For a young physician-scientist seeking a career in academic medicine, choosing a residency can be stressful and difficult. But the decision can be eased by breaking it down into three questions: Which clinical field(s) should I choose? Should I consider a "research" or short-track residency program? And finally, what specific programs should I consider? Answering each of these questions in turn will help you assemble a residency short list that, hopefully, contains your perfect-fit residency.

What clinical specialty is right for me?

One way to approach this question is to determine what has worked for thousands of M.D.-Ph.D. graduates before you. Andriole et al. (1) and Brass et al. (2) found that the most popular specialties among M.D.-Ph.D. graduates were internal medicine, surgery, pediatrics, radiology, neurology, and pathology. More recent data suggests that some additional residency specialties are rising in popularity among M.D.-Ph.D. graduates: dermatology, radiation oncology, and psychiatry (3).

Definitions

-Residency: A 3- to 5-year clinical training program in an accredited graduate medical education specialty that begins after medical school.

-Internship: A historical designation for the first year of your residency.

-Fellowship: A subspecialty training that follows residency. This can last 1 to 3 years.

-Specialty: A broadly defined area of clinical study, such as internal medicine, neurology, or pediatrics.

-Subspecialty: Categories within defined specialties in which doctors can receive additional training following completion of a specialty program. For example, subspecialties of internal medicine include but are not limited to critical care medicine, hematology, infectious disease, and oncology. The Accreditation Council for Graduate Medical Education (ACGME) maintains lists of residency programs by specialty/subspecialty.

Also visit the ACGME Web site for a more extensive glossary of terms related to medical education and residency.

Although it's interesting to know what those who've come before you on the physician-scientist path have chosen, your decision should be based on your own aptitudes and proclivities. The first step is to make a list of clinical specialties that fit well with your research interest.

As an example, let's consider a student who has recently completed a Ph.D. in neuroscience. Clinical specialties that could fit that research interest include neurology, child neurology, neurodevelopmental disabilities, psychiatry, neuropathology, radiation oncology, neurosurgery, child psychiatry, and so on. A student who did his Ph.D. in immunology might consider laboratory medicine, anatomic pathology, clinical immunology, allergy, rheumatology, gastroenterology, hematology, transplant medicine, or dermatology. With all of these choices, how will you settle on just one?

Once you've identified an area you're interested in, you might try a clinical clerkship or elective in the area to determine whether it's a good fit. But there are problems with that approach. The first is that what you do as a medical student usually has no relationship to what your life would be like as a physician-scientist working in this clinical area. Another problem is that you'll enjoy a clerkship more (and think you like that clinical specialty) if you have a good rapport with the attending and/or the residents and interns on the service, so this isn't a fair test. Finally, in some specialties clerkships and electives just aren't available.

So a better idea is to find and shadow a physician-scientist (not a physician who does not participate in research) in that area. This exposure will give you an idea of the day-to-day life in that clinical specialty and whether that lifestyle fits your personality and goals.

Consider my example. I am a clinical pathologist with a focus on clinical immunology. Usually, clinical-pathology professors do not have months "on service" and months "off service." Instead, we continuously oversee the hospital's clinical laboratories, develop new testing procedures, and consult with floor physicians about test results and interpretations. If you shadowed me, you would learn that I spend at most a couple of hours each day on my clinical work, leaving ample time for research. You would also learn that I have to switch "hats," between research and clinical work, several times per day.


Robin G. Lorenz

I love this type of integration, but other physician-scientists wouldn't. They would rather have a dedicated month or two for clinical work and then focus on their research for the rest of the year. Only you can decide what works best for you and your personality.

This is why early shadowing experiences in multiple clinical areas can be extremely important. My advice is to start doing these types of clinical exposures with physician-scientists at your institution during your early graduate years. Don't wait until you return to clinic to start thinking about your future clinical specialty.

A second way of approaching a residency decision is to ask if the specialties you're most interested in are physician-scientist "friendly." Look around your own institution. How many faculty members in that specialty continue to have significant research and clinical components of their careers? When you attend national meetings for your research, look to see which speakers are M.D.s or M.D.-Ph.D.s. Ask faculty members at your institution and these meetings about their clinical specialty. Would they choose it again? How -- and how effectively -- do they juggle research and clinical service? What percent of their time do they spend at each? After hearing their answers, decide whether you can see yourself doing what they do. If it seems like a good fit, then that is a clinical specialty you should consider.

