Why You Should Consider the MD/PhD Career Path

Part 2: Why you should consider the MD/PhD career path

As a first-generation student, I didn’t know about the existence of MD/PhD programs until late in college. My premed advising office lacked experience to prepare me adequately to be a competitive applicant. I relied on independent research and summer research programs to acquire the resources and skills needed to apply competitively. The more I learned about the career path, the more certain I became that it was the best path forward for me. I am biased, and I will make a compelling case that the MD/PhD path is a high value, underappreciated alternative to medical school and graduate school alone.

• A caveat: while I believe the 5 reasons below are compelling reasons to pursue MD/PhD training, these are not what I advise you state in the MD/PhD application or interview. There is indeed an element of gaming to the admissions process, and it would serve you well to learn the rules. I will do my best to teach you how to play the game based on my successes and failures in the process. I will cover the “correct” answers to the Why MD/PhD question in another post, which focuses on becoming an academic physician-scientist whose clinical work informs laboratory work, and vice versa, and provides a synergy that cannot be realized through either training path alone. Since this is a rather cookie-cutter response, you must convey these elements through the lens of your unique story and life experiences, which I can help you develop and deliver with authenticity.

Value

It’s no longer noteworthy that college is expensive, and that higher education is over-saturated. Fortunately, a medical degree continues to have great earning potential. However, if you, like myself — even with Pell grants and working jobs — had to accumulate debt during college, the prospect of acquiring an additional ~$200,000 in student loans for medical school tuition, not including living expenses, is a heavy burden. You might ignore this burden with the prospect of earning enough money to pay it off as a physician, but it will be paid slowly, over the course of 5–20 years, with interest accruing, pushing you to work more to pay off your debts sooner. Assume that $250K in student loans were taken between college and medical school at an interest rate of 6%, resulting in $15,000 of added interest per year, incentivizing you to work more for the next decade to pay it off quickly. I’m sure there are financial tricks to reduce this burden, but I’m making a general case. Now that you have acquired a pile of student debt from medical training, an element of sunk cost fallacy might also emerge: “I’ve spent so many years training and have all this debt I must pay, I must continue being a physician to pay off the debt”. Even if being a physician is causing you to burn out?

• It’s important to remember that what we think we want to do for the rest of our lives at age 22 is likely to differ greatly from what we want to be doing at age 50…investing in career mobility and independence of your future self is, I think, is the best financial decision one can make.

While the MD/PhD path is not one to pursue for financial reasons alone, the ROI on the dual degree path is enticing: medical school and graduate school tuition are free (to you), you receive a pre-tax stipend of $30–45k (depending on location), you graduate with knowledge that can be applied across science and medicine, and you have long-term career mobility across academia, industry, government, and clinical practice. Many people might balk at this idea that the ROI of MD/PhD exceeds MD alone, claiming: “In 4 years of working as a physician, the salary and benefits that I would earn far exceeds the value of a PhD.” Maybe, if money was your sole career motivation, but what I’m talking about is value. Most people want a fulfilling career that they can drop and switch to something new if they’re no longer fulfilled. It’s possible to do this with an MD degree, but I would argue it’s more challenging and less common compared to the person with an MD/PhD.

Quick math on ROI:

• cost of medical school 4 years at $50K/year = $200k
• cost of graduate school 4 years at $30k/year = $120k
• stipend for 8 years at $32k/year = 256k
• conferences and travel 4 years = 10k.
• $200k + $120k + $256k + $10k = $586k, which, over 8 years, comes out to ~73k/year while earning both an MD and a PhD (using UW-Madison’s MSTP, as a stipend example), without accruing interest from medical school debt when you begin your career.
• At 73k/year, this is approximately the salary of both a postdoctoral scientist with ~4 years of experience, and a PhD graduate who goes directly to industry.

As an MD/PhD, not only do you know how to provide medical care to people (practical skills), but you also have savvy with modern science, technical communication, big data, signal vs noise, and a clear sense of what each the MDs and PhDs, alone, lack. You will be sought after for employment, competitive for residency programs, and able to move laterally and vertically with less resistance through career discovery. The ROI on MD/PhDs, for me, is strikingly favorable.

