This post is intended for students in a dual degree program, such as an MD/DO/PhD. I give some advice, but take it with a grain of salt — everyone takes their own path. 

Changing views 

When I was finishing graduate school, I wanted to apply for a post-doc rather than a residency.  During clinical rotations, my viewpoint shifted.  I wanted to continue clinical training.  Things change.

Versatile skills

Because things can change during training, I would recommend developing versatile skills—i.e., skills that apply to many different areas—during graduate training.  For me, much of this came from coursework. I took many courses, but the ones that gave me the skills that were most versatile were the most foundational, some of which I audited rather than took, such as undergraduate probability and mathematical statistics.  Following up on this, I benefited from widely applicable courses in statistical inference, linear models, Bayesian statistics, graphical models, and causal inference.  Survival analysis is also essential to clinical trials.  Some of the more advanced courses provide more mathematical maturity, but one can start research without them.

Another fundamental skill is programming (and expressing things using matrix operations—i.e., linear algebra). I recommend learning a scripting language (R, Python, etc).  You can sometimes study more complex objects using simulations than you can with closed-form equations (although you can often study a complex phenomenon by using a simple example).  A final highly versatile skill is optimization. Beneath everything is an optimization problem (it is the essence of statistical estimation, or learning).

Also, going from clinic to research and back and forth, where different languages were used, along with great coaching, strengthened my ability to communicate. Of all the skills, communication is one of the most versatile.

Statistics and clinic

It is pretty neat to go from research in medical decision making to clinical medicine. In general, I saw my research everywhere in clinical medicine, not just in the literature, but also on the floors. I saw the equations behind the risk scores, behind the decisions.  It allowed me to think about how to better incorporate evidence into healthcare.  To me, being able to do this was the major deliverable of my training.

If there is time, I highly recommend studying probability and statistics, and in particular statistical decision theory. It will help you see the math behind clinical medicine. Also, a strong understanding of core topics in statistics among healthcare providers helps them better direct their medical research toward high-value things, such as adjusting lab reference ranges, adjusting treatment effects, adjusting test characteristics, or predicting side effects in addition to primary outcomes like mortality. 

Day-to-day tips

The transition from PhD back to medical school is a challenge. After I finished my PhD, a few days before starting clinical rotations, I went to the hospital, and I tried to form some positive memories.  For example, I went to the cafeteria, and found food I liked, or I chatted with a friend. 

Another day to day tip: a program alum (Benjamin Plog) gave the following advice during a seminar: structure the PhD like a 9-5 job, it will make it easier to transition back to clinical rotations. Even if it is not possible to do this in the early years, I would recommend trying to do it in the later years.  If sleep schedules get off track, which can happen during graduate school, I recommend mindfulness/meditation—this can help you rest, even if you are having trouble sleeping.

Also, treating research like a job, where I showed up every day and recorded my work, led to more steady progress than waiting around for inspiration to strike. I also documented everything, including partial progress (especially partial progress, as, in my opinion, ultimately everything is partial progress). I had a document for my advisors at each meeting, and I sent a follow up each Friday.  This was sometimes tedious, but it helped us stay on the same page, helped me show progress, and helped me get input early, which made writing manuscripts easier. 

Finally, if you are in stats research (or maybe any field of research), I would check out J. Michael Steele’s advice on statistics grad school.

Your own path

We live in a competitive society. Note that competition can be fun and useful.  However, it does not need to influence you too much. Even if you are not the best in medicine or research, know that you are in the intersection, you will be good at that, and that is valuable.  

It helps to cultivate an inner sense of achievement. It might consist of celebrating a problem you are making progress toward solving, or identifying a personal milestone in your work, etc. For me, one of these milestones was a 2-minute presentation I gave to my class at the very end of medical school, in which I advocated for sometimes-neglected treatment effect heterogeneity analyses. I knew what I was talking about, and I could tell that the message resonated. Being able to do this—to travel to a distant academic land, find something there, and then bring it back to others—felt very meaningful.

I will say, although you should focus on your internal progress, take care to still meet external expectations (although sometimes they can be overwhelming, sadly).  If you decide to work too much according to your own goals, it can impact your grades, test scores, etc. These things matter for what comes next.  In particular, your residency application will depend a lot on your third year of medical school, even though third year is just one year of 8+, and your residency application will impact the next 3-7 years of your life.

The intersection

You will be at the intersection of the field in which you do research and medicine. Being good in an intersection takes discipline, because it’s sometimes tempting during training to go too far toward research or medicine.  I did the former by taking many years in the graduate phase (although my own story was complex, because I transferred and switched departments). 