Now let's look to the data for some guidance. Paik et al. report that graduates from a Medical Scientist Training Program (MSTP, the National Institutes of Health's M.D.-Ph.D. institutional training program) are more likely than M.D.-only graduates to go into radiation oncology, child neurology, pathology, dermatology, and neurology (3). They are less likely to go into family medicine, emergency medicine, and obstetrics/gynecology. This correlates with previously reported data that M.D.-Ph.D.s who go into family and emergency medicine, dermatology, and ophthalmology have the highest likelihood of ending up in private practice, whereas pathology, psychiatry, pediatrics, neurology, radiation oncology, and internal medicine have the lowest percentages of M.D.-Ph.D. graduates ending up in private practice (2). Every situation is different, but certain clinical specialties have better track records of supporting physician-scientist careers.

Should I do a "research" or "short-track" residency program?

Intuitively, this may seem like an easy question. It seems obvious that a research or short-track residency would be best for a physician-scientist. But there's almost no outcomes data to say which approach is most often successful. So, just like the residency choice, it's ultimately a personal decision. Are you comfortable with the idea of being away from research for the next 3 to 5 years? If the answer is no, then you should consider research-based residencies. What are they? Read on.

This article is adapted from a presentation given by Robin Lorenz at the 2010 Annual Meeting of the American Physician Scientists Association.

Many residency programs offer a "short-track" for residents who wish to pursue careers in basic science or translational research. In internal medicine and pediatrics, there are guidelines for how these programs must be organized. The American Board of Internal Medicine Research Pathway requires residents to complete 24 months of internal medicine training followed by 12 to 24 months of clinical subspecialty training (depending on the subspecialty), and at least 3 years of research training. Compare that with a typical internal medicine residency: 36 months followed by 24 to 36 months of subspecialty training.

The American Board of Pediatrics offers two research pathways. The Accelerated Research Pathway is designed for candidates who are committed to an academic career in a pediatric subspecialty. In this pathway, residents complete 2 years of general comprehensive pediatric training followed by 4 years of subspecialty training, with a minimum of 1 year of that in clinical training. The Integrated Research Pathway is open only to individuals with an M.D.-Ph.D. degree. It offers 24 months of core pediatrics training and up to 12 months of research training.

Other clinical specialties do not have specific, board-certified research pathways but instead offer similar training pathways designed by the institution. A partial list of these research residency programs can be found on the American Physician Scientists Association (APSA) Web site. Some programs require applicants to indicate interest in research and short-track pathways when they apply, whereas others allow residents to join during their first year of residency. The best advice is to review the program Web site and speak directly with the residency director. This will allow you to determine how their application process works and it will alert them that you are interested in doing research during your residency and fellowship.

Many institutions use these programs to locate future faculty members. The Physician Scientist Training Program in Internal Medicine, a research-oriented residency training program at Washington University School of Medicine in St. Louis, has reported that more than 80% of the residents who completed the program remained in academic medicine, and about 70% of those had faculty positions at Washington University (4). (For more on research residencies, see "Making Room for Research During Residency.")

Where should I go?

This part of the decision is perhaps the hardest, as there are no right or wrong answers. A program that is perfect for one M.D.-Ph.D. graduate may be completely wrong for another. First, make a list of your goals and another list of the qualities your perfect residency program would have. Consider questions such as:

1) Does the residency have protected time for research?

2) What type of community are you (and your family) looking for?

3) What parts of the country are you willing to live in for the next 4 to 6 years?

4) What are the outcomes for residents/fellows graduating from the program? What proportion stays in research?

5) What faculty members at that institution might you want to do research with? Would you be restricted to faculty in your clinical department?

6) Is there any guarantee of a fellowship position?

7) Does the program offer resources to support research?

8) Are career-development courses or training offered?

When interviewing, if you are interested in doing research as part of your residency/fellowship, pay attention to how the department chair and the more senior faculty members talk about the program. Do they emphasize research? How many physician-scientists are in the residency program and how many are on the faculty? If a program is serious about allowing you to do research, then they should be eager to set up additional interviews for you with potential research mentors.