Opportunity

“But the MD/PhD path is more competitive… I don’t have the grades. My MCAT isn’t high enough. It’s too long.” These excuses are signs of an opportunity. Here are 5 considerations to keep in mind:

1. The MD/PhD application is designed to provide a more holistic view of applicants and thus the numbers bear less weight. I would argue, subjectively, that the MD path is more competitive than the MD/PhD path — though, objectively, the overall matriculation rates are similar (35.9% for MD/PhD, 36.2% for MD in 2021–2022 cycle). Medical schools in the 2021–2022 cycle received nearly 1.1 million applications from 62,443 students, whereas MD/PhD programs received almost 33,300 applications from 2091 students — it’s no wonder that the MCAT score and GPA serve as an essential weed-out mechanism to sift through the massive application pool for medical school admissions. I argue that students should not be deterred from MD/PhD because they perceive it to be more competitive than MD. If you put in the time to obtain quality research experiences and work hard to evaluate Why MD/PhD, the MCAT score and GPA diminishes in relative importance. At some schools certainly, and at many other programs, too, I presume, the MD/PhD committees have a strong influence on whether a student is accepted, so long as minimum requirements are met for medical school admissions. There is more to being an effective physician-scientist than scores, and the greater depth of the MD/PhD application offers ample opportunity to assess non-numerical qualities, such as science communication skills and character traits.
2. The prerequisites for being a competitive applicant to MD/PhD programs are not extraordinary. I had 2 years of research during college and one 3rd author publication. However, I had a great relationship with my research mentors, I focused on deeply understanding the scientific method, and I pursued quality experiences over quantity. Critically, my story and vision were engaging to the admissions committee, and I learned to communicate my why effectively with broad audiences. I graduated with honors, my grades were good (3.72), and my MCAT score was around the average (510). I still interviewed at several excellent programs and matriculated into a top-notch MSTP. The point is, there’s more to this game than numbers, don’t count yourself out prematurely.
3. As a MD/PhD graduate, you will be a competitive applicant for residency. As is evidenced by the Pass/Fail nature of medical school grades, and now also the USMLE STEP1, there is an evident shift from selecting for high exam scores to the more well-rounded characteristics that cannot be identified through multiple-choice exams. MD/PhD training is a foot in the door to interview at most residency programs, providing the applicant with greater decision-making power for where they might end up for the next phase of their training. I acknowledge the low probability of being able to select where exactly you want to go, but anecdotal evidence from the past several graduating MD/PhD cohorts at UW-Madison suggests that a majority match into programs among their top choices. The research experience and maturity that is developed from 3–4 years of learning from failed experimentation and gaining deep knowledge of a subject are attractive qualities for residency programs as well as for institutions that conduct cutting-edge research. Even for those more clinically oriented residency programs, the ubiquity of clinical research initiatives at such programs still make the research skills gained during a PhD a valuable asset.
4. You can apply broadly across the U.S. with a greater likelihood of acceptance to an out-of-state program. If I had done the MD only path, I would have been incentivized financially to remain in-state. If you live in California, for example, you might want to stay in-state, but considering how competitive the California medical school system is and the high volume of applicants that also want a sunny and 75 experience, you better have the grades, MCAT score, research and clinical experience, and stand out. If instead you apply out-of-state, the cost of tuition tends to increase for most state schools and there is a reduced likelihood of acceptance relative to your in-state peers. From my experience, it seems that MSTPs select for out-of-state students (UW-Madison MSTP 2021–2022: 100% out-of-state, and on average, across all MD/PhD programs, 75% of matriculants are out-of-state students). In contrast, MD programs at public universities select for in-state students, which is largely due to the funding support provided to keep doctors at home (AAMC).
5. As science and medicine becomes more tech-enabled, the demand for PhDs in industry will likely diminish, and given the exodus of young PhDs away from academia (this deserves its own post), there is a growing supply and demand problem. The inherent value of a PhD in science and engineering, however, remains the same and is critically important for the development of our future society. The MD/PhD path provides a practical value (direct service to people) that the PhD alone lacks. I acknowledge that teaching students does provide direct value to people, yet the internet is increasingly reducing the value of this service relative to what physicians provide. However, perhaps a similar argument can be made that the value of the MD will also diminish over time, given AI-assisted diagnostics and the excess of MD graduates relative to available residency positions (Figure 1), but overall, the roles of a clinician are too nuanced, and the demand for eldercare is growing too fast to be supplanted anytime soon. If you want a PhD because you desire a deep dive into a topic of interest, and you also recognize the diminishing lifestyle flexibility of a post-PhD career, the MD further credentials you to apply scientific acumen to serve people directly. Plus, if you do choose a career like pathology, then you could work from home on your iPad reviewing high-resolution images with diagnostic hints from AI and devoting yourself to whatever you really want to be doing with a nice salary and autonomy. I’m only partially joking.

