M.D.-Ph.D. Program Harvard Medical School Fall 1995 Newsletter

Articles in this issue:

Twenty-Five Years of Women M.D.-Ph.D.s


by Nancy Andrews, M.D.-Ph.D.

In this year of anniversaries for women at Harvard Medical School (75th for DMS, 50th for HMS) special recognition should be given to the small group of women who have elected to pursue combined degrees. Twenty five years after the first female student was admitted to the Harvard M.D.-Ph.D. Program, this group is large enough and influential enough to stand out. A celebratory dinner was held on November 14, to bring together women students and a sampling of women physician-scientist faculty, several of whom are graduates of the Harvard program.

Under the gaze of prominent Harvard medical men, staring down from portraits lining the Aesculapian Room, a new generation of physician-scientists gathered at the Harvard Club to talk frankly about their chosen careers. Accustomed to being among very few women in professional settings, many of us felt the delightful oddity of gathering as a strong, talented group of women in a traditional Harvard haunt. As if to emphasize the contrast, an almost entirely male group of surgeons gathered for a different event one floor below us.

The primary purpose of the dinner was to introduce junior and senior women M.D.-Ph.D.s to each other, so that younger participants could get a glimpse of life after school (if not after Harvard), and older participants could compare notes with their younger colleagues. There was remarkable diversity in the research interests of both groups, and many examples of differing career paths begun with M.D.-Ph.D. training. Small group discussions let students voice their questions and concerns, and faculty discussed how these have been addressed in their own lives.

Dr. Mary Ellen Avery (Hopkins '52) contributed an historical perspective, and pointed out that Harvard still has a long way to go in appointing women to senior positions. She felt that this was not due to deliberate exclusion, but rather neglect - that women are forgotten when candidates are sought for awards, honors, promotions and chairmanships. She encouraged students and younger faculty to make an effort to remember their female colleagues when asked to make nominations, and to create a supportive network to help install women in important positions. While Harvard lags behind other institutions in recruitment of female faculty, she felt that there is still hope for the future.

How to "do it all" successfully is a major concern for women (and men) trainees, and the participating faculty represented a variety of successful strategies for blending research, clinical medicine and family life. One of the most troubling personal concerns for students is how to work parenting in to a busy career schedule. It was clear at the dinner that many common ideas on this issue are myths. In contrast to old dogma, it is rare for a woman scientist to elect not to have children because of her career-most choose to have children and do so. It is also a common misconception that parenting damages one's professional life; on the contrary, many physician-scientist parents of both sexes feel that the personal satisfaction and perspective gained from having children adds an extra dimension to their work, and helps them deal with stresses more effectively than non-parents. And importantly, as demonstrated by the faculty at the dinner, there is no one way to bring together career and family.

A few tips that seem reasonable for any professional trying to mix a busy work schedule with a balanced personal life:

  • Set priorities and feel comfortable with them. Once you have made up your mind, don't feel guilty, and don't blame career problems on family choices.
  • Learn to be adaptable, and to take unknowns and surprises in stride.
  • Learn to be a creative problem solver.
  • Be efficient (if you can).
  • Delegate when possible, and give up some control; don't feel bad if that means giving up traditional roles.
  • Wear sensible shoes.

We hope that this dinner will become an annual event. Sometime in the future, when opportunities are more balanced, this type of gathering should bring together students and faculty of both sexes, for open dialogue about the issues we all face in becoming physician-scientists.

Nancy Andrews (M.D.-Ph.D. Class of 1987) is an Assistant Professor of Pediatrics.

A Conversation with David Seldin, M.D., Ph.D.


by Rob Hurford

David Seldin graduated from the M.D.-Ph.D program at Harvard Medical School in 1986. He completed a two year residency in Medicine at the Brigham and Women's Hospital, followed by a year and a half of clinical work in Hematology and Oncology also at the Brigham. Dr. Seldin then returned to research as a fellow in the laboratory of Dr. Philip Leder, where he showed that deregulated expression of casein kinase II contributes to the development of lymphoma in mice. Last year, Dr. Seldin was appointed Assistant Professor of Medicine at Boston University Medical School. Currently, he spends most of his time pursuing research interests in oncogenesis. He also sees patients for one month out of the year as an Attending Physician in Hematology and Oncology.

Now that you have completed the M.D.- Ph.D. Program as well as postgraduate training in both medicine and research, what do you think about the goal of having a dual career in research and clinical practice?

M.D.-Ph.D training in some ways is a way of postponing decision making because you pursue training in both clinical medicine and research. The idea is that you will have a combined career that balances both of the skills. Some people used to say that they would try to split their time 60-40 or 70-30 between research and clinical practice. One of the things that has happened in academic research over the last five years or so is that it has become much more competitive to get grants funded. People who are and will continue to be successful at basic research are people who focus the majority of their time on research. Even with dual training people need to make more focused decisions about their career as time goes on. Clinicians who don't practice medicine close to full time are going to encounter difficulty keeping their jobs and supporting their salaries in academic medicine, particularly in a very crowded and competitive system like Boston. Still, I think that dual training is a good thing to do. While it may not be the most efficient and rapid way to get into a research career, it does give you important perspective.

