BACK TO THE FEATURE INDEX

In varying hues of black and grey, with the occasional glint of a shiny blouse or tie, tired interviewees came streaming out of the Caspary Auditorium at the Rockefeller University in New York City. After six interviews with faculty members from the medical and graduate schools, the Friday lecture series provided a welcome break. It didn't take long for exclamations, hugs, and handshakes to follow as people greeted friends from the "interview trail." The MD/PhD universe is relatively small, and the interviews intense; a level of camaraderie had materialized over the course of an interviewing season.

In contrast to medical school admissions, the process of selecting and applying to MD/PhD programs is largely unknown to students before they begin the application process. I became aware of the existence of these programs relatively early in college via a few brief interactions with an MD/PhD trainee who was completing his thesis in a lab I had joined. Apart from this informal introduction, very little information was available to me on the aims and mechanics of MD/PhD programs and the process of selecting and applying for them. Given the limited number of trainees, and relative youth of medical scientist training programs--the National Institutes of Health (NIH) formally began funding their first programs in 1964--this dearth of information is hardly surprising. But for those in need of guidance, it is regrettable.

How, then, do people choose an MD/PhD program? Ad hoc, generally. Many people I knew picked MD/PhD programs primarily based on the reputation of the medical school, assuming that good research opportunities would be available. A few aimed to work with particular PhD thesis advisors. Both--the quality of the medical training program and the areas of active research--are important criteria, but it is hard to know how to weigh these and other factors. Whereas the interviews themselves expose applicants to a myriad of program philosophies and designs, each MD/PhD program director has a particular opinion about what is important. After you've visited several campuses, those polished PowerPoint presentations start blurring together. When it comes to making a sound, informed choice of an MD/PhD program, one more factor enters in: Most applicants don't try to do so. Due to the alleged difficulty of being accepted to these programs, most students pay more attention to making themselves appealing and getting through the process. Scrutinizing the program is the last thing on their minds.

NIH plays an important quality-control role by periodically examining how each Medical Scientist Training Program (MSTP)-designated program is run. MSTPs constitute less than half the number of MD/PhD programs in the United States; but MSTPs have special importance because, for an MD/PhD training program to be awarded an MSTP training grant, the program must satisfy NIH's standards for the training of physician-scientists. NIH examines indicators such as the track record of graduates in academic medicine positions, time to graduation, overall student happiness, how well the program integrates the medical and scientific training, and most importantly, the quality of the scientists and science available to the MD/PhD students; NIH manifests disapproval or approval of a program by decreasing, increasing, or maintaining the number of funded trainee positions at that institution. NIH's evaluation is provided as a written commentary, which gives important information about how the program is perceived to function--how much "value" the training program provides toward the students' future careers as physician-scientists.

Even though NIH enforces/encourages a set of standards, students at different programs have very different experiences. These differences arise, in part, from the basic philosophies of the different MD/PhD programs. I found the overall philosophy of the institution and program to medical scientist training to be an especially useful way of differentiating MD/PhD programs. I was looking for a program that mediated the interaction between the medical and graduate schools and did more than play lip-service to integration between the two. This kind of integration may be manifested in many forms, including iterations of molecular medicine courses, longitudinal clinical training, and reduced graduate course or clinical elective requirements.

At some institutions this sort of integration is simply very difficult to achieve, despite the best efforts of the program. If both the medical and graduate schools are unbending monoliths, redundancies in requirements can be introduced, day-to-day scheduling problems may result, and the time to graduation may be unnecessarily lengthened. I felt that it was essential for the director, and the program itself, to have some stature in the culture of the institution in order to facilitate changes if needed. Furthermore, attitudes toward the graduate and medical years can differ greatly at programs, often as a function of the vision of the program director. With programs aiming to produce graduates at specific points along the physician-scientist continuum, it was essential that I was comfortable with their attitude.

Although it is imperative to examine the program structure, there is no point in doing so if the research one is interested in is not represented at the school. Depending on the importance of this factor on an applicant's priority list--it is very high for most people--it can trump most other factors in the decision process.

Not all such views are fixed, however; nor should they be. I had the interesting experience of applying and interviewing with one field in mind, only to find my interests expanding with almost every faculty interview in other disciplines. Indeed, a large number of students change their interests as they are exposed to new topics and experiences once they matriculate.

Interests change; it's important to be able to change with them. Although I was repeatedly told that I only needed to find one good mentor/thesis advisor, I tried to perceive the atmosphere and richness of the academic community. All programs tout the "collaborative" and "open" atmosphere of their institution; these claims merit further investigation through conversations with students and faculty both within and without the institution. Even though I was initially drawn to the more prominent members of an institution's faculty--the ones I was most likely to have heard of before joining the institution--I quickly found myself paying more attention to younger investigators and their new perspectives on larger research problems. Ultimately I chose the Tri-Institutional program--a collaboration of Weill Medical College of Cornell University, the Rockefeller University, and the Memorial Sloan-Kettering Cancer Center. In a host of positively contributing factors, the depth and breadth of research played one of the most prominent roles in my decision to attend the Tri-Institutional program.

Before I started visiting campuses, I was under the impression that the training and experience at well-regarded medical schools was more or less the same. While interviewing, however, I learned that medical curricula and the degree of flexibility in training structure varies quite a bit. Although I am not experienced enough to know how the differences in training manifest themselves in clinical settings, these differences have a big impact on the training experience. For example, because there would be such a large gap between the final clinical years and the beginning of medical school, I did not think that a traditional, purely didactic curriculum would be as useful as those that also included a problem-based learning aspect. For me, the option of completing a clinical rotation before starting graduate work sounded appealing, although this is a matter of personal preference. Again, due to the relative youth of the programs, few objective measures exist to evaluate the success of the different training models. I briefly considered other factors, such as locations of hospitals and accessibility of faculty, although I didn't find a decision-changing differential among my top choices.

The initial focus of my applications was the quality of academics at an institution, regardless of location, and as a result, I interviewed throughout the country. It did not take many visits to different areas of the country to realize that location would play an important role in my decision. It hardly escapes many applicants' notice--it didn't escape mine--that their tenure in one place will be, on average, 7 to 8 years. The location, be it urban, bucolic, or a compromise between the two, will play a large part in determining quality of life. Although I definitely considered schools elsewhere, the idea of living in a large city was attractive. The setting of the biomedical complex also can be decisive. I had come to value a liberal arts setting as a result of my undergraduate college experience, yet I also wanted to be connected to larger, more academically diverse campus. I struck a satisfying balance by finding a solely biomedical institution amidst an immensely diverse setting, New York City.

Finally, for all the careful planning and deciding, a wide range of largely subconscious factors culminate into a gut feeling. While I tried to remain objective, I could see no point in attending a school for 7 years if there was not a good "fit." Second visits were extremely important for meeting faculty, students, and possible classmates, and refreshing faded memories.

In order to address the lack of the information on MD/PhD programs from the applicant's perspective, I set up a Web site at intransit.us. Current MD/PhD trainees and applicants contribute firsthand reviews of their interview experience and first impressions of various programs.

Although I have spent an admittedly short time in my chosen program, I have been consistently pleased with my interaction with faculty, my classmates, and the general atmosphere. As I said at the outset, the community of MD/PhD applicants is small and thus we stay in touch, regardless of what program we eventually chose. Most of us are satisfied with the programs we chose, which indicates that the mutual selection process must be working, from the students' point of view, at least. So far, so good.