Training models: Summary

Clin Invest Med 1997;20(4):262-263

The follow-up data available from the MD/PhD program and the SSP seem to indicate that both models are reasonably successful in producing graduates capable of holding down positions as clinician scientists in academic medicine (spending 50% to 90% of their time in research). However, so far the numbers are too small to allow definitive judgements. Moreover, there has been little opportunity to apply adequate evaluative measures of the research competitiveness of these individuals (i.e., number of peer-reviewed grants, impact of publications, number of publications, etc.). Probably the most comprehensive analysis of follow-up data will emerge from the MSTP graduates in the United States. This information will be very helpful in assessing the Canadian MD/PhD programs, as well as establishing a standard against which to judge other models.

Some weaknesses in each model were identified. For the MD/PhD program, the general criticism was that there could be too great a gap from the time of graduation with an MD/PhD to the next opportunity to do research training because of the length of the postgraduate clinical training period. It was pointed out, however, that in the United States this deficiency had been corrected by creation of special clinical/residency research streams targeted to MD/PhD graduates; these streams allow such individuals to maximize research time during the postgraduate clinical training phase (i.e., a minimum of 2 to 4 years to do research, with the research years being counted as credit toward specialty board certification). This type of program has not been possible in Canada because of the Royal College of Physicians and Surgeons of Canada requirements that only 1 year out of 4 be dedicated to research. However, a number of the faculties of medicine in Canada are beginning to address this issue. The needs of Canadian MD/PhD graduates could be accommodated by the SSP (in surgery) or the model developed by Dr. Phillipson, perhaps all within the CIP guidelines. There is a real need to make the CIP more flexible, allowing more time for research to be counted toward completion of specialty requirements.

Concern was expressed that, regardless of which model was favoured, the total number of research training years might still be inadequate over the long term. Even if candidates obtain a PhD, they are still expected to compete with non-MD scientists who have usually completed 4 to 6 years of postdoctoral training, in addition to their PhD. How can this requirement for extra research time be fitted into the already "crowded" postgraduate clinical training period? As discussed earlier, there is an urgent need to design special clinical/research residency programs for this purpose. There was also unanimous agreement that some of the requirements for more research years could be met through the development of a "junior" faculty phase, to begin with the initial faculty appointment and to allow total protected time for research for several years. This recommendation is discussed in more detail in the next section.

A number of retreat participants emphasized the fact that exceptional research training could be obtained without going through a formal PhD. However, there was consensus that if such a PhD-equivalent training pathway is selected, care must be taken to ensure:

1. sufficient time for full-time research (3 to 5 years); and
2. an appropriate environment that allows for rigour and concentrated exposure to the fundamentals of the chosen field of study.

There was agreement that the available training models (e.g., MD/PhD or SSP) were appropriate as "primary" research programs. There was consensus that, in order to enhance both models, there was an urgent need to design clinical/research residency programs for those in the clinician scientist training stream.

Recommendation

That a special task force be set up to study the problem and recommend to the Royal College of Physicians and Surgeons of Canada ways to increase the flexibility of its training requirements. Practically, this recommendation might be implemented through the Royal College CIP Committee.

In the end, clinician scientists will have to accommodate themselves to the sometimes competing, sometimes complementary, but always exhausting, duality of their existence. The "coping" mechanisms are likely to involve a combination of inherited and learned skills.

Major "turn-offs" for MD/PhD students*

1. Research supervisors who want to know why they are wasting their time in medical school.
2. Clinical teachers who want to know why they are wasting their time in graduate school.
3. University faculty (family and friends) who insist they won't be able to do first-class research and be excellent physicians.
4. Governments that shrink the number of postgraduate clinical training slots so that by the time the students graduate with an MD/PhD, internship (PGY1) positions are unavailable.
5. Classmates who talk about (or are already) making money and also have time for a social life.
6. Parents who want to know when they will become real doctors.

* An identical set of turn-offs is experienced by participants in SSP programs -- but at a later stage.