Remember, you can always make certain choices that can help you stay centered. One of these is choosing an advising team. This is particularly important for dual degree students. In general, they say choose a mentor, not a topic, which I think is good advice. When choosing mentors and advisors, think, what kind of person do you want to be like? What is their track record with students? What is the average time to degree? One could also say choose a department, not a topic, because it takes a village to train a graduate student. Does the department have a track record of working with dual degree students? Etc.

Choosing a topic is also important.  Sometimes hot topics can lead to longer duration of degree, so keep this in mind; extending your graduate training beyond 4 or 5 years can make it hard to return to medical training. I think, getting a 4 year PhD and then doing 2 years of research during residency or after is better on average in terms of life and physician-scientist career than getting a 6 year PhD and then doing no research in residency. A 4 year PhD may feel like you are moving fast, but remember who you are, and your place in the intersection.

This said, even if you make a good decision about mentor and topic, your PhD might take a long time, for reasons outside of your control. In general, I wish PhD degrees were fixed-length. 

Small decisions during the PhD can also make a difference. Sometimes, I found I wanted to make choices, like spending extra time, taking a new project, or submitting to the best possible journal.  Sometimes this was out of excitement, sometimes it was to fill a hole.  If this happens to you, and it is the former, it may be possible to find excitement in your current project (I like Steele’s advice (link in the text somewhere above) to help with this). If you are instead doing these things to fill a hole, try to understand why this might be the case.  Is it competition? Insecurity?  Try not to be mindful about not letting things like this influence your choices too much.

If you are upset about spending less time on research, rest assured that there will be time in the future for it. PSTPs allow one to combine residency and research. The PSTP structure facilitates a physician-scientist career.  As far as I know, most internal medicine PSTPs include a fellowship, so they are 6+ years with 3 of these years being research (so you can re-start topics you might have found interesting during the PhD).  This is ideal if one wants to do a fellowship, but difficult if not. Psychiatry has PSTPs that do not require a fellowship.  

Ultimately, there is a tension between the clinical-research balance I recommend and the 7 years I took to study statistics. For me, because I ended up studying medical decision making, I felt like I was never too far away from medicine, though. I think, if I had focused more on the basics earlier, I could have saved time. The topics I studied in the end, once I had mastered the basics of probability and statistics, were sitting right in front of my face at the beginning (I often recall Eliot’s poem on seeing the same thing with new eyes).

However you choose to do things, listen to your gut, and I hope my story helps build your intuition.

Life

I always found it challenging to seek balance in terms of work and personal life. Common advice is to start your life during the MD/PhD degree, which can be 8+ years. My ability to do this was best when I sought out predictable environments as much as possible, both in research and clinical specialty. To me, predictability is often as important as hours in terms of being able to also have a life outside of work. Things might sometimes feel too predictable. However, for me, life brings enough excitement in its own right.  In addition, all of the transitions between programs in a dual degree will also bring excitement (and stress).

Balance may be productive in its own right; in the process of taking time to focus on things outside of work, you might discover things about yourself that not only improve life, but also make you better as a healthcare provider and a scientist. Also, pursue balance for the sake of balance.

In general, community is important. As I went through training, I began to prioritize community more, partly due to Covid, which occurred during my graduate studies. I always remember loving statistics. One day, though, during the pandemic and having just done 5 hours of mathematical derivations alone in my apartment, I realized: I like statistics, but I also really liked talking to people about statistics.

Try to hold on to the community, somehow. I still don’t really know how to do this well, because degree programs are temporary. Many of your PhD friends will leave when they find jobs. Many of your medical school friends will leave in the match. I wish there were more academic jobs and more residency spots, and therefore it were easier to stay in one place geographically, and to then maintain community. 

Community also leads to organization, and working together for a better future. Friends outside of research and medicine can also help in terms of community that is not as dependent on the academic job market or the match. As I progressed in my program, I tried to make work-life boundaries clearer, in that I tried to separate my friends outside of work from my colleagues. I think this helps one achieve a kind of equanimity in the workplace and outside, which I wish I had more of when I was earlier in training.

Specialty

Another major decision is specialty. If you don’t know what specialty you would like to apply into, clinical experiences during your PhD years, which were called Longitudinal Clerkship Experiences in my program, can really help.  I would recommend trying to find a preceptor who might then write a letter of recommendation for your residency application, since it is hard to scramble for letters during third year, especially around application time. Longitudinal Clerkships can also be used to find a specialty that you would feel alright with. No need to love it; you can always change your mind later.

In general, the longer you are in research (or the longer it feels), the more LCEs you should do.  This may be tough. The longer you are in the PhD, the more you will feel pressure to finish. However, specialty choice is a major decision. The harder third year is, the more difficult it is to make a major decision, and the longer you in research (or the longer it feels), the harder third year will be.

