MD/PhD programs -- the Canadian experience
Mel Silverman, MD
Sandy McGugan
Clin Invest Med 1997;20(4):255-6.
Dr. Silverman is Professor of Medicine and Director of the Institute of Medical Science and MD/PhD Program, and Ms. McGugan is Administrative Coordinator, MD/PhD Program, University of Toronto, Toronto, Ont.
The role of MD/PhD programs in the training of clinician scientists is well established in the United States but is a more recent addition to the training options in Canada.
The University of Toronto put the first integrated, fully functional Canadian program in place, beginning in 1984. McGill University followed shortly thereafter, accepting its first students in 1987. Although allowances had been made for individual students to do a PhD in conjunction with their medical school training at the University of British Columbia, the University of Alberta and the University of Western Ontario, MD/PhD programs were administratively formalized at these institutions only recently. One half of all Canadian medical schools (the University of British Columbia, the University of Alberta, the University of Calgary, the University of Western Ontario, the University of Toronto, McGill University, l'Université de Montréal and Dalhousie University) now offer MD/PhD programs, and plans are under way to implement such a program within the next 2 years at l'Université de Sherbrooke.
In February 1997, the University of Toronto MD/PhD Program sent a questionnaire to all Canadian faculties of medicine to elicit some basic data on existing programs. Fifteen out of 16 questionnaires were returned. What follows is a brief overview of the current status of MD/PhD training in Canada, based on the responses.
As of January 1997, there are 51 students enrolled in combined-degree programs across Canada (Table 1). There is a direct correlation between the size of a program and the length of time it has been in existence. For example, the largest enrolments are at the University of Toronto (24) and McGill University (14), compared with the other 6 programs, which have anywhere from 1 to 4 students currently enrolled. Not surprisingly, the larger programs attract the greatest number of applicants (McGill University receives approximately 35 applications per year and the University of Toronto from 40 to 50) and have a large entering class, whereas the small programs average 5 applications per year.
The maximum number of students entering MD/PhD programs in Canada in 1996 was 18; there were 3 to 5 at each of the 2 large programs, and 1 to 3 at the rest. This number will likely remain at about this level because of the recent emergence of most of the programs. Even if the entry rate is not restricted by admissions committees, it will probably remain small for the first few years until the programs are well publicized to prospective applicants.
With approximately 75 applicants competing for positions this year, program directors are in an enviable position. They will be limited only by the financial resources available to support students and program administration.
Financial support for students is common to all Canadian programs, primarily through the MRC and its new MD/PhD Studentship Awards. All but 1 program reported faculty financial contributions to student support, and 5 out of the 8 programs have students supported through external agencies. Only 1 program has successfully established partnerships with industry.
The amount of funding per student varies from 1 program to another. Fifty percent offer support for the graduate phase, plus the final 2 years of medical school. Three programs provide support for the graduate phase only, and 1 offers full funding for 7 years.
The route to the combined degrees is usually either sequential or integrated. Several programs (e.g., those at the Universities of Calgary, Alberta, Toronto) offer both options, while others restrict students to sequential (Dalhousie and McGill Universities) or integrated (University of Western Ontario) options only. MD/PhD students are encouraged to pursue research in any graduate department in the Faculty of Medicine, and usually obtain the PhD degree before returning to complete the clinical years of medical school.
Follow-up data
Since the average length of the combined degree programs is 7 to 8 years, graduates of these programs have emerged only in the last few years. Long-term follow-up data will accumulate with time, but the survey revealed the following short-term statistics.
To date there have been a total of 15 graduates from Canadian MD/PhD programs, all within the last 5 years. They are nearly all currently undertaking residencies in areas such as internal medicine (2), anesthesia (2), neurology (2), urology (1) and neuropathology (1). One University of Toronto graduate completed his neurosurgery residency at the University of Western Ontario and recently took a junior staff position in neurosurgery at the University of Toronto.
It may be premature to say that MD/PhD programs have succeeded in attracting, training and ultimately contributing to the cadre of clinician scientists in Canada. The number of applicants to our programs is consistent and growing, and our graduates appear to be moving in the right directions. In all likelihood our longer-term follow-up data should be similar to data from the US, where 90% of MD/PhD graduates from the top 8 programs have gone on to successful careers as clinician scientists in academic medicine or in research institutes. In fact, the Harvard MD/PhD program recently completed an alumni survey that confirmed overwhelmingly that its graduates fulfilled the expectations of the training program. Of the 107 graduates who had completed their residency training, 9 became professors, 24 associate professors, 50 assistant professors and 9 instructors. Nine individuals held positions in industry as CEOs, vice-presidents, division directors or senior research scientists, and 2 were NIH chiefs.
The recent interest in and resurgence of MD/PhD programs in Canada coincides with the initiation of the MD/PhD Studentship Program by the MRC. This new initiative will fund only 10 students per year, to a maximum of 40 at any one time. However it has provided the catalyst to expand the number of MD/PhD programs across Canada and the number of students in each program. The peer review process at MRC sets the standards, so that no one can question the selection criteria of the entrants. And the fact that these students must complete and defend a PhD in the school of graduate studies, as all graduate students do, validates the MD/PhD "product."
MD/PhD training is relatively cost-effective when compared with the level of support required to put an MD through a graduate program after residency: the cost is $107 065 ($15 295 for 7 years) for an MD/PhD student versus $168 000 ($42 000 for 4 years) for a resident (dollar estimates based on average 1996 MRC stipends). The MRC studentships form an important nucleus for the funding of these programs, but a variety of sources and resources will be required to allow programs to reach their potential.
The cumulative evidence suggests that Canadian medical schools have worked out effective integration of undergraduate MD and PhD training and that the MD/PhD program is emerging as a highly successful model for training clinician scientists. Some schools have begun to address the need for clinical/research residency programs that maximize research time, specifically targeted to graduates of MD/PhD programs. Such programs are essential to ensure that these individuals acquire the postdoctoral experience necessary to make the transition to independent investigator status.