Increasing disparity in number of residency spots available and MD graduates

Time

Time is another key feature of why the MD/PhD career path is worthy of consideration. As of writing, I am in my 5th year of MD/PhD training, currently in my laboratory planning to do an experiment after writing this section. One of my friends, who I started medical school with in 2018 and who graduated in summer 2022, is meanwhile quite busy in their first year of residency training. Given all the boxes that one needs to check during medical school, 4 years is not much time to decide confidently on which residency to pursue. This decision will largely influence your work-life balance and working environment for life, so it should not be made lightly. If you know what area of medicine you want to pursue after exploring specialties through clinical rotations for a couple of years, then great! If you are uncertain, for example, whether you like radiology or internal medicine more, you might feel pressured to decide before you are ready or have the experience needed to make a fully informed decision, which might not come until you’ve finished your first year of residency with an uncomfortable feeling of dissatisfaction. No worries, though, you can take a year off, do a research year or two, and reapply for a different program. Had there been more time to explore and gain experience, then this crucial decision might have been made correctly the first time. If instead, you had pursued the MD/PhD path from the start, you would have had this extra time and experience, with the addition of a PhD’s worth of knowledge and publications, to make a more informed decision.

Having the time to think more deeply about what it is that you want to pursue is a blessing and one of the reasons I am most content with my decision to take a longer training path. Some people might retort: “Yeah, MD/PhDs love to procrastinate making life decisions…”, to which I say, yep, what’s the hurry? I’m getting paid to experiment in a lab to my heart’s content and then go home without needing to study for exams and prepare for clinic. I can rotate through different specialties, work closely with select physicians, build relationships, and gain a more comprehensive, accurate view of what a life working in a particular specialty might entail. You also have time for hobbies, learning new skills, and maturing as a person. For example, I want to develop more computational skills, so I spend time tinkering with small projects, watching Youtube, using Coursera, making a website and MD/PhD advising business (coming soon!), and applying data science tools to my research projects. I also like to garden and cook, and now I cook the produce of my garden after long days in lab. The MD path can be a whirlwind. You will have some time to do hobbies in medical school, but you have a limited time to get the scores, do clinical research, obtain letters, develop experience, and distinguish yourself. This is difficult when, for the first 2 years of medical school, you’re constantly studying or memorizing information that, frequently, turns out to be clinically irrelevant minutiae. Then, during the first clinical year, you’re running around the hospital rotating in different specialties trying to orient yourself, and by the time you do, it’s time for a new specialty. That leaves your final year to pinpoint a field of interest and make an important decision about your life course. I’m anxious even writing about it.

In addition, there’s another angle to the value of time in MD/PhD training. When I talk with some ambitious applicants, I hear statements like: “I want to make world-changing discoveries that lands my name in textbooks,” and “I want to write the book on modern cancer treatment”. The MD/PhD path is also for those who are centrally focused on becoming the best of the best in science and medicine. You want to cure cancer, cure Alzheimer’s, cure aging! Ambitious and naïve, yes, but it’s the type of energy and passion needed to spend the long hours in lab and clinic, honing your craft, and becoming the world’s expert in your niche. If I were to pursue my current path to its fullest academic extent, I would become 1 of maybe 10 people in the world who is a retinal surgeon, structural biologist, and cellular neurophysiologist.

