The United States Medical Scientist Training Program
Bert Shapiro, PhD
Clin Invest Med 1997;20(4):251-4.
Dr. Shapiro is Chief of the Cellular Section, Division of Cell Biology and Biophysics, and Director of the Medical Scientist Training Program, National Institutes of Health, Bethesda, Md.
Contents
Within the biomedical science community the need for investigators with both medical and basic research training has long been recognized. To help meet this need, the National Institute of General Medical Sciences (NIGMS), 1 of the 2 dozen institutes or divisions at the NIH, established the MSTP to encourage and support the training of students with outstanding credentials and potential who, through an integrated program of scientific and medical study leading to the combined MD/PhD degree, are motivated and qualified to undertake a career in biomedical research and academic medicine. The program's goal is to prepare its graduates to function independently in both basic research and clinical investigation.
The MSTP was established in 1964 with the awarding of grants to 3 medical schools or graduate institutions. By 1968 the number had grown to 7; there were 14 by 1974, 28 by 1987, and today there are 33. The 33 programs involve 37 degree-granting institutions with a total of 825 trainees, at a total cost of about US$21 million.
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Overview of the MSTP and student funding
Graduates of the MSTP differ from most scientists in having had the medical training required to investigate problems of disease in humans. They differ from most clinicians in having had the extensive research background in the biological, chemical, physical, behavioural, engineering or computer sciences needed to bring the fundamental knowledge and insight of these disciplines to clinical investigation. The majority of the graduates go on to careers in basic biomedical or clinical research while holding appointments in clinical departments of medical schools or at other medical research facilities such as the NIH.
MSTP grants are made to universities and their medical schools, which are responsible for the program operation and trainee selection. The awards are usually for 5-year terms. Both new and renewal proposals must compete for available training funds from the NIGMS. Initial review is by peer review panels that are responsible for the review of several other categories of training grants as well as MSTP. The composition of these panels is diverse and includes scientists and trainers with expertise in biochemistry, cell biology, immunology, biophysics, pharmacology, neurobiology, genetics, trauma, physiology, biomedical engineering and medicinal chemistry, among others. The reviewers include both MDs and PhDs and represent both public and private educational institutions. Although the panels are limited by fiscal and manpower resources as well as scheduling, site visits for most applications, both new and renewal, are conducted by a small team that reports back to the parent committee. The site visits are designed to provide information beyond that available in the written application, and they often provide a unique opportunity to talk with current and potential trainees about their backgrounds, career goals, scientific interests and accomplishments. The review criteria include quality and depth of the applicant pool, past training record, institutional support, training faculty and training plan. After initial peer review, the MSTP training grants and reviews are subject to review by the National Advisory General Medical Sciences Council. After these reviews are completed, the institute staff makes funding decisions as part of the institute's overall training budget decisions.
The time between entry to the program and receipt of both degrees is not fixed and varies among students and programs. Typically, most of the students finish in 7 or 8 years. Although some programs graduate most of their students in 7 years, more programs retain most students for 8 years. Programs that have students enrolled for 9 or more years are a cause of concern. Although the legislation enabling the support of graduate students limits NIH support to 5 years for each trainee, waivers to allow NIH support for MSTP students for 6 years are granted routinely. Although some institutions try to support each MSTP student for the maximum 6 years, most use such support for only 2 to 4 years. Thus, overall, at any one time, only half of the dual-degree students enrolled at these 33 institutions are actually receiving the MSTP training grants. However, one condition of the award of a training grant to a grantee institution is that students receiving support from the MSTP grant are also supported by some other means for their entire MD and PhD training. That means that if a student is supported for tuition and stipends for the first 3 years of his or her training, then he or she will continue to receive a stipend and either have tuition waived or paid for from some other source for the remaining 4 to 5 years. Therefore, the median debt for dual-degree training at the time of graduation is zero, in contrast to the median debt of US$30 000 (in 1990) for medical school graduation. More recent figures for some private medical schools anticipate an average debt of US$120 000 or more. The schools receiving MSTP training funding also train some dual-degree candidates who never receive MSTP support. These non-MSTP candidates account for about one-quarter of their total MD/PhD enrolment. Recent figures available (1994) showed that 147 students received dual degrees with some MSTP support and that an additional 29 students received degrees from the MSTP institutions without any MSTP support. In most cases all, or almost all, of these students were also supported by other sources and managed to graduate debt free. In addition to the medical schools receiving MSTP support, most others (perhaps 70 to 80) offer some opportunity for students to obtain a joint degree. Some of these institutions have well-organized programs, comparable to those receiving NIH training support. However, the total number of graduates from all of these schools in 1993 was only 73. Recently, some MSTP institutions have expanded their total dual-degree admission so that these students constitute a significant proportion of the class entering medical school. For example, the University of Pennsylvania intends to admit 30 MD/PhD students, fully 10% of the entering class. The University of California at Los Angeles has been authorized by the dean of medicine to admit dual-degree students to the level of up to 18% of the class. As in other state medical schools, the MD/PhD admissions are not restricted by in-state residency requirements.
