M.D.-Ph.D. Program Harvard Medical School Spring 1999 Newsletter

Articles in this issue:

Life After Graduation: How the Class of `99 Made Their Choices

by Anh Tuan Nguyen-Huynh

For seven years I had planned to become a clinician-virologist. It only took three months to convince me that I would become a head-and-neck surgeon, instead.

My change in plan comes as a surprise to many people who know me, my Ph.D. advisor included, yet it feels perfect to me. There is nothing else I would rather do. Why didn't I think of it sooner? If Surgery had been my last core rotation instead of my first one, would I have made the change? Would I have had the time to do so?

Timing is a peculiar aspect of the decision making process for M.D.-Ph.D. students. On one hand, we have three to five extra years with which to ponder how to find a niche for ourselves in medicine. (How effectively we explore this issue during our Ph.D. years is another matter entirely.) On the other hand, our actual clinical time can be abbreviated because not all of us re-enter the medical school cycle as third-year students in July. For those who miss the July re-entrance, the time shortage is particularly acute because the third-year clerkships-Surgery, Medicine and Women's and Children's Health-must then be taken in a succession of three-month cycles, with no opportunity for late third-year electives.

Those of us graduating from the M.D.-Ph.D. Program this year have cast our career moves in diverse directions. How did these different choices evolve? Can some lessons be distilled from our collective experience? To find out, I asked the members of the graduating class.

Internal Medicine
Levi Alec Garraway: "Internal Medicine has always been among my top two or three choices. I like seeing patients, so other options like Pathology or post-doctoral fellowship are not as appealing. I'm planning on a fellowship in Hematology-Oncology, and I'm considering short-tracking."

Alice P. Tsang: "Since the first year of medical school, I had an inkling that I would go into Internal Medicine." Her experience in clinical rotations only confirmed her choice. "I love the depth of thinking in Medicine that I did not find in other fields. I'm also planning to short-track into a Hematology-Oncology fellowship."

Hanna Yoko Irie: "I knew even before medical school that I'm more of a Medicine person than a Surgery person. I don't really get much enjoyment out of cutting or sewing things. I thought about Obstetrics, however. In terms of research, Obstetrics is a wide open field with a lot of opportunities in Immunology which is my area of research. In the end it was my sub-internship in Medicine at MGH that clinched it for me. I'm thinking of a fellowship in Rheumatology or Endocrinology."

Family Practice
Susanna L. Choi: "I am not a model M.D.-Ph.D. student. I would like to focus on clinical medicine and make a difference in people's lives. I don't see myself able to combine science, medicine and family. I do enjoy bench research, which makes it hard for me to break away. But I have to choose something that I can be happy with 10-15 years down the road rather than something people expect me to do. My ideal residency choice would have been one in Women's and Children's Health which doesn't exist. Family Practice is the closest fit for me."

Neurosurgery
Patrick B. Senatus: "I did research in Neuroscience, so it is natural to consider Neurology and Psychiatry in addition to Neurosurgery. I was lucky in my first year in medical school to have a mentor who was an Orthopedics resident. He took me into the OR and his lab, and I could see early on that a surgical practice could be combined with scientific research. From my choice of Ph.D. project [the electrophysiological properties of neostriatal neurons in culture] to my clerkship experience, it became clear that I am a hands-on person, and I like to see the results of my actions right away or in a few days. In Surgery, I can actually spend more time with my patients and do more for them [than in other fields]. In Neurosurgery, I have a level of comfort with the type of problems we deal with from day to day, and it's so effortless that six hours feel like half an hour."

Daniel J. DiLorenzo: "I have an interest in making implantable devices that goes all the way back to my grade school days building robots. I know I want to be at the intersection of basic research, functional neurosurgery and microelectronics. The Neurosurgery program in Salt Lake City, Utah, matches my criteria exactly. I also want to be involve in the business aspect of bringing a new technology product to the market."

Otolaryngology
Konstantina M. Stankovic: "As a Ph.D. student in the MIT Speech and Hearing Program I had a sneak preview for the attractions of the specialty. On the research side there is a nice mix of physics and biology while on the clinical side there is a nice mix of medicine and surgery. I was also influenced by good role models at the Massachusetts Eye and Ear Infirmary."

