By Rosanne Spector
Photograph by Trujillo-Paumier
Most people make no distinction between a medical school professor with an MD and one with a PhD.
To them, a doctor’s a doctor.
But those who work in biomedicine know the MDs are usually the clinicians — the type of doctors who see patients. And the PhDs spend their days at lab benches or computers, trying to understand what makes bodies tick. They also know that MDs and PhDs exist in parallel worlds with surprisingly little interaction.
“To a certain extent, the groups speak separate languages,” says Seung Kim, MD, PhD, director of Stanford’s Medical Scientist Training Program, which offers a combined MD/PhD.
Increasingly, medical schools are promoting mixing among the groups, spurred by the belief this will spark health-care innovation. Will this truly boost discovery and patient care? No one knows. But what is clear is these programs breed experts in the many cultures of medicine.
“In the first years of training to become a medical doctor, you learn pharmacology, anatomy, physiology and pathology. This material and your experiences with patients color what you see as the realm of possibilities for scientific exploration. Students pursuing basic scientific research rarely get exposed to any of this,” Kim says.
Crossover programs give students a common language, he says.
“It’s like what my father told me when I was learning German: ‘If you don’t think and dream in German, you won’t know German.’
“It’s similar with medicine: If you don’t think in the language of medicine, you won’t know medicine.”
Despite calls from medicine’s leaders to encourage mixing between the clinic and lab, the numbers of those earning combined MD/PhDs are dropping off nationwide. “That’s because in the last 30 years, everything — in clinical medicine, as well as in research — has gotten more specialized,” says professor of neurobiology Ben Barres, MD, PhD. “So if you want to train in both, it just keeps taking longer and longer.” Barres leads the Master’s of Science in Medicine program, a course of study launched in 2006 that submerges graduate students in medical school life for two years before sending them back to the lab.
Stanford hosts several other programs that similarly encourage mingling. One prominent example is the Advanced Residency Training at Stanford program, begun in 2007, which admits two residents or fellows a year to earn a PhD. Another is the Biodesign Innovation Fellowship, founded in 2000 to turn biomedical researchers, physicians, engineers and business professionals into medical device inventors — with eight new fellows this year.
Alumni from these programs and others like them might well feed an explosion of medical discovery. And even if they don’t, their skills as translators offer insights into the disparate biomedical worlds.
Jacob Brenner earned an MD and a PhD in Stanford’s Medical Scientist Training Program. Now he’s in the thick of the Biodesign program, inventing a new (top secret, for now) biomedical device.
Are the worlds of MDs and PhDs really so different? “Yes, but they have at least one thing in common: They tend to be skeptical of each other. The MDs think the PhDs don’t know the practicalities of the medical world and what’s a realistic type of therapy. On the flip side, the PhDs frequently are concerned that MDs aren’t trained to judge the scientific merit of claims.”
So how do they differ? “You can just talk with someone and usually know which they are. It’s little things — like biologists on average are more into nature and going hiking, and med students have a much higher rate of long-distance running. In my first week of medical school I got several invitations from classmates to triathlons and marathons. That’s something I didn’t see at all during my PhD.”
Other differences? “A hospital is super, super hierarchical. That permeates the MD culture. It’s striking: In basic science journals they never give authors’ degrees after their names. But medical journals always have their degrees. I think that’s very indicative of the attitudes of some physicians — that they’ll judge people by whether they have an MD. A PhD is less likely to think that way.”
Any misconceptions? “People confuse medicine with science. Medicine is applying knowledge that’s already been accumulated. In science, you’re trying to create new knowledge. I think medicine rewards you a lot more for your total amount of knowledge and how quickly you apply it. Science rewards you a little more for creativity and critical thinking.”
Next? “I want to more heavily focus my career in translational medicine. I really like the idea of having a product at the end of your work that goes to patients. I used to want to do basic science — mathematical modeling of signaling networks — so this is a very big switch.”
Holbrook Kohrt earned his medical degree from Stanford in 2005 and then completed his residency in internal medicine. He joined the Advanced Residency Training at Stanford program last fall to earn a PhD focusing on skills needed to design and analyze clinical trials.
Surprises: Before entering ARTS, Kohrt worried that he might not be as stimulated by the time-consuming lab experiments, compared with the patient interactions in the clinic. “But actually it’s a lot of fun when you come in and you see how your mice are doing and how the tumors are growing,” he says.
Life in the lab vs. life in the clinics: “Clinical practice involves a very high-paced, quick decision-making process, and there’s a relatively short time for finding out whether you made the right or wrong decision,” he says. That’s in stark contrast to the world of lab experiments where it takes months or years to know an outcome. “Figuring out the paces of the two different worlds is actually pretty hard to adjust to.”
But Kohrt also sees the benefit of inhabiting both worlds. “The satisfactions are so different and they come on such different levels; they sustain each other,” he says. “Without the satisfaction of seeing the patient, it can be depressing when a series of experiments doesn’t go well.”
Aha moments: Kohrt’s goal is to work at an academic medical center where he can direct a lab and see cancer patients one day a week. His experience in ARTS is driving home just how demanding such a career will be. “It’s difficult and incredibly time-consuming to try to do basic science and do clinical practice. To be able to do both well is much more difficult than I previously imagined — but well worth it.”