The 2 keys to a successful MSTP are the quality of the candidates and the design of the program. The candidates are generally acknowledged to be both the best medical students and the best biomedical graduate students at each institution. The students almost uniformly have outstanding academic records and score highly on the MCAT exams. A prerequisite to admission is a proven interest and ability in research, and most students have extensive research experience. Many of the students at the most competitive institutions have been the first author on publications. The mean number of completed applications to an institutional MSTP is about 200, with only 64 invited for interviews. Of these, about 21 are made offers of acceptance in order to enrol 9 first-year students. Some programs receive over 400 MSTP applications a year to enrol 12 students. (Admission to the MSTP implies automatic admission to any of the biomedical graduate programs at the participating institutions; the student selects a specific graduate program or department only after completion of 1 or more years of training.) Since the majority of the applicants have outstanding credentials, the admission committees can focus on career goals, scientific experience and ability, and intellectual energy. All these traits are needed to succeed in the combined curricula that are found in successful MSTP institutions. Originally, the training fell mainly into a pattern of 2+3+2, in which the first and last 2-year periods were devoted to medical training, and the middle approximately 3 years were devoted to a graduate stint. Over the past 3 decades the medical training has been slightly compressed while the graduate training has expanded. In addition, it is common to have some meshing of the two. For example, in some programs, the students arrive in the summer before medical school in order to do rotations in graduate laboratories. They may even enrol in a graduate core course in lieu of some of the beginning medical curriculum. In one program, the students study histology independently on their own time so that they can enter directly into pathology. In fact, these students routinely get the highest grades in the pathology course. In many programs, the trainees continue to rotate through graduate laboratories while they are enrolled in the first year of medical school. Many programs expect the students to participate in journal clubs while still in their preclinical medical years. Conversely, while students are in their graduate phase, they often retain their medical interests. One program has a regular "follow a clinician" course solely for MSTP students during their graduate studies. Others have "virtual grand rounds" with a discussion of the scientific questions raised by clinical cases. Most programs are moving to require MSTP students to finish their dissertation before entering their final clinical clerkships. So that these students have an extended window of entry to the clinical rotations, many programs allow entry in a wide variety of specialties as a first rotation and have reduced the number of months for this final phase of training to 14. During the entire medical/graduate training, MSTP students meet regularly for socials, seminars, retreats, discussions and advisory sessions. The programs work hard to create and maintain an identity for these students that is distinct from either graduate or medical students. This creation of an identity and esprit de corps is crucial to the success of a program.
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Post-MD/PhD
The vast majority of MSTP graduates pursue residencies, although a few have elected to enter postdoctoral training instead. The record for achieving the most prestigious matches in the US is remarkable. Because of the 30-year history of excellence and the more than 1500 graduates still active, MSTP graduates are found in the most selective residency programs. Some residencies that allow or encourage extensive research activities may even be predominantly staffed by MSTP graduates. Although the most current data are still being assembled, the most popular specialties for the graduates are medicine, pathology, pediatrics and neurology. Within medicine some fields, such as hematology/oncology and endocrinology, are especially popular. Pediatrics has shown a recent surge because of a rising interest in human genetic diseases. Pathology has always been popular because of its appeal to those interested in cell biology and biochemistry. A continuing rise in the number of students obtaining their PhD in neuroscience has led to an increase in interest in neurology. Surgery has never been a common choice but is emerging as a selection among the students obtaining their degree in biomedical engineering, as is radiology.