No matter what, because returning to clinical training can be challenging, people can have trouble choosing a specialty: feeling afraid of choosing any specialty. If you notice this, it may be worth stepping back and trying to identify the stressors rather than trying to force a decision.

Like in grad school with choosing a topic, my sense is that it is sometimes worth choosing a mentor (or an environment) instead of a specialty. If you are still having difficulty choosing a specialty, which can be stressful, it might be helpful to note that you are, in the process, learning about yourself, and you can be yourself in multiple different specialties.

As a dual degree student, also, your ability to find a career that suits you is further facilitated by your role as a researcher. For example, you might find that you want to go into radiology, but you like talking to patients. You might realize that there are two parts to this: you like to help people, and you like to talk to people. As a radiologist, you help people (on a large scale), so that requirement is fulfilled. To fulfill a career goal of being around people—besides making sure to talk with radiology colleagues—research, with labs, conferences, etc, can help. 

Teaching hospital

After being in research, I found it difficult to return to clinicals, because I worried that my mistakes might cause harm. Nowadays, post-Covid, everyone wears jackets/fleeces. The white coats, and the medical student’s short white coats, are all out of vogue. I, however, always used to wear my short white coat, because I considered it a reminder to my team that I was a student and therefore needed someone to double-check my work.  The feeling that one needs to be double-checked may be more pronounced the longer one is away from clinic (or the longer it feels one is away), and it is a conscientious and caring instinct.  I though encourage you to feel more free to make mistakes than I felt.  To learn, you must feel free to make mistakes. There will be many people on your team that will prevent any mistakes you, as a medical student make, from causing harm: they are trained to teach medical students in this way. 

Also, often, especially as a learner, it is not mistakes that are so bad, but, instead, missing the big picture. To see the big picture, one needs to take risks, and make mistakes; sometimes it helps to present without notes, etc, even if just to yourself.  It’s difficult, because seeing the big picture is not necessarily about ignoring details, it is about synthesizing them, and this is a difficult thing to do, at least for me (maybe I process information differently, and also on top of this my medical language had atrophied during my research years).

Feedback

In research or in medical training, if given feedback, even if you feel singled out, try to think of it as a gift. A Dean of Research (Dr. Dewhurst) once said something during a research seminar like: although criticism can hurt, there is also a pearl. Often, how feedback feels is a function of the person giving it, but the truth in the feedback is valuable regardless.

A scaffold

Ultimately, medicine is information overload. It helps to have a scaffold when presenting a case. As a medical school professor, Dr. Fong, told us, the differential is a great scaffold. So, when thinking about approaching a case, it can be helpful to think first about the differential, and then structure the presentation around it.  Mention symptoms that help you narrow the differential (and order tests and labs to do this too). That is how healthcare providers think, and that is what they expect to hear about.

For dual degree students re-entering clinical training, who might have lost vocabulary and knowledge during the PhD, shelf and step exams can be a major stressor.  I think it is helpful to learn to think about a differential during exam questions as well, as I describe here. This might or might not work for everyone, but it made studying much more engaging for me. Also, if you, like me, study on a treadmill, and cannot easily highlight or write, this is a way to stay engaged without this.  

Community in school

I would recommend staying in touch with others in the dual training program.  They might be in different departments, but they will be talking about the same things: the day-to-day grind, thesis proposals, thesis defenses, transitions, clinical work, etc.  Take advantage of structured, consistent opportunities within your program to do this, such as dinner seminars and conferences. It is nice to be on your own path, as any dual degree student will be, but it can be very difficult to be isolated, especially in high-pressure academic environments. Also, although you can obtain similar community in the clinical world or the research world alone, and this is important, too, take care when avoiding dual degree events in favor of departmental or medical school events; this may tempt you to go too far in one direction or another (e.g., to take extra time in graduate school or to leave graduate school early).

Also, I would recommend to keep in contact with administrators, mentors, and other role models. They can help you through graduate training in a way that works for you. When returning to third year, medical school advisors can help as well in terms of easing back into clinical work and thinking about specialties.

Improving patient care as motivation

In the end, I really liked the dual degree, because I got to do research, which I find fascinating, and clinical work, which I find engaging, but, beyond both, I felt like my overall meaning was always derived from trying to improve patient care. This was a guiding light. It is a gift to work to try to relieve suffering, and I would highly recommend it in any career.  As a dual degree, you might do varying degrees of patient care, but you still will have had the training, and the direction that comes with it. This does not necessarily mean you have to sacrifice your life for the good of humankind; it can feel like a lot to try to help people with one’s work—it can make it become entangled sometimes in the meaning one has in life in general, which is a double-edged sword. However, even making a small dent in terms of bettering the condition of humankind can help, sometimes in big ways.