Anh T. Nguyen-Huynh: "Choosing Otolaryngology after all these years planning for Internal Medicine was quite a change in direction for me. That I enjoyed dissecting all the nerves and vessels in anatomy lab might have given me an early clue, but I did not recognize it. What really brought about the change was quite fortuitous. On the day that I had to figure out my third-year schedule, I scanned the books on my shelves and realized that I would like to read Netter's Atlas of Human Anatomy most of all. Thus, I picked Surgery for my first rotation, and the rest was history. The excitement of surgery and the challenge of operating in the head and neck were what attracted me initially to Otolaryngology. In addition, I also like everything else about the specialty, especially the people in it."

Radiology
Luis C. Maas, III: "I did my Ph.D. in functional MR [magnetic resonance], so I knew I would enjoy research in the field of Radiology. I also enjoyed the clinical experience in my elective rotation [in Radiology]. I considered Internal medicine, but of all the fields in medicine, I find the schedule of Radiology most suitable for doing both serious research and clinical work."

Post-doctoral Fellowship
Bernardo L. Sabatini: "I considered Neurology but the field does not appreciate electrophysiology right now. I considered Neurosurgery but couldn't see myself doing surgery. Psychiatry is very appealing to me, but in the end I choose to do a post-doc. I like science because I am motivated by freedom and like the stimulation of hard problems. As M.D.-Ph.D. students we have had great opportunities to train in science and medicine, but there is still much more to learn in both areas. The truth is, in 10-20 years, I really want to be in a lab, and I don't want to do medicine as a hobby."

James R. Morris: "It is a difficult decision to give up clinical medicine now, but I really love the research that I've done. I started applying to residency programs but did not enter the Match. In my case it's mostly a matter of timing. From my Ph.D. work I've come up with new ideas and many questions nagging for answers. Receiving a Harvard Junior Fellowship makes it possible for me to continue doing what I love. Otherwise, I might have gone into Pediatrics, or college teaching."

Or P. Gozani: "I really enjoyed my Ph.D. research, so I was leaning toward doing a post-doc even before I returned to medical school. I took my third year rotations seriously, however. I've always wanted to do basic research, so residency doesn't seem like the most efficient way to achieve my career goal. I'm also interested in starting up a bio-tech company."

Management Consulting
Chistoph H. Westphal: "I graduated early in November 1998 and have been working for McKinsey. Management consulting is like a post-doc. People do it not as a career but as a stepping stone to something else. I'd like to run my own company someday and want to gain more business experience. I have three patents from my Ph.D. work. I went through 16 months total of clinical medicine, but I don't think I'll ever feel like a practicing doctor. What I miss a lot is academic science. I was very lucky with my research, but now I've really closed the door there."

Undecided
Marc T. Awobuluyi: "I'm deferring graduation to November, 1999, because I'm not categorically sure about what I want to do. I thought of Cardiology as compatible with my research interest, but I don't have the patience for Internal Medicine. I find the style of the surgeons more of my own. Now I'm thinking about Reconstructive Surgery or Opthalmology.

The lessons learned
Whereas the circumstances surrounding each decision above are unique to the individual, and the reasoning behind each choice is personal, the collective experience of the graduating class also contains a few pearls of wisdom. In some instances, these have been hard lessons learned.

To help other M.D.-Ph.D. students in their quest for their own niche in medicine, here is our advice:

Return in July
Returning to medical school in July is a unanimous recommendation because it maximizes flexibility in scheduling clerkships. This is particularly important if you are undecided with regard to specialty.

The scheduling flexibility is also important if you are interested in any Early Match specialty, such as neurosurgery, otolaryngology or opthalmology, according to Tina. The best time to take such electives is at the end of the third year, and you can not do that unless the big three-month clerkships of Women and Children's Health, Surgery, and Medicine are taken starting in July.

Finish Ph.D. work before returning
Even more important than returning in July is finishing your Ph.D. work before returning. The transition period is a critical time requiring your full attention. Any left-over Ph.D. work can cause a big distraction.

