M.D.-Ph.D. Program Harvard Medical School Sprint 1996 Newsletter

Articles in this issue:

Admissions: Not an Exact Science

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

With a growing pool of well-qualified applicants and shrinking National Institutes of Health (NIH) support, competition for M.D.-Ph.D. funding at Harvard is more intense than ever before. Funded positions for incoming students reached a high of fifteen per year between 1992-1994, but dropped dramatically to approximately five per year in 1995 and 1996, due to a combination of NIH cutbacks and a decrease in other support sources. Meanwhile, a resurgence in interest in medical careers has driven the number of undergraduate M.D.-Ph.D. applicants to a record high.

The formula for the perfect application to the Harvard M.D.-Ph.D. Program seems to be as well-guarded a secret as the recipes for Coca Cola and Kentucky Fried Chicken. This year nearly 400 applications were received from undergraduate students representing over 120 schools and an age range of 20 to 41 years. The average GPA of applicants was 3.67 (with a low of 2.50); most had double digit MCAT scores. Twenty one diverse faculty members were given the task of distilling this distinguished group to extract the five students offered fully funded Medical Scientist Training Program (MSTP) positions.

The Subcommittee on Admissions is chaired by Dr. Steven Beverley and the application process is coordinated by Jennifer DeAngelo and Linda Burnley. Based on review by a screening admissions subcommittee, about 1 in 5 applicants were offered interviews. The proportions of men (68%), women (32%), and minorities (13%) interviewed were nearly identical to their representation in the initial applicant pool. The interviewed group was enriched for Harvard undergrads (9% of total applicants, 21% of interviewed students), and relatively depleted of students from less competitive schools. The average GPA of the interviewed group was 3.88. All interviewed applicants had prior research experience, and most had had at least one serious lab stint. But in the end only 5 of 76 interviewed students (1.3% of the total applicants) received the desired "yes" in the mail. What made them stand out from their peers?

In contrast to other HMS and HST interviewers, M.D.-Ph.D. Admissions Committee members focus on prior research record, and reference letters detailing the applicant's level of contribution and commitment. The M.D.-Ph.D. interviewer expects each applicant to discuss a significant project, and to show a broad understanding of her/his field. While evidence of hard work is a plus, top students must also demonstrate creativity, and a more advanced approach to science. Most applicants have worked in more than one lab, but students who have had one or two very intense experiences fare better than those who have had many superficial encounters with science. Students with degrees in biological and chemical sciences tend to be accepted over those with degrees in social sciences and engineering; non-science majors are rarely competitive. In general, stronger applicants have completed four undergraduate years, and some have spent an additional year working full time on a research project. Though the committee does not define preferred research areas and no deliberate attempt is made to accept students with a variety of interests, the entering class tends to be quite diverse.

In the end, the Admissions Committee invariably has more talented applicants than funded positions, and it is forced to make difficult decisions. A few applicants are put on a waiting list, though it is unusual for an acceptee to turn down a funded position. Some very strong candidates are encouraged to seek funding through alternative training grants, such as individual NIH-sponsored fellowships for minority students. Other strong candidates are encouraged to matriculate at Harvard, and to reapply the following year for MSTP funding through the "second cycle" admissions process. Approximately four second cycle students are selected annually to receive funding for their last two years of medical school.

Harvard is strongly committed to dual degree training, and up to forty percent of each class entering the Division of Medical Sciences graduate programs consists of M.D.-Ph.D. trainees. Although NIH support of the MSTP is being subject to cutbacks affecting all federally funded scientific pursuits, the need for well-trained physician-scientists is clearly growing as technology brings basic research developments into the clinics. Future growth of the M.D.-Ph.D. Program will undoubtedly depend on new initiatives to secure funding from industry and philanthropies.

Nancy Andrews (M.D.-Ph.D. Class of 1987) is an Assistant Professor of Pediatrics and a member of the Subcomittee on Admissions.

A Conversation with Paul Farmer and Jim Yong Kim

by Molly Lanzarotta

Why would an anthropologist need an M.D.-Ph.D.? And why would a clinician dedicated to serving the world's under-served communities pursue a dual degree?

Both of these questions are answered in the careers of Paul Farmer and Jim Yong Kim, two alumni who benefited from a John D. and Catherine T. MacArthur fellowship that for a limited time provided five year grants for Harvard social science students interested in pursuing M.D.-Ph.D.s. Though this funding is no longer available, and the Medical Scientist Training Program grant which currently funds most M.D.-Ph.D. students is directed primarily towards the biological sciences, Jim Kim hopes that the experiment of his dual degree education will be replicated:

"I see the responsibility that Paul and I have is to try to combine our roles in a way that will lead some funding organization to think it's worthwhile to support these kinds of programs." If any foundations are searching for exemplary results, Kim and Farmer are as far as they have to look.

In 1987, as M.D.-Ph.D. students, the two founded Partners in Health, a non-profit organization that now, nearly ten years later, supports community-based health programs in the U.S., Haiti, Peru and Mexico. In Haiti, besides establishing a clinic that provides care for 35,000 people a year, the organization has helped build and fund 16 schools. In Chiapas, Mexico, the focus has been a program that trains Guatemalan refugees in public health initiatives. In 1993, Farmer won a five -year $220,000 MacArthur Award which he turned over to Partners in Health in order to establish the Institute for Health and Social Justice as its educational component.

Farmer has published two books about Haiti, and in collaboration with Kim and their colleagues at the Institute for Health and Social Justice is editing a book series that will be entitled,Critical Perspectives on Health and Social Justice.