Mindset

Next, I want to compare the distinct mindsets of medicine and research. I have been a medical student, and I am currently a graduate student. I have experienced both fields and have been fully immersed in their cultures. How can two fields be so complementary and yet so at odds intellectually? The PhDs think the MDs are expensive fools, and the MDs think the PhDs are esoteric fools. I guess that makes me an expensive, esoteric fool. Jokes aside, the box-checking operating system of medical training can make the pre-clinical years feel robotic. As students move from lecture halls into the hospital, the hierarchy of medicine is an added hindrance for students to break out of this mode and think for themselves. Speak up at the wrong place and wrong time, you might get a hasty comment on your evaluations (subjective grades are used to determine competitiveness for residency) — at least, this is the fear of many students, and whether this is perceived or real makes little difference when it modifies the behavior of the student. On the positive side, MDs learn to manage the tremendous responsibility of caring for the health and wellbeing of vulnerable people; the decisions must be made decisively considering multiple perspectives, with analyses of risk, and focused on harm reduction in a team-based model of care. It is not trivial, and each patient presents a wholly new set of conditions to consider. You are unlikely to learn this degree of empathy, decisiveness, and teamwork as a graduate student in a research lab.

While PhDs are also subjected to the rules of hierarchy, the research training nonetheless incentivizes independent, critical thinking. The nature of research affords graduate students more freedom to trial and error. The mindset of an experimentalist encourages creativity and allows one to follow lines of inquiry to the end of curiosity. Aside from meeting with a thesis committee, there’s few boxes to check. You learn by doing and doing often results in failed experiments. The troubleshooting that follows is far more instructive than many courses you will take. This open-ended process is also part of the reason why PhDs can take 6 years and postdocs 8 years to complete their projects at the upper bound.

In terms of coursework in medical school, it is notoriously known for being like “drinking water from a fire hose”. It’s a deluge of mnemonics, books, flashcards, videos, and writing information that spans microscopic to macroscopic topics. In contrast, depending on the graduate program, the significant overlap between medical school and graduate school coursework can lead to waiving of course requirements, freeing up more time to focus on creative experimentation and taking the courses you want to take. For example, in my Cellular & Molecular Biology PhD program, I only have a single course requirement; therefore, I can take courses like Machine Learning and Statistics or Computational Neuroscience.

Lifestyle

Given the above 4 reasons why you should consider the MD/PhD career, lifestyle goals are clearly a big part of this decision. Generally, I believe that people are poor judges of what their future selves might specifically desire; however, it is probably safe to assume that people desire freedom to decide for themselves how they will spend their time: with family, with friends, on hobbies, traveling, starting businesses, etc. Personally, I like variety and context-switching. Therefore, I select for paths that will equip me with the skills and flexibility to pivot and follow my curiosity and passions. I want to be immune to the notion of a sunk cost fallacy. I believe the MD/PhD path integrates the best components of each solo degree while leaving the negative attributes as an option, instead of as a tradeoff.

Honestly, I get bored if I do one thing for too long — and coming from a person who is pursuing the academic path with the most schooling, this is a measured statement. A little bit of this, a little bit of that, and the capacity to adapt across disciplines is highly attractive to me. Traditionally, for MD/PhDs, this would mean you have a clinical practice and run a laboratory. Ambitiously, you might also engage with industry. BUT, you might interject, you won’t be as good of a doctor or scientist if you split your time between them. I think these interjectors underestimate the bandwidth of the human potential. If Jiro dreamed of more than sushi, who knows what he could have accomplished. Seriously, although there is merit to becoming more skilled if you focus on one task rather than on two tasks, especially if that task is working as a surgeon, I believe that engaging in duality, particularly the dialectical variety, opens a door to a perspective that neither task alone could have provided. This cross-disciplinary perspective is far more valuable and generally practical, in my mind, than the progressive iterations on perfection that occur at the margins of singular talent.

How do you want to be spending your time in your 50s? Will it be driven by the same career goals and ambitions that you have in your late 20s? Considering how my personal goals have shifted from college to now, I suspect that I have no accurate idea. I’m preparing for this uncertainty throughout MD/PhD training and shooting for the stars along the way.