"Tie up stuff in the lab before coming back to the clinic," Susanna advises from her own experience. "Set yourself up to be a full time medical student." Marc, who spent a lot of time in lab after he had returned to clinical training found "busy lab work frustrating."

Having to deal with too much unfulfilled obligation could compromise your clerkship performance, enjoyment and learning. Even though several of us pulled off successful thesis defenses during clinical rotations, none of us were happy we had to.

Be careful with the first rotation
All M.D.-Ph.D. students interviewed express some degree of uneasiness with returning to medical training after 3-5 years of absence. The adjustment period reportedly lasts anywhere from two weeks to three months.

"The transition is very anxiety provoking," says James. He also surmises that "a lot of it is a confidence issue." Perhaps, but some of it also has to do with fund of knowledge and frame of mind. Even if you have an even start in July, the students fresh out of the second year are going to be quicker on the trigger with facts.

"My return was a humbling experience as I had just defended my thesis and was feeling like I was on top of my field," says Tina. "In terms of knowledge, I never really felt up to speed," Marc concedes. "In terms of functioning in the clinical setting, performing H and P, presenting, researching the literature, etc., it took about a month."

The good news is that, as Alec points out, "doing well in rotations has little to do with amount of knowledge and much to do with enthusiasm and care for patients." Nevertheless, "the first rotation is sacrificial," Dan warns. Thus, it would be wise not to schedule something important like Medicine or another rotation in which you want to excel in the first month back.

Most graduating students would concur with Alec that you should "start with a rotation that has direct patient care such as Neurology or Surgery so that you can learn hospital routines such as H&P, labs, orders, progress notes, etc." If you are still trying to finish up your thesis defense, perhaps you might want to consider Hanna's suggestion. "I started with Pathology and would recommend it to buff up pathophysiology," she says. "It helped me learn to present cases. It was also flexible enough to enable me to defend my thesis during that time." Radiology could also serve the same purpose.

Pros and cons of longitudinal clinical experience
The Longitudinal Course in Clinical Medicine seems ideal for the M.D.-Ph.D. students about to return to the wards, but few actually took advantage of this experience. Alec and James recommend it "not because you learned so much medicine," James says, "but because it really helped you get comfortable with seeing patients." Marc, on the other hand, did not find the experience helpful. The end of the Ph.D. phase is also a very hectic time when you will be doing the last set of experiments, writing up results for publication, and preparing for thesis defense. Your number one priority should be completing your Ph.D. work in time for a July re-entrance to medical school. "Concentrate on your thesis," Luis says. "Get it done!"

Exploring specialty choices
Sometimes we need to be reminded that the number one resource at Harvard is its people. In your quest for information on different specialties, talk to as many people as you can, at all levels of training. "Find out what their lives are like," says Marc. In particular, "talk to M.D.-Ph.D. students and graduates, your faculty advisor and Ph.D. advisor," says Luis. "You might get a skewed view if you talk just with residents in training," Tina cautions. "You need to talk with attendings to get a sense of what it's like to practice that specialty as a profession." As early as possible, find yourself one or several mentors and keep in touch regularly, Alec advises.

Other suggestions for checking out a specialty include skimming through the relevant journals in the library or attending Grand Rounds. "An early elective can help you rule a specialty in or out," Patrick says.

Away electives can be used to learn about residency at an outside institution. Certain competitive programs grant residency interviews preferentially to those who have done electives with them. Find out from your advisors where this is true and sign up for an elective there if that's where you really want to go. Keep the audition electives to a minimum, however. The fourth-year electives, in particular, are your chances to do things you might never get to do again, so don't squander them once you already know what you want to do for residency.

Making the decision
There is no universal guidance for making the most out of your medical and scientific career. Hopefully, the stories of our choices give you some hints and stir up some feelings.

For M.D.-Ph.D. students, making the most invariably involves figuring out "how much research you want to do in the future," says Hanna. In addition, your choice ought to be based on how you feel about practicing your specialty during training and 10-15 years down the road. As Susanna has said, make sure you choose something that you can be happy with, rather than something people expect you to do because you are an M.D.-Ph.D.