As with the other questions, we can look to the literature to see where other M.D.-Ph.D. graduates went for their residency/fellowship training. For 2004 to 2009 graduates, the top five institutions (including all their affiliated hospitals) were Harvard University; the University of California, San Francisco (UCSF); the University of Pennsylvania; Washington University in St. Louis; and Stanford University (3). Paik et al. also report the top residency programs choices for M.D.-Ph.D. students in various specialties (3): In internal medicine, Brigham and Women's Hospital and Massachusetts General Hospital were the top choices, followed closely by Washington University and Stanford University. In pathology, Brigham and Women's Hospital was the top choice, followed by UCSF, Massachusetts General Hospital, and the University of Pennsylvania. In pediatrics, the top choice was Children's Hospital of Boston, followed by Children's Hospital of Philadelphia.

But in the end, your choice will depend on your particular goals and the answers to these questions. It also will depend on whether you feel the "fit" is right. For each residency that fits your criteria, be proactive. Let the program know you are interested and stay in contact. Make sure you know their requirements for USMLE Step II scores (and whether they need them before making their match list). If your score will not be reported by this date, let the residency director know. Most programs know that M.D.-Ph.D. students are doing shortened clinical clerkship training and are often willing to make exceptions to the date by which they require USMLE Step II scores. The bottom line is to communicate.

In summary, you need to be a well-informed consumer and you need to start early. Read about the role of physician-scientists in various specialties (5-10). Take advantage of national career-development meetings and conferences for M.D.-Ph.D. students. Some of these are very specialized, such as the American Gastroenterological Association's "Attracting MD-PhD Students into Gastroenterology" and the Association for University Professors of Neurology's "Combining Clinical and Research Careers in Neuroscience." Others, including the National M.D.-Ph.D. Student Conference and the APSA regional and annual meetings, give a broad exposure to top scientists and clinical investigators from multiple fields. An up-to-date listing of these types of meetings is maintained on the APSA Web site.

Above all, you need to find a program that will facilitate the development of your research-oriented career and provide the appropriate mentoring to assure your success as a physician scientist.

References

1. Andriole DA, Whelan AJ, Jeffe DB. Characteristics and career intentions of the emerging MD/PhD workforce. JAMA. 2008;300(10):1165-73.

2. Brass LF, Akabas MH, Burnley LD, Engman DM, Wiley CA, Andersen OS. Are MD-PhD programs meeting their goals? An analysis of career choices made by graduates of 24 MD-PhD programs. Acad Med. 2010;85(4):692-701.

3. Paik JC, Howard G, Lorenz RG. Postgraduate choices of graduates from medical scientist training programs, 2004-2008. JAMA. 2009;302(12):1271-3. PMCID: 2778489.

4. Muslin AJ, Kornfeld S, Polonsky KS. The physician scientist training program in internal medicine at Washington University School of Medicine. Acad Med. 2009;84(4):468-71.

5. Buchholz TA, McBride WH, Cox JD. Preparing for the future of radiation oncology. J Am Coll Radiol. 2007;4(8):560-2.

6. Hauser SL, McArthur JC. Saving the clinician-scientist: report of the ANA long range planning committee. Ann Neurol. 2006;60(3):278-85.

7. Fenton W, James R, Insel T. Psychiatry residency training, the physician-scientist, and the future of psychiatry. Acad Psychiatry. 2004;28(4):263-6.

8. Wu JJ, Davis KF, Ramirez CC, Alonso CA, Berman B, Tyring SK. MD/PhDs are more likely than MDs to choose a career in academic dermatology. Dermatol Online J. 2008;14(1):27.

9. Santoro SA, Mosse CA, Young PP. The MD/PhD pathway to a career in laboratory medicine. Clin Lab Med. 2007;27(2):425-34; abstract ix.

10. Clark JM, Hanel DP. The contribution of MD-PhD training to academic orthopaedic faculties. J Orthop Res. 2001;19(4):505-10.

Robin G. Lorenz, M.D., Ph.D., is the director of the University of Alabama, Birmingham, Medical Scientist Training Program and chair-elect of the Association of American Medical Colleges (AAMC) Graduate Research, Education, and Training (GREAT) Group M.D.-Ph.D. Section Steering Committee.

Robin G. Lorenz, M.D., Ph.D., is the director of the University of Alabama, Birmingham, Medical Scientist Training Program and chair-elect of the Association of American Medical Colleges (AAMC) Graduate Research, Education, and Training (GREAT) Group M.D.-Ph.D. Section Steering Committee.
10.1126/science.caredit.a1000114