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The MD-PhD Path: How Should It Be Done?

Bing Siang Gan
Canada
9 January 2004

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A clinician-scientist--or clinician-investigator, or whatever name one chooses--is a clinician who thinks about improving diagnosis and treatment for his/her patients and makes an effort to find a rational answer to unsolved questions. Much has been written about how to become a clinician-scientist, but most of it has focused on the ideal sequence of training, the research environment, remuneration, and so forth. There are few articles available that focus on how someone actually goes through the process.

When I started medical school about 25 years ago, I was naive and I didn't know what road I was embarking on. I actually didn't even want to become a doctor, and would have preferred to be an engineer. Nonetheless, the university admissions process threw me a curve ball and assigned me a spot in a professional school that many people would have killed for. This serendipitous start was typical of my training. Through medical school in Europe, a graduate degree in medical science in Calgary, and eventually a PhD followed by an MD degree, I rolled into a combined career in medical research and clinical medicine, with little planning and a lot of luck.

As a young, impressionable MD in PhD training, I followed the well-trod path and went on to clinical specialty training in plastic and reconstructive surgery. I decided not to go into practice but rather follow the academic pathway further and so completed two more years of subspecialty training at venerable institutions such as the University of Toronto and Harvard University. The years went by and I crisscrossed from pure science to pure clinical training.

However, when I was offered my first academic clinical position with a mandate to obtain "peer-reviewed external funding from agencies such as the Canadian Institutes of Health Research (CIHR) within a 3-year span," it was soon evident that, despite my solid training, I had a lot to learn if I was to be able to be seen as a competent scientist and be able to survive the tough peer-reviewed grant process. Although I was viewed as a stellar scientific surgeon during my clinical training, when it came to competing with full-time researchers, I was clearly limited by the lack of an up-to-date armamentarium of technological knowledge and scientific trivia, as well as a credible track record of success in scientific publication.

To be able to compete in a science environment, I would require additional postdoctoral research training, time to familiarize myself with a body of knowledge that had been uncovered during my clinical training, and a credible focus of research connected with my clinical specialty. More importantly, I would need to produce a body of work in the form of presentations, abstract, and journal articles. I also learned that the seven or eight clinical papers that I churned out whilst a 100-hour-a-week clinical trainee really did not carry much scientific weight.

I took another 2-year postdoc in a cell biology laboratory, which was unrelated to my previous research training, but it had become a hot breeding ground of novel scientific findings. These were even harder years than my clinical training, with long hours in the lab and heavy clinical responsibilities. For the first time, I was confronted with having to choose between patients in need and running my gels and splitting my cells. With a determination to succeed in both aspects, the working days became longer and longer. In retrospect I probably did not do either very well.

However, I remained committed to the vague concept of academic medicine. I moved to a centre where the concept of a single-person surgeon-scientist was split into one surgeon with a scientific focus, complemented by a scientist with a strong translational research focus. The thought behind this concept was to allow the surgeon to be recognized as a leader in clinical medicine with a strong footing in the scientific analysis of the clinical problem. It would also allow the scientist the opportunity to collaborate with a recognized clinician on a narrow clinical problem in a centre of excellence with broad access to patient material. Using this approach, I have been able to secure peer-reviewed external research funding from agencies such as the Natural Sciences and Engineering Research Council of Canada (NSERC) and CIHR. This took 7 years, more than twice as long as was expected of me in my first academic appointment.

What have I learned?

I have learned many things over the years. For young people at the beginning of the road to a clinical research career, I view my negative experiences not as discouragements but rather warnings about possible mistakes along the way.

First and foremost, one has to really want to combine science and medicine. There are so many factors that make it unappealing for a doctor to embark on an academic career that I have difficulty summing them up:

• An extremely long period of training, almost certainly taking 12 to 14 years (3 to 4 years of undergraduate, 4 years of medical school, 5 years of residency, 3 to 4 years of research training, and 1 to 2 years of clinical subspecialty fellowship training);

   

• Reduced remuneration during training and a virtual absence of a peer group after training;

   

• A heavy workload that impacts on time spent with family and friends;

   
• A constant need to compete for funds and recognition; an eternal sense that not enough attention is being given to patients while also always having an underlying sense of incompetence in science; and many more.

I have read and heard many times about the thrill that accompanies a new discovery and the excitement of seeing your name in print, and to a certain extent I have found this to be true. However, the beauty of this is really in the beholder's eye. In the end, it is the attempt to solve small clinical mysteries that matter to me most, to answer a seemingly trivial question that a thinking medical student may ask you on rounds.

When I look back and I ponder where I came from, where I am, and how I got here, I think that the most important issues that young academic trainees should consider are these:

• When should you do your research training? Is it better upfront or at the end?

   

• What specialty should you choose? Should it be one that you like, or one that creates more research opportunities?

   

• What kind of research should you contemplate? Should it be basic science, clinical epidemiology and statistics, translational research, clinical trials, or something else?

   

• Should you work with others of similar training or be in a diverse group and rely on "cross-fertilization"?

   
• How much sacrifice can you ask of your spouse and children in order for you to indulge in this highly stressful and less well-paid career?

Answering these questions is difficult and for each trainee the solutions will be highly personal. Pursuing an academic career is very much like doing research itself: never quite clear in advance where it is going to lead, but always surprising during its evolution.

Bing Siang Gan, MD PhD FRCSC FACS, is associate professor in the departments of surgery (plastic and orthopaedic surgery), physiology and pharmacology and medical biophysics at the University of Western Ontario, London, Canada.

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