MD/PhD Programs—A Call for an Accounting

In 1964, the legendary director of the National Institutes of Health (NIH), James Augustine Shannon, convinced Congress to authorize the creation and funding of the Medical Scientist Training Program (MSTP).¹ Following peer review, the first awards were made to 3 academic medical centers. The goal of the MSTP was (and is) to encourage training of physician-scientists by providing NIH funds to institutions and by offering full scholarships to a small group of unusually committed medical students interested in pursuing MD and PhD degrees in parallel.

From this seed, a large forest has grown. Today, 40 MSTP programs at 45 degree-granting institutions are funded by the NIH.² Even more notable, about 75 additional medical schools have MD/PhD programs self-funded from a variety of institutional sources.³ Thus, almost all allopathic medical schools in the United States have dual-degree programs. These programs were meant to be small and elite, and they remain so. Currently, about 3% of all US medical students receive dual degrees at commencement annually (500 of 16 000 newly minted physicians). At any one time there are about 3600 MD/PhD students in US medical schools and academic health centers.

In this issue of JAMA, Andriole and colleagues⁴ report on the career intentions of MD/PhD graduates of US medical schools during the 7-year interval from 2000 through 2006. They found certain characteristics that distinguished dual-degree graduates from the much larger pool of those receiving an MD only. Four characteristics stand out: dual-degree recipients had lower educational debt, higher receipt of medical school scholarships and grants, greater planned career involvement in research, and less demographic diversity (ie, fewer women and members of underrepresented minorities).

The study by Andriole et al raises many more questions than it answers. Do their findings concur with or differ from earlier studies of career intentions? What is the relationship (for dual-degree recipients) between career intentions at graduation and subsequent career performance, accomplishments, and evolution? Does physician sex impinge on the career plans and performance of dual-degree recipients? Given that the NIH spent about $42 million on the MSTP in fiscal year 2007, an investment far exceeded by that of the grantee institutions (Bert I. Shapiro, PhD, Program Director, Medical Scientist Training Program, National Institute of General Medical Sciences; written communication, August 7, 2008), is the United States receiving good value for its money?

First, it is unknown whether the career intentions of students surveyed between 2000 and 2006 differ from those of prior MD/PhD cohorts, because there has been no regular survey of prior cohorts. Graduating medical students have been completing the graduation questionnaire prepared by the Association of American Medical Colleges since 1978, but previous results have not differentiated MD/PhD program graduates from those obtaining the MD degree only. Such comparisons would be important in developing projections of the needs of the medical research workforce, particularly given the changing demographics, goals, and specialty choices of today's young physicians.

Second, no reliable database exists to track what dual-degree recipients do with their careers, as contrasted with what they say they intend to do. The only comprehensive national survey of the careers of MSTP graduates was conducted by the National Institute of General Medical Sciences (the NIH institute sponsoring MSTP programs from their inception) and Vanderbilt University and reported in 1998.⁵ The report, which focused on MSTP cohorts enrolled between 1970 and 1990, revealed that MSTP graduates were more likely than other medical school graduates to receive postdoctoral fellowship support, to hold academic appointments, to receive external research funds, to apply for NIH grants, and to have published more. Impressive findings to be sure. What, then, explains the absence of any such report covering the past 2 decades, particularly in light of the dramatic proliferation of such dual-degree programs? The explanation for the lack of program evaluation may be poor coordination and communication among sponsors and institutions, lack of resources, or focus on other priorities. However, other explanations might include discouraging outcome trends; a “circling of the wagons”; or lack of sincerity about MD/PhD students' stated interests in research careers, generated by concern about increasing medical school indebtedness. These competing hypotheses need resolution. In this era of tight funding for medical research, the cost/benefit ratio must be assessed for each publicly funded program, including the MSTP.

Third, because sex parity has been reached among medical school matriculants in the past 2 years, the participation of women in dual-degree programs can be evaluated more intelligently. The good news is that an increasing fraction of MD/PhD matriculants are women; this will likely reach 50% in about 10 years.⁶ The bad news is that there is significantly greater attrition of women from MD/PhD programs before graduation (as noted by Andriole et al), and at key steps thereafter (Timothy J. Ley, MD, Washington University Medical School, St Louis, Missouri; written communication, August 1, 2008). The academic medical research community must work harder to encourage women to stay the course by, among other approaches, asking women what would matter to them, by improving mentoring, by fashioning user-friendly child-care facilities, and by developing flexible tenure clocks that make it easier for women to leave and return to the scientific workforce as their personal lives dictate. This litany of remedies is not new.^{7 - 8} Applying them, however, has not yet produced much improvement and will require a tectonic shift in the culture of academic institutions—particularly medical ones—and among those who lead them.

Fourth, is the United States getting a satisfactory return on its investment in dual-degree programs? The vast majority of physician-scientists do not receive dual degrees, are saddled with large and increasing educational debts, and evolve their scientific careers in ways quite different from MD/PhDs.^{6 ,9 - 12} Would a larger investment in loan repayment programs or other instruments (eg, medical student research fellowships) for these “late bloomers” offer value as good as (or even exceeding) that provided to support dual-degree recipients? More than ever, setting priorities for research investments is vital because there have never been sufficient funds to meet national needs, and there is every reason to expect this situation to continue indefinitely. The social forces that led Shannon and his compatriots to realize, 44 years ago, the importance of rigorous scientific training for a small fraction of medical students have changed over time. Thus, the assumptions underpinning dual-degree programs must be tested again in the current generation.

As the 50th anniversary of the initial MSTP awards approaches, it is essential to conduct a full accounting of this program, for which the visibility and institutional cachet far exceed its size. Program directors from the National Institute of General Medical Sciences, the Association of American Medical Colleges, and academic medical centers must lead this effort and establish a database that can be queried longitudinally in a transparent fashion. The health of the US forest of dual-degree programs must be examined without further delay, so that whatever planting, pruning, and planning are needed can be carried out in a manner befitting this national resource. It is past time to look carefully at the trees—as well as the forest.