and beyond.
• Extensive research experience. If you plan to get a PhD in one of the laboratory sciences, then prior laboratory experience counts heavily, particularly if you spent a year or more in the same laboratory. Summer laboratory experience can be helpful because they are usually opportunities to do research full time, but summers are short. Whenever possible, you should try to do research during the academic year, or at least spend multiple summers in the same lab. If you are planning a PhD outside of the laboratory sciences, seek equivalent experiences. The idea is to be sure you like the experience and to create a track record upon which your past performance can be judged and your future success predicted.
• Letters of recommendation. The most important letter(s) are from the faculty members or other senior investigators with whom you worked. The letters should ideally comment on your talents, skills, and potential for success as an independent investigator. If you are working with a senior faculty member, it is very helpful if he or she can compare you with other students with whom he or she has worked. Note that such a letter is not necessarily the most appropriate for an MD-only application. MD/PhD program admissions committees are usually most interested in your talent and ability as a physician–scientist, although they will definitely also consider whether you are likely to become a successful and caring physician. Fortunately, medical schools allow you to submit more than one letter of recommendation.
• Your plans for the future. Because training to be a physician–­investigator is so costly in terms of your time and the school’s resources, your career goals should be compatible with MD/PhD training. Becoming a full-time practitioner is a laudable goal, but does not require a PhD in addition to an MD. Your goal as a trained physician–investigator should be to spend at least 75% of your time on research. You do not need to know the specific problem you want to work on at this point (many do not, and it is likely to change), or with whom you would like to train, but your commitment to becoming an investigator should be clearly communicated in your essays and interviews, and you should have given thought to what will be required.

HOW DO I DECIDE WHERE TO APPLY?

Some applicants have decided that they want to work in a particular field or with a particular faculty member. For them, choosing where to apply is defined by where that faculty member works or where the field is best represented. Most applicants have only a general idea of what they might want to work on in the future and know that their interests are likely to evolve as they are exposed to new things. For them, choice will be defined by issues such as the reputation of the school (hopefully not based solely on U.S. News and World Report rankings!), the success of the graduates of the program (be sure to ask!), and geography. Schools vary in the difficulty of gaining admission. The directors and nonfaculty administrators of MD/PhD programs nationwide are a large pool of resources that you can tap. Most of us get e-mail from future applicants all the time. Take advantage of our willingness to talk with you. Ask questions about the things that are important to you.

FINAL THOUGHTS

I began this perspective with the confession that I am a physician–scientist and I like what I do. It is not unusual these days to encounter articles and opinion pieces that lament the difficulty of becoming and remaining a physician–scientist. I will not cite them here—you can find them on your own. Fortunately, our society is still willing to make a large investment in biomedical research through the NIH and through numerous foundations. If you want to become a physician who discovers the new stuff, there are jobs waiting to be filled. However, you will need good training and great mentorship as you learn the skills needed to be a physician and a research team leader. Good luck with your decision.

Acknowledgments

My thanks to my colleagues who direct MD/PhD programs, the NIH for supporting physician–scientist training (including my own), and the hundreds of MD/PhD candidates and alumni who have taught me so much over the past 20 years.

Abbreviations used:

DOI: 10.1091/mbc.E17-12-0721

1 www.aamc.org/data/facts/enrollmentgraduate/ .

2 www.aamc.org/students/research/mdphd/ .

3 http://mdphd.gpp.nih.gov .

• Akabas MH, Tartakovsky I, Brass LF. (2018). The National MD–PhD Program Outcomes Study. American Association of Medical Colleges Reports.
• Brass LF, Akabas MH, Burnley LD, Engman DM, Wiley CA, Andersen OS. (2010). Are MD–PhD programs meeting their goals? An analysis of career choices made by graduates of 24 MD–PhD programs . Acad Med , 692–701. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Ginsburg D, Shurin SB, Mills S. (2014). NIH Physician–Scientist Workforce (PSW) Working Group Report. [ Google Scholar ]

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MSTP student thinking of industry

• Thread starter Mud
• Start date Apr 2, 2013

Full Member

• Apr 2, 2013

obscurehero

• Apr 6, 2013

I actually have a question for you, if you feel like answering. Why do you need to continue your clinical training to work in pharma? You're already a good 3-5 years into your graduate training and you want to add another 8-10 years? I guess from everything I've heard, you could do a post-doc and transition into pharma quite nicely. Why wait so long?  

