In the mid-1960s, leadership within the National Institutes of Health (NIH), private foundations, and academic institutions recognized that the explosion of information in the biomedical sciences created opportunities for translational research on human disease. Their efforts resulted in the creation of training programs to produce joint MD-PhD physician-scientists who would bring the insights of clinical practice into their research and vice-versa. Thirty-three years later, empirical analysis is needed to evaluate the impact of these programs in academic medicine.
The MD-PhD program at the University of Pennsylvania (Penn), which was initiated in 1969 and has 255 total graduates, provides a locus for such a study. Penn's MD-PhD program has 167 current trainees and offers joint degrees in 19 separate programs including 8 in traditional biological sciences as well as 11 other programs, such as philosophy, demography, health care policy, and law. Similar analyses of MD-PhD programs have been published in recent years. A 1995 study of the 147 graduates of the Duke University program from 1970 to 1990 showed 74% working in academic medicine or research, with 82% of these holding full-time faculty appointments and conducting major efforts in research.1 Another study of MD-PhD graduates from Washington University showed that 89% of graduates who had completed their medical training were working in academic medicine or at the NIH.2
Data on graduates of Penn's MD-PhD program (1969 to 1998) were collected by self-report, in the form of curricula vitae requested annually by the MD-PhD program office, and by direct phone solicitation. This information included graduates' current career appointment (academic institution, government or private research institute, industry, or private/hospital clinical practice) and career trajectory (postgraduate fellow, assistant professor/staff scientist, associate professor/senior scientist, professor/section chief, and department chair/director). The questionnaire also surveyed the percent of time spent on research, clinical practice, teaching, and administration, as well as records of publications and funding. Information on national trends in residency selection (PGY-1) was obtained from the March 13, 1998, registry of the National Residency Match Program.
The response rate for the survey of Penn's 255 MD-PhD graduates was 85% (n = 216).
Because of recent changes in the allocation of residency positions, our analysis focused on MD-PhD students graduating in the period 1992 to 1998. Ninety-nine percent of the graduates during this period entered residency training (64/65). The most common choices among Penn's MD-PhD graduates mirrored those of the national pool of medical graduates: internal medicine (23.1%), pediatrics (18.5%), pathology (10.8%), and surgery (9.1%). However, compared with residents at large, Penn MD-PhD graduates disproportionately favored neurology and neurological surgery, ophthalmology, and otolaryngology over the fields of emergency medicine, family practice, and orthopedic surgery. Further data are available online.
Of the 216 responding MD-PhD graduates from 1969 to 1998, 35.2% (76/216) were still in training as of November 1998. Of the 140 MD-PhD graduates who had completed their training by the time of the survey: 83.6% (117/140) held positions as academic faculty, 5.7% (8/140) held positions at government or private research institutes, 4.3% (6/140) were in industry, and 6.4% (9/140) were in full-time private or hospital-based clinical practice(Figure 1).
Overall, 92.1% (129/140) of the MD-PhD graduates who completed their training defined their current positions as containing a significant research component. Within the past 12 months, 93% (130/140) had published a peer-reviewed manuscript; within the past 36 months, 98.4% (138/140) had. As many as 92% (129/140) currently serve as principal investigators on funded projects of any kind; 87% (122/140) are principal investigators on extramurally funded projects. Sixty-seven percent (94/140) listed their research commitment as greater than 50% of their efforts; 82% (115/140) reported less than 50% clinical effort. Nearly all of Penn's MD-PhD graduates listed administration and teaching as significant but minor components of their activity (less than 25% effort) (Figure 2).
Among graduates who entered academic medicine and had completed their training by the time of the survey (n=140), there was a steady increase in the number that entered junior and senior positions. After 6 to 10 years postgraduation, 74.2% of these graduates held the rank of assistant professor or higher; at 11 to 15 years, 100% held the rank of assistant professor or higher; and at 16 years or more, 100% held the rank of associate professor or higher, with 58.5% as full professor or equivalent. Further data are available online.
A major goal of MD-PhD programs is to produce academic leaders who use their interdisciplinary training as physician-scientists. The data gathered from the 216 respondents who graduated from 1969 to 1998 reveal that Penn's MD-PhD graduates enter academic and other research positions in high numbers. Overall, more than 90% of MD-PhD graduates who have completed their clinical training report that research is a significant professional activity. This is supported by observations that 89.3% hold positions in academic or research institutions, and that more than 90% of graduates published a peer-reviewed manuscript and served as a principal investigator on an extramurally funded project within the preceding year. We note that these results were obtained primarily through self-reporting from graduates without independent verification. Another potential limitation to this study is the uncertain status of the 15% of graduates (39/255) who did not respond to the survey.
Our results indicate, however, those the career positions held by Penn's MD-PhD graduates are markedly different from that of Penn's MD trainees and more similar to those of biomedical science PhD trainees. Although 24.3% of MD graduates hold academic faculty positions, 73.4% are in full-time private or salaried clinical practice, in contrast to only 6.4% of the MD-PhD graduates. Graduates of Penn's biomedical science PhD program also favor academic positions (55.2%), although they are distributed more heavily in basic science departments (82.4%), compared with academic-track MD-PhDs (8.8%). A much greater proportion of PhD graduates also track to positions in industry (33.5%) than is seen in either the MD-PhD (4.3%) or MD (1.6%) groups.
The combination of basic and clinical training, which serves as an integral part of MD-PhD training programs, is evident in the activities of program graduates. More than 98% of graduates selected clinical residency training, and nearly 75% of graduates who had completed their training retained clinical activity despite an active research effort. Although the level of effort in research and clinical areas varied widely among individual graduates, there was a clear trend toward research rather than patient care.
Several preferences were noted in the selection of residency programs by Penn MD-PhD graduates. Recent Penn program graduates entered 8 fields more frequently than the national average for residents: general surgery, neurology/neurological surgery, ophthalmology, otolaryngology, pathology, pediatrics, psychiatry, and radiology. Of these, chi-square analysis indicated that neurology/neurological surgery, ophthalmology, otolaryngology, and pathology were significantly favored. At this time, it is not possible to determine whether these trends are due to perceptions of these fields' compatibility with research activities, the perceived strength of Penn's clinical training in these fields, or other factors unrelated to the structure of the MD-PhD program itself. Taken together, this information indicates that Penn MD-PhD graduates enter academic medicine in significant numbers, retain a varying mix of basic research and clinical activity, and generally progress in academic positions. Analyses of other MD-PhD programs in the country will be useful in determining how these characteristics compare with national MD-PhD graduates.
Schwartz P, Gaulton GN. Addressing the Needs of Basic and Clinical Research: Analysis of Graduates of the University of Pennsylvania MD-PhD Program. JAMA. 1999;281(1):96-99. doi:10.1001/jama.281.1.96-JPU2-2-1