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Follow-up data
The critical question is, what is the career outcome of this selection and training? The NIGMS is currently in the midst of a comprehensive survey of all graduates. We seek information on current position, extent of research and clinical activities, nature of research (clinical v. basic), sources of funding (past and present), career path (residencies, fellowships, appointments) and areas of specialty. These are to be compared with those of several carefully selected control groups. The pilot studies that we conducted were designed to test our polling techniques and did not represent a sufficiently large and representative sample to allow us to draw any conclusions. However, several MSTP institutions have maintained complete records of their graduates and, therefore, can provide some of this information for a limited sample. What is remarkable is that the data from each institution are comparable. Washington University, for example, finds that, of the students who had completed residency training, 86% were in academic institutions, and of these more that 90% were spending more than 75% of their time in research. At Stanford, with a smaller sample and briefer history, of their total of 83 graduates by 1991, 5 were professors, 9 associate professors, 21 assistant professors, 23 postdoctoral fellows, 14 in residencies, and 4 in private practice. Of the academic faculty, 7 were in basic sciences and 23 in clinical departments.
Recently, Dr. George Abraham, the MSTP director for the program at the University of Rochester, has solicited data from other MSTP programs and assembled and analysed them. The data are from 16 of the currently funded 33 programs that have been running for at least 10 years. Twelve of these programs are over 15 years old, and 8 are over 25 years. The median number of graduates is 88. He found that the records from the different institutions corresponded so closely that he has provided pooled data. The average time to completion varied with the institution, but the overall median was close to 7.5 years. The 1541 graduates from these 16 institutions can be divided into 2 groups: 50.5% are into their careers and 49.5% are still in postgraduate training. Eighteen percent are women. (Over the years the percentage of women has increased and is currently about 23%, compared with the percentage of women in medical school enrolments of just under 40%.) Of those past training, 83.2% are in academic careers, and 16.8% are in practice. Of those still in training, 70% are in residency, and 30% are in fellowships. The academic positions are distributed as follows: 48% assistant professor, 25% associate professor, 10% professor, 14% other, 2% in industry and 1% in pretenure positions, e.g., senior instructor. The overwhelming majority of academic appointments are in clinical departments (including pathology). The residency/fellowship specialties are distributed as follows: internal medicine, 32%; pathology, 16%; neurology, 7%; psychiatry, 7%; anesthesiology, 3.5%; ophthalmology, 2.5%; radiology, 2.5%; oncology, 2%; and surgery, 2%. The data are not as complete on faculty research funding but show that 75% of the MSTP graduates with academic appointments are funded for their research. The ratio of total grants over the entire MSTP academic cadre is 0.921 to 1; for NIH grants, the ratio is 0.719 to 1.
The record of MSTP graduates is so well known in US medical schools that they are the most sought-after candidates for positions in clinical departments. The widespread belief is that they can serve as intellectual bridges between the clinician and the basic researcher. Many graduates retain regular consults or even serve regularly as attending physicians while pursuing basic research. Their high level of energy, motivation, intelligence and training allows at least some of them to be both active clinicians and researchers. Questions have been raised, however, as to whether MSTP graduates are not predominantly PhDs, doing research that is often very similar to that pursued by PhD scientists. In addition, concern has been expressed that, although the program has been very successful in providing scientists who are conversant with medical problems and who provide an intellectual bridge between the 2 worlds, it has failed to train a significant number of researchers involved with patient-oriented clinical research. Many physicians and scientists have been concerned about the perceived shortage of patient-oriented researchers and would like to find a way of adding or directing MSTP programs to produce such scientists. One of the purposes of the comprehensive survey of MSTP graduates is to evaluate the categories of research pursued. Whatever its outcome, training of clinical researchers is probably the most actively debated current issue in regard to this program.