To the above, the MDs and the PhDs have very different roles during the drug development process. MDs actually administer medications, manage side effects, and do history and physical during the intake process -- i.e. act like a doctor. This is why often specialty/sub-specialty clinical training is necessary for this kind of a job. Most certainly needs a medical license. PhDs generally do the preclinical design/animal model development aspects as well as the data analyses aspects, but the MDs can do that as well. The salary level for the MD research clinicians is considerably higher (as they have to match the salary level for outside MD clinical jobs) and there is more promotion room for MDs IMHO to management. While pharma "outsource" clinical trials to CROs, they still need to hire MDs. This route is always gonna be there. However, you have to realize that this route has its own issues, including the lack of professional autonomy, lack of a scientific community and transparency, and possible bottleneck for promotion. You'll be answering to superiors who have ZERO scientific training and it can be very discouraging. And the salary isn't necessarily higher, depending on the clinical specialty. For the original poster, the answers you are looking for aren't necessarily easily answered by people on this board, who are much more informed about a career pathway in academia. I would recommend you to talk to people in your department who had successfully navigated an industry transition. Aside from going directly into industry via the clinical investigator route during trials, if you are just strictly more interested in the business side of things, there are also other paths that you might want to consider, such as MD/PhD->no residency->equity research/ibank->pharma business development or MD/PhD->management consulting -> lifesciences VC/PE, MD/PhD -> postdoc-> lifesciences startup, etc. For each of these pathways, if you are interested the best way is DIRECTLY contact the principles involved in that specific instance. For instance, if you have a decent set of credentials as an MD/PhD graduate, you can directly pitch yourself to a lifesciences startup as long as you believe your experience and training somehow fit into their broad vision. Also, realize that NONE of these things are necessarily better in many aspects compared to research +/- clinical care (i.e. the classic 80/20 model). While the NIH is clamping down on funding medication trial per se, a straight drug trial is boring anyway, and they ARE still interested in developing novel trial techniques and personalization, biomarkers, longitudinal studies, combination strategies, etc. etc. Did you know that HALF of NIH's budget is devoted to clinical research? Don't be blindsighted by the fact that everyone you know does bench research and that it's insanely competitive. It's still very much feasible to survive in academia as a clinical investigator and a clinical trialist. In the private world, you do whatever the CEO says. Are you ready for that kind of life where you sit in a cubicle for 5 years waiting for your next promotional review by a committee of salesmen? That was what I gathered after investigating some of the situations in the banking world. I said hells no. I'd rather do 100% private practice than THAT. There is a reason why tippity top people stay in academia, and it's not all just inertia. Be very very careful. Talk to lots of people before labeling yourself as destined this or that.  

MSTP Director

The MD/PhD contacts in industry, all of them, did clinical residency, even those doing R&D.  

• Apr 7, 2013

I have a follow-up question. If you're seriously considering industry, when in your career path do you make the jump? It seems that all the MD/PhDs in industry I know did this: MD/PhD -> residency -> fellowship -> instructor/postdoc -> assistant professor -> full professor x 5-10 years -> industry -> return to academia (where I met them) It seems that if you want to do industry, that's not a very direct way to get there at all.  

No Meat, No Treat

debateg said: I have a follow-up question. If you're seriously considering industry, when in your career path do you make the jump? It seems that all the MD/PhDs in industry I know did this: MD/PhD -> residency -> fellowship -> instructor/postdoc -> assistant professor -> full professor x 5-10 years -> industry -> return to academia (where I met them) It seems that if you want to do industry, that's not a very direct way to get there at all. Click to expand...

obscurehero said: I actually have a question for you, if you feel like answering. Why do you need to continue your clinical training to work in pharma? You're already a good 3-5 years into your graduate training and you want to add another 8-10 years? I guess from everything I've heard, you could do a post-doc and transition into pharma quite nicely. Why wait so long? Click to expand...

gutonc said: There are a fair number of 1-2 year drug dev fellowships out there that are generally done near/at the end of a fellowship (I'm an oncologist so I only really know about that specific approach). It's a pretty good way to get a view of industry while still having the opportunity to go back to academics if you want. I have a few friends who have done them and have gone all directions afterwards (industry, academics and PP). Click to expand...

debateg said: Thanks, that's useful information. Do you know of any starting point to find such fellowship? I can find fellowship for PhDs applying as a postdoc, but I can't seem to find much for clinical fellows that are receiving clinical training at an academic institution. Click to expand...

Thanks for the replies everyone. Still so much to learn... That said, I'd rather keep things on the academia side of things anyway so this of less concern to me.  

Dear all, OP here. I'd like to thank you all for your input. Obscurehero: As several posters mentioned in the thread, I want to do residency since it will allow me to do clinical work and increase the value I am bringing to the table. I do like patient contact, and I am trying to find a way to integrate patient care with scientific pursuit. This approach seems like the ideal use for a dual degree. Sluox: I will carefully look at this. I like the idea of drug trials, and I had assumed that they were done pretty much entirely through industry. I had also been concerned about being able to get funding, so I was very interested to hear that the NIH devotes so much to clinical trials. I am still interested in industry, but I will be careful to make sure I know the good and the bad before committing to anything. Thank you Fencer, Sluox and Gutonc for your information and replies. Mud  

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