If you ultimately want to pursue a career in research, is it worthwhile to do a residency and subspecialty training?

That is a tough question. I think that the last few years have validated the concept of M.D.-Ph.D training. Even with shrinking research funding, it has become clear that biomedical research needs to relate very strongly to human disease. So, perhaps we are entering the golden age of the M.D., Ph.D. in research. But the question is how far to take clinical training and that remains a tough question. For myself personally, I enjoyed the clinical training, and I'm glad to be able to continue to participate in patient care and in teaching medicine. If you were only going to apply for jobs in a basic science department there would not be any great benefit of clinical training. On the other hand, if you want to be in a department of medicine it is nice to have subspecialty training and a clinical niche to fit in.

Given this idea that you need to focus on either research or clinical medicine, what role do you see for people in the M.D.-Ph.D program who decide they want to do clinical medicine? For example, clinical trials or general academic medicine jobs?

If you want to do clinical trials and have a Ph.D. that involved math and statistics it could be useful training. This question is very much in evolution right now. We are in an uncertain time for clinicians and clinical research. I think that the makeup of academic medicine is very different from what anyone visualized even a few years ago. There are funding changes in Medicare payments to academic hospitals, changes in the structure of residency programs and changes at the NIH. In Boston it is clear that the clinical programs at tertiary care hospitals are going to have to shrink.

You have to do what you enjoy and the key in the future is going to be focus. I think that there is going to be less and less opportunity for the kind of heterogeneous careers that people had in the past. In the past, I would have predicted that I would spend more time in clinical medicine than I do now. But, the fact that my clinical time is very controlled and limited enables me to pursue research and grants.

What would you encourage people to look for in a thesis lab?

Intellectually, there are benefits to doing a Ph.D. in one area and a postdoc in another area, then working out your own research program. But, again, because of external funding pressures, keeping your career as coordinated and focused as you can turns out to be beneficial. In my experience and that of my peers, if you have some relationship between your Ph.D. degree, postdoctoral work, and what you set out to do in your own lab, NIH sees a long term commitment to an area. In general principles, you need to try and push the decision making earlier than people had to in the past. If you see yourself as a clinician doing clinical research, then acquire the skills to be outstanding at that. If you can identify your basic research interests as soon as possible, try to focus your graduate training and thesis work on the problems you see yourself being interested in in the future.

What guidance can you offer for residency and subspecialty choices?

In my own career, my Ph.D. work was related to immunology and inflammation. In my clinical training I became more interested in hematology and molecular oncology. I chose my specialty training in hematology-oncology and completed a postdoc in a lab where I could work on those kinds of problems.

It is helpful if you can coordinate your clinical career with your research interests. On the other hand, one of the good things about modern science is that most areas of biology use overlapping techniques and almost everyone "does" molecular biology. It is certainly possible to make changes in the focus of your research and bring skills from one area to another.

For people interested in medicine, what about short-tracking [i.e. two years of internal medicine instead of the normal three years followed by subspecialty training]?

Short-tracking is a good idea. If you have decided that you want basic research to be the main focus of your career, you have to think strongly about taking some shortcuts in your clinical training.

Although things will probably change before people in the program start looking for positions, what is the job market like now?

The current job market is very tough. Five years ago, academic research was supported by profitability in clinical medicine. A successful academic center had excess income that was used to support the research endeavors of the institution. Obviously, as reimbursements, patient populations and bed occupancy shrink, the profits of clinical departments have gone way down, and thus, they cannot shift money into supporting salaries of researchers and research in general. Clinical departments have been unable to continue to expand their research activities and consequently researchers have to be very self supporting. So, the hiring of researchers has decreased and the support available to them has decreased. This situation is in flux and will depend very much on global changes in medicine in the next few years. But, I think that the days of academic positions being readily available for people who did pretty good research have probably gone forever. With the NIH funding 10-15% of grant applications, people need to be able to seek alternative sources of funding from other agencies or relationships with drug companies.

Even with these difficulties, are you glad that you did the M.D./Ph.D. program?

Yes, I think that I am glad. I can't predict the future of medicine or academic medicine and although I have emphasized that it is important to focus your career and think seriously about what you want to do down the line, it is still very important to end up doing something that you like. Since I'm still at a relatively early stage in developing an independent career, I can't answer the question completely. I am certainly hopeful that by having dual training in this tough era I will be able to be competitive and continue doing what I like doing.

Rob Hurford (HST Society) is an M.D.-Ph.D. candidate in Genetics.

Health Care in Rural China: What Should China Be?


by Tammy Chang

There's an old Chinese adage: traveling ten thousand miles is more valuable than reading ten thousand books. This past summer I received the Paul Dudley White Traveling Fellowship from the Enrichment Programs Office and took a journey half way around the globe to the People's Republic of China. During the 8 weeks that I was there, I collected many valuable experiences-enough to affirm that the people who made up that proverb weren't just rambling vagabonds who didn't like to read.