Forecasting the future is always a risky business. Best to rely on your knowledge of yourself, your likes and dislikes. If your soul searching results in a plan, but you are not sure how it's going to turn out, go for it anyway. "You've got do what you love," says James. Take it from there.

Anh Tuan Nguyen-Huynh is a member of the M.D.-Ph.D. Class of `99.

From Bench to Beeper: Returning to the Clinics

by Saumya Das

September fifth. The date had been on my mind for a while now. The day I was to start my first clinical rotation. The day I had to urge those now dormant synapses that had formed during the first two years of medical school to start firing again. A situation that has been faced countless times by returning M.D.-Ph.D. students in the past and one that will continue to confront and confound the future generations of physician-scientists. I had chosen radiology as my first rotation, one that did not call into use clinical skills like the physical exam or "procedures," but focused more on textbook knowledge. Still, it did require remembering what the names of the eight carpal bones are, and how they are supposed to be aligned, knowledge that was now a distant memory.

I think all of us who take the plunge back into the clinical world share some common fears. For the past few years, we had been at the forefront of cutting-edge research, blazing a trail down hitherto untrodden paths, pretty much the expert on some tiny area of biomedical research. And now, we would have to leave the pedestal and descend to the bottom of the hierarchy, into an area where we knew hardly anything, and where our actions would have few consequences for the way things are run. We were soon to be part of a system whose mysteries were still not revealed to us. How does one cope? Well, here is my advice.

1. Drop the pride you feel after having finished your Ph.D. and having published all those papers. That is quite an accomplishment, but remember that the reason you joined this program was that you wanted to be a student for a long time. And once again you are in terrain where you have a lot to learn, probably from people who are younger than you.

2. Remember that a lot of medicine is empirical, so some things you are told to do may not be as grounded in rigorous scientific fact as you are used to. Different physicians may treat the same condition in different ways (a matter of style). Take this in stride, and start developing your own style.

3. Do not be overwhelmed by the amount of knowledge you need to amass. Your mentors do not expect you to start off as savvy clinicians. But they do expect that you will learn as the months go by. So try to read a page or two about the patients you admit and see. You will be surprised at how much you will have learned at the end of the rotation.

4. Do not be too concerned about whether you will outperform your peers to bag that coveted HH. Try to learn at your own pace. Don't try to admit four patients a night just to impress your intern. You will probably not learn anything and may end up botching something important. Then you might start resenting your workload, the rotation, the hospital, and soon you will be in a dark tunnel with no end in sight. A corollary to this is to start off with rotations in areas where you may not want to match.

5. Do not get depressed if you feel that your opinions are not being taken seriously. I think that most residents and fellows do respect your intelligence and the fact that you have completed a Ph.D. That does not necessarily translate into having good clinical judgment. So try to listen to why they chose not to follow your plan, and you will probably gain some clinical insight.

Finally, the secret weapon: you will find that a fair number of your colleagues from medical school are now Residents and perhaps even Attendings. Bonding over the glory days of the first two years of medical school will ease your rotation-until the beeper goes off and you are sent on another errand, but that is a different story.

Saumya Das is an M.D.-Ph.D. candidate in the class of 2000.

Admissions Update

Selection of the M.D.-Ph.D. class entering HMS in September, 1999, is now complete.

We congratulate the new M.D.-Ph.D. class and look forward to welcoming them in September: Vassilious J. Bezzerides (University of Washington, Seattle), Yeang H. Ch'ng (Yale), Irene A. Chen (Harvard), Sophie C. Currier (MIT), John P. Dekker (Wesleyan), Robert S. Griffin (Swarthmore), Shannon C. McDonald (Ohio State), Christina E. Mills (Stanford), Bradley J. Molyneaux (Dartmouth), Patrick K. Safo (SUNY, Stony Brook), Ryan B. Turner (University of Maryland, Baltimore County), Brian G. Turner (University of Maryland, Baltimore County). We also congratulate students accepted through the Second Cycle application process: David S. Jones (Holmes), Vidyasagar Koduri (HST), Irwin H. Lee (Peabody), and Katherine P. Lemon (Holmes).

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