Paul Farmer is currently an Assistant Professor of Medical Anthropology in the Department of Social Medicine and Jim Yong Kim is an Instructor in Social Medicine at Harvard. Both are attending physicians at Brigham and Women's Hospital in Boston.

What prompted you to pursue an M.D.-Ph.D.?

Paul Farmer: My feeling about doing a Ph.D. is that you're offered the possibility of rigorously examining a body of literature and there are few people who are really able to do that without some sort of discipline. For a medical student or physician it is an exceedingly difficult task to take on by yourself. Any of the -ologies: sociology, medical psychology, anthropology, microbiology, cell biology -- each of them has its long history of development. To review that as a doctor or as a medical student or resident -- I just can't see it happening. Whereas, if you do an M.D.-Ph.D., you're really forced to engage these subject matters just as much as the other doctoral students.

Jim Kim: The MacArthur Foundation program had just been announced when I was a first year medical student. I hadn't even known it was possible to do a social science Ph.D. and an M.D., or that they could be integrated in a meaningful way.

Arthur Kleinman is one of the great examples of someone who has combined the two and who is still active in both fields. I had been reading Arthur Kleinman and Leon Eisenberg's work as an undergraduate. I think Dr. Kleinman and Dr. Eisenberg's vision of training physicians who would be active in both areas was really very forward thinking. In fact, Dr. Kleinman came to Harvard the same year that I came and it was a great surprise and very encouraging to see that he was here and that he and Dr. Eisenberg had received a grant to train a cohort of people in medicine and the social sciences. I did it because it just sounded so great, but it was also a leap of faith.

Many physician-scientists feel it's necessary to, at some point, choose between a research/teaching career and a clinical career. But you both have added yet other roles -- social advocate, community activist, founders of "Partners in Health" -- how do you find balance?

Farmer: The dilemma between research work and clinical work is long-standing and very much part of the dilemma I face. But, you know, I'm not so sure that being a community activist makes it more difficult. Being a doctor to people who don't have access to other doctors, that's an overlap with social advocacy. And then my research and most of the writing I do is about related questions, for example, how do social factors --I've been studying gender inequality, racism and poverty -- how do they affect the distribution and outcome of infectious diseases? I teach courses that are closely related to those topics, so, in a way, this sort of work, though it makes it harder in terms of hours in a day, also offers a sort of unifying principle to the three parts of my life: the clinical, the research and the teaching. Whereas, if you look at other people who do, say, molecular biology, and are fascinated by clinical care -- there's more division in their lives.

I think that for me most of my research is around issues of direct clinical significance and most of my clinical interests are tightly related to my research interests. So, in being an activist or advocate around issues of poverty and access to care, it all kind of comes together.

Kim: In terms of our scholarship, we've set up an institute called the Institute for Health and Social Justice. It's a tremendous amount of work, but also a godsend in the sense that Paul and I have relatively protected times when we can think specifically about the interaction between social science and medicine. Women, Poverty, and AIDS, the book that Paul is editing and just finishing with our colleagues at the Institute, is a perfect example of how we're looking at specific clinical data but also at world political economy to try to understand how large-scale forces are shaping the HIV epidemic in the world.

This year, the book that I'm editing is called The New World Order and the Health of the Poor. In it, we're looking at everything from third world debt to World Bank activities to the World Health Organization and how trends in the world economy impact very specific health outcomes and health issues. So, for example, we look at World Bank programs and their relation to multi-drug resistant tuberculosis in Peru. By looking very closely at links at those levels, we feel that we're doing academic work while also trying to use whatever kind of data we can to better understand a clinical situation.

That juxtaposition of clinical data with social science insight -- we've gotten better at it as time has gone by, rather than getting pushed into one field or the other.

What do you think you have to offer in the work you do that an M.D. or a Ph.D. alone couldn't offer?

Farmer: I doubt that an M.D.-Ph.D. who sees patients can really rival a Ph.D. in terms of production. After all, the Ph.D. doesn't have a beeper going off all the time and doesn't have patients calling, day in, day out, because they're constipated. The advantage of having both degrees, in my opinion, is that a practicing physician brings what you might call the vitality of practice to all of his or her work, so that there's rarely any doubt that what is being considered is relevant to some of the problems facing patients.

That vitality of practice is helpful -- it helps shape questions, it helps shape interpretations, and it helps shape differential rankings of importance of research problems. I don't think we need everybody to be an M.D.-Ph.D., but I think that in a university setting where you have a lot of people with doctorates, having some M.D.-Ph.D.s is particularly helpful if you're trying to link a vast research endeavor to the problems faced by the sick. The more practicing physicians in the mix the better.

A humane connection to suffering is important to the research endeavor. Now, that might sound ludicrous to some scientists. Is it necessary to be moved by suffering in order to do good research? A lot of people would think it's not, but I'm not so sure. I think one of the things M.D.-Ph.D.s can do is bring that concern, based on exchange with people who, unlike ourselves, are very sick, into the research university.

Do you think there is a particular role for the physician-scientist to play in developing countries?

Kim: I think it depends on the individual. I think that there's nothing about the technical, intellectual or clinical training physician-scientists receive that necessarily prepares them for making a real impact on the health of poor people in developing countries. My take on this is that very highly trained and educated people have been working on these areas of development and health for a long time and things in many ways are getting worse. So, if people who have training as M.D.s and Ph.D.s just join one of the large, multi-lateral institutions that are often more interested in their own survival than addressing tough issues in developing countries, then I think their role would be just like anyone else's role. But, if individuals with M.D.-Ph.D.s look at this from the perspective of trying to change social inertia, then I think they can have a great role, their training can be tremendously important.

Molly Lanzarotta is the Special Projects Coordinator for the M.D.-Ph.D. Program.

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