MD/PhD = Double Doctors = Double Trouble
By: S. Amanda Ali
Consider a day in the life of a physician, whose responsibilities include examining patients, performing diagnostic and therapeutic procedures, liaising with medical and non-medical specialists to optimize patient care, teaching medical students, staying current with medical advances, serving on boards, and attending meetings. Now consider a day in the life of a scientist, whose responsibilities include conducting experiments, analyzing data, reading literature, writing grants, publishing results through the peer-review process, supervising graduate students, serving on committees, and attending conferences. Then consider a day in the life of a physician-scientist whose responsibilities include all of the above. Excelling at either of these professions is admirable, but excelling at both is fantastical.
The training of a physician-scientist doubles as a selection process to weed out the faint of heart. Four years of undergraduate studies, 2 to 6 years of graduate school, 2 years of postdoctoral research, 4 years of medical school, and 2 to 6 years of residency and specialization equal a lot of time, effort, and money spent on higher education. Many institutions offer a harmonized version of this training, including the University of Toronto. Their 8 to 9 year MD/PhD curriculum produces fully accredited physicians who have completed graduate work according to the PhD guidelines of the School of Graduate studies. This still requires a minimum of 12 years of formal and expensive education, a commitment that selects for the particularly keen.
From this extensive training, physician-scientists acquire interdisciplinary knowledge which facilitates their translational contributions to biomedical research and patient care, but this interdisciplinarity also presents a challenge to physician-scientists. Physicians and scientists are trained in very different environments to embody very different values. Academia is peer-oriented, with great importance placed on the peer-review process. Medicine is patient-oriented, with doctors aiming to treat and cure individual patients. Popular culture perpetuates stereotypes of scientists as crazy, socially-awkward nerds (The Big Bang Theory), while physicians are portrayed as attractive, level-headed experts (Grey’s Anatomy). Scientific concepts are frequently challenged by scientists, while medicine is sold to non-expert consumers. Scientists convince disbelieving peers while physicians handle submissive patients. Academia is slow-paced, with skeptical scientists facing few hard deadlines. Medicine is fast-paced, with decisive physicians reacting to emergency situations. At the centre of these colliding worlds are physician-scientists, with their innate drive to excel and desire to gain acceptance from peers.
Recently, a survey on physician-scientist education was conducted among the students in the MD/PhD program at the University of Toronto. Regarding the balancing of clinical and research responsibilities, and performing both at a high level, one student explained, “I’m concerned about being an excellent world-class researcher AND an excellent physician. The reality is that to be one or the other is already to be an exceptional person.” Some perceive a lack of respect and recognition, and feel the, “additional training to become a physician-scientist often leads to…less respect from both medical professionals and researchers.” Because of their educational promiscuity, physician-scientists are frequently not accepted as “real” doctors, nor “real” scientists, so their work may be subject to more scrutiny and less recognition. Alternatively, based on the way in which physician-scientists are revered for their unique ability to speak both science and medicine, their work may be less scrutinized and gain higher recognition than their single-discipline peers.
Evaluating the relative success of physician-scientists over their single-discipline peers is challenging because in both science and medicine, the metrics required for measuring success are severely lacking. Supposedly, the number of articles a scientist publishes in high-impact journals, and the number of patients a doctor treats and cures reflect their skill; but current metrics do not integrate the multi-factorial responsibilities of these professionals. For example, there are no conventional methods for assessing the quality of teaching and mentorship offered by scientific supervisors in laboratories or by medical doctors in hospitals. Mentoring is an established determinant of the success of a trainee, and has been defined as, “the provision, by an already successful and secure academic, of resources (but not obligations), opportunities (but not demands), advice (but not orders) and protection,” from unwarranted scrutiny. (Sackett 2001) Therefore, the ability of a physician-scientist to mentor trainees should be considered an indicator of their career success.
But it’s not.
Physician-scientists exhibit a characteristic drive to do more, do it better, and do it faster. As mentioned, the requisite training selects and breeds a cohort of hardworking overachievers, but surely this takes a toll. Many double doctors seem to execute their enviable multi-tasking capabilities on autopilot, with very little sleep and sustenance from the coffee and cookies at meetings. To speak negatively or criticize a physician-scientist is almost taboo because their role in bridging the gap between bench and bedside is essential for biomedical progress. This, combined with the lack of appropriate metrics, has resulted in very few studies examining the successes and failures of physician-scientists relative to their single-discipline peers. Yet the need for these studies is evident, if based solely on the fact that physician-scientists have double the responsibility of their peers. It is common to praise physician-scientists as the ultimate translators of medical research without questioning the cost at which this skill comes; but when considering the small army of subordinates, patients, and students influenced by physician-scientists, questioning becomes necessary.
So are physician-scientists spreading themselves too thin? Are they adequately equipped to fulfill their job description? Do they have the time to stay current on both medical and scientific literature? Can they review this literature in a meaningful way, so as to synthesize and apply the findings to their work? How is their bedside manner affected? Are their experimental methods relevant? Do they make significant contributions to supervisory committees and advisory boards? Is mentoring of medical and graduate students a priority? How well do they interact with colleagues and establish collaborations? What is the impact on their family and quality of life?
Undoubtedly, physician-scientists will have an advantage in some areas, but a disadvantage in others. In December 2011, the Association of American Medical Colleges published a model outlining the factors involved in the career success of physician-scientists. According to the model, personal factors such as education, personality, psychosocial milieu, and demographics, as well as organizational factors, such as institutional resources, training, mentoring/networking, and conflicting demands contribute to the extrinsic and intrinsic career success of physician-scientists. This model is meant to serve, “as a conceptual framework for research into what does and does not work in efforts to develop a positive career trajectory for aspiring physician-scientists.” (Rubio, Primack et al. 2011) The utility of such a model would be greatly improved if also applied as an evaluative tool to monitor the success of physician-scientists over the course of their careers. Doing so will begin to generate answers to the many questions about the pros and (equally important) cons of being a physician-scientist.
Rubio, D. M., B. A. Primack, et al. (2011). “A comprehensive career-success model for physician-scientists.” Acad Med 86(12): 1571-6.
Sackett, D. L. (2001). “On the determinants of academic success as a physician-scientist.” Clin Invest Med 24(2): 94-100.