The Need for More M.D.-Ph.D. Hybrids, and What Colleges Are Doing About It

Back in 1979, The New England Journal of Medicine warned of a crisis: The ranks of physician-scientists — typically, holders of both an M.D. and a Ph.D. — were fast shrinking, threatening science’s ability to translate basic discoveries into actual cures.

Some 37 years later, the warnings are still coming. They might have even intensified.

The same challenges that existed back then still loom now. Training for two graduate degrees takes extra time and money, and institutions and funders offer too little guidance and coordination to help students make it through.

New developments have helped compound those problems. The knowledge required of physicians and researchers has only grown more complex. Meanwhile, growing tuition costs have encouraged medical students to pursue specialization and billable hours rather than multifaceted expertise and grant competitions.

This “depressing set of trends” has left the nation seriously deficient in physician-scientists, the director of the National Institutes of Health, Francis S. Collins, told his advisory committee last month. The government could help by directing more grant money toward young physician-scientists, he said. But the bigger problem, he said, may be universities’ clinging to outdated and inefficient models for producing such scholars. “We’re losing the battle,” Dr. Collins lamented.

At first glance, the numbers give little cause for alarm. The nation’s annual output of combined M.D.-Ph.D. graduates has risen steadily since 1982-1983, when the Association of American Medical Colleges began tallying figures. It identified 133 such scholars at the time; in the past academic year it counted about 600.

But that’s only a piece of the picture. Many physicians without Ph.D.s play valuable research roles. The time they spend on research versus patient care is not well documented, and it is widely feared to be declining.

“It’s not as easy as tracking straight Ph.D.s, and where they end up and how they’re trained,” said Freddy T. Nguyen, a postdoctoral research associate in chemical engineering at the Massachusetts Institute of Technology who founded of the American Physician Scientists Association.

At least a couple of major points are clear. One is that over the past 20 years, NIH grant awards to researchers with a Ph.D. have grown most years, while grant awards to those with an M.D. or a combined M.D.-Ph.D. have held flat.

The other is that it now takes students longer to earn an M.D.-Ph.D., which means the payoff is delayed. The average length of time to complete an M.D. degree is four years, while the average for an M.D.-Ph.D. now exceeds eight, according to the medical-colleges association. That average has risen from about 6.5 years back in the 1980s, due largely to increases in the Ph.D. portion, as scientific discovery grows ever more complicated, Dr. Nguyen said.

That longer time frame is a clear discouragement to M.D.-Ph.D. hopefuls, said Hannah A. Valantine, a professor of medicine at Stanford University who now serves as chief officer for scientific work-force diversity at the NIH.

Dr. Valantine has a daughter seeking an M.D.-Ph.D. at Stanford. The professor fears that her daughter often repeats course material she took as an undergraduate at Yale. Dr. Valantine also has a more-personal concern: that eight to 10 more years of schooling may cost her a chance at becoming a grandmother.

“So I’m here to fix this problem,” said Dr. Valantine, her voice cracking with emotion, to Dr. Collins and his advisory panel. “This is more important than the diversity problem, I’m sorry,” she said, referring to her own efforts to boost minority representation in medical science.

Following a ‘Passion’

Shortening those educational times has become a major focus of some institutions. Dr. Collins highlighted an effort at the Cleveland Clinic, which has established a program within the medical school it runs with Case Western Reserve University that is specifically designed to produce physician-scientists — but without the Ph.D.

Case Western and the Cleveland Clinic offer a traditional M.D.-Ph.D. program covering about eight years, but the alternative takes just five. It produces M.D. graduates who have a master’s degree in a research field or a more abbreviated version of researcher training.

The program gives students the “extra flexibility to choose the field of our passion,” said W. Alexander Cantrell, a student now in his second year in the program at the Cleveland Clinic Lerner College of Medicine.

Along with their M.D. training, Mr. Cantrell and his classmates complete a yearlong research project “run exactly like a master’s-level research project,” said James B. Young, executive dean of the Lerner College.