In terms of research work, I divided my time between two projects. Half of my time was spent in the city of Beijing, living in Beijing Medical University. There I worked with the Network for Training and Research in Health Economics and Financing of the Ministry of Public Health. The Network was finishing a three-year research project entitled, "Study of Health Care Financing and Organization in Impoverished Rural Areas of China," undertaken in collaboration with Harvard School of Public Health and with the financial support of UNICEF and IHPP. The goals of the study were to characterize the current condition of health care in impoverished rural areas of China, to define the flaws in the financing and organizational structures, and, most importantly, to formulate policy recommendations that will correct the existing problems. Joining their research team, I sat in on their meetings discussing policy options, participated in data analysis, and drafted the English version of their final report.

The rest of my time in China was spent in the rural county of Fangshan, about 43km southwest of Beijing. There I conducted my independent research project, a case study of the county's health delivery system. I interviewed numerous local government officials, administrators, hospital directors, physicians, and health care workers and visited hospitals and township health centers. I formed some basic conclusions about what is ailing Fangshan's health delivery system. Through literature searches, I found that the difficulties I perceived in my field study applied to the majority of rural China. Essentially, the current predicaments in China's rural health care delivery systems are the result of the country's transition from a planned economy to that of a free market economy. Perhaps a more poignant description of the situation is revealed by the prevailing catchphrase, "socialist market economy," pushed by the Chinese central government as the binding framework in which economic reform must proceed. The inherent contradictions in the effort to uphold socialist ideals while catapulting toward a market economy has caused unique dilemmas in many arenas, including health care delivery.

Health care in China, previously deemed a charitable industry, was centrally designed and regulated to be accessible and affordable. To that end, the widely acclaimed three-tier health care delivery system was developed in which each county has one hospital, each township one health center, and each village one health post as well as rigid pricing guidelines to keep user fees below the ever inflating costs of providing the services. Although still considered public institutions managed by the local government, hospitals and health centers are now, for all practical purposes, financially independent. Whereas formerly funded by the government, health institutions now receive little subsidy and are encouraged to be self-sufficient. To support themselves, they depend on drug prescriptions and new high technology procedures (such as CT scanning) since the pricing policy allows these services a profit margin. As a result, there is often over-prescription of drugs and over-utilization of expensive diagnostic or therapeutic protocols.

Besides competition from increasing numbers of private practitioners, there is also fierce competition between the health centers. Each attempt to acquire the newest technologies and best-trained personnel in order to attract a limited patient population results in a considerable waste of resources. All hospitals and health centers I visited were heavily over-staffed since the county government has a commitment to provide employment to all its residents. For example, 13 health care professionals were employed in one health center in Fangshan that receives no more than 20 ambulatory visits per day. In addition, health centers that fail to compete and cannot sustain themselves financially are not allowed to dissolve. One health center I visited was in such financial trouble that staff wages had not been paid in two months. The county government insists on maintaining health centers in similar situations for the outward appearance of the integrity of the three-tier system.

Overall, my impressions of the state of health care delivery in rural China were of incompatible and conflicting policies as well as an overall ambiguity in the vision of what China should be.

Tammy Chang (Peabody Society) is an M.D.-Ph.D. candidate in her second year of medical school.

Retreat Renews Perspective, Enthusiam


by Anne West

The Annual Retreat of the M.D.-Ph.D. Program provided a delightful opportunity to have my sense of perspective renewed (Woods Hole, September 29-October 1). Seeing colleagues at various stages along the trek through the program helped to remind me of the enthusiasm of the early days of anatomy and the exciting transition to the lab, as well as helping to allay my fears about the impending onset of the wards, and the eventual transition to, yes, some sort of job-like activities.

I especially enjoyed the keynote address of Dr. Reed Pyeritz, Professor of Human Genetics, Medicine and Pediatrics at the Medical College of Pennsylvania and Hahnemann University and Chair, Department of Human Genetics, Allegheny-Singer Research Institute. One of the first official graduates of Harvard's M.D.-Ph.D. Program in 1975, Pyeritz has had one of those 80/20% lives in science and medicine that we all dream is possible. He has spent his career studying Marfan's syndrome-a genetic disease caused by mutations in the extracellular matrix molecule fibrillin. This connective tissue disorder presents as hyperflexibility (double-jointedness) and, much more troubling, aortic aneurysm. The clinical side of Pyeritz's work involves human genetics with the sufferers of this disease, as well as innovative approaches to working with the aortic aneurysms, which are a significant cause of death in this population. The science side of his work has involved the identification of the chromosomal locus of the disease gene, cloning of the gene product and discovering how the mutations in this protein relate to the pathophysiology of the disease. It is a time in the history of Marfan's syndrome that is made for the M.D.-Ph.D. mindset, with an understanding at all levels of analysis-human, clinical, patho-physiological, genetic, and biochemical.

Hearing Dr. Pyeritz's talk, it became clear to me that even when the smallest decisions (should I go back to the wards in July or December?) seem capable of ruining the grand plans of M.D.-Ph.D.-hood, nevertheless, the world holds many exciting opportunities for us, who hopefully are well prepared by our breadth of training to seize whatever comes our way.

Anne West (Cannon Society) is an M.D.-Ph.D. candidate in Neuroscience.

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