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After I had finished the theoretical part of medical school at a Dutch University in 1995, I chose not to move on to the internship right away. Instead, I decided to spend some time on a student research project on mechanisms of neuronal death in neurodegenerative disease. I had no idea what I was getting into. After a short period of basic training, I was able to work with experimental animals and was allowed to handle human brain tissue, which was very exciting for a medical student who was used to merely handling books. I noticed that the Ph.D. students surrounding me, who were mainly biologists, were much ahead in most aspects of doing research. This, I realized, was because my medical school education had been mainly focussed on the professional training necessary to be able to practice as a physician. But the enthusiasm of my colleagues was contagious, and I stayed in the lab for nearly 2 years. This first encounter with research had stopped me from taking for granted the knowledge available to modern medicine.

I finished medical school in 1997 and started working as a resident in the University Medical Centre Nijmegen, the Netherlands. There I was offered the opportunity to combine my further medical training in internal medicine with a Ph.D. project. I became a "resident in training to become a clinical investigator" ( agiko in Dutch). In the Netherlands, the possibilities for combining a Ph.D. and an M.D. are growing, but they vary considerably among different universities as well as among different medical specialties. The funding for the research project also varies. Grants may be provided by the university itself, the Netherlands Organization for Scientific Research, or a third party. I received a 3-year grant from the Netherlands Heart Foundation. My program consisted of 3 years of full-time research combined with a 5-year residency. In practice, I switched four times between both jobs.

My Ph.D. is in the field of the autonomic control of blood pressure in humans. I found this project particularly appealing, because it consists of physiology experiments in both healthy subjects and patients. Of necessity these experiments, which involved invasive assessment of haemodynamics and the administration of vasoactive drugs, can only be performed by a physician investigator.

Working with patients in research is essentially different from clinical work, in the sense that the investigator relies on the participation of the patient instead of the other way around. Before even starting the actual experiments, the project is extensively reviewed by the ethics board. Then there is the process of recruiting patients who meet the inclusion and exclusion criteria, informing them about the aims and risks of the studies, and getting them to participate at a convenient time and be properly prepared. As a resident, I had already become very familiar with the other departments in our hospital, which made it easier to cooperate with them and to recruit patients from other specialists. Working with "human material" is a big challenge and is completely different from preclinical research. Nonetheless, I have been able to use the technical and communication skills I had picked up during my medical training.

In order to keep in touch with my medical training during the periods spent on my Ph.D. research, I participated in the ongoing local and national courses for residents in internal medicine. In addition, I was occasionally asked to help out in the emergency room or on the wards. Switching from research to clinical work can feel like being torn away from your Ph.D. project. A full-time residency can be physically very demanding. Apart from caring for patients, you have to study, prepare presentations, and keep up with relevant medical literature. It is certainly time-consuming and requires careful time management. On the other hand, interruption of your Ph.D. by clinical work can be a positive. I considered it to be a time-out, which enables you to think about the direction of your future research and to efficiently plan experiments. In my personal experience, a residency is not necessarily a good time for paper writing, although supervisors may expect differently.

A combined M.D./Ph.D. project is the best training for M.D.s who want a career that combines patient care with research. In my opinion, the involvement of M.D.s is important in both clinical and preclinical research. M.D.s who choose not to pursue a career in research can benefit from an M.D./Ph.D. project as well. It helps one develop a better sense for evidence-based medicine and the ability to critically appraise the medical literature. Most importantly, in my experience, it is simply great to participate in the field of research, on which quality in clinical care relies.