Those specializations include traditional basic research, biomedical ethics, a master’s in public health, and even a master’s in business administration, Dr. Young said.

Mr. Cantrell has chosen orthopedic surgery. One of his projects involves collecting data on patients to help predict which are more likely to need surgery. Mr. Cantrell said he found the Cleveland Clinic program helpful in clarifying his career path because of the early opportunity it gives students to mix clinical and research work.

“It’s most important to wed research and medicine together,” Mr. Cantrell said. “It’s supposed to be a collaborative effort.”

Dr. Collins is cheering it on. At a time when online education allows for wide experimentation in formats, rigid eight-year M.D.-Ph.D. programs seem “crazy” and outdated, he told his advisory group. The Cleveland Clinic example is a case of “trying to blow thing up and start over,” he said.

A Competitive Advantage

Less clear, though, is whether the Cleveland Clinic option is truly replicable. The Lerner College provides full tuition — worth about $120,000 per student per year — to annual classes of 32 students.

That assistance is important. Federal grant support covers educational costs for most Ph.D. students and M.D.-Ph.D. students, but those seeking only an M.D. typically have to cover their own school bills. The median education debt for an M.D. student is about $180,000, according to NIH figures.

Still, many other medical schools in the United States could create something similar to the five-year Cleveland Clinic option, Dr. Young said. He acknowledged, however, that the program is still new enough — the first five-year class began in 2004 — that it’s too early to have strong data on long-term outcomes.

Stanford, which has both a traditional four-year medical school and a seven-and-a half-year M.D.-Ph.D. route, is working on plans to give the M.D. students more research options short of a Ph.D., said Lloyd B. Minor, dean of medicine there.

Many of Stanford’s students are already doing that on their own. One M.D.-Ph.D. candidate, Steven A. Sloan, estimated that about half of Stanford’s M.D.-only students already add a fifth year to include some research training. Those students do not intend to become researchers, Mr. Sloan said; they’re seeking a competitive advantage in winning admission to a residency program.

Still, Dr. Minor said, M.D. students who gain even a year of research experience are valuable to the nation’s scientific enterprise. They often become physicians who are eager and able to run clinical trials.

Rethinking the Standard Path

The biggest decline among physician-scientists has come among “late bloomers” — students who choose a research path late in their training or even after medical school, Dr. Nguyen said. In those cases, financial challenges are the most likely factor, as debt-ridden graduates are forced to focus on their clinical practices, he said.

The backgrounds and goals of medical students are becoming more diverse, Dr. Minor and Dr. Nguyen said, so it’s unlikely that universities could simply make M.D. programs faster by cutting courses.

But the traditional pattern of the M.D.-Ph.D. pathway — two years of medical school, four years of researcher training, then two years of clinical training — could be rethought, Dr. Nguyen said. Moving the Ph.D. training toward the end of the clinical experience, for instance, might produce graduates with a stronger sense of their research interests and priorities, thereby helping direct the greatest resources to the most promising candidates, he said.

Mr. Sloan, for his part, questions the wisdom of creating too many alternatives to the M.D.-Ph.D. pathway. He is now in the seventh year of his M.D.-Ph.D. program, with a concentration in neuroscience, and has seen that everyday life can continue amid the grind. Cutting back on the research training, Mr. Sloan said, would probably leave graduates struggling to compete with Ph.D.-level counterparts for grant support in a tight environment.

The slog of an M.D.-Ph.D. program “kind of selects for those people who are in it for the long run,” Mr. Sloan said. As for the possibility of the nation losing talented physician-scientists just because of the commitment it requires, Mr. Sloan is not especially worried. “I’ve thought about that a lot,” he said, “and I’m just not convinced that that’s the case.”

Paul Basken covers university research and its intersection with government policy. He can be found on Twitter @pbasken, or reached by email at paul.basken@chronicle.com.