Future: Kohrt believes the direction he’s taking will enable him to meld the worlds of clinical practice and basic science. He’s in the cancer biology program, training in clinical trial design and statistical analysis rather than the traditional, more biology-focused subjects. “It’s fantastic because I’m learning what’s most relevant, and that is: How do I translate everything I’m doing in the lab to the clinic?”
Why he likes it: It’s difficult to see cancer patients for whom effective therapies don’t yet exist, Kohrt says. “So to be able to come back to the lab and work on what I was wishing for a few hours earlier, there can’t be anything more rewarding than that.”
Christine McLeavey is a graduate student in neuroscience and in the Master’s of Medicine program. Her dissertation research: treating spinal cord injury and chronic pain using light.
Surprises: When McLeavey was an undergraduate at Princeton, the ruthlessly competitive “pre-med personalities” she encountered before choosing her major turned her off. (She decided on physics.) But she found that Stanford medical students were nothing like what she expected. “It’s fantastic how everyone pulls each other along. If people make a study guide, they share it; if they make flash cards, they share it. There are no grades, and I think that makes a big difference,” she says.
Life among medical students vs. life in the lab: “Each medical school class is very much a unit. You go through all these crazy experiences with each other, starting with the anatomy lab dissection. There’s one big e-mail list. All of a sudden these are 90 of your closest friends.”
Now that you’re back in the lab…“It’s a totally different mind-set. The medical school world is very intense but you know what you should be doing all the time. In the lab, you have to figure out what you want to do with your day. I’m trying to take the organization skills I had to use in the med school world and apply them.”
What’s changed: “Before the medical school experience, I didn’t have a good sense of what would be a reasonable treatment — or what would be too ridiculous and no doctor or patient would have anything to do with. Now I get that. I also think more about the fact that every treatment has a side effect. So as a researcher, I’m thinking not just about the goal, but also the collateral problems a treatment might cause.”
Future? “I think everyone who goes through this program has pangs of, ‘Oh, maybe I should be a doctor.’ My original plan was to go into pure neuroscience research but now I’ve moved more toward the application side of things. I’d like to have projects that involve working directly with doctors.”
Tracy Holmes is a graduate student in chemical engineering who has completed his third year of the Master’s of Medicine program. His research focuses on drug development — in particular, on a newly identified antibiotic compound, guadinomine, isolated from the bacterium streptomyces.
How med students differ from engineers:
“Well, they’re much more focused on practical aspects of medicine and health care, whereas scientists oftentimes are more focused on fundamental principles of medicine,” says Holmes. But there are a few more differences, he says. “Engineers don’t like to memorize — at all — and med students know that it’s part of the territory.”
Surprises: “When I got into the medical program, I was already really busy with engineering coursework, so I didn’t realize what I was getting myself into! It’s funny — I was so busy, I didn’t even realize I’d be dissecting human cadavers on the first day of classes. I thought they’d give us a little time to warm up to it.”
Life changing? “The program confirmed that medicine’s the direction I want to go in. I’m more interested in research that will affect people directly — either saving lives or making people’s lives better.”
Benefits: “I think making friends in both med school and engineering has enriched my graduate experience. I enjoy being a part of both social networks.
“Also, people think I’m a medical expert in the lab. I do appreciate that I can explain medical concepts when they come up. One such instance was, ‘What does the spleen do?’ That came up in one of our journal clubs and people turned to me for the answer.”
Julia Rasooly is a graduate student in bioengineering who has completed the second year of the Master’s of Medicine program and has decided to get an MD. Her area of focus is molecular imaging, involving the development and use of imaging technology to study intact biological systems.
Life in the lab vs. life in the clinics: Rasooly observed very different cultures. “In the lab, I would plan out my experiments for the entire day, or week, and I felt that I had a lot of control over my time. I was usually the only one working on my project. In the clinics, it is more about teamwork and all about the patient. Life also seemed very fast-paced in the clinics, and involved a lot of paperwork and administration.”
Misconceptions: After delving into the medical classes, Rasooly grew more interested in learning about the U.S. health-care system and reform efforts. Through her work in the clinics and an outreach experience in Mexico where she found poorer populations had higher vaccination rates for children ages 1 to 4 than did their U.S. counterparts, she became even more passionate about getting involved in health-care reform. “Some Third-World countries have better health-care regulations than the United States, so it was an eye-opener,” she says.
Aha moments: “I always had a passion for making things happen,” Rasooly says, and that’s what initially drew her into the field of bioengineering, where she could devise technical solutions that would help improve patient care. “But during the first year of graduate school I realized that although I may have had the engineering and basic biological tools, I didn’t have sufficient knowledge of medicine and the pathophysiology of diseases to be able to fully grasp and identify the medical needs in the clinic,” she says.
Why she likes it: “I noticed that many hard-working and intelligent engineers and scientists are working on discoveries that may not be easily translatable to the clinic. And many physicians don’t know enough about the basic sciences and engineering to be able to communicate the needs to the scientists. If I’m fluent in both science and medicine, I can become an intermediary,” Rasooly says. “Applying engineering to medicine is critical to being able to bring about better, novel solutions to needs in medicine.”
— Additional reporting by Susan Ipaktchian