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For some students, medical school just isn't enough

A growing number are getting degrees like PhDs, MBAs and MPHs to learn—and earn—more

From the September 1998 ACP-ASIM Observer, copyright © 1998 by the American College of Physicians-American Society of Internal Medicine.

By Bryan Walpert

Leigh Hochberg started medical school eight years ago and doesn't expect to finish for at least one more. Slow? Hardly. The Emory University student took a five-and-a-half-year break from his medical studies to pursue a PhD in neuroscience.

Mr. Hochberg is among a growing number of medical students pursuing a combined degree. In 1997, 401 medical school graduates had received funding for an MD/PhD, more than double the number of MD/PhD students a decade earlier.

And though an MD/PhD degree is probably the best-known combination for medical students, there are plenty of other options. Students are also combining medical degrees with master's degrees in public health and in business administration, and residents are also combining training in multiple programs. (See "Residents look to combined programs for the best of two worlds,".)

Why would someone want to add to the already hefty burden of medical school? Medical students say the main reason they get a PhD is to combine their love for medicine and basic science. Besides, they are often fully funded for both medical and graduate schools by the Medical Scientist Training Program (MSTP), which is run through the National Institute of General Medical Sciences.

Other students work toward a master's degree to get the background in management or policy they need to help shape a health care system increasingly focused on preventive medicine, the bottom line and managed care. These programs also offer an additional credential that could help open doors to research grants and management positions.

"At one time, physicians' views were that they were going to practice medicine and they were going to practice in a single discipline," said Deborah Danoff, FACP, assistant vice president within the division of medical education at the Association of American Medical Colleges (AAMC) in Washington. Today, however, she noted, physicians want more opportunity to be involved in policy setting, population-based activities and management issues surrounding the delivery of health care.

Research

Opportunity is certainly one of the reasons Sanjay Kumar decided to work for a combined MD/PhD degree. The Johns Hopkins University student, who has completed two years of the program, said he sees growing competition for both research funding and positions.

"It's an advantage to have some career versatility," said Mr. Kumar, who is interested in molecular biophysics and bioengineering. "The more options you have, the better you can prepare yourself to fill certain niches in the workplace."

"PhDs have a lot of anxiety about competing for jobs," added Bert Shapiro, PhD, director of the MSTP program. But when MSTP students hit the job market, he said, "people clamor to hire them."

Even so, Mr. Kumar allowed that job security was the "less altruistic" reason for pursuing his double degree. His primary motivation, he said, is to do something "useful to humanity. It's very easy to do science in a vacuum ... and never stop to think what the impact is, how what you are doing is going to benefit other people."

In fact, the ability to translate bench research into a clinical setting is often what interests many of these students—and ultimately what makes physicians with PhDs so valuable.

"Often what they want to do is learn enough medicine that they can make their science more relevant to the relief of human suffering," said Stephen Desiderio, MD, PhD, a professor of molecular biology and genetics and director of Hopkins' MD/PhD program." In an era when biology is increasingly able to address human suffering, that's not a particularly naive thought at all."

Students come to these degrees with varying orientations toward clinical or research work. If the direction of graduates from Johns Hopkins is any indication, however, most MD/PhD graduates tend to pursue research. A recent survey of the school's graduates between 1980 and 1993 found that of those who had finished postgraduate training, 81% were in academic positions, where they were presumed to be doing some research, 12% were in public or private research institutions and 6% were in industrial research.

Whatever background students have, keeping a clear idea of their goals is key in helping them navigate what can be a very grueling path. The median length of an MD/PhD program is seven years, according to figures provided by the AAMC. Typically, students spend a couple of years in medical school, pursue their graduate work and research, then return to medical school and try to recall terms and ideas they haven't dwelled on in several years.

"There's certainly a transition period in going from graduate school to medical school after a hiatus that can last up to five and a half years," said Mr. Hochberg.

Public health

It doesn't take quite as long to combine an MD with a master's degree. Students at the University of North Carolina (UNC) School of Medicine in Chapel Hill, N.C., for example, take a year off after their third year of medical school to pursue a master's of public health (MPH) at the School of Public Health across the street. Similarly, medical students at Emory University can earn an MPH degree between their third and fourth year of medical school, so the overall process takes only five years. And at George Washington University, students can finish both degrees in four years.

Still, adding a master's degree requires medical students to switch academic gears. MD/MPH students take courses in areas like biostatistics, epidemiology and health care policy. The idea is for students to learn how to work with populations and to prepare them for positions in management, policy and leadership in academia, managed care or private practice.

"These are people interested in taking the lead in this new world of managed care," said John E. McGowan Jr., MD, director of the MD/MPH program at Emory University, professor of epidemiology at the Rollins School of Public Health and professor of pathology at Emory's School of Medicine.

Russell P. Harris, FACP, MPH, co-director for UNC's new combined program, said the degree will probably produce three kinds of physicians: clinician leaders who see patients most of the day but are also interested in leading quality improvement committees in their group practice or managed care group; clinician managers such as managed care medical directors; and health services researchers who work in academia or for managed care, studying how to organize care for groups.

In medical school, "You're taught how to take care of individual patients one at a time," Dr. Harris said. "But if you're trying to be a medical director of a managed care group, the challenge is to answer questions like 'How do I organize care for the 10,000 people with diabetes?'" Adding a master's degree can help physicians better solve these problems.

Brian Diamond, MD, MPH, received his double degree with a focus on health promotion and disease prevention from George Washington this year. He expects to go into family practice and work in community health programs, designing curricula teaching children and adults about nutrition and other issues. He said much of what he learned in MPH classes will come in handy, particularly the courses on maternal and child health, education and learning theory and grant proposal writing.

Business administration

Students pursuing the administrative aspects of an MPH degree might find common ground with their colleagues working on business degrees. Students who combine an MD and a master's of business administration (MBA) are likely to end up running hospitals, managing HMOs or working in policy. "But we train them first and foremost to be physicians," said Norman S. Stearns, FACP, a professor of medicine and director of the MBA in health management program at Tufts University in Boston.

Medical students at Tufts earn their MBA by taking business classes at Tufts and nearby Northeastern and Brandeis Universities. The curriculum includes typical core-business courses such as accounting, business planning, economics, organizational behavior, financial analysis and management. It also includes health-related business courses on topics like health care systems, national health policy and management information systems related to health care. Students take some of the courses in the summer before the first year, some during the first year of their MD—often at night—and finish up the next summer. They can earn both degrees in four years.

Shervin Rabizadeh, a student in the Tufts program, believes that furthering his education will help him to better handle the business aspects of health care, though he doesn't know exactly how he'll use his MBA. "I know if I go into practice for myself it will help me manage the practice," he said. "If I decide to work in a hospital, it will help me manage different divisions. All I know is I want to be a clinician first and use this to assist me in dealing with anything that occurs in terms of administration or management."

The University of California, Davis, School of Medicine offers an MD/MBA program to give physicians the skills necessary to help shape a health care system increasingly focused on the bottom line. "I think many physicians stand on the sidelines wringing their hands about what's going on with medicine—HMOs and managed care," said Ernest Lewis, MD, associate dean of admissions and student affairs. "The goal of the program is to prepare some people to function in that setting in an intelligent way so they can be movers and shakers in terms of shaping the future."

Similarly, Tufts hopes to give physicians the opportunity to run health care organizations now headed by non-physicians who do not necessarily see health care from a clinical perspective. "We want to educate physicians who will become leaders in shaping the health care system in a way that ensures access, quality and affordability for all," Dr. Stearns said. "That is not the way we believe a non-physician MBA manager thinks."

Janel Pandya, another student in the Tufts program, sees physician control as an important reason for combined programs. "As medicine has become more and more infiltrated by business, people with business training have come in to take over the running of hospitals or even physician practices," she said. "I like the idea of being in control of my profession. Medicine was once that way. With programs like MD/MBAs, hopefully it will be that way again in the future."

Bryan Walpert is a freelance writer in Denver.


Residents look to combined programs for the best of two worlds

When Robert K. Horowitz, ACP-ASIM Associate, graduated medical school in 1993, the dean giving out degrees noted that Dr. Horowitz planned to do a combined medicine/pediatrics residency. "I guess Rob just can't decide," he joked.

While some people might assume that residents like Dr. Horowitz choose combined programs because of indecisiveness, nothing could be further from the truth. A growing number of medical school graduates are choosing combined residencies because they want to treat their patients from cradle to grave.

Family practice programs boast that they offer the same type of training, but some residents prefer to narrow their training to focus more on medicine and pediatrics than broader generalist training. In general, med/peds residents spend less time in specialty rotations such as obstetrics/gynecology and more time in the hospital than they do in family practice programs.

The number of institutions offering med/peds programs nearly doubled from 56 in 1985 to 106 this year. In addition, smaller numbers of residents are combining their internal medicine training with programs in emergency medicine, psychiatry, neurology, physical medicine and rehabilitation, preventive medicine and even family practice.

These combined programs, which last four years in the case of pediatrics and preventive medicine, and five years for most others, take advantage of redundancies in training to shave a year or two off the time it would take to complete residencies in both areas. Residents split their training equally between the two specialties and then take boards in internal medicine and pediatrics.

Combined training programs allow physicians to take advantage of complementary skills. Many patients who come to a physiatrist for rehabilitation services, for example, have multiple medical problems. It therefore makes sense for physiatrists dealing with stroke, brain injury or degenerative diseases to have a deeper training in internal medicine so they can either address those problems directly or communicate better with consulting internists, noted Richard Eisenstaedt, MD, program director of the internal medicine residency program at Temple University Hospital in Philadelphia.

However, some students may choose combined programs for other reasons. "It may be that there are a few students who see the writing on the wall relative to physician work-force considerations," said Herbert S. Waxman, FACP, the College's Senior Vice President for Education. "They figure that this relatively unique type of training may give them a leg up in the future."

In general, though, those enrolling in many of these combined programs are too few to trumpet a trend or attribute interest to market forces. Medicine/neurology filled only four slots in this year's match, while medicine/psychiatry filled only 26.

Med/peds programs, on the other hand, filled 420 positions this year through the Match. Though that's a drop in the bucket of the more than 20,000 positions offered in the Match, the number of residents in med/peds programs has grown by 160% since 1988.

Med/peds combined programs started in the late 1960s, sparked at least in part by the emergence of family medicine as a cradle-to-grave specialty. More recently, it has grown because of the emphasis on primary care medicine by managed care.

"At a time of national emphasis on primary care, pediatrics and internal medicine tend to enjoy a particularly high esteem in most medical schools, particularly in the eastern half of the country," said John K. Chamberlain, FACP, a practicing med/ped in Rochester, N.Y., who chairs the med/peds section of the American Academy of Pediatrics.

"There's a great need for people who have generalist skills," said Susan D. Wolfsthal, FACP, residency program director at the department of medicine at the University of Maryland School of Medicine in Baltimore. "One of the advantages of med/peds over family medicine is they are able to deal with more complex illnesses because they have more training dealing with acute illnesses."

Dr. Horowitz, who is completing his residency at the University of Rochester, said that the depth of training in two specialties drew him to the combined residency. Nevertheless, he would not say that his training is superior to family medicine.

Indeed, med/peds offers tremendous flexibility to medical systems attempting to grow their primary care base in new geographical areas. As Dr. Chamberlain explained, health plans can send out med/peds to generate referrals in an area that may not yet support both full-time pediatricians and internists.

A 1994 study found that two-thirds of med/peds graduates work in primary care and that 85% of those are practicing both specialties, according to Dr. Chamberlain. Of the 21% of med/peds graduates who subsequently trained in a subspecialty, half continue to treat children and adults.

"It doesn't mean the practice of internal medicine or pediatrics is failing to satisfy the needs of graduates," said Richard J. Glassock, MACP, chairman of the department of internal medicine at the University of Kentucky College of Medicine and chairman of the Residency Review Committee for Internal Medicine. "There has always been a group of physicians who want to cover a broad spectrum of ages. In the past, they gravitated to family practice. Now some of them are gravitating to medicine/